HEENT Flashcards
Acute rhinosinusitis (ARS)
Definition
Inflammation of the mucosal lining of nasal passages and paranasal sinuses, lasting up to 4 weeks, caused by allergens, environmental irritants, and/or infection (viruses [majority], bacteria, and fungi [rare])
- Allergies and viral are most common causes
- Avoid antibiotics unless you know micro; you must know the causative bug as to choose the right drug
Acute bacterial rhinosinusitis (RBRS)
Secondary bacterial infection of paranasal sinuses, usually following viral URI; relatively uncommon in adult stand children
<2% of viral URIs are complicated by ABRS. In the majority, ABRS will resolve without antimicrobial therapy *may resolve spontaneously; abx rarely needed
Maxillary and frontal sinuses are most affected; fluid is trapped inside the sinuses → 2º bacterial (S. pneumoniae, H. influenzae)” or viral infection
- hx of a “bad cold” or flare-up of allergic rhinitis
Principles of Empiric Antimicrobial Therapy
- Definition
- Questions to as prior to choosing an antimicrobial
- Applicable to choice of intervention in all infectious diseases to direct antimicrobial therapy, optimize treatment success and minimize development of resistant pathogens
The decision-making process in which the clinician chooses the agent based on patient characteristics and site of infection
- What is/are the most likely pathogen(s) causing this infection?
- What is the spectrum of a given antimicrobial’s activity?
- What is the likelihood of a resistant pathogen?
- What is the danger if there is treatment failure?
- What is the optimal safe antimicrobial dose?
- What is the duration of the shortest but effective course of therapy?
Streptococcus Pneumoniae
1. Diseases caused by S. Pneumoniae
2. Description
3. Resistance
- COMPS
+CAPS, ABRS (#1 cause of ABRS)
Conjunctivitis
Otitis media
Meningitis
Pneumonia
Sinusitis - 100 strains
Gram+ diplococci
#1 adult ABRS causative organism - > /= 25% drug-resistant (DRSP) via altered protein-binding sites that limit certain antibiotic’s ability to bind to the pathogen
Haemophilus Influenzae
1. Diseases caused by H. influenzae
2. Description
3. Resistance
- COMPS
+CAPS, ABRS
Conjunctivitis
Otitis media
Meningitis
Pneumonia
Sinusitis - Gram- bacillus
#2 adult ABRS causative organism - > /= 30% penicillin-resistant via production of beta-lactamase that breaks up beta-lactam ring in most penicillins including amoxicillin, ampicillin. Most cephalosporins are stable in the presence of beta-lactamase
Moraxella Catarrhalis
1. Diseases caused by M. Catarrhalis
2. Description
3. Resistance
- Less common pathogen in ABRS, AOM, uncommon cause of CAP
- Gram- coccus
#3 adult ABRS causative organism - > /= 90% pencillin-resistant via beta-lactamase production
Transillumination
Turn off the light (darkened room)
Place a bright light source directly on the surface of the cheek (on maxillary sinus). Instruct patient to open mouth and look at the roof of the mouth (hard palate) for a round glow of light). Compare both sides.
The “affected” sinus has no glow or duller glow compared with the normal sinus. For frontal sinusitis, place the light under the supraorbital ridge at the medial aspect and compare glow of light
ABRS
- Clinical presentation
- When treating, consider resistant presence:
URI-like signs and symptoms, either:
- Persistent and not improving >/= 10 days
- Severe (Fever >/=102º F, >39ºC, purulent nasal discharge, facial pain, >/= 3-4 days)
- Worsening, or “doubling-sickening” (initial improvement URI-like sx, then worsening with fever, headache, nasal discharge, usually p 5-6 days of illness)
- Posterior pharynx: purulent dark-yellow to green postnasal drip
- Sinuses: tender to palpation on the front cheek (maxillar) or on frontal sinus area above inner canthus of the eye
- If seen with allergy flare-up, possible swollen (boggy) nasal turbinates
- Fever seen more often in children than adults
- Transillumination (frontal and maxillary sinuses): POSITIVE (“glow” of light on infected sinus is duller than normal sinus)
If no risk for resistance → Initiate first-line antimicrobial therapy
If yes risk for resistance → Initiated second-line antimicrobial therapy
If improved after 3-5 days → Complete 5-7 days of antimicrobial therapy
If worsening or no improvement in 3-5 days → Broaden coverage or switch to different antimicrobial class, if continues to worsening or no improvement in 3-5 days → Refer to specialist; CT/MRI to investigate noninfectious causes or suppurative complications +/- sinus/meatal cultures for pathogen-specific therapy
cacosmia
Bad odor in nose
ABRS
Treatment Options: mild vs severe case
If mild, uncomplicated in healthy patient → symptomatic treatment without abx
- Oral fluids
- Saline nasal irrigation PRN
- Follow up in 10 days (if better, no abx needed)
- If sx worsens or have not resolved on follow-up → initiate abx
If severe symptoms (toxic, high fever, pain, purulent nasal or post nasal drip for >/=2-3 days, maxillary toothache, unilateral facial pain, sense of bad odor in nose (cacosmia), initial symptom improved, then worsening of symptoms), immunocompromised, or symptoms persist > 10 days (or have worsened) → Initiate abx
Most cases of adult ABRS are viral; only 0.5-2% of cases are bacterial
ABRS
Antibiotic Treatment
1. First-line therapy
2. If allergy or alternative antibiotics
3. What if treatment failed with above interventions?
- Amoxicillin-clavulanate (Augmentin) 1,000/62.5 mg or 2,000 mg/125 mg one table PO BID x 5-7 days
- If PCN allergy or alternatives:
- Type 1 allergy (e.g., anaphylaxis, angioedema) → Levofloxacin 750 mg PO daily or doxycycline BID x 5-7 days
- Type 2 allergy (e.g., skin rash) → Cefdinir (Omnicef), cefpodoxime (Vantin), cefuroxime (Ceftin) PO BID x 5-7 days - If symptoms persist despite treatment (purulent nasal discharge, sinus pain, nasal congestion, fever), switch to another abx.
- If on amoxicillin → amoxicillin-clavulanate (Augmentin PO Q12H x 10-14 days OR levofloxacin (Levaquin) 750 mg daily
- If current sinusitis → Refer to otolaryngologist
- Nasal irrigation may help use only sterile water (not tap water) with saline packet
ABRS
Risk for antibiotic resistance
Most common:
<2 or >65, daycare attend
Prior systemic antibiotics with the past month
Less common risks:
Hospitalization within p 5 days
Comorbidities (DM, COPD)
Immunocompromised
ABRS
Symptomatic or Adjunct Treatment (Rhinosinusistis or Oritis Media)
1. Pain or fever
2. Drainage
3. Cough
- Naproxen sodium (Anaprox DS) PO BID or ibuprofen (Advil) PO QID PRN
- Acetaminophen (Tylenol) Q4-6 hours PRN
- Naproxen sodium (Anaprox DS) PO BID or ibuprofen (Advil) PO QID PRN
- Increase oral fluids will thin mucus
- Oral decongestants such as pseudoephedrine (Sudafed) or pseudoephedrine combined with guaifenesin (Mucinex D)
- Topical decongestants (i.e., afrin): use only for 3 days max or will cause rebound
- Saline nasal spray (Ocean spray) 1-2 x Q2-3 hrs PRN
- Steroid nasal spray (Flonase, Vancenase) if allergic rhinitis
- Mucolytic (guaifenesin) and ↑ fluid to thin mucus
- Increase oral fluids will thin mucus
- Dextromethorphan (Robitussin) QID
- Benzonatate (Tessalon Perles) prescription: Swallow with water; do not crush, suck, or chew; toxic for children <10 years (seizures, cardiac arrest, death)
- ↑ fluid intake
- avoid exposure to cigarette smoke and alcohol
- Systemic steroids are not recommended
- Dextromethorphan (Robitussin) QID
ABRS
Symptomatic treatment in ABRS (nonpharmaceutical management)
- Saline nasal irrigations
- Intranasal corticosteroids when ABRS is accompanied by allergic rhinitis
Directions:
With sterile saline (do not use tap water, some have bacteria → abscess)
1. Spare opposite nare with opposite hand; if same side, will spray directly on septum → increases risk for epitaxis
2. Keep your nose over your toes → extra drainage out (↓ SE)
True or false:
The US FDA advises that the adverse effects associated with fluoroquinolones (cip-, levo-, moxifloxacin[-floxacin suffix] generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections who have other treatment options.
