Exam 3 HEENT Treatments Flashcards
Bells Palsy
Tape eye shut at night, wetting drops to keep eye moist if patient can’t close it
Corticosteroids - Prednisone - MAINSTAY
artificial tears
what it it is viral pathology? acyclovir
Horners Syndrome
MAP
Trigeminal Neuralgia
Anticonvulsants: carbamazepine, gabapentin
TCAs: Ami -Nor - triptyline
Surgery: rhizotomy and neurectomy
Blepharitis
keep lids clean
avoid make-up
lid massage w/ abs ointment
baby shampoo/ lid cleanser
Chalazion
warm compresses
steroid injection
surgery
Ectropion
artificial tears
surgery
Entropion
surgery
artificial tears
abc ointment (azithromycin)
Hordeolum
warm compresses
abc ointment
lid hygiëne
PO abs if periorbital cellulitis
cataract
surgery - new lens
Conjunctivitis viral
cold compresses
steroids topical
artificial tears
Conjunctivitis bacterial
tobramycin
trimethoprim + polymyxin B
gentamycin
ECN ointment
conjunctivitis allergic
Ah drops - olopatadine
cold compresses
steroids
artificial tears
Dacryocystitis
Empiric abs
IV abs
I/D
dacryocystorhinostomy
Pinguecula
artificial tears
steroids
Pteryguim
surgery - autograft
artificial tears
Uveitis
Mydraitic / cycloplegic gtts (cyclopentolate, tropicamide)
topical corticosteroids - mainstay (prednisone?)
PO steroids
acute otitis external
external ear
pain relief ( NSAIDS and Tylenol) eradication of infection with ciprofloxacin or ofloxacin
mastoiditis organisms
strep pneumo
H flu
M cat
always a complication of AOM 80%
mastoiditis
external ear
pipercillin - tazobactam plus vancomycin
narrow down ATB once culture is back from tympanocyntesis
myringotomy
mastoidectomy if no improvment in 48 hrs.
Eustachian tube dysfunction
Viral URI cause - systemic decongestants (pseudo ephedrine) intranasal decongestants (oxymetazoline) auto inflation but not with active infection Allergic cause - desensitization or intranasal steroids
acute otitis media
sensorineural hearing loss b/c scarring TM
mot resolve spontaneously
systemic pain: ibuprofen, acetaminophen, oxycodone, hydrocodone
topica painl: antipyrine, benzocaine, lidocaine (contraindicated with TM perforation)
if ABS indicated then first line is amoxicillin, cephalosporins,
augmentin
ofloxacin,
ceftriaxone (IV), clindamycin if PCN allergy
failure of sec ABS then clinda + 3rd gen ceph.
otitis media w/ effusion
not like AOM cause this is not painful, AOM is painful
90% resolve spontaneously AH decongestants corticosteroids ABS all are unproven to work tympanovstomy tubes - surgery
chronic otitis media
conductive hearing loss b/c TM is perforated
organisms are: Pseudomonas, Proteus, staph
Tx: ofloxacin or ciprofloxacin with dexamethasone (steroid) , these are topical ABS
Definitive Tx: TM repair (90% success), mastoidectomy if irreversible infection
cholesteatoma (acquired or congenital) - retraction of TM interrupts normal squamous migration - keratin accumulates
osteoclastic activity
surgical - excise all of it or it will recur
remove infected debris, keep ears dry, ATB drops or maybe steroid drops
congenital disorder of the middle ear = EAC ATRESIA from agenesis of EAC
narrowing of EAC b/c of failure to develop completely
results in conductive hearing loss
Overly patent (branching) ET
avoidance of decongestants
myringotomy to decrease TM stretch
congenital disorder of the middle ear = MICROTIA (anotia)
small, collapsed or only a lobe
anotia = complete absence of the ear and canal
congenital disorder of the middle ear = Lop Ears
folded down or protruding
Tx: otoplasty
congenital disorder of the middle ear = Low Set
upper pole below eyebrow level, check kidneys
congenital disorder of the middle ear = PRE AURICULAR TAGS
cosmetic problem
TM perforation
will usually resolve on own
avoid water
surgically close the TM
surgically repair ossicle chain
Hematoma of external ear
compression of ear
I / D
compression
TAPE IT!
