Eye trauma/ HEENT I Flashcards
Etiology of orbital fractures
- blunt trauma
- MVAs
- industrial accidents
- assaults
Who most commonly gets orbital fractures?
adolescent males
Bones of the orbit
hint: 7
- sphenoid bone
- zygoma
- maxilla
- ethmoid bone
- palatine bone
- lacrimal bone
- frontal bone
What makes up the superior wall of the orbit?
- frontal bone
- lesser wing of the spheniod bone
What makes up the inferior wall of the orbit?
- maxilla
- zygomatic bone
- palatine bone
What makes up the medial wall of the orbit?
thinnest wall
- ethmoid bone
- maxilla
- lacrimal
- sphenoid
What makes up the lateral wall of the orbit?
thickest wall
- zygomatic bone
- sphenoid bone
Six extra ocular eye muscles and actions
lateral rectus-abduction medial rectus-adduction superior rectus- up and in inferior rectus- down and in superior oblique-inferior and lateral inferior oblique-superior and lateral
Three sinuses
- maxilla
- frontal
- ethmoid
Where are the canthal ligaments
medial canthal- corner of the tarsal plate to the orbital wall
lateral canthal- lateral aspect of the orbit
What does the infraorbital nerve supply
lower eyelid, nose and upper lip
What does the supraorbital nerve supply?
upper eyelid, forehead and scalp
What are the four orbital fracture types?
- orbital zygomatic fracture (tripod fracture)
- nasoethmoid fracture
- orbital roof fracture (rare)
- orbital floor fracture (most common)
What is a blowout fracture
orbital floor fracture without fracture of the orbital rim with herniation of the contents
Complications of a blowout fracture
- alteration of support mechanism for extra ocular muscles
- EOM can become entrapped
- entrapment of inferior rectus and damage to infraorbital nerve)
Pure blow out fracture
bone fragments involving the central area of bone
Impure blow out fracture
fracture line extends to orbital rim
Mechanism of blow out fracture
force of blow–>backward displacement of eyeball–>infraorbital pressure increases–>fracture in the weakest portion of the orbital wall
Symptoms of orbital fracture
- facial pain
- ocular pain on movement
- neuropraxia
- diplopia
- color changes
- floaters, hazy vision, fog
- flashers, veil or curtain
- foreign body sensation
Physical exam findings of an orbital fracture (inspection)
- periorbital edema and ecchymosis
- depression/defect of the orbit
- epistaxis
- CSF leakage
Physical exam findings of orbital fracture (palpation)
- nerve neuropraxia
- emphysema
- pain
- step off deformity
Initial Assessment of orbital fracture: what do you do/check?
EYE EXAM
- visual acuity
- pupils
- cornea
- funduscopic exam
- EOMs
- conjunctiva
- eyelids
- color perception
Eye examination findings with orbital fracture
- lid laceration
- periocular ecchymosis
- hypoglobus
- subconjunctival hemorrhage
- hyphema
- traumatic mydriasis
- epipora
- corneal abrasion
- ruptured globe
- vitreous hemorrhage
- retinal detachment/tears
- EOM entrapment
What xray views are you going to get for an orbital fracture?