True.
Deviation from guideline. Avoid using fluoroquinolones untill last choice.
Possible adverse effects:
- Spontaneous tendon rupture
- Aortic aneurism/dissection
- Tendonitis
Which antibiotic is not effective in ABRS?
Macrolides (-mycins)
Ex:
- azithromycin
- clarithromycin
- erythromycin
- TMP-SMX (bactrim)
These are not recommended in ABRS treatment due to rising resistance rates
ABRS
1. Initial/first-line empiric therapy + second-line
- Amoxicillin-clavulanate 500 mg/125 mg PO TID, or l875 mg/125 mg PO BID for 5-7 days
- Will miss DRSP
- High dose (HD, 3-4 g/d) amoxicillin needed against DRSP.
- Clavulanate, as a beta-lactamase inhibitor, allows amoxicillin to have activity against beta-lactamase-producing organisms, such as H. influenzae, M. catarrhalis
- Coverage: +/- and beta-lactamase - Amoxicillin-clavulanate 2000 mg/125 mg PO BID for 7-10 days
- Gives coverage to DRSP
OR
Doxycycline 100 mg PO BID or 200 mg PO daily
- If allergic to amoxicillin, miss DRSP
- DO NOT give to pregnant or lactating, photosensitizing (2º burns)
- 0 < 8 - graying of teeth
- Doxycycline: effective against non-resistant S. Pneumoniae. DRSP treatment failure risk, activity against Gram- organisms.
- Stable in presence of beta-lactamase.
- Doxycycline: Pregnancy risk category D
ABRS
- If beta-lactam allergy
Allergy to antimicrobials with beta-lactam ring, such as penicillins, cephalosporins
- But does carry a lot of risks, FDA says do not use fluoroquinolones, but can bring DRSP
- Doxycycline 100 mg PO BID or 200 mg PO daily
OR - Levofloxacin 500 mg PO daily
OR - Moxifloxacin 400 mg PO daily
*Respiratory fluoroquinolones (FQ): activity against DRSP, Gram- organisms, stable in presence of beta-lactamase
Major rationale for use of respiratory FQ is the presence of DRSP risk. See FDA advisory on limiting FQ use.
ABRS
- Treatment for antibiotic resistance or failed initial therapy
- Amoxicillin-clavulanate 2000 mg/125 mg PO BID
OR - Levofloxacin 500 mg PO daily
OR - Moxifloxacin 400 mg PO daily
All options with activity against DRSP, Gram- organisms, stable in presence of and/or active against beta-lactamase
Otitis Media and Rhinosinusitis: Serious Complications
Refer all to ED STAT!
- Mastoiditis: red and swollen mastoid that is tender to palpation
- Preorbital or orbital cellulitis (more common in children: Swelling and redness at periorbital area, double vision or impaired vision, and fever. Abnormal EOMA (extraorbital muscles) movements of affected orbit (check CNs, EOM). Altered LOC or mental status change
- Meningitis: Acute onset of high fever, stiff neck, severe headache, photophobia, toxicity. Positive Brudzinski or Kernig sign
- Cavernous sinus thrombosis: Patient c/o acute onset of severe headache inferring with sleep, abnormal neurologic exam, confusion, febrility. Life-threatening emergency with high mortality!
What is a substrate?
A medication or substance that is metabolized/biotransformed by the isoenzyme, utilizing this enzyme in order to be modified so it can reach drug sit of action and/or be eliminated
- Cannot be broken down if with an inhibitor to be cleared
Clinical example:
CYP450 3A4 substrate examples:
Sildenafil (Viagra)
atorvastatin
Simvastatin
Alprazolam (Xanax)
About 50% of all prescription medications are CYP450 3A4 substrates.
Other commonly utilized CYP450 0isoenyzmes include 1A2, 2D6, 2C9, 2C19, 299.
**3A4 - Most important for interaction
What is an inhibitor?
A drug or other substance that blocks the activity of the isoenzyme, limiting substrate excretion, allowing increase in substrate levels, with possible risk of substrate-induced toxicity
CYP450 3A4 = erythro-, clarithromycin
Concomitant use of one of these antibiotics with any of the aforementioned CYP450 3A4 substrates results in an increase in substrate levels.
Clarithromycin + simvastatin = statin-induced rhabdomyolysis risk
Clarithromycin + alprazolam = increased sedation, fall risk
Drug-drug Interactions
- Why is this important?
- What areas are high-risk for drug interactions to happen?
- Knowledge of the most common drug-drug interactions is critical to certification and clinical practice success. Drug-drug interactions are the 2nd most common cause of why NPs getting sued (think coumadin with many drug-drug interactions)
- Liver (most serious consequence of interaction; protein binding fighting for site)
- Kidney
- Blood
What is an inducer?
Accelerates the activity of the isoenzyme so that the substrate is pushed out the exit pathway, leading to a reduction in substrate level; will spit out substrate faster
Example: St. John’s worth = CYP450 3A4 inducer
Concomitant use of St. John’s wort and 3A4 substrate can lead to reduced target drug levels and diminished therapeutic effect, possible treatment failure
Example: St. John’s wort + COC use = Off-loading of estrogen/progestin, leads to excessive spotting, potential contraceptive failure
What is CYP450?
Cytochrome P450 (CYP) is a hemeprotein that plays a key role in the metabolism of drugs and other xenobiotics (Estabrook, 2003). Understanding the CYP system is essential for advanced practitioners (APs), as the consequences of drug-drug interactions can be profound.
Drug metabolism occurs in many sites in the body, including the liver, intestinal wall, lungs, kidneys, and plasma. As the primary site of drug metabolism, the liver functions to detoxify and facilitate excretion of xenobiotics (foreign drugs or chemicals) by enzymatically converting lipid-soluble compounds to more water-soluble compounds. Drug metabolism is achieved through phase I reactions, phase II reactions, or both. The most common phase I reaction is oxidation, which is catalyzed by the CYP system.
Conductive Hearing Loss
1. Location
2. Cause
3. Weber Result
4. Rinne Result
5. Treatment
- Outer ear; temporary middle ear and out.
