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543 > HEENT > Flashcards

HEENT Flashcards

1
Q

Chalazion is chronic inflammation of ___________

More common in (age)

A

meibomian gland

adults 30-50 (androgen hormones cause sebaceous secretion)

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2
Q

Physical findings of chalazion:

how to differentiate between stye and chalazion?

A

non-tender palpable nodule inside eyelid margin

Styes tend to be painful and angry-looking

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3
Q

Differential diagnoses of chalazion

A
  • hordeolum (stye)
  • blepharitis
  • if recurrent: consider SCC, sebaceous carcinoma, meibomian cancer (esp in elderly)
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4
Q

What is recommended for treatment of chalazion?

A
  • antibiotics not indicated (it is a granulomatous inflammation)
  • warm compress QID
  • frequent handwashing
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5
Q

Hordeolum is infection of _______ or _______ usually caused by (pathogen) ________

A

infection of meibomian gland or eyelash follicle

Staph aureus

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6
Q

What are some predisposing conditions to development of hordeolum? (5)

A
  • recurrent blepharitis
  • seborrheic dermatitis
  • rosacea
  • poorly controlled diabetes
  • hyperlipidemia
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7
Q

Hordeolum: assessment should rule out cellulitis

What are signs of

  • preseptal cellulitis
  • periorbital cellulitis
A

Preseptal: ocular pain, eyelid swelling, erythema, fever

Orbital: symptoms of preseptal AND swelling causes pain with extraocular movement, diplopia or blurred vision, proptosis, fever

**need to refer to ER for CT

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8
Q

Patient education points for hordeolum

A
  • will resolve without rx
  • warm compresses QID
  • handwashing
  • lid hygiene
  • discard all eye makeup
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9
Q

Blepharitis

predisposing risk factors?

A
  • diabetes
  • candida
  • seborrheic dermatitis
  • psoriasis
  • rosacea
  • demodex mites
  • use of isotretinoin for cystic acne
  • contact lens use
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10
Q

Blepharitis

3 pathophysiological causes

A

most common:
-meibomian gland dysfunction: inadequate flow of oil/mucous into tear duct

  • staph aureus
  • seborrheic: shedding of skin cells block glands
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11
Q

Blepharitis

Common recurrent symptoms?
Associated symptoms with
-seborrheic
-staph
-meibomian gland?
A

Burning and itching, tearing, photophobia, dry flaky lids, dry eyes
Transient blurred vision (better with blinking)

all 3 will have lid swelling and erythema

Seborrheic: flaking, nasolabial erythema, scaling

Staph aureus: burning/tearing/itching, recurrent stye/chalazion

Meibomian gland dysfunction: frothy thick discharge and chalazion, may have rosacea or seb dermatitis

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12
Q

Blepharitis

  • specific questions to ask on history?
  • pertinent positive findings on exam
A

History

  • itching/burning/pain
  • change in facial products
  • visual change/pain

-hallmark characteristic findings: redness and irritation of eyelids with crusting/flakes on eyelids or eyelashes

may have ectropion/entropion if recurrent

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13
Q

Blepharitis

First line treatment?
Patient education points?

A

Symptomatic management for mild-mod symptoms

  • warm compresses QID x 10 min
  • lid massage (immed after compress)
  • lid hygiene (baby shampoo)
  • artificial tears
  • handwashing
  • avoid triggers (smoking, allergens, contact lens, old makeup)
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14
Q

Blepharitis

What is the next step if blepharitis does not respond to symptomatic tx?

When is a referral to ophtho warranted?

A

-topical abx (bacitracin or erythro ointment) at bedtime x 2 weeks

  • severe or refractory symptoms not responding to topical abx
  • severe eye pain/visual change/photophobia
  • suspicious for malignancy (recurrent unilateral)
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15
Q

Corneal epithelium is innervated by CN _____

A

CN V (trigeminal)

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16
Q

Corneal abrasions from contaminated material eg farming equipment is at high risk for ________

A

bacterial keratitis

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17
Q

What are symptoms associated with corneal abrasion?

A
  • sudden onset eye pain
  • FB sensation
  • watery red eye
  • photophobia
  • blurred vision
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18
Q

Risk factors for stomatitis / recurrent aphthous ulcers

A
  • Oral trauma
  • history of RAS
  • ?deficiency in iron/folic acid/zinc
  • Hormonal changes
  • stress
  • food/chemical sensitivity

possible link to SLS in toothpaste

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19
Q

Stomatitis: what systems to assess during physical exam?