- AP
- PA
- Caldwell view
- Waters view
- Towne view
Gold standard for orbital fracture diagnosis
CT scan
-axial and coronal view
Other diagnostic test for orbital fracture
- forced ductions test
- fluorescein stain
- Hertel Exophtalmometer
Major associated complications w/ orbital fracture
- blindness
- long term diplopia
- infection
- EOM entrapment
- orbital dystopia/cosmetic issures
- neuropraxia
- intracranial bleed
Non surgical treatment for orbital fractures
- ice
- nasal decongestants
- if sinus involved, broad spectrum abx
- corticosteroids for orbital edema with diplopia
- avoid aspirin and nose blowing
What are the indications surgical repair of an orbital fracture
- restrictive strabismus
- CT evidence of muscle entrapment
- enophthalmos <2mm
- oculocardiac relfex
- hypo ophthalmos
- large floor fracture
When should you emergently consult ophthalmology with an orbital fracture
- rupture
- retro orbital hematoma
- retinal detachment
What requires a 24 hr follow up with a specialist when it comes to orbital fracture
- muscle entrapment
- enopthalmos or orbital dystopia resulting in facial asymmetry
- naso orbital ethoid fractures with injury to medial canthal ligament or lacrimal apparatus
What is hyphema
grossly visible blood in the anterior chamber d/t tears on the vessels of the cillary body or iris
Peak incidence of hyphema
10-20 years old
males>females
What causes hyphema
- trauma (blunt or penetrating)
- spontaneous (less common, usually underlying condition)
Hyphema symptoms
- decreased visual acuity
- photophobia
- pain
Hyphema physcial exam findings
- layer of blood in anterior chamber
- decreased visual acuity
- photophobia
- anisocoria
- elevated intraocular pressure
How to diagnose hyphema
-clinical diagnosis
ophthalmoscope
slit lamp
tonopen
Treatment of hyphema
- eye shield on affecred eye
- bed rest, dim lighting/limited activity
- cyclopentolate or homatropine
- PO pain control (avoid ASA and NSAIDs)
- anti emetics for n/v
Complications of hyphema
- intractable glaucoma
- optic atrophy
Posterior Synechiae
iris adheres to lens
Peripheral Synechiae
iris adheres to cornes
Symptoms of corneal foreign body
- pain
- foreign body sensation
- photophobia
- tear
- red eye
- blurred vision
What do you do on physcial exam for foreign body in the eye
- visual acuity
- inspection of eye and eyelid
- slit lamp
- fluorescein stain
Corneal foreign body physical exam findings
- normal or decreased visual acuity
- conjunctival/cilliary injection
- VISIBLE FOREIGN BODY
- rust ring
- excessive tear production
- corneal edema
- corneal perforation with deep foreign body
Differential diagnosis for corneal foreign body
- keratitis
- intraocular foreign body
- corneal abrasion
Medical management for corneal foreign bodies
- topical abx (cipro,erythro)
- topical cycloplegic
- tetanus if not UTD
What is the layer most commonly involved in corneal abrasions?
endothelium
What nerve innervates the cornea
trigeminal
Symptoms of a corneal abrasion
- pain
- foreign body sensation
- photophobia
- tears
- red eye
- blurred vision
Differentials for corneal abrasion
- acute globe rupture
- retained foreign body
- infectious keratitis
- corneal ulcer
- acute angle glaucoma
Physical exam for corneal abrasion
- visual acuity
- slit lamp exam
- fluorescein stain
Exam findings for corneal abrasion
- normal/decreased visual acuity
- conjunctival/cilliary injection
- visible foreign body
- rust ring
- excessive tear production
- corneal edema
Treatment of corneal abrasion
- topical erythro ointment
- topical cipro drops for contact lens
Infectious causes of corneal ulcer
-bacterial
VIRAL
-fungal
-amoebas
Non infectious causes of corneal ulcers
- exposure keratitis
- severe allergic disease
- severe dry eye
- inflammatory/autoimmune
- vit A deficiency
Bacterial cause of corneal ulcer
pseudomonas (contacts) moraxella liquefaciens (DM,alcoholic, immunosup) strep staph MRSA
Viral cause of corneal ulcer
HSV/ zoster
Amoeba cause of corneal ulcer
- acenthamoeba
- contaminated water
- contact lens with poor hygiene
Risk factors for corneal ulcers
- contacts
- previous eye surgery
- hx of HSV
- immunocompromised
- topical or systemic steriod use
Symptoms of corneal ulcer
- pain
- photophobia
- tearing
- reduced vision
- lid and ocular swelling
- injected conjunctiva/eyelid
- foreign body sensation
- miotic pupil
- clear or mucopurulent discharge
Exam findings for corneal ulcer
- punctate or diffuse branching dendritic lesions (HSV)
- corneal ulceration
- hypopyon
- anterior cell/flare
Diagnosis of corneal ulcer
- slit lamp and fluorescein stain
- culture and gram stain or PCR
Bacterial corneal ulcer treatment
fluoroquinolone
Viral corneal ulcer treatment
acyclovir
always start if dendritic pattern
Pain management for corneal ulcers
- topical cycoplegics
- oral NSAID or analgesia
What will some corneal ulcer perforations require?