- Sound is being BLOCKED (earwax, foreign object, damaged eardrum, serous otitis media [infection], bone abnormality)
- Sound lateralizes to affected ear (buzzing sound heard louder in the affect ear due to increased tissue density)
- Negative (Bone > Air); bone conduction better than air conduction
- Often self-resolves post cerumen impaction removal; post URi or AOM resolution. Rarely, further pharmacologic or surgical intervention is needed. In other words, time and/or remove obstruction
Sensorineural Hearing Loss
1. Location
2. Cause
3. Weber Result
4. Rinne Result
5. Treatment
- Inner ear; Vestibulocochlear nerve (CN VIII)
- Inner ear or nerve becomes damaged (advanced age, ototoxic medications, immune disorders, trauma)
- Sound lateralizes to the unaffected ear (go to good ear) (buzzing sound heard lower or not at all in affected ear)
- Positive or normal (not helpful); air conduction better than bone conduction
- Hearing aids or cochlear implants possible options with expert consultation
COVID-19 vs Seasonal allergies
1. Symptoms more common of COVID 19
2. Symptoms common of both
3. Symptoms more common of seasonal allergies
- Fever and chills
- Muscle and body aches
- New loss of taste or smell (later symptoms, 5-7 days)
- Nausea or vomiting
- Diarrhea
- Shortness of breath or difficulty breathing
- Fever and chills
- Cough
- Fatigue
- Headache
- Sore throat
- Congestion or runny nose
- Cough
- Itchy or water eyes
- Itchy nose and throat
- Sneezing
- Similar symptoms in the past
- Itchy or water eyes
Allergic Rhinitis (AR) Treatment: A combination approach
1. Definition
2. First-line therapy/non-pharmacologic
- Allergic rhinitis (AR) is an inflammatory, IgE-mediated disease due to genetic and environmental interactions and characterized by nasal congestion, rhinorrhea (nasal drainage), sneezing, intraocular and/or nasal itching.
- Blue-tinged, pale, and/or swollen (boggy) nasal turbinates associated with increased clear nasal discharge
- May be accompanied by itchy nose, sneezing, and nasal congestion
- Mucus clear
- Posterior pharynx → thick mucus, with colors including clear, white, yellow, or green (r/o sinusitis); cobblestoning (hyperplastic lymphoid tissue)
- Undereye “circles” (venodilation)
- Children may have transverse nasal crease from frequent rubbing (allergic salute) - Allergen avoidance/environmental control
1st line therapy in any allergic disorder: Patient education to AVOID THE ALLERGEN whenever possible (carpets, Hepa filter, plastic cases on pillows, no pets on bed, close windows at night)
AR Treatment: Inhaled Pharmacologic
Controller therapy to prevent symptoms by preventing formation of or inactivating inflammatory mediators
1st line control therapy due to high efficacy: Intranasal corticosteroids (INCS)
Ex: Fluticasone propionate (Flonase) BID, triamcinolone (Nasacort AQ) 1-2 sprays daily
- blocks 6 inflammatory mediators
- takes 6 days to work
Intranasal antihistamine (IAH) - can be used indefinitely
Ex: Azalastine (Astelin, Astepro) -OTC
- Daily or BID
- Rapid symptom relief
- Nose over toes to ↓ SE (sedation ↑ 60%)
Cromolyn sodium nasal spray TID (less effective than steroids)
AR Treatment: Oral and ocular pharmacologic
Reliever therapy to relieve acute symptoms by blocking action of histamine, a potent inflammatory mediator
2nd generation oral antihistamines
Ex: - Loratadine (Claritin)
- Cetirizine (Zyrtec)
- Levocetirizine (Xyzal)
NOT 1st generation antihistamine use (diphenhydramine [benadryl] due to sedation risk)
Ocular antihistamine – helpful in managing allergic conjunctivitis signs and symptoms
Ex: - Olopatadine (Patanol, Pataday)
- Azelastine (Optivar)
- Bepotasine (Bepreve)
Use decongestants (e.g., pseudoephedrine, or Sudafed) PRN. Do NOT give to infants/young children
AR Treatment: Adjunct/Additional Therapies
- What medication should generally be avoided or advised against?
Leukotriene modifier - blocks controller
Ex: Montelukast (Singulair) PO
- Best as add-on therapy if symptoms not adequately controlled with intranasal corticosteroids
- With use, FDA-mandated neuropsychiatric warning → Behavioral changes, depression, suicidal (FDA warning)
Systemic corticosteroids
- Long-acting (depot) injectable or oral systemic corticosteroid use not advised due to adverse effects including adrenal suppression, ↓ bone density
Refer to allergist!
AR Treatment: What treatment can be used if initial therapies are inadequate? Possible complications?
Immunotherapy to restore tolerance to allergen by reducing its tendency to induce IgE production; 2 types - SubQ, Slit (sublingual immunotherapy)
For patients who have inadequate response with standard AR therapies, with specialty consultation, given by injection or sublingual
- Give small quantities to ↓ reaction
- 3-5 years to work
Complications: Acute sinusitis, AOM
Bacterial Conjunctivitis
- Onset with one eye
- discharge yellow/green/purulent
- crusty
Blepharoconjunctivitis
- Inflammation of lid margin → scaling of lids and margin
Tx: Johnson’s baby shampoo, hydrocortisone
Allergic conjunctivitis description
- Bilateral, intermittent
- Rope-like, thick, sticky discharge
Angle-closure glaucoma description
- PAINFUL, pupil, dilated
Ophthalmologic EMERGENCY!
Chlorpheniramine
1st generation antihistamine; crosses blood-brain barrier
Oral Cancer
1. Most common type of cancer causing oral cancer:
2. Risk factors (potent vs less potent)
3. Risk factor reduction
4. Clinical Presentation
5. Diagnostic studies
6. Treatment
- Squamous cell carcinoma (SCC) = 95% of cases
- Most potent risk factors: Longstanding HPV infection, especially HPV-16 (high risk HPV); tobacco use, alcohol misuse
Less potent but significant risk factors: Male gender, advancing age (2/3 of individuals age >55 years at time of diagnosis) - HPV-9 immunization
- Reducing HPV-15 acquisition
- Avoidance/cessation of tobacco use
- HPV-9 immunization
- Painless, ulcerating oral lesions, usually present for many months prior to presenting clinically
- Adjacent lymphadenopathy = immobile, nontender nodes usually >1 cm in diameter
- Painless, ulcerating oral lesions, usually present for many months prior to presenting clinically
- Referral for lesion biopsy
Additional imaging based on results - Refer to ENT or oral maxillary surgeon
Syphilitic chancre
- Painless, self-resolving 2-3 weeks
- anal-genital region
Aphthous stomatitis
- Painful (canker sore)
- Node would be tender
Oral candidiasis
- non-ulcerating, but expect white coating of tongue & uncomfortable
When to measure visual acuity:
1. What does the guideline say? What test/item is used to measure visual acuity?
2. At what age should 20/20 vision occur?
3. When should you refer to eye care specialist?
- Guideline says to do it on every child and adult, with comprehensive physical examination in adult or child. Typically done in office with SNELLEN CHART. Refer to eye care specialist for additional eval if patient fails test. Have patient use appropriate vision aid (contact lens, eyeglasses) if normally used.
- 20/20 vision by age 6 years; 20/30 at 5 years. Refer out if abnormal.
- If they miss 2 items on a line, they flunk that line.
- 20/100 - stand 20 feet from Snellen to see 100 feet with perfect vision - With any eye complaint.