A
  • oral
  • cervical lymphadenopathy
  • derm: r/o hand foot mouth (look at palms and soles)
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20
Q

Define difference between minor and major aphthous ulcers:

  • size
  • pain
  • duration
A

Minor aphthous ulcers: <1 cm, mildly painful, last 7-14 days

Major aphthous ulcers: >1 cm, very painful, last 4-6 weeks

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21
Q

Name 4 differential dx for stomatitis:

A
  • oral HSV
  • hand foot mouth (coxsakievirus)
  • Kawasaki (red tongue)
  • side effect of medication (eg chemo)
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22
Q

Use of viscous lidocaine for stomatitis:

2 precautions with prescribing:

A

• 2% viscous lidocaine: applied directly to surface or ulcer OR as swish/spit

* Not for use in children <3 (seizures, cardiopulm arrest, death)
* Do not chew/eat gum for 60 min after use
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23
Q

Stomatitis:

-when to refer?

A

To oral surgeon/ENT if ulcers >1-5 mm deep OR last longer than 3 weeks

Cardiology if suspected Kawasaki

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24
Q

Subconjunctival hemorrhage:
-commonly caused by:

-chronic diseases:

A

-increased intrathoracic pressure with exertion (coughing, vomiting, labour)

  • HTN
  • diabetes
  • long term hemodialysis
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25
Q

Signs and symptoms of subconjunctival hemorrhage?

Components of physical exam:
visual acuity is _____
-check _____

A
  • painless red eye, often unilateral
  • blood between conjunctiva and sclera

normal visual acuity
-check BP to r/o systemic HTN

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26
Q

Subconjunctival hemorrhage:

Treatment?
Education?

A
  • no rx needed
  • will resolve over weeks
  • if recurrent: work up for HTN or blood dyscrasia
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27
Q

Dry eyes

What are the 3 layers that comprises a tear film?

What can cause dry eyes?

A
  • outer lipid layer (Meibomian)
  • middle aqueous (lacrimal)
  • inner mucinous (goblet cells)

Causes:

  • systemic illness (eg Sjogren’s, rheumatoid)
  • aging
  • dry environment
  • medications: TCA, anti-histamines, diuretics, isotretinoins
28
Q

Dry eyes

Components of physical exam?

A

Exam of both eyes

  • fundoscopy
  • mouth (dry?)
  • check skin, thyroid and joints (r/o systemic cause)
29
Q

What are red flag signs of acute angle glaucoma?

A

rainbow halos, red painful eye, pupil dilation

30
Q

What are the 3 classic hallmarks of Sjogren’s triad?

A
  • chronic dry mouth
  • dry eyes
  • arthritis
31
Q

What class of medication may REDUCE the risk of dry eyes in adults?

A

ACE-I

*consider in use for pts who have concurrent HTN

32
Q

The majority of nose bleeds come from: ________

Posterior bleeds originate from ______

A
  • 90% anterior
  • Kiesselbach’s plexus

Posterior bleed:
-sphenopalatine artery

33
Q

What are some risk factors for recurrent or severe epistaxis?

A
  • Anticoagulation
  • foreign body
  • chronic use of nasal steroids
  • systemic causes: bleeding disorders, HTN
  • Trauma
  • Tumors
  • pregnancy
  • cocaine use
34
Q

Signs and symptoms differentiating anterior and posterior bleed

A

Anterior: bleeding from one nare, may be able to visualize source at the septum
Posterior: “brisk” arterial hemorrhage, patient reports swallowing blood

35
Q

Components of physical assessment for epistaxis

A

Exam:

  • vitals
  • airway patency (sit and lean forward)
  • use topical lidocaine before nasal exam
  • nares: unilateral bleeding + purulent discharge = foreign body; bilat purulent discharge = sinusitis
  • look at pharynx: blood flowing down throat = sign of posterior bleed
  • derm: mucous membranes, pallor, purpura/petechiae/ecchymosis
36
Q

What is the main cause of rhinosinusitis?

What are the main organisms in:

  • acute rhinosinusitis?
  • chronic rhinosinusitis?
A

90-98% secondary to viral
0.5% will develop bacterial sinusitis after 10 days

Acute: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
Chronic: Staphylococcus aureus, Pseudomonas aeruginosa

37
Q

What is the pathophysiology behind the transformation from viral to bacterial sinusitis?

