Eye, ear, nose, and throat problems Flashcards
What is conjunctivitis and what causes it?
Inflammation of the bulbar and/or palpebral conjunctiva
- Commonly viral, but can be bacterial or allergic
- If viral, commonly presents with URI, rhinorrhea, other common cold symptoms
Conjunctivitis clinical presentation
- Allergic → ocular itch
- Viral → no itch, common cold symptoms
- Bacterial → clear to purulent discharge
Conjunctivitis treatment
- Viral → self limiting
- Allergic → ocular and systemic antiallergic medications
Four ophthalmological emergencies
- Angle closure glaucoma
- Anterior uveitis
- Retinal detachment
- Ocular injury
What is angle closure glaucoma (aka acute glaucoma)?
Sudden, marked increase in IOP
- Can be diagnosed with tonometry (normal 8-22), but in outpatient will need to refer out
Angle closure glaucoma treatment
Goal: prompt IOP lowering and inflammation relieving with meds
- Beta blocker drops
- Alpha-2 agonist drops
- Miotic or cholinergic drops
- Oral carbonic anhydrase inhibitors
What is anterior uveitis (aka iritis)?
Most common form of intraocular inflammation and involves the eyes anterior uveal tract (iris and ciliary body)
- Risk factor: underlying autoimmune disease (HLA-B27 serotype positive)
Anterior uveitis clinical presentation?
- Rapid onset unilateral dully painful red eye with discomfort
- Pain radiates to the temple and periorbital area
- Vision change
- Pupil constricted, nonreactive, irregularly shaped
Anterior uveitis treatment
- Medications to assist in pupillary dilation (corticosteroids) via drops, injections, or systemically
- Treatment of underlying autoimmune disease
What causes retinal detachment?
Inflammatory and/or vascular abnormalities or injury that allows fluid to build up encouraging separation of the inner retinal layer from the retinal pigment epithelium
Retinal detachment clinical presentation
- Sudden onset, unilateral decreased visual acuity
- Change in visual fields (“curtain being pulled down”)
- New onset light flashes, floaters, wavy visual field
- NOT red or painful
Retinal detachment treatment
- Special surgery performed by ophthalmologist
- No pressure should be put on eyeball
- No vigorous physical activity
Ocular injury clinical presentation
- Pain/discomfort
- Decreased visual acuity and/or visual field alteration in affected eye
Ocular injury treatment
- Immediate referral to ophthalmologist or ED for evaluation
What is primary open angle glaucoma (POAG)?
Elevated IOP caused by abnormal drainage of aqueous humor through the trabecular meshwork
- Slowly progressive peripheral vision loss
- “Silent thief of vision”
Primary open angle glaucoma clinical presentation
- “Glaucomatous cupping” on fundoycopic exam (cup-to-disk ratio >0.3)
What are the three Ps of primary open angle glaucoma (POAG)?
- Preventable
- Risk factors: AA, DM, family history, history of eye trauma, advanced age
- Painless
- Permanent (peripheral vision loss is irreversible)
Primary open angle glaucoma treatment
- Reduce production of intraocular fluid (beta adrenergic antagonists, alpha-2 agonist, carbonic anhydrase inhibitor)
- Increase fluid outflow (prostaglandin analogues, biotic or cholinergic agents)
- Surgical interventions by specialist
Three eyelid disorders
- Hordeolum
- Chalazion
- Blepharitis
What is a hordeolum?
Forms as a result of a staph infection of the eyelid hair follicle with resulting focal abscess
- Recurrent lesions common in presence of meibomian gland dysfunction
Hordeolum clinical presentation
Sudden onset warm, painful, swollen, red lump
Hordeolum and chalazion treatment
Warm compresses to area for 10 minutes or more, 4-5 times a day until clear
What is a chalazion?
Common eyelid condition that occasionally follows hordeolum
- Eyelid sebaceous gland obstruction and inflammation
- Without infection
Chalazion clinical presentation
Slowly developing, non tender, hard, localized eyelid swelling without redness or heat
- Single lesion
What is blepharitis?