If significant change from baseline → eye care specialist for additional evaluation, particularly if findings are of new onset.
Ex: A patient presenting with the triad of red eye, painful eye, and new-onset vision change → PROMPT referral to ophthalmology (EMERGENCY).
Possible causes:
- herpes zoster
- angle-closure
- anterior uvitis
When to measure visual acuity:
1. What does the guideline say? What test/item is used to measure visual acuity?
2. At what age should 20/20 vision occur?
3. When should you refer to eye care specialist?
- Guideline says to do it on every child and adult, with comprehensive physical examination in adult or child. Typically done in office with SNELLEN CHART. Refer to eye care specialist for additional eval if patient fails test. Have patient use appropriate vision aid (contact lens, eyeglasses) if normally used.
- 20/20 vision by age 6 years; 20/30 at 5 years. Refer out if abnormal.
- If they miss 2 items on a line, they flunk that line.
- 20/100 - stand 20 feet from Snellen to see 100 feet with perfect visionPap - With any eye complaint.
If significant change from baseline → eye care specialist for additional evaluation, particularly if findings are of new onset.
Ex: A patient presenting with the triad of red eye, painful eye, and new-onset vision change → PROMPT referral to ophthalmology (EMERGENCY).
Possible causes:
- herpes zoster
- angle-closure
- anterior uvitis
Papilledema
Caused by increased intracranial pressure, regardless of etiology, with patient report of a new-onset “blind spot” in the visual field.
-Optic disc swollen with blurred edges due to ↑ intracranial pressure 2º bleeding, brain tumor, abscess, pseudotumor cerebri
d/t ↑ ICP, brain hem., or brain tumor
Tx: CT scan
Arteriovenous (AV) nicking
Stiffened, thickened arterioles, seen with chronic, poorly-controlled HTN, usually without visual change (narrowing of the arteriovenous vessel)
Grade 2 HTN retinopathy
Hemorrhagic lesion
Caused by high great HTN or proliferative DM retinopathy, trauma, with patient complaint of new onset “floaters” in visual field
- bleeding, can be lasered
- will have normal vision again
* Get HTN under control
A deeply cupped optic disc or disc cupping
As a result of acute angle-closure glaucoma, typically with new-onset unilateral eye discomfort, redness, blurred vision; physiological cup
If >50% of optic disc → EMERGENCY!
- Measured using the “cup-to-disc” ratio; the “cup” of the optic disc is the center, and the surrounding area is the “disc.” As glaucoma progresses, the cup-to-disc ration becomes abnormal
If ax → @ risk for glaucoma “suspects”
Lid ectropion
Lid everts out, not normal
What does it mean when an eye has a white reflex? Possible causes?
- Retinal blastoma
- malignancy of eye
- cataracts
→ Refer to Opthalmology
Macular degeneration
Central vision loss
- leading cause of blindness
In blue eyes (most common), smokers, DM, Fam Hx
Tx: Develop Amsler Grid
Presbyopia
Gradual onset blurring of near vision
- abnormal Snellen test
- Will need reading glasses
Glaucoma
Open-angle glaucoma (more common)
- <20 pressure, normal tonometry
- loses peripheral vision
- Needs to be followed by eye care 2x/year
- Needs field of dept testing at 40-50 years
Presbycusis
Age-related hearing changing
- Bilateral, sensineural (background noise)
Pharyngitis
- Bacterial vs viral
- Treatment
Bacterial (GABHS)
- Significant anterior cervical lymphadenopathy
- Frontal headache without body aches
- Patchy exudates in posterior pharynx
- “The sore throat started all of a sudden”
Viral
- Clear nasal discharge
- Hoarseness
- Scattered small vesicles on soft palate and tonsils
- Generalized body aches
- “The sore throat started after my nose started to run”
Treatment: * Oral penicillin or amoxicillin is preferred over parenteral therapy
- Azithromycin is not considered a first-line therapy d/t antimicrobial resistance
** Still need to swab and culture in child, but swab in adults!
Presbyopia
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy
- Hardening of lens; age-related visual change due to decreased ability of the eye to accommodate and focus due to stiffening of the lenses; near vision is affected with decreased ability to read small print at close range; usually starts at age 40 years
- Close vision problems
- Nearly all >/= 45 year olds need reading glasses or other similar correction
Senile Cataracts
1. Etiology/Definition
2. Clinical presentation + Risk Factors
3. Possible Treatment/Therapy
- Lens clouding
- Progressive vision dimming
- Distance vision problems
- Close vision usually retained and often initially improves
- Progressive vision dimming
Risk Factors: Tobacco use, poor nutrition, sun exposure, systemic corticosteroid therapy
- Potentially correctable with surgery, lens implant
Open-angle glaucoma
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy
- Painless, gradual onset of increased intraocular pressure → optic atrophy
- Loss of peripheral vision if untreated
- Avoidable with appropriate and ongoing intervention
- Loss of peripheral vision if untreated
- > /= 80% of all glaucoma
- Periodic screening with tonometry, assessment of visual fields
- Treatment with topical miotics, beta-blockers, others, or surgery effective in vision perservation
- > /= 80% of all glaucoma
Angle-closure glaucoma
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy
- Sudden increase in intraocular pressure
- Usually unilateral
- Acutely RED
- PAINFUL eye with vision change
- Halos around lights
- Eyeball firm when compared to other
- Usually unilateral
- Immediate referral to ophthalmology care for rapid pressure reduction via medication, possible surgery
Age-related maculopathy (macular degeneration)
1. Etiology/Definition
2. Clinical presentation + Risk factors
3. Possible Treatment/Therapy
- Thickening, sclerotic changes in retinal basement membrane complex; caused by gradual damage to the pigment of the macula (area of central vision) → severe visual loss or blindness
- Usually asymptomatic during early stages
Painless vision changes including DISTORTION OF CENTRAL VISION (central vision loss).
- Reports that straight lines (doors, windows) appear distorted or curved
- Peripheral vision is usually preserved
On fundoscopic exam, drusen (soft yellow deposits in the macular region) often visible.
- Usually asymptomatic during early stages
Risk Factors: Aging, tobacco use, sun exposure, family hx
* Leading cause of blindness in elderly; more common in smokers
- Dry form (atrophic): Given few treatment options, prevention should be the goal. Develops over decades, no treatment available.
- More common (85-90%)
- “less severe” than wet form
Wet form (exudative): Laser treatment for photocoagulation to obliterate neovascular membrane; intravitreal injection of anti-vascular growth factor. Develops relatively quickly, usually over months
- 80% of vision loss (choroidal neovascularization)
- Refer to ophthalmologist
- Patient is given Amsler grid (focus eye on center dot and view grid 12 inches from eyes). Patient checks visual field loss daily to weekly (center of grid is distorted, blind sport or scotoma, or wavy lines)
- “Ocular” vitamins:” lutein and zeaxanthin with zinc; consult with ophthamologist before taking ocular vitamins
Anosmia, hyposmia
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy
- Neural degeneration
Anosmia - partial of full loss of smell
Hyposmia - reduced ability to detect odor - Diminished sense of smell, with resulting decline in fine taste discrimination
- Accelerated by tobacco use
Presbycusis
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy
- Loss of CN VIII sensitivity
- Difficulty with conversation in noisy environment
Person can hear but cannot understand what is said - Accelerated by excessive noise exposure; hearing aids helpful
Cerumen Impaction
1. Etiology/Definition
2. Clinical presentation
3. Possible Treatment/Therapy
- Conductive hearing loss
- General diminution of hearing
- Cerumen removal helpful in improving hearing
Suppurative conjunctivitis (non-gonococcal, non-chlamydial)
1. Common pathogens
2. Recommended antimicrobial
3. Treatment considerations
- S. aureus
- S. pneumoniae
- H. influenzae
- Outbreaks d/t S. pneumoniae
* Contagious for 24 hours
- S. aureus
- Primary: Ophthalmic treatment with FQ ocular solution (cipro-, levo-, moxifloxacin)
Alternative: Ophthalmic treatment with polymyxin B with trimethoprim solution - Most S. pneumoniae are resistant to tobramycin, gentamicin
- Relieve irritative symptoms with use of cold artificial tear solution
What is pink eye? How do you treat it?