A

Transition from viral –> bacterial due to decreased mucociliary clearance –> colonization of bacteria on retained mucous secretions –> proliferate as they are trapped in sinuses

38
Q

What is the definition (time) of:

  • acute sinusitis
  • subacute sinusitis
  • chronic sinusitis
A
  • acute: up to 4 weeks
  • subacute: 4-12 weeks
  • chronic: 12+ weeks
39
Q

What are some history questions to ask during assessment of rhinosinusitis?

A
  • duration >10 days or >12 weeks
  • “double sickening” symptoms: gradually feel better, then feel worse again
  • recent URTI
  • recent dental infection
  • allergies
  • home treatments
  • for kids: look for FB
  • hx of swimming/diving/flying
40
Q

What systems should be assessed during a physical exam for rhinosinusitis?

A
  • eyes: r/o periorbital cellulitis
  • ENT: edema, discharge, patency, polyps, foreign body
  • infected mucosa will look red and swollen, allergic will look boggy (purple/blue)
  • dental: r/o abscess
  • sinuses: frontal, maxillary, ethmoid
  • lymphadenopathy
  • neuro exam if suspected meningitis or intracranial abscess
41
Q

What are some signs and symptoms of rhinosinusitis?

PODS

A

4 main symptoms PODS:

  • pain and pressure (facial)
  • obstruction
  • discharge (mucopurulent)
  • smell loss (anosmia)

Other:

  • headache
  • dental/ear pain
  • fever (usu with acute sinusitis), fatigue, cough, mouth breathing
  • sour bad taste (halitosis) is usually a sign of bacterial sinusitis
42
Q

What are some potential complications (red flags) for rhinosinusitis?

A

Meningitis, pre-septal/orbital cellulitis, subperiosteal/intracranial abscess, epidural abscess, cavernous sinus thrombosis

43
Q

What is the treatment approach for

  • acute rhinosinusitis
  • chronic rhinosinusitis
A

Acute viral: supportive, OTC analgesics and decongestants, saline irrigation

Acute and chronic bacterial: saline irritation and antibiotics

44
Q

What is the first line antibiotic for acute bacterial rhinosinusitis?

What is the alternative first line if there is an allergy to PCN?

A

Amox-Clav or amoxicillin

alternative: doxycycline

45
Q

What is the role of decongestants in rhinosinusitis?

  • eg of decongestant?
  • what should patients be taught?
A

Decongestants: to correct underlying mucosal edema

  • must limit use to 3 days to prevent rebound congestion and rhinitis medicamentosa
  • overuse of oxymetazoline can lead to body being dependent on its vasoconstricting properties
  • caution with HTN or cardiac disorder

eg oxymetazoline (Afrin)

46
Q

What is the role of intranasal corticosteroids in rhinosinusitis?

eg of INCS?

-what should patients be taught?

A

Nasal corticosteroid sprays: to reduce nasal inflammation

  • lean forward, angle spray towards cheek, minimal sniffing
  • never use with head back (in sniffing position) or pointing to septum

eg Flonase (fluticasone), Nasonex (mometasone), Rhinocort (budesonide)

47
Q

What is the role of antihistamines in rhinosinusitis?

-what should patients be taught?

A

only for use if allergic symptoms

consider allergy testing
removal of triggers

48
Q

What are some co-morbidities associated with Tempomandibular Joint Dysfunction>

A

Comorbidities: mood disorders: anxiety, depression, PTSD, hx of abuse

  • RA
  • teeth grinding (bruxism)
  • joint trauma
  • poor head/cervical posture
49
Q

TMJ

  • what are the muscles involved?
  • what nerve is involved?
A

Muscles: masseter, temporalis, pterygoid.

CN V (trigeminal) V3

50
Q

Describe components of the physical exam for TMJ dysfunction

CN nerve exam is focused on which 2 nerves?

A

Exam: focus on TMJ, head and neck

  • mandibular ROM
  • alignment of teeth
  • tenderness and crepitus
  • pain with dynamic loading: bite down on cotton ball/tongue depressor between upper and lower canine –> compresses contralateral TMJ
  • bruxism: sign of wear and tear to teeth
  • posture: slouching, leaning
  • neuromuscular exam of head, neck and face: palpate muscles of neck and shoulders

CN exam focused on CN V (trigeminal) and CN VII (facial) nerves

51
Q

What are 4 categories of signs/symptoms of TMJ dysfunction?