Inflammation and/or staph colonization of the meibomian glands at the base of each eyelash
Blepharitis clinical presentation
- Has been present for a number of weeks to months prior to presentation
- Lid redness, crusting, flaking
- Mild burning, itching, grainy sensation
Blepharitis treatment
- Warm compresses multiple times/day
- Gentle cleansing of lid margin with diluted baby shampoo
- Application of topical antibiotic (bacitracin) to lid margin
Otitis externa risk factors
- History of recent ear canal trauma (vigorous use of cotton swab or other item to clean the canal)
- Conditions in which moisture is held in ear canal (cerumen impaction, frequent swimming)
- Freshwater aural exposure
Otitis externa clinical presentation
- If fungal → itch, thick and white ear discharge
- Ear pain with tragus palpation or application of traction to pinna
- Progressing over 1-2 days
- Purulent or serous, foul smelling discharge
Otitis externa (swimmer’s ear) treatment options
- Ciprofloxacin otic drops with hydrocortisone
- Addition of corticosteroid results in faster resolution of symptoms
- Use ear wick with ear edema (left in place for 2-3 days)
- Drops containing neomycin and amino glycoside should not be used if tympanic membrane rupture is present or suspected
- To prevent reinfection, ear drops of 1:2 mixture of white vinegar and rubbing alcohol after swimming
- NSAIDs or acetaminophen for pain management
What is a complication of otitis externa?
Malignant or necrotizing OE - occurs in OE when patient is immunocompromised
- Infection invades deeper soft tissue → osteomyelitis occurs of temporal bone
- Imaging → CT and MRI
- Treatment → surgical debridement, parenteral antimicrobial therapy
What causes acute otitis media in teens and adults?
Eustachian tube dysfunction allowing negative pressure to be generated in middle ear → enables pharyngeal pathogens to be aspirated into middle ear
- Eustachian tube dysfunction caused by viral URI or untreated allergic rhinitis
Acute otitis media clinical presentation
- Tympanic membrane erythema
- Loss of tympanic membrane mobility
- Visible bony landmarks
- Ear pain
Acute otitis media treatment
Adult AOM treated with antimicrobials (pediatrics “watch and wait”)
- Standard dose oral amoxicillin if no prior antibiotic used within the last month
- If recent antibiotic use → high dose amoxicillin, amoxicillin-clavulanate, cephalosporins for 5-7 days
- Ibuprofen or acetaminophen for pain relief
What is Menieres disease?
Inner ear disorder that causes episodes of vertigo
- Believed to result from idiopathic endolymphatic hydrops (condition of increased hydraulic pressure within inner ear)
Meniere’s disease clinical presentation
- Onset: early to middle adulthood with peak incidence in 40-60s
- Fluctuating hearing loss
- Low tone tinnitus
- Ear pressure
- Episodic vertigo (aural fullness)
Meniere’s disease diagnosis
- Nystagmus (rhythmic oscillations of eyes)
- Slow movement toward one side (affected side)
- Rapid correction to midline
Meniere’s disease diagnostic tests and maneuvers
- Weber test lateralizes to unaffected ear
- Rinne test is normal (air exceeds bone conduction)
- Positive romberg test
- Performing pneumatic otoscopy in affected ear elicits nystagmus
- May have positive Dix-Hallpike test coexisting BPPV
Meniere’s disease treatment
- Antihistamines or antiemetics
- Benzodiazepines (do not treat underlying condition)
- Thiazide diuretics (do not help after attack is triggered)
- Systemic corticosteroids
What causes anterior epistaxis (nosebleed)?
Localized nasal mucosa dryness during winter months and trauma
Allergic rhinitis symptoms
- Sneezing
- Pharyngeal and ocular itch
- Nasal congestion
- Rhinorrhea
- Postnasal drip
Treatment options for patients with symptom complaints (allergic rhinitis)
- Nasal congestion is dominant complaint
- Intranasal corticosteroid
- Oral decongestant (sudafed)
Treatment options for patients with symptom complaints (allergic rhinitis)
- Intermittent sneezing, nasal itching, and rhinorrhea
- Oral antihistamine
- Intranasal antihistamine (astelin)
Allergic rhinitis treatment options for mild vs moderate/severe symptoms
Mild → oral antihistamine
Moderate/severe → intranasal corticosteroid, intranasal antihistamine, combination therapy
Antibiotic classes that is associated with the highest rates of antibiotic allergy
Beta lactams → pencillins, cephalosporins
- IgE mediated type I reaction
- Rapid onset maculopapular skin eruption
- Urticaria
- Pruritus
- Cough and bronchospasm
- CV compromise (tachycardia, hypotension)
What is acute bacterial rhinosinusitis?