Viral conjunctivitis
- “pink eye,” usually caused by adenovirus, often self-limiting
- Relieve irritative symptoms with use of cold artificial tear solution
Otitis externa (Swimmer’s ear)
1. Common pathogens
2. Recommended antimicrobial
3. Treatment considerations
* Which medication should be avoided if TM puncture is suspected?
- Pseudomonas spp., anaerobes, S. epidermidis
- Acute infection often with S. aureus
- Fungi rare etiology - For milder disease: Acetic acid with propylene glycol and hydrocortisone (VoSoL) drops
- For mod-severe disease: Otic drops with ciprofloxacin with hydrocortisone
- For milder disease: Acetic acid with propylene glycol and hydrocortisone (VoSoL) drops
- Systemic (oral or injectable) antimicrobial seldom needed
- Ear canal cleansing important. ↓ risk of reinfection by use of eardrops of 1:2 mixture of white vinegar and rubbing alcohol after swimming
- Do not use neomycin-containing product if puncture TM is suspected
- Systemic (oral or injectable) antimicrobial seldom needed
Malignant Otitis externa in person w/ DM, HIV/AIDS, or on chemotherapy
1. Common pathogens
2. Recommended antimicrobial
3. Treatment considerations
*What is this patient at an increase risk of?
- Pseudomonas spp., in >95%
- Oral ciprofloxacin for early disease suitable for outpatient therapy
- Other options are available if inpatient therapy warranted in severe disease
- Oral ciprofloxacin for early disease suitable for outpatient therapy
- Risk for osteomyelitis of the skull of TMJ
- MRI/CT imaging to rule out osteomyelitis often indicated.
- ENT consultation with surgical debridement should be considered.
- Obtain cultures of ear drainage or results of surgical debridement
- Parenteral antimicrobial therapy often warranted for severe disease
- Risk for osteomyelitis of the skull of TMJ
Exudative Pharyngitis
1. Common pathogens
2. Recommended antimicrobial
3. Treatment considerations
- Group A, C, G Streptococcus
- Viral
- HHV-6
- N. gonorrhoeae
- F. necrophorum
- Group A, C, G Streptococcus
- Group A beta hemolytic strep (GABHS) with documented positive strep screen or throat culture (associated with rheumatic fever) → proceed to antimicrobial therapy
- 1st line: Penicillin V PO x 10 days or benzathine penicillin IM x 1 dose if adherence an issue
- Alternative: 1st or 2nd generation cephalosporin x 4-6 days
- Alternative in severe IgE-mediated beta-lactam allergy: Azithromycin x 5 days, clarithromycin x 10 days, clindamyucin x 10 days (all PO)
- Up to 35% of S. pyogenes isolates resistant to macrolides
- Group A beta hemolytic strep (GABHS) with documented positive strep screen or throat culture (associated with rheumatic fever) → proceed to antimicrobial therapy
- Vesicular, ulcerative pharyngitis, usually viral
- Only 10% of adult pharyngitis d/t Group A Streptococcus (GAS). More common in children, teens, younger adults. Major rationale to treat GAS is prevention of rheumatic fever and eradication of organism to ↓ transmission
- No treatment recommended for asymptomatic group A Streptococcus carrier (neg for strep)
- For recurrent culture-proven S. pyogenes infection, consider coinfection w/ beta-lactamase-producing organism; treat with amoxicillin-clavulanate or clindaymycin
- Vesicular, ulcerative pharyngitis, usually viral
Corneal Ulcers
1. Definition/Population
2. Clinical presentation + diagnostics
3. Most common pathogens
4. Complications
5. Treatment
- Soft contact lens users
- Severe eye pain
- Foreign body sensation
- tearing
- photophobia
*Look for a whitish lesion on the cornea by using a penlight and/or performing a slit lamp exam and fluorescein dye test
- Severe eye pain
- Pseudomonas
- Staphylococcus
- Streptococcus
- Pseudomonas
- Can cause permanent impaired vision because of scarring or perforation
- Ophthalmologic emergency! → Refer to ED!
Herpes Keratitis
1. Definition/Population
2. Clinical presentation + diagnostics
3. Most common pathogens
4. Complications
5. Treatment
1 & 2. Acute onset of severe eye pain, photophobia, tearing, and blurred vision in ONE eye.
- Fluorescein dye (black lamp in a darkened room to search for fernlike lines in the corneal surface); corneal abrasions appear round or irregularly shaped
- Herpes zoster ophthalmicus: eye findings accompanied by acute eruption of crusty rashes following the ophthalmic branch (CN V) of the trigeminal nerve (one side of forehead, eyelids, and tip of nose)
- Fluorescein dye (black lamp in a darkened room to search for fernlike lines in the corneal surface); corneal abrasions appear round or irregularly shaped
- 2 types of herpesvirus that can affect the eyes:
- Herpes simples → due to self-inoculation “cold sore,” herpes whitlow → called herpes simplex keratitis
- Herpes varicella zoster (shingles) → usually due to singles of the trigeminal nerve (CN V) → herpes zoster ophthalmicus - Infection permanently damages corneal epithelium → corneal blindness
- Refer to ED.
Acute Angle-Closure Glaucoma
1. Definition/Population
2. Clinical presentation + diagnostics
3. Most common pathogens
4. Complications
5. Treatment
OPHTHALMOLOGIC EMERGENCY!
1 & 2. - Elderly patient with acute onset of severe eye pain accompanied by:
- headache
- nausea/vomiting
- halos around lights
- lacrimation
- decreased vision
PE:
- mid-dilated pupil(s) that is oval shape
- Cornea appears cloudy
* If rise in intraocular pressure (IOP) is slower, patient may be asymptomatic
- With chronic angle-closure glaucoma, the patient may be asymptomatic or report a dull ache and blurred vision
- Fundoscopic exam → cupping of the optic nerve
- Permanent blindness
- Refer to ED!
Multiple Sclerosis (Optic Neuritis)
1. Definition/Population
2. Treatment
- Young, Caucasian woman in heer 20-30s reports:
- Loss of vision acuity over hours to days
- Color vision is affected
- A central scotoma (blind spot central vision) is common
- Other neuro symptoms: aphasia, paresthesia, abnormal gait, spasticity
- Daily fatigue on awakening and worsens as the day goes on
- Higher than normal temp will worsen symptoms (Uhthoff phenomenon)
- Has recurrent episodes
- Young, Caucasian woman in heer 20-30s reports:
- Refer to neurologist
Uhthoff phenomenon
A transient worsening of neurological symptoms related to a demyelinating disorder such as multiple sclerosis when the body becomes overheated in hot weather, exercise, fever, saunas, or hot tubs.