Barotrauma
yawn, sneeze
autoinflation
decongestants - pseudophedrine
if severe: Myringotomy
Foreign Body (ear)
Warm water irrigation cerumenolytics - EPO colase curette or forceps lidocaine mineral oil DO NOT ADD WATER why? organic substances will swell
Open Angle Glaucoma
Prostaglandin - latanoprost, bimatoprost
B-adrenergic - timolol
Combination drops - better compliance
Laser therapy or surgery
Closed Angle Glaucoma
halo around lights, steamy cloudy cornea Primary: IV azetazolamide Diuretics - acetazolamide anterior chamber paracentesis once IOP is down then topical pilocarpine Secondary: systemic azetazolamide treat cause
Optic neuritis
unilateral
inflammation of optic nerve
if demyelinated : prednisolone
treat cause = MS, DM , HTN
Papilledema
bilateral
inflammation of optic disc progressive vision loss tX: treat HTN/mass weightless Acetazolamide - PO or injection cerebral spinal shunt optic nerve fenestration
Retinal Detachment
unilateral-painless, 25% turn b/l
retinal tear / tractional detachment = pre-retinal fibrosis Tx: laser photocoagulation cryotherapy sub retinal drainage pneumatic retinoplexy (bubble therapy)
Retinal vascular occlusion - ARTERY (unilateral)
cherry red spot on fovea and box car segmentation of VEINS (not arteries)
ocular massage, O2, lay flat, IV acetazolamide , anterior chamber paracentesis (like closed glaucoma)
IV thrombolytics (heparin, coumadin- uhhh! cause it is a clotting issue)
Retinal vascular occlusion - ARTERY due to Giant Cell Arteritis (GAS) or Temporal Arteritis —- JC
corticosteroids
biopsy of temporal artery (ouch!)
Retinal vascular occlusion Vein (unilateral)
neovascular glaucoma - photocoagulation
intravitreal triamcinolone for macular edema - steroid injection into the eye
tissue plasminogen activator (TPA) into retinal venous system for strokes
neovascular glaucoma
photocoagulation
macular edema
intravitreal triamcinolone
Proliferative Diabetic Retinopathy
vessel proliferation
neovascularization
control BG, BP, lipids, monitor renal function
Tx: pan retinal laser photocoagulation (NIGHT / COLOR LOSS) or vitrectomy (do this before hemorrhage occurs and causes tractional retinal fibrosis
mydriatic drops
IF MACULAR EDEMA - LASER PHOTOCOAGULATION
NON - proliferative diabetic retinopathy
not forming new vessels
Hypertensive Retinopathy
worse in young patients with rapid rise in BP
breaks endothelial integrity
occludes capillary arterioles
(cotton-wool spots, retinal hemorrhages, edema, exudates)
CHRONIC HTN - INCREASES DEVELOPMENT OF ATHEROSCLEROSIS - and retinal arterioles become narrow and tortuous (copper silver wiring, AV nicking, superficial hemorrhages - flame)
Strabismus (eyes don’t line up) problem with EOMs
vertical = hyper/hypotropia
horizontal = exotropia (eyes turn out)/esotropia (eyes turn in)
Tx: glasses, exercises, eye muscle surgery
Amblyopia - “lazy eye”
one eyes experiences a blurred view while the other is normal
most common vision loss in children - only seen in children (one or both eyes)
strabismic amblyopia
brain ignores the eye that isn’t straight, decrease in vision
deprivation amblyopia
congenital cataract or othercontition deprives eye of vision
refractive amblyopia
unequal amount of refractive error, brain ignores the worse eye
amblyopia treatment
glasses may help
patching the normal eye (allows weaker eye to get stronger)
Atropine eye drops in good eye to make it blurry
surgery on eye muscles if from strabismus
Hyperopia - farsightedness
“plus” or CONVEX lens
Myopia - nearsightedness
light rays at converging at a point before the retina
“minus” or CONCAVE lens
Presbyopia