- cyanoacrylate glue
- conjunctival graft
- conjunctival flaps
- corneal transplant
Complications of corneal ulcer
- corneal scarring
- corneal perforation
- anterior or posterior synechiae
- glaucoma
- cataracts
- blindness
What is the semi circular canals function
organ for body movement
What is the cochlea for
organ for hearing
Which nerve relays info from the vestibular labyrinth to the cerebellum, ocular nuclei or spinal cord?
vestibular portion of CN VIII
What do the posterior semicircular canals detect?
head tilts down towards the shoulder
What do the lateral semicircular canals detect
head shakes side to side in a “no” motion
What do the superior semicircular canals detect?
head nods up and down in a “yes” motion
What do the otolith organs sense
gravity and linear acceleration
What does the utricle detect?
- horizonatal movement in the head
- registers accelerations in horizontal plane
What does the saccule detect?
- vertical
- registers acceleration in vertical plane
Where does the eustachian tube run?
anterior wall of the middle ear into the nasophasrynx
What is the wider part of the eustachian tube?
nasopharyngeal and tympanic ends
What is the narrowest portion of the eustachian tube?
bony isthmus
How is the eustachian tube different in children than in adults?
- shorter, more horizontal tubes
- immature floppy elastic cartilage
- larger adenoids
What happens when the eustachian tube is compromised?
air trapped in the middle gets absorbed creating negative pressure–> TM retraction
Normal function of the eustachian tube
- equalization of pressure across tympanic membrane
- protection of middle ear from infection and reflux of nasopharyngeal contents
- clearance of middle ear secretions
What causes blockage of the ET?
- ALLERGIC RESPONSE
- URI
- sinusitis
- chronic OM
- congenital/acquired stenosis
- neoplasms
What causes dysfuntion of the ET?
- blockage
- failure of tube to open
What are the two types of ET tube dysfunction
- dilatory dysfunction
- patulous dysfunction
What causes dilatroy dysfunction of ET
- inflammation
- pressure dysregulation
- acquired anatomic abnormalities
What is dilatory dysfunction of ET
the tube does not dilate
What is patulous dysfunction of the ET
valve incompetency, chronic patency (stuck open)
What does pt complain of with ET dysfuntion
- fullness in the ear
- mild to moderate decrease in hearing
- possible “popping” sound during yawning or swallowing
- ear pain
Exam findings of ET dysfunction
- retracted TM of affected side
- decreased TM mobility
Halmark of dilatory ET dysfuntion
- hearing loss
- abnormalities of TM (retraction, middle ear effusion)
Otoscope exam w/ dilatory ET dysfunction
- effusion
- scarring
- thickening of TM
What does weber test show w/ dialtory ET dysfunction
lateralization to affected ear (conductive hearing loss)
Hallmark of patulous ET dysfunction
autophony- pt hears own voice amplified
Physical exam findings of patulous ET dysfunction
- breathing induced excursions of the TM
- sensorineural hearing loss
Treatment of dilatory ET dysfunction
TREAT UNDERLYING ETIOLOGY
- antihistamines
- decongestants
- nasal steriods
- valsalva
Treatment of patulous ET dysfunction
- treat if severe sx >6 weeks
- hydration, mucous thickening agents
- ventilation tubes if severe
Treatment of ET dysfunction
- referral to ENT
- nasal endoscopy
- balloon dilation
- surgery if mass or continued OM w/ effusion
- CT or MRI w/contrast if >3 mnths unilateral sx or middle ear effusion with increased risk of malignant
What is vertigo
symptom of illusory movement
Dysfunction in peripheral input causes what sx in vertigo
- sudden onset
- tinnitus
- hearing loss
- horizontal nystagmus
Dsyfunction in central input causes what sx in vertigo
- gradual onset
- no associated auditory sx
What are the two types of vertigo
- peripheral
- central
Causes of peripheral vertigo
More benign
- BPPV
- vestibular neuritis
- Meniere’s disease
- Herpes zoster oticus
- acoustic neuroma
- aminoglycoside toxicity
- superior semicurcular dehiscence syndrome
Causes of central vertigo
More serious
- migraines
- cerebral tumor on CN VIII
- chiari malformation
- brain ischemia
- TIA
- MS
Key to diagnosing vertigo
- duration
- hearing loss
What provokes BPPV
Specific head movements
- turning in bed
- tilting head backward to look up
What causes BPPV
calcium debris in semicircular canals (most common posterior)
Vertigo sensation in BPPV
- short in duration
- ear pain, hearing loss, tinnitus are absent
BPPV can be a residual affect of what
Meniere’s disease
Epidemiology of BPPV
> 60 y/o
females>males
Clinical presentation of BPPV
- rapid onset of dizziness or spinning
- nystagmus (classic)
- nausea/vomiting
Diagnosis of BPPV
- Dix Hallpike positional testing
- electronystagmography
- MRI/CT to rule out other causes
Treatment of BPPV
Symptomatic treatment
- antihistamines
- antiemetics
- benzos
- scopolamine
What does PT or neuro do for BPPV
vestibular rehab
- gaze stimulation exercises
- repositioning maneuvers
- surgery: rare, only after 6 months
What causes vestiular neuritis
viral or postviral inflammatory disorder affecting the vestibular portion of CN VIII
Is vestibular neuritis benign and self limiting
YES
Vestibular neurities
vertigo without hearing loss
Labrynthitis
vertigo with unilateral hearing loss
Clinical presentation of vestibular neuritis
- rapid onset of severe, persistent vertigo
- nausea and vomiting
- gait instability (toward affected side)
- nystagmus on affected side
- head thrust
Imaging for vestibular neuritis?