Orbital Cellulitis
1. Definition/Population
2. Clinical presentation + diagnostics
3. Most common pathogens
4. Complications
5. Treatment
*Caused by acute bacterial infection of the orbital contents (fat and ocular muscles)
1. - Acute onset of erythematous swollen eyelid with proptosis (bulding of the eyeball)
- Pain in affected eye
- Unable to perform full ROM of eyes (abnormal EOM exam) with pain on eye movement
- More common in young children than adults
- Look for history of recent rhinosinusitis or URI.
- See URI.
- Serious complications.
- Refer to ED!
Retinal Detachment
1. Definition/Population
2. Treatment
- Sudden onset of floaters (or increase in floaters)
- Associated with “looking through the curtain” sensation
- Sudden flashes of light (photopsia)
- Central vision may be intact or lost if macula is detached.
- Sudden onset of floaters (or increase in floaters)
- Refer to ED!
Photopsia
Sudden flashes of light
Auricular Hematoma
1. Definition
2. Complications
3. Treatment
Direct blunt trauma to the ear that can cause bleeding in the auricular cartilage.
Hematoma should be drained asap. If not drained, it can result in cauliflower ear.
More common in wrestlers, boxers, and mixed martial arts fighters.
Acoustic Neuroma (Vestibular Schwannoma)
1. Definition
2. Clinical presentation
3. Treatment/Referral
Patient in 50s-60s with unilateral hearing loss (sensorineural) and tinnitus, which has been present for about 3-4 years.
- More common in Asians
- Tumor of acoustic nerve (CN VIII)
S/S
- Unsteadiness with walking
- Episodes of veering or tilting, fluctuating in severity
- May have facial paresis and paresthesia
Refer to neurologist!
Cholesteatoma
1. Definition
2. Clinical presentation
3. Lab/Diagnostics
4. Treatment/Referral
1 & 2. History of chronic or recurrent otitis media infection
Complains of:
- hearing loss and intermittent ear discharge (otorrhea) from one ear that is purulent and foul smelling
PE:
- perforation of TM on the superior quadrant + cauliflower-like or pearly-white mass
AND/OR
- Intact TM with missing landmarks with the white mass visible behind the TM
* Mass is not cancerous, but can erode into bones of the face and damage the facial nerve (CN VII).
- Tympanogram will be abnormal (straight line)
- Antibiotics and surgical excision and repair
Refer to otolaryngologist
Battle sign (Basilar Skull Fracture)
1. Definition/Etiology
2. Clinical presentation
3. Lab/Diagnostics
4. Treatment/Referral
- Parietal bone is most fractured
- Linear fracture most common, followed by depressed basilar skull fractures.
- Causes in adults: falls, assaults, care collisions, and penetrating missiles.
- Parietal bone is most fractured
- “Raccoon eyes” (periorbital ecchymosis) + bruising behind the ear (mastoid area), appears 1-3 days after trauma
- PE (after trauma) does not show these two clinical signs immediately.
- Search for clear, golden serous discharge from ear or nose (up to 20% of temporal bone fractures)
- Hemotympanum (blue to purple color of the TM), caused by blood inside the middle ear
** The findings of Battle sign, raccoon eyes, hemotympanum, and otorrhea/rhinorrhea → highly suggestive of serious head injury
- “Raccoon eyes” (periorbital ecchymosis) + bruising behind the ear (mastoid area), appears 1-3 days after trauma
Other possible findings:
- brain hemorrhage
- brain injury
- CN injury
- Imaging
- Refer to ED!
Clear, Golden Fluid Discharge from the Nose/Ear
(Otorrhea/Rhinorrhea of Cerebrospinal Fluid)
What does this indicate?
Indicative of a basilar and/or temporal skull bone fracture. If accompanied by the Battle sign, raccoon eyes, and hemotympanum → serious head injury → Refer to ED!
Avulsed Tooth
Is this an emergency? Treatment?
Considered a dental emergency. The sooner reimplanted, the better the outcome!
If young child and primary tooth, do not implant.
If permanent, avoid touching root, handle only the crown.
Rinse in normal saline, irrigate socket with normal saline and reimplant tooth
Afterward, have patient bite down on gauze and refer to dentist ASAP!
Store tooth in cool milk or saline, or store inside cheek (buccal sulcus) if unable to reimplant
Peritonsillar Abscess
1. Definition & S/S
2. Treatment
- Severe sore throat
- Difficulty swallowing
- Odynophagia (pain on swallowing)
- Trismus (jaw muscle spasm making it difficult to open mouth)
- “hot potato” vopice
- Unilateral swelling of the peritonsillar area and soft palate
- Affected area is markedly swollen and appears as a bulging red mass with uvula displaced away from the mass (uvula displacement)
- malaise
- fever
- chills
- Severe sore throat
- Refer to ED!
Odynophagia
Pain on swallowing
Trimus
jaw muscle spasm making it difficult to open mouth
Diphtheria
1. Definition & S/S
2. Treatment
- Sore throat
- Fever
- Markedly swollen neck (“bull neck”)
- Low-grade fever
- Hoarseness
- Dysphagia
- The posterior pharynx, tonsils, uvula, and soft palate are coated with a gray to yellow pseudomembrane that is hard to displace
** Very contagious
**Contact prophylaxis required
- Sore throat
- Refer to ED!
Virchow’s Node
1. Definition & S/S
2. Treatment
AKA Troisier’s Sign/Node
1. - an enlarged and hard left-sided supraventricular node(s)
* Associated with malignancy, especially in adults >/= 40 years; highly suggestive of cancers of the stomach, colon, pancreas, gallbladder, kidneys, ovaries, testicles, prostate, or lymphoid tissue
The left supraventricular lymph node drains vai the thoracic duct, abdomen, and thorax.
Workup:
- thorough history
- physical exam
- lab testing
- imaging
- Refer to surgeon for biopsy!
Normal Findings for the EYES:
1. Fundi
2. Cones
3. Rods
4. Macular (and fovea)
- Veins are larger than arteries; veins are darker (in color) than arteries
- For color perception, sharpest (20/20 vision)
- For low-light vision (night vision), peripheral vision
- Responsible for our central vision, sharpest vision (20/20 vision), and color vision. The center of the macula is called the fovea; contains large numbers of cones. Diseases of macular → loss of central vision
Blepharitis
1. Definition & S/S
2. Treatment
- Chronic condition caused by inflammation of the eyelids (hair follicles, meibomian glands); associated with seborrheic dermatitis and rosacea. Lid may be colonized by staphylococcal bacteria.
- Intermittent exacerbations
- Itching or irritation on the eyelids (upper/lower or both)
- gritty sensation, eye redness, and crusting
- Inflammation of the edges of the eyelids where the eyelashes grown
- tiny oil glands at the base of the eyelashes become clogged
- eyelids (upper and/or lower) are red, irritated, and itchy
- small scales like dandruff may be present
- tends to recur
- may be associated with dandruff, seborrheic dermatitis, or rosacea
- Johnson’s Baby Shampoo with warm water: gently scrub eyelid margins until resolves. Consider topical antibiotic solution (erythromycin eye drops_ to eyelids BID/TID (lid hygiene); commercial eyelid scrub products are available.