Inflammation of the lining of the membranes of the paranasal sinuses caused by bacterial infection
Acute bacterial sinusitis diagnostic criteria
Presents with URI-like symptoms with persistent or worsening symptoms for 10+ days who continue to have (viral infections improve after 5-10 days):
- Maxillary/facial pain
- Purulent nasal discharge
“Double sickening” → 3-4+ days of URI-like symptoms that gradually improve and then suddenly worsen
Severe illness (pain and fever) that occurs 3-4 days after onset of symptoms
Acute bacterial sinusitis treatment (first line and second line therapy)
First line → amoxicillin-clavulanate
Second line (if allergic) → doxycycline
What is the most common form of oral cancer? How does it present?
Squamous cell carcinoma (SCC)
- Painless
- Firm ulceration or raised lesion
- Present for a number of months prior to presentation
- Lymphadenopathy → immobile nodes >1 cm, non tender
Oral cancer management considerations
Referral to otolaryngology or oral surgery
What is acute bacterial pharyngitis?
Group A beta-hemolytic streptococcus (GABHS) - aka strep throat
- Common in school aged children
Acute bacterial pharyngitis clinical presentation
- Sore throat
- Fever
- Large, beefy tonsils with white exudate
- Pharyngeal erythema
- Palatal petechiae
- Bilateral anterior cervical lymphadenopathy
What is scarlet fever?
Associated with bacterial pharyngitis (usually on second day of illness)
- Scarlatiniform rash
- Fine sandpaper-like texture
- No pruritus
- Starts on trunk and spreads widely (sparing palms and soles)
Acute bacterial pharyngitis (strep throat) and scarlet fever treatment
- PCN formulations (if PCN allergy without immediate reaction, oral cephalosporin; if PCN allergy with immediate reaction, azithromycin or clindamycin)
- Consider c. diff when prescribing clindamycin
- Salt water gargles, throat lozenges, analgesics (ibuprofen, acetaminophen)
True/false: Patients with bacterial pharyngitis are no longer contagious within 24 hours of starting antimicrobial therapy and when without fever
True
Three complications that can occur with acute bacterial pharyngitis (strep throat)
- Peritonsillar abscess
- Acute glomerulonephritis
- Rheumatic fever
Peritonsillar abscess clinical presentation
- Progressively worsening sore throat
- Unilateral
- Trismus
- Drooling
- Muffled, “hot potato” voice
- Erythematous, swollen tonsils with contralateral uvular deviation
- Cervical lymphadenopathy
Peritonsillar abscess clinical presentation
- Progressively worsening sore throat
- Unilateral
- Trismus
- Drooling
- Muffled, “hot potato” voice
- Erythematous, swollen tonsils with contralateral uvular deviation
- Cervical lymphadenopathy
Peritonsillar abscess management
- Prompt US or CT of affected region
- Referral to ED and speciality ENT
What is infectious mononucleosis?
Acute systemic viral illness caused by EBV (DNA herpes virus) that enters the body via oropharyngeal secretions
- Affects B lymphocytes
Infectious mononucleosis clinical presentation
- 3-5 day prodrome → headache, malaise, myalgia, anorexia
- Acute symptoms (last 5-15 days) → fatigue, exudative pharyngitis, tonsillar enlargement, fever, headache
- Anterior and posterior cervical lymphadenopathy, splenomegaly and hepatomegaly
Infectious mononucleosis diagnostic testing
Heterophile antibody test (monospot)
- Positivity increases during the first six weeks of illness
Infectious mononucleosis treatment and management
Supportive therapy or
- Systemic corticosteroids (prednisone) to treat pharyngeal obstruction
- Avoid amoxicillin or ampicillin → can cause rash (thought to be result of altered immune system during infection)
Infectious mononucleosis important patient education considerations
- Avoid collision or contact spots for at least one month to avoid splenic rupture
- Consider US examination before clearing for sports