if concerned for lesion or stroke causing sx
-MRI/MRA for infarct
Treatment for vestibular neuritis
- corticosteriods
- symptomatic treatment (antihistamines, antiemetics)
- vestibular rehab
Prognosis of vestibular neuritis
- self limiting
- usually a few days to 1 week
- may have non specific dizziness and imbalance for months
Meniere’s disease
peripheral vestibular disorder attributed to exces endolympathic fluid pressure
Another name for Meniere’s disease
labyrinthine hydrops
What does Meniere’s disease cause
episodic inner ear dysfunction
Risks for Meniere’s disease
- allergies
- stress
- viral
Classic presenting sx of Meniere’s
-vertigo
-sensioneural hearing loss
-tinnitus
UNILATERAL
Audiometry in Meniere’s disease
+ low frequency sensorineural hearing loss
Electronystagmography in Meniere’s disease
+ unilateral reduced vestibular response
Caloric testing in Meniere’s disease
loss/impairment of thermally induced nystagmus on affected side (nystagmus goes towards warm, away from cold)
Goals of Meniere’s treatment
- reduced frequency and severity of vertigo attacks
- reduced or eliminiate hearing loss and tinnitus
- minimize disability
- prevent disease progression (hearing loss and imbalance)
Acute Meniere’s diease treatment
- antihistamines
- antiemetics
- benzos
- anticholinergics (scopolamine)
Long term Meniere’s treatment
- lifestyle adjustment
- salt restriction
- limit caffeine and nicotine
- limit alcohol
- diuretics
Nondestructive procedures for Meniere’s
- surgery on endolymphatic sac
- intratympanic glucocorticoids
- postive pressure pulse generator
Destructive procedures for Meniere’s
- intratympanic gentamicin injection
- surgical labryinthectomy
- vestibular nerve resection
Semicircular canal dehscence syndrome AKA…
Minor’s syndrome
What is semicircular canal dehiscence sydrome
thinning of the bone that separates the superior semicircular canal from the middle cranial fossa
What provokes vertigo in semicircular canal dehiscence syndrome
coughing, sneezing, valsalva maneuver
What is Tullio phenomenon
vertigo induced by loud sounds
How is semicircular cana dehiscence syndrome diagnosed
high resolution CT of the temporal bone
What is tinnitus
perception of sound in proximity of head in the absence of external source
Pulsatile tinnitus
-like listening to your own heartbeat
What can cause pulsatile tinnitus
- vascular disorders
- arteriovenous shunts
- venus hums
- ET dysfunction
- arterial bruits
Non-pulsatile tinnitus
unilateral clicking tinnitus secondary to middle ear spasm
Presbycusis
sensorineural hearing loss with aging, or any acquired high frequency hearing loss commonly associated with tinnitus
Otosclerosis
condition of abnormal bone repair of the stapes footplate bone
Chiari Malformation
occurs when low lying cerebellar tonsils causes tension on the auditory nerve
Diagonistics for tinnitus
- audiometry to R/O associated hearing loss
- MRI if unilateral esp with hearing loss to R/O retrocochlear lesion