- Warm compress to eyelids BID - QID during exacerbations to soften debris and relieve itching
- Johnson’s Baby Shampoo with warm water: gently scrub eyelid margins until resolves. Consider topical antibiotic solution (erythromycin eye drops_ to eyelids BID/TID (lid hygiene); commercial eyelid scrub products are available.
Normal Findings: Ears
1. Bones
2. TM
3. Pinna
4. Tragus
5. Cartilage
6. Cerumen
- AKA Ossicles of the ear: Malleus, incus, and stapes
- Stapes → smallest bone in the body - Appears translucent off-white to gray color with the “cone of light” intact.
- Lateral process of the malleus is located at the upper quadrant of TM and lies in front of the pars flaccida. The pars tensa is located on the lower aspect and appears to bulge slightly. It is the area of the TM where the cone of light is visible - Has a large amount of cartilage; blunt trauma can result in a hematoma; drain asap to avoid damage to cartilage. If untreated → cauliflower ear
- A small cartilage flap of tissue on the front of the ear
- Found on the nose and ears; does not regenerate; refer injuries to plastic surgeon
- Ear wax; the color range from yellow to dark brown
What is Tympanogram?
Most objective measure test for presence of fluid inside middle ear (results in a straight line vs. a peaked shape; graph). Acute otitis media (AOM) and serous otitis media will show a straight line on testing.
Normal Findings: NOSE
1. Kiesselbach’s plexus
2. Turbinates
3. Cartilage
4. Septum
- Located on anterior inferior aspect of nose (lower 1/3); an anterior nosebleed if result if the area is traumatized
- Only the inferior nasal turbinates are usually visible; medial and superior turbinates are not visible without special instruments. Bluish, pale, and/or boggy nasal turbinates are seen in allergic rhinitis
- Lower third of the nose is cartilage; if damaged, does not regenerate
- Nasal divider. Perforation can result of cocaine inhalation, which is a potent vasoconstrictor → Refer to plastic surgeon for repair.
Sinuses
Air-filled cavities in the skull.
Four types:
- Ethmoid
- Maxillary
* Both above are present at birth
-Front (at age 5)
- Sphenoid (age 12)
By 12, a child’s sinuses are nearly at adult proportions
Normal Findings: Mouth (mucous membranes, gums, tongue, teeth)
Mucous membranes are pink to dark pink and moist.
Look for ulcers, fissures, leukoplakia, and inflammation. If gums are red and swollen, patient may have gingivitis (gums may bleed when brushing teeth) or be taking phenytoin (Dilantin) for seizures (gingival hyperplasia).
Tongue should not be red of swollen (glossitis)
Normal adult has 32 teeth
Leukoplakia
White-to-light gray patch that appears on tongue, floor of mouth, or inside cheek. R/o oral cancer. Chewing or smoking tobacco, alcohol abuse, and HPV are risk factors for oral cancer
Aphthous stomatitis
Canker sores
Painful shallow ulcers on soft tissue of the mouth that usually heal within 7-10 days.
Unknown cause.
Treatment: Magic mouthwash (combination of liquid diphenhydramine, viscous lidocaine, and glucocorticosteroid); swish, hold, and spit Q4H PRN.
Other options: Orabase cream/ointment (OTC)
Vermilion Border
Vermilion border is the edges of lips
oral commisures
Corners of the lips; the corner of the mouth, at the point where the upper and lower lips meet
Cheilosis
- Definition
- Etiologies
- Treatment
an inflammatory condition that causes cracking, crusting, and scaling of the corners of the mouth
aka perleche
- Painful skin fissures and maceration at the corners of the mouth d/t excessive moisture
- More common in elderly with dentures
- Can be acute or chronic
Multiple Etiologies:
- 2º infection with Candida albicans (yeast) or bacteria (Staphylococcus aureus).
- Overesalivation
- Poorly fitting dentures
- Nutritional deficiencies (B2-riboflavin, B3-niacin, B6-pyridoxine, or B9-folic acid)
- Lupus
- Autoimmune disease (Sjogren’s syndrome)
- Irritant dermatitis
- Squamous cell carcinoma
In children:
- Pacifier use
- Lip licking
- Thumb sucking
Treatment:
- Check Vit B12; consider checking other B vitamins (B3, B6, B9)
- Remove underlying cause. Check if dentures fit correctly; if loose → dentist
- If yeast infection suspected → microscopy with potassium hydroxide (KOH) → If + (pseudohyphae and spores) → topical azole ointment (e.g., clotrimazole, miconazole) BID
- If staphylococcal infection → culture and sensitivity (C&S) → If +, treat with topical mupirocin ointment BID
- When infection has cleared → barrier cream with zine or petroleum jelly at night
* High rate of recurrence
Perleche
an irritation at the corners of the lips. When someone suffers from perlèche, the corners of the lips become very red and dry, and can sometimes turn whitish in colour. There are often fissures or crusts that can occasionally bleed
aka cheilosis
Salivary Glands
3 salivary glands:
- parotid
- submandibular
- sublingual
May become infected (sialadenitis, sialadenosis, mumps) or become blocked with calculi (“stone”, sialolithiasis)
Sailadenitis
a swollen salivary gland. It’s caused by infections, autoimmune diseases and salivary gland stones. When a salivary gland becomes inflamed, it can stop functioning. Sialadenitis usually goes away in about a week
Sialadenosis
nonneoplastic,non-inflammatory swelling of the salivary gland in association with acinar hypertrophy and ductal atrophy. Sialdenosis presents as non-tender swelling that is often bilateral and symmetric. Sialadenosis is often associated with systemic metabolic conditions
Sialolithiasis
a condition in which stones (calculi) form in your salivary gland or ducts, blocking the flow of saliva. These stones, usually made of calcium phosphate and hydroxyapatite, can cause facial pain and swelling. Symptoms may occur on one side (unilateral) or both sides (bilateral)
Mumps (Parotitis)
1. Definition/Population
2. Clinical Presentation
3. Complications
4. Treatment
- School-aged children to adult
- Acute onset of fever
- headache
- fatigue
- myalgia
- anorexia
Within 48 hours, the salivary/parotid gland(s) become swollen and tender
- can be unilateral (25%) or bilateral
- Cheek appears puffy
- Angle of jaw on the involved side appears swollen
- Swelling and tenderness usually subsides in ~1 week - Rare complications but can include orchitis (of one testicle)
- Meningitis
- Encephalitis
- Deafness - Nationally notifiable disease; report ALL cases to local or state health department
Tonsils
1. Normal findings
2. Possible diseases
3. Most severe complication
4. Treatment
- AKA palatine tonsils; made up of lymphoid tissues
- Butterfly-shaped glands with small pore-like openings that may secrete thick white exudate (mononucleosis) or purulent exudate (yellow-to-green color; strep throat) - Mono
- Strep throat
- Peritonsillar abscess (quinsy) → serious deep-neck infection; rare complication of tonsillitis
- Mono
- Airway obstruction!
- Refer to ED!