PEHT

A

Pain: dull constant unilateral facial ache, waxes and wanes

  • may radiate to ear/temporal/posterior neck
  • worse by jaw motion (after meals)

Ear symptoms: painful, fullness, tinnitus

Headache: frontal/temporal/occipital, radiates to jaw/temple/forehead, worse in morning

TMJ: clicking, decreased ROM, locking –> worse in morning

52
Q

What are some differential diagnoses for TMJ dysfunction?

What is a red flag differential?

A
  • dental abscess
  • sinusitis
  • ear disorders (AOM, OME, eustachian tube)
  • trigeminal neuralgia
  • headache
  • post-herpetic neuralgia

RED FLAG:
-giant cell arteritis

*will have headache, jaw claudication, palpable tender temporal artery, visual symptoms

53
Q

What is the treatment approach for TMJ dysfunction?

what is the first line rx?

A
  • self care
  • rx if persistent symptoms

first line:
NSAIDS (eg naproxen, ibuprofen)
limit use to 10-14 days OR topical diclofenac

54
Q

Referrals for TMJ dysfunction?

A

PT for TMJ exercise, biofeedback, posture, massage

Dentist: bite guard / splint

Surgeon for trigger point/botox/injection or surgery

55
Q

What are some predisposing risk factors for tinnitus?

-most common cause?

A

*anxiety, depression, high stress levels (common cause)

Ototoxic medications

Ear: cerumen, TM perforation, middle ear effusion, eustachian tube dysfunction

Anemia

HTN

TMJ syndrome

56
Q

examples of medications that cause/exacerbate tinnitus?

A
  • aminoglycosides
  • ACE-I
  • benzos
  • fluoroquinolones
  • loop diuretics
  • furosemide
  • PPIs
  • antidepressants (sertraline, TCA)
57
Q

What are the 3 types of hearing loss?

-what anatomical part is involved?

A

-conductive: external or middle ear

-sensorineural:
inner ear or CN VIII

-mixed: combo of conductive and sensorineural hearing loss

58
Q

What is presbycusis?

A

-age related damage to cranial nerve VIII

59
Q

What are questions to ask during history taking for assessment of hearing loss?

A
  • Exposure to noise?
  • recent/chronic ear infections?
  • Self care of ears?
  • Discharge, pain, dizziness
  • Medications
  • Occupation/hobbies, use of ear protection
60
Q

Describe NORMAL findings associated with Weber and Rinne test

A

Weber: sound comes from midline

Rinne:
AC>BC
ie air-conducted sound hear 2x longer than bone-conducted sound

61
Q

What is the finding in CONDUCTIVE hearing loss with Weber and Rinne test?

A

CONDUCTIVE

Weber:
-sound comes from affected ear

Rinne:
-BC>AC on affected ear

62
Q

What is the finding in SENSORINEURAL hearing loss with Weber and Rinne test?

A

SENSORINEURAL

Weber:
-sound comes from normal ear

Rinne:
AC>BC (same as normal finding)

63
Q

most common cause of acute pharyngitis?

A

viral (20-45%)

*adenovirus, rhinovirus, coronavirus

64
Q

what is the hallmark feature of diphtheria?

A

grey pseudomembrane covering pharynx

adherent, bleeds when removed

65
Q

What are the hallmark signs and symptoms of GAS?

Centor criteria

A 
• Tonsillar exudate
• Tender ant cervical lymph nodes
• No cough
• Fever >38
*age (3-14)

May also have petechiae to palate, scarlatina rash, strawberry tongue

66
Q

What are the hallmark signs and symptoms of mono?

A

sore throat (85%)
fatigue
mod to high fever
symmetrical posterior cervical LN

67
Q

Red flag signs for pharyngitis?

A

Airway obstruction:

  • hot potato/muffled voice
  • drooling
  • stridor
  • sniffing/tripod position
  • bulging edematous pharynx

Deep Space Neck Infection eg peritonsillar abscess

  • unilateral severe sore throat
  • drooling
  • hot potato voice
  • unilateral deviated uvula
  • severe sore/stiff/swollen neck

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