plus lenses for near work (reading distance)
Age-related macular degeneration
laser photocoagulation - reduces druse, but it can still progress For neovascular (WET) - vascular growth inhibitors intravitreal injection For Atrophic (DRY) - no treatment
Presbycusis
sensoneural hearing loss
hearing aid
Coenzyme Q10
Otosclerosis
conductive hearing loss
hearing aid
stapedectomy
tinnitus
avoid excessive noise
mask tinnitus by music or hearing aid
avoid ototoxic medications - gentamicin
TCA’s
Vertigo
vestibular suppressants
benign (paroxysmal) positional vertigo
dix hall pike DX
Eply maneuver (trying to get otoliths back into utricle)
N/V/Tinnitus
horizontal nystagmus (like peripheral vertigo)
anti vestibular medication
benzodiazepines (diazepam)
AH (meclizine)
Meniere Disease
Triad = vertigo, hearing loss, tinnitus
distention in the inner ear and impaired reabsorption of endolymphatic fluid
caloric test
FTA-ABS - fluorescent treponemal abs absorption
diuretic - azetazolamide
If severe - intratympanic gentamicin, intratympanic corticosteroids, surgery, AH, low sodium diet = first line,
Labyrinthitis
viral infection of the inner ear
vertigo (days to weeks) and hearing loss
does not have tinnitus like MD
Tx: AH, benzodiazepines
if febrile - abs
if herpes - Ramsay hunt syndrome - acyclovir
symptomatic TX: vestibular suppression like benzodiazepines and AH
Acoustic Neuroma (vestibular schwannoma)
Benign tumor of CN VIII sheath - schwann cells)
depends on severity: observation, surgical excision, radiation
if from neurofibromatosis TII (bilateral acoustic neuromas) - then consider chemotherapy with bevacizumab (which is a vascular growth inhibitor used in “wet” ARMD)
can consider surgical excision
but we also may choose not to treat considering patient population
Alkali burns
immediate topical anesthetic (proparacaine, tetracaine)
copious amounts of irrigation 2-3L
double eversion of the lids to remove material
remove particles with forceps or moist cotton swab
Irrigate until pH of 6.8 - 7.4
NO ACID FOR A ALKALI BURN CAUSE IT WILL CAUSE AN EXOTHERMIC REACTION AND CAUSE FURTHER BURN
Mydriatic / cycloplegic drops to dilate pupil and paralyze the ciliary muscles
ABS ointment
maybe PO narcotics
check IOP
Acid burns
cause more damage then alkali, but less serious b/c acids do not penetrate as deeply but they can still cause blindness ex. nail polish remover / battery acid topical anesthetic copoius irrigation (water ot ringers) DO NOT NEUTRALIZE WITH ALKALI check for ulcerations PO narcotics
Thermal Burns
burn of the lids, cornea, conjunctiva
(superficial or severe)
Tx: systemic analgesia, topical anesthetic, mydriatic drops if corneal invlovement
UV radiation
actinic keratitis, snow blindness, welders arc burn
burns conreal epithelium cuasing pain photophobia
Tx: PO analgesics, Mydriatic drops and abs , topical anesthetic for eye exam (DO NOT LET PATIENT TAKE HOME)
Corneal Ulcer
corneal transplant - universal donor so no type and screen
Can be caused by: acanthameoba keratitis, fungal keratitis, herpes simplex keratitis, exposure keratitis (eyelids do not close) = dendritic lesions, FB, SJOGRENS (dry mouth and eyes)
Tx: pain meds, protective glasses, corticosteroids drops, Empiric ABS (like dactrocystitis) but taper off when culture is back
Corneal Abrasion
Sx: tearing, photophobia, blurry vision
regenerates 24-28 hrs
tx aimed at pain relief and infection prevention
cycloplegics for ciliary spasm
Patch for pain releif but no patch if fingernails, plant or CL
abrasions form contacts need pseudomonas coverage so give them cipro
DO NOT GIVE PRESCRIPTION FOR TOPICAL ANESTHETICS FOR HOME!