Possible diseases in Posterior Pharynx
- Postnasal drip (from acute sinusitis, allergic rhinitis) → Lying supine worsens a postnasal drip cough
- Chronic sinusitis → chronic cough
- Retropharyngeal lymph nodes → mildly enlarged and distributed evenly on back of throat (allergies, allergic rhinitis)
Hard palate: look for any openings (cleft palate), ulcers, redness
Uvula: Should be in midline position; displaced if infected and abscessed (peritonsillar abscess)
Lymph Nodes
- Locations in head and neck
- Anterior cervical nodes (superficial chain) drain lymph from the skin and superficial surfaces of the anterior neck → enlarged with viral or bacterial infections (strep throat)
- Posterior cervical nodes (superficial chain) drain the scalp, neck, and skin of the upper thoracic area → mononucleosis can cause posterior cervical lymphadenopathy
Benign variants: What is geographic tongue?
Tongue surface has a maplike appearance; patches may move from day to day.
Patient may complain of soreness with acidic foods, spicy foods
Bening variants: What is torus palatinus?
Painless bony protuberance midline on the hard palate (roof of the mouth
- may be asymmetric
- skin should be normal
- does not interfere with normal function
Bening variants: Fishtail or split uvula
Uvula is split into two sections and resembles a fishtail
- may be a sign of an occult cleft palate (rare)
Bening variants: Physiologic Gaze-evoked Nystagmus
- On prolonged, extreme lateral gaze, a few beats of nystagmus that resolve when the eye moves back toward midline in health patients is normal
- can also be caused by brain lesions
What is Hypertensive Retinopathy?
- Copper and silver wire arterioles (caused by arteriosclerosis)
- Arteriovenous nicking → compression of vein by an arteriole as it passes over it; appears as if “nicked” or missing a small area
- Retinal hemorrhages
What is Diabetic Retinopathy?
- Microaneurysms (small bulges in retinal blood vessels that often leak fluid) caused by neovascularization (new fragile arteries in the retina that rupture and bleed)
- Cotton-wool spots (fluffy yellow-white patches on the retina)
What are cataracts? Symptoms? Age population?
Opacity of the lens of the eye, which can be central ()nuclear cataract) or on the sides (cortical cataract)
Up to 20% of older adults (ages 65-74) are affected; however, cataracts can appear at any age from infants (congenital cataracts) through adults to the elderly
Symptoms:
- difficulty with glare (with headlights when driving at night or sunlight)
- halos around lights
- blurred vision
What are Koplik’s Spots?
- Clusters of small red papules with white centers inside the cheek (buccal mucosa) by the lower molars
- pathognomonic for measles (rubeola)
What are nasal polyps?
- Painless, soft round growths inside the nose (look for fleshy mass inside nasal cavity; may have blockage on one side of the nose)
- Intranasal glucocorticoids (fluticasone or budesonide twice a day) are used as first-line treatment. If poor response or recurrent sinus infection → Refer to ENT specialist for surgical treatment
- ↑ risk of aspirin sensitivity or allergy
What is Hairy Leukoplakia?
- Elongated papilla on the lateral aspects of the tongue that is pathognomic for HIV infection
- Caused by Epstein-Barr virus (EBV) infection of tongue
What is leukoplakia of the oral mucosa/tongue?
- Bright-white plaque on the inner cheeks (buccal mucosa) caused by chronic irritation, such as from chewing tobacco or snuff
- Rule out ORAL CANCER!
- Refer to oral surgeon for biopsy
EENT Terminology: Palpebral conjunctiva
Mucosal lining side eyelids
EENT Terminology: Bulbar conjunctiva
Mucosal lining covering the eyes
EENT Terminology: Buccal muscosa
Mucosal lining inside the mouth
EENT Terminology: Soft palate
Area where uvula, tonsils, and anterior of throat are located
EENT Terminology: Hard palate
“Roof” of the mouth
EENT Terminology: Hyperopia
“Farsightedness”
- Distance vision is intact, but near vision is blurry
EENT Terminology: Myopia
“Nearsightedness”
- Near vision intact, but distance vision is blurry
EENT Terminology: Amblyopia
“Lazy eye”
- Usually starts in infancy. The affected eye has reduced vision. → Refer to ophthalmologist
EENT Terminology: Miosis
Excessive constriction of the pupil of the eye
EENT Terminology: Ptosis
Dropping of the upper eyelid
Vision Testing:
1. Distance Vision
- What if person is illiterate?
2. Near Vision
3. Peripheral Vision
4. Color Blindness
- The Snellen Chart
- measures central distance vision
- If person is illiterate, use the Tumbling E chart
- Must stand 20 feet away from the chart
- Patient wears glasses, test the vision with glasses on both eyes (OU), right eye (OD), and left eye (OS) - Read small print
- Use “visual fields of confrontation” exam
- Look for blind spots (scotoma) and peripheral visual field defects
- Use “visual fields of confrontation” exam
- Use Ishihara chart
Vision Testing: Visual Test Results
1. Snellen Test
2. Legal Blindness
- If 20/60:
- Top number (numerator): Distance in feet at which the patient stands from the Snellen or picture eye chart (always 20 feet and never changes)
- Bottom number (denominator): The number of feet at which the patient can see compared with a person with normal vision (20/20 or less). Number changes, dependent on patient’s vision
- In this example, the patient can see at 20 feet what a person with normal vision can see at 60 feet - Legal blindness: best corrected version of 20/200 or less or a visual field <20 degrees (tunnel vision)
Children’s Vision normals
By 6 years → visual acuity (retina or CN II) is 20/20 in both eyes
Use Snellen chart with child, standing at 20 feet.
If child’s vision is not at least 20/30 in either eye by age 6 → Refer to ophthalmologist
Hearing Tests:
1. Weber Test
2. Rinne Test
- Place tuning fork midline on forehead
Normal: No lateralization.
- Lateralization (hears the sound in only one ear or sound is louder in one ear) is abnormal finding. - Place tuning fork first on mastoid process, then at front of ear. Time each area.
Normal: Air conduction (AC) lasts longer than bone conduction (BC); can hear longer in front of ear than on mastoid bone; AC > BC
Hearing Tests: Sensorineural Hearing Loss
Inner Ear
- Damage (or aging) of the cochlea/vestibule and/or to the nerve pathways (CN VIII or acoustic nerve)
Presbycusis
Meniere’s disease
Ototoxic drugs (oral aminoglycosides, erythromycin, tetracyclines, high-dose aspirin, sildenafil)
Stroke
- Usually results in permanent hearing loss
Weber Test: Lateralization to “good ear” (sound is heard louder in the ear that is normal)
Rinne Test: AC > BC
Hearing Tests: Conductive Hearing Loss
Outer ear and middle ear
- Any type of obstruction (or conduction) of the sound waves
- Blockage of outer ear and/or fluid inside middle ear
EX: Otitis media
Serous otitis media
Ceruminosis
Perforation of tympanic membrane
Otitis externa
Weber Test: Lateralization to “bad” ear (sound is heard louder in the “bad” or affected ear)
Rinne Test: BC > AC
Corneal Abrasion
- Acute onset of severe eye pain with tearing
- Reports feeling of foreign body sensation on surface of the eye
*Always ask any patient with eye complaints if they wear contact lenses
Contact Lens-Related Keratitis
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
1 & 2. - Acute onset of red eye
- Blurred vision
- Watery eyes
- Photophobia
- Sometimes a foreign-body sensation in affected eye
- Hx of using contacts past prescribed time schedule, sleeping with contacts, bathes/showers or swims with contacts, extended lens use, and use of tap/well water or poor disinfection practices
- Fluorescein dye strips with Wood’s lamp