HEENT Flashcards
What are cataracts?
Opacificaiton + clouding of lens
5 D’s
Cataracts clinical manifestations
- Vision is hazy, blurred, or dimmer
- Photosensitivity
- See “halos” around lights + Glare
- See a progressive decline in vision over months to years
Cataracts Objective findings
What PE assessments and findings?
- NO conjunctiva REDNESS
- PAINLESS
- Full eye + neuro exam
- Pupil exam NORMAL (PERRLA)
- ABNORMAL red reflex
- Dull, extinct, or shady
- ABNORMAL red reflex
- Test visual acuity
What do you need to rule out first?
Cataracts differentials?
Macular degeneration
Diabetic retinopathy
RF?
What are cataracts commonly A/w
↑ AGE
Cataract Risk Factors
- Age
- Diabetes
- UV exposure
- Systemic steroid use
- HTN, CKD, HIV
- Eye trauma Hx
- EtOH use
- Tobacco use
Cataracts Patient Education
Cataract surgery contraindication
- Avoid night time driving
- Surgery is low-risk
- NO SRG if have active URI/coughing, or poorly controleld BP
Cataract Surgery
What to do pre-op?
What to do post-op?
- Med reconcilliation pre-op
* Alpha-adrenergic antagonist - Flomax → Floppy Iris Syndrome - Post-op:
- No heavy lifting, no straining
- Eye drop administration
- Wear sunglasses
- Go to urgent care if experiencing abrupt changes
Three things
Eyes complication signs/symptoms → ED
- ONLY IF ABRUPT CHANGES
- Sudden vision changes
- Darkening of vision
- Eye pain!
Definition
What is macular degeneration?
Types?
Degenerative disease of central portion of retina
Dry (non-exudative) + Wet (exudative)
Macular degeneration clinical manifestations (BOTH)
- Change in central vision
- Difficulties adapting to the dark
- Dark spots in vision
- Distorted straight lines
- Colors may appear less vivid or darker
Dry macular degeneration clinical manifestations
- Retinal atrophy
- Build-up of drusen (yellow deposits)
- Gradual central vision loss
- Fuzzy or distorted vision
- Scarring + thinning of retina
Wet macular degeneration clinical manifestations
- New blood vessels forming → swelling + bleeding into retina
- Sudden OR gradual central vision loss
- Blindspot in central vision
Macular degeneration PE techniques
Full eye + neuro exam
Test visual acuity
DX test for macular degeneration and purpose
Amsler grid
ID central cision defects - used for monitoring progression
Dry macular degeneration Pharmacologic txs
AREDs or AREDs2 for non-smokers only
These carry risk for lung cancer
Wet macular degeneration pharmacological txs
Intravitreous INJs w/VEGF inhibitors
Dry macular degeneration Nonpharmacological Txs
Risk modification
* Tobacco cessation
* UV protection
* BP + lipid control
Wet macular degeneration Nonpharmacologic txs
Photodynamic therapy
Laser coagulation txs d/t vessel changes
Macular degeneration Risk Factors + Referral education
- Age
- Tobacco Usage
- FMHx → Should see opthamology
- HTN
- HLD
Referral + regular F/U + Monitor w/Amsler grid
Definition
What is glaucoma?
Types?
- Condition resulting in progressive damange to optic nerve → vision loss
- peripheral → central vision loss
- Causing dysfunctional drainage of aqueous humor
- Types
- Primary angle-closure (ACUTE)
- Primary open-angle
Acute-angle closure glaucoma: clinical manifestations
- ↑ IOP (not definitive as this can still happen w/normal pressure)
- ABRUPT CHANGES
- Redness
- Eye PAIN
- Vision loss
- H/A
- Halos (as opposed to painless halos in cataracts)
VISION EMERGENCY DO NOT MISS
TX W/IN HRS
Primary open-angle glaucoma: clinical manifestations
- GRADUAL ↑ IOP d/t dysfunctional drainage → peripheal vision loss → central vision loss
- Bilateral s/s
- Painless = silent blinder
Glaucoma Objective findings
Glaucoma PE techniques
- Full eye exam
-
Optic cupping
- Look at ratio of cup size to disk (see a clear circle)
- Optic nerve fibers to brain damaged + destroyed from ↑ IOP on nerve cells → axon loss
Glaucoma differentials
Macular degeneration
Severe open-angle glaucoma
Angle-closure glaucoma pharmacologic txs
- Eye drops
- Systemic meds to ↓ IOP (short term)
Open-angle glaucoma pharmacologic txs
- Eye drops
- Prostaglandin analogs
- Lantoprost
- BBs (timolol)
- Combo products
Meds that will interact with glaucoma meds
Why avoid these?
SSRIs
Antihistamines
Decongestants
These will ↑ IOP
Angle-closure glaucoma nonpharmacological txs
Iridotomy to ↓ pressure
* Drill small hole in iris to allow drainage
* Acute occlusion of anterior chamber angle
Open-angle glaucoma nonpharmacological txs
- Laser txs
- Surgery - trabulectomy
- creating. ashunt to allow drainage
Glaucoma risk factors
- ↑ age
- FMHx
- Tobacco usage
- HTN
- Nearsightedness (myopia)
- ↑ IOP
- ↑ Prevalence in black, Latinx pop
Glaucoma referral management
Monitoring
- Routine testing of visual acuity
- Measuring IOP + visual field testing + dilated exam
- Ask about medication adherence
- Opthamology visits
Diabetic retinopathy
- Resulting from chronic effects of DM
- ↑ A1c = ↑ DM retinopathy risk
- Damanged blood vessels d/t hypergylcemia
Diabetic retinopathy clinical manifestations
- May be asymptomatic
- Floaters or light flashes
- Sudden vision loss if hemorrhage occurs
(overall) Diabetic retinopathy objective findings on exam
- Microaneurysms
- Dot-blot hemorrhages
- Cotton wool spots
Non-proliferative DM retinopathy objective findings
- Microaneurysms
- Hemorrhages
- Blockages
- Dilation of larger vessels
- Macular edema
- NO NEW BLOOD VESSEL GROWTH
Proliferative diabetic retinopathy objective findings
- Presence of abnormal blood vessels
- Likely to leak → bleed
- ↑ scar tissue on retina
- ↑ retinal detachment
- ↑ fluid → glaucoma
- ↑ risk of optic nerve damange
- CAN CAUSE BLINDNESS
Diabetic reitnopathy DX
- Dx on fundal exam
- Retinal scanning
- Can take retinal photo early in disease process
Diabetic retinopathy pharmacological interventions
- Fenofibrate to slow progression
- VEGF INJs little evidence
- Intravitreal corticosteroids amin for macular edema
Diabetic retinopathy nonpharmacological interventions
Tx managed by opthamology
* Address poor glycemic control
* Pan-retinal photocoagulation
Diabetic retinopathy Risk Factors
- Poor gylcemic control
- Duration of dx
- HTN
- HLD
- Pregnancy
Best treatment(s) for DM retinopathy
PREVENTION
* Control BS, BP, Lipid level
* Monitor A1c%
* Early detection prevention
* Screening eye exams
* DM II should have opthalmologic exam at time of dx + annually
Definition
Dry eye syndrome
Two types and conditions with each
- Tear film deficiency
- Ocular surface disease
- Dysfunction teaar sydnrome
- Aqueous:
- Sjogren’s hyposecretion
- Evaporative:
- Meioban gland dysfunction
- Poor eyelid disclosure
- Insufficient blinking
Dry eye syndrome clinical manifestations
- Paradoxical XS tearing
- Dryness
- Foreign body sensation
- Burning or stinging
- Itchiness
- Ocular fatigue (screen)
- Blurriness relieved by blinking
symptoms worsened in extended periods of visual concentration + low-humidity
Dry eye syndrome PE findings
Unremarkable
Dry eye syndrome Diagnostic tests
Which meds aggravate this condition?
Which med to AVOID?
- Fluoresein dye for corneal abrasion
- Shirmer test
- Complete PE for systemic causes
- Complete ROS
- Review med history
- Diuretics
- Anti-histamines
- TCAs
- Avoid VASOCONSTRICTORS
Dry eye syndrome differentials
Trichiasis, Conjunctivitis, Corneal abrasion, Systemic causes
Dry eye syndrome pharmacological txs
- Artificial tears 6x/day
- Fish oil, vitamin D
- Specialist (short course topical steroid - Cyclosporine); Low dose PO abx
Dry eye syndrome nonpharmacological txs
- Avoid extended periods of visual concentration
- Avoid direct drying effect of A/C or fan
- Lid hygiene
Hearing loss types
Most common hearing type
Conductive
Sensorineural (age-related) - presbycusis
Concerning hearing loss signs/symptoms
All rapid onset
* Severe vertigo
* Ataxia
* Fevers
* Head trauma
* Neurological deficits: H/A dizziness, imbalance
Hearing loss exam tests
Finger rub
Whispered Voice test
Weber and Rinne
bone condution vs air conduction
Weber vs. Rinne test
How does each show conductive vs. sensorineural hearing loss?
Where would each localize to?
Conditions of external ear
- Cerumen impaction
- Otitis externa
- Foreign body
Conditions of middle ear
- Cholesteatoma
- Otitis media w/effusion
- Otosclerosis
- TM rupture
- Eustachian tube dysfunction
Systemic labs for hearing loss
- CBC w/diff
- Syphilis
- ESR
- ANA
- RF
- TSH
- CT or MRI for structure cause
Hearing loss nonpharmacological txs/patient education
Cochlear implants (moderate to profound sensorineural hearing loss)
Hearing aides
* Face patient when speaking
* Minimize background noise
Hearing loss referrals
Referral for formal audiometry
Referral to ENT/neuro
Referral to ED if abrupt onset of s/s
Definition
Tinnitus
Perception of hearing sound when there’s no sound in environment
Tinnitus etiologies
- Toxins
- Noise or barotrauma
- Eustachian tube dysfunction
- Acoustic neuroma
- Vascular abnormality
Tinnitus etiologies
- Toxins
- Noise or barotrauma
- Eustachian tube dysfunction
- Acoustic neuroma
- Vascular abnormality
Tinnitus clinical manifestations
What do the different sounds heard indicate?
- Hearing buzzing, ringing, hissing, whistling
- UNL or BL
- Constant or intermittent
- High pitched, continuous → sensorineural hearing loss
- Low-pitched → idiopathic or Meniere disease
- Pulsating/rushing → vascular cause
- Clicking → TMJ
- Any neuro s/s: ear pain, dizziness, discharge, etc
- Insomnia
Tinnitus PE exams
Ear + neuro exam
TMJ assess
Auscultate for bruits
Tinnitus differentials
- CNS lesion
- MS
- Vestibular schwannoma (DO NOT MISS)
Tinnitus diagnostics
- Systemic labs: CBC w/diff, ESR, glucose, TSH
** MRI + CT to R/o CNS lesion**
Tinnitus nonpharmacological tx
Earplugs
White noise machine
Tinnitus Risk factors
Referrals
Risk Factors
* Syphilis
* Lyme Disease
* Referral to audiogram, ENT, or neuro
Cerumen impaction wax description
Dry, dark, immobile, malodorous
Cerumen clinical manifestations
- UNL or BL s/s
- Fullness
- Hearing loss
- Ear pain + discomfort
- Tinnitus
- Vertigo or dizziness
2 things
How is cerumen impaction DX
When patient has s/s and cannot assess ear d/t cerumen
Objective finding cerumen impaction
PE assessments
- Wax partially or full occludes TM
- Assess for bleeding + drainage
- PE preauricular, posterior auricular lymph nodes
Cerumen impaction differentials
- Foreign body
- Otitis media
- Otitis externa
- TM perforation
- Eustachian tube dysfunction
Cerumen impaction pharmacological txs
Ear wax removal drops:
* Carbamide peroxide drops x 3-5d
* Cortisporin drops x 2-3d after irrigation if risk for otitis externa
Cerumen impaction nonpharmacologic txs
Using currette or irrigation for removal
Cerumen impaction risk factors
Q-tip usage
Ear plug usage
Hearing aides
Earbuds
Hx questions to ask if patient has cerumen impaction
Ask about…
* Hx of tympanostomy tube
* Surgery
* TM rupture (irrigation)
* Immunocomp: excoriation
Cerumen impaction patient education
- Clean external ear only
- Avoid ear swabs/small objects inot ear
- May use debrox drops 1-2x/week
- Individuals who use hearing aides are at higher risk for impaction
Definition
Cholesteatoma
What kind of hearing loss
- Collection of skin cells in middle ear or mastoid → benign tumor
- Middle ear issue; congential/acquired
- Conductive hearing loss
Cholesteatoma
Primary vs secondary
Primary: eustachian tube dysfunction
Secondary: post TM perforation
Cholesteatoma clinical manifestations
These can recur
* Erosion
* Hearing loss
* Malodorous drainage
* Tinnitus
* Vertigo
PE exams cholesteatoma
External/internal ear exam
Neuro exam
Cholesteatoma differentials
- Squamous cell carinoma
- Adenocarcinoma
- Acoustic neuroma
- Otitis externa
- Chronic otitis media
- Foreign body
Cholesteatoma definitive treatment
SURGERY
* F/U w/ENT post-op
* Referral to ENT + audiogram
Cholesteatoma pharmacological tx if otitis externa/AOM present
Antibacterial agent
Chronic inflammation of cholesteatoma →
- Balance issues
- Meningitis
- Brain injury
- Tinnitus
- Vertigo
Low vision parameters
20/70 or <
Legal blindness parameters
20/200 or <
Vision screening
USPSTF has no recommendations BUT
AAO: > 65y.o. comprehensive eye exam Q1-2yrs