Foreign Body (eye)
Removal: topical anesthetic, irrigate with NS, try moist cotton swab, 25 guage needle bevel up to try and poke it out using a slit lamp
Dispostion: topical ABS, cycloplegics, oral analgesics, tetanus,
Hyphema
blood in the anterior chamber from trauma or surgry
grade 1 = less than 1/3 chamber filled
can clot and get stuck
Tx: monitor IOP resloves in 5-6 days
Globe rupture
DO NOT MEASURE IOP
from severe trauma it can rupture the thinner parts of the eye like the sclera and limbus
anisicoria - irregular pupil
Tx: do not manipulate eye, elevate the head of bed, protective shield, Broad specturm ABS, tetanus, sedation and analgesics and antiemetics for anti vomitting (cause vomitting increases IOP when can cause the globe to ooze)
NPO ?
Blow out fracture
can trap inferior rectus and disrupt upward gaze
most COMMON is the inferior wall (maxillary sinus)
fracture followed by medial wall (ethmoid)
Tx: not an emergency, can repair up to 3-10 days later, waters view xray showing maxillary sinus cloudy, CT, oral ABS
Nystagmus
help with school or social situation
regular eye exams
contacts better then glasses
surgically you can reattach the extraocular muscles
Medical: BOTOX or Baclofen - CNS depressor
Temporal Arteritis
AKA Giant cell artritis and also seen with retinal ARTERY occlusion
JAW CLAUDICATION
Tx: immediate prednisone
polymyalgia rheumatica - disease of connective tissue causing pain and stiffness of muscles
Preseptal Cellulitis
PO ABS
hot packs
caused by staph or strep
no eye involvement so there is no eye pain when eye moves
Infection of the eyelids and periocular tissue ANTERIOR to the orbital septum
Postseptal Cellulitis
Admit
IV ABS - broad spectrum w/ anaerobic and aerobic coverage
eye involvement so eye movement are painful
Infection of the eyelids and periocular tissue POSTERIOR to the orbital septum
How can you differenciate between post and pre septal cellulitis?
get a CT w/ contrast and you can see if the globe is involved or is it just preseptal
Diagnostic Criteria for Temporal Arteritis
you need 3 of the 5:
- > 50 y.o.
- unilateral headache, new onset
- temproal artery tenderness
- ESR > 50 mm
- abnormal biopsy of temporal artery = vasculitis
Common cold
adenovirus, rhinovirus nasal saline decongestants (pseudoephedrine) analgesics (acetaminophen) worse symptoms: nasal steroids (fluticasone), nasal anticholinergics (ipratropium), oral steroids taper EBM - zinc decrease illness time
Influenza
orthomyxovirus
Neuraminidase inhibitors: oseltamivir, zanamivir
patient education - quadravelent vaccine
Rhinitis
allergic: saline drops, avoid potential sources, corticosteroids, AH (loratadine- claritin), decongestants, nasal anticholinergics, mast cell stabilizers
Vasomotor: avoid irritant
Medicamentosa: discontinue decongestants
severe: immunosuppressants
nasal polyps
nasal corticosteroids
excision if no improvement
Olfactory dysfunction
evaluate reversible cause: infection, allergies, tumor
NO TX FOR PRIMARY OLFACOTRY DYSFUNCTION
Epistaxis
first line: direct pressure for 15 min, sitting position leaning forward (if still bleeding consider posterior bleed)
second line: nasal stimulants vessel constriction: cocaine, phenylephrine, oxymetazoline, cauterize with silver nitrate
If bleeding persists: nasal packing with ABS cephalexin or clindamycin. If anterior pack for 5 days, of posterior consult ENT
if severe: nasal artery ligation
Sinusitis
patient education - will improve in 2 weeks w/p treatment
nasal washes ot steam
Mild: NSAIDS (ibuprofen), nasal decongestants pseudo ephedrine, nasal corticosteroids - fluticasone
Moderate/severe: ABS for 10 days - first try penicillin (augmentin, amoxicillin). If PCN allergic then tetracycline (doxycycline) or macrolide (azithromycin). refractory treatment = quinolone (levofloxacin, moxifloxacin)
Chronic: antibiotics for 3-4 weeks and same ABS as acute
Cavernous Sinus Thrombosis
start IV antibiotics immediately - PCN (Nafcillin) + cephalosporin 3rd ben (ceftriaxone) or vancomycin if MRSA is considered
Heparin is considered
Skull fractures
any open skull fracture requires ABS
Maxillary - wire shut
Mandibular - need surgery within couple days
Basilar - admit and aggressive evaluation (raccoon and battle sign)
Nasal FB
UNILATERAL NASAL DISCHARGE!!
vasoconstrictors (phenylephrine, oxymetazoline)
remove object with alligator forceps, wire curette, suction, positive pressure technique
if can’t remove then ENT follow up
nasal fracture
LATERAL NASAL XRAY
tetanus update - anytime if open wound
antibiotics if open - PCN and if allergic then doxy or azithromycin
ENT follow up
Septal hematoma
I / D - bilaterally
packing x 2-5 days
oral ABS
ENT follow up
Angioedema
Discontinue suspected agent like AH, Steroids, Epi (IM, SubQ)
Surgery or Procedures: Endotracheal intubation, Cricothyrotomy
MILD: observe in ED, Oral meds
Moderate: admit
Severe: admit to ICU crib kit at bed side
Airway assessment
LEMON Look externally for physical clues Evaluate 3:3:2 rule- three finger width between incisors, three between mandible an hyoid and two between hyoid and thyroid Mallampati - class 0-4: 0 = can see epiglottis 1 = SP, Fauces, Uv, pillars 2 = SP, F, U 3 = SP, U 4 = SP not visible Obstructive - soft tissue swelling, obesity Neck mobility - ROM
What are the 7 P’s of Rapid Sequence Intubation?
Preparation - 10 min before Pre oxygenation - 5 min Pretreatment - 3 min Paralysis - induction Protection - 30 sec after Placement - Proof - 45 sec after Post- Intubation management - 60 sec after
Hereditary Angioedema
Generally refractory to these Tx: anabolic steroids, C1 esterase inhibitor, (berinert & Cinryze)
Kvllikrein inhibitor (Kalbitor $$$$$)
Bradykinin 2 receptor antagonist, Firazyr
Glossitis
Nutrition replacement
Glossodynia
burning and pain of tongue
stop smoking
benign
consider: Anxiolytic or Gabapentin ( also used in trigeminal neuralgia )
Aphthous Ulcer
maybe related to herpes Virus 6
Tx is supportive:
Diclofenac, or corticosteroids with adhesive base (or Orabase)
oral mouthwashes / prednisone
Oral Candidiasis (thrush)
Oral antifungals: Fluconazole
Nystatin liquid
Clotrimazole
If they have dentures then maybe Nystatin powder on them
Oral Herpes Simplex (cold sores)
Supportive Care: will go away on own,DO NOT GIVE CORTICOSTEROIDS
Magic Mouthwash (BMX)
1. benadryl - diph
2. Maalox
3. Xylocaine
Viscous Lidocaine 2%
If severe: oral antivirals like acyclovir
Oral Leukoplakia
Biopsy - premaglignant hyperkeratosis
ENT consult
Monitor for development into SCC
Oropharyngeal Abscesses
I / D
IV antibiotics like PCN, Macrolides, Cephalosporins
admit
cricothyrotomy kit besides
If peritonsillar (quinsy) then consider a tonsillectomy or oral ABS in minor cases
If sublingual (ludwig angina) then consider bilateral submittal incisions if airway threatened
Parotitis (Sialadenitis) viral
Self limited
analgesics
Parotitis suppurative (bacterial)
IV ABS to cover staph PCN Cephalosporins Clindamycin for MRSA often requires I / D admit
Parotitis Juvenile recurrent
supportive care - analgesics
oral ABS like PCN or cephalosporins
Sialolithiasis
Whartons duct most common
CT w/o contrast
stone removal
consider gland excision if severe or recurrent
Procedures: duct dilation, (make sure clamp proximal duct) or distal duct incision
Newer options: Extracorporeal shock-wave lithotripsy and fluoroscopically guided basket retrieval
Sialendoscopy
diseases of mouth and gums
normally strep mutant main pathogens
Increased acid
and decrease saliva
caries
loss of integrity of tooth enamel from hydroxyapatite dissolution maybe be from infection acid or no saliva
Tx: Fluoride rinse / topicals
Gingivitis
bacterial and particles constantly forming plaque and forms TARTAR
gums become red swollen and can bleed easily but this can be reversed with cleaning
no loss of bone and tissue
Periodontitis
forms from not treating gingivitis
the gums pull away from the teeth and form pockets and harbors bacteria and particles and then the bacterial toxins break down the bone and connective tissue and can destroy the gums and bones
Necrotizing Ulcerative Gingivitis (trench mouth, Vincents Infection)
Spirochetes and fusiform bacilli
painful acute gingiva inflammation and necrosis
Tx: warm half strength peroxide rinses
ABS 10 days
dentinal gingival curettage
Temporomandibular jaw disorders
NSAIDS (naprosyn)
massage
if severe: carbamazepine
Patient edu: jaw rest, soft food, avoid teeth clenching
Skeletal muscle relaxants - methocarbamol
Tricyclic antidepressants - nortriptyline
Corticosteroids - prednisone taper
Surgery: correct anatomic abnormalities 5% of cases
Acute Strep Pharyngitis
WE ONLY TREAT STREP TO PREVENT RHEUMATIC FEVER
first line - PCN, penicillinVK , penicillin G (bacillin LA)
amox, cephalosporins
If PCN allergic: clinda, azithromycin, clartihramycin
Surgery: tonsillectomy if recurrent
if peritonsillar abscess then I / D
Mononucleosis
EBV supportive care NSAIDS, tylenol , chloraseptic steroids but not recommended warm saline for throat gargles 4x / day avoid contact sports
Diphtheria
Corynebacterium diphtheria gram +, drooling
grey membrane on tonsils extending to throat
Tx: STAT antitoxin form horse, PCN, erythromycin
isolation until 3 consecutive neg. cultures
remove membrane broncho/laryngoscopy
prevention: vaccine, booster
education - vaccine isolation
croup
steeple sign
acute laryngotracheobronchitis cause by parainfluenza
“Barking cough”
inspiratory stridor
worse at night - cool air outside during drive
steam in bathroom
Epiglossitis
from H. influenza type , 45 yo cause vaccine started in 80s
cherry red epiglottis, and thumbprint sign
Admit to ice/picu
airway protection
ceftriaxone
Foreign Bodies (throat)
trachea - ziemlich maneuver or cricothyrotomy , bronchoscopy and extraction
Esophagus - glucagon, benzodiazepines, if meat then papain,
swallow test with coke etc
Laryngitis
viral URI and common cause of hoarseness
rest voice
supportive care
stop smoking
NSAIDS
acetaminophen
Chloraseptic
No ABS
Sleep Apnea (obstructive)
you need @ lest 5 events of apnea / hr that last as long as 10 sec during a polysonmnogrpahy sleep study
education - weight loss
Tx: continuous positive airway pressure (CPAP)
Mandibular advancement splint (MAS)
surgical repair
general head and neck CA
chemo w. radiation ( cetuximab, methotrexate, 5 FU, cisplatin, docetaxel)
Oral CA
surgical excision
Salivary CA
parotid most common and are benign
Tx: excision (careful of facial nerve)
Larynx CA
chemo first
then
induction therapy w/ 3 agents : 5 FU, cisplatin, docetaxel
Neck CA
excision, radiation, chemo
Hx: drooling, dyspnea, odynophagia, dysphagia
PE: trismus - spasm of jaw muscles, Drooling, lymphadenopathy
TNM Staging 0 - III
no Nodes involved (N0) and no metastasis (M0)
but III can have N1
N0
no regional LN involvement
N1
metastasis to a single ipsilateral LN
N2
metastasis to a single ipsilateral LN but 3 - 6 cm
N2c
LN involvement to contralateral
N3
metastases in LN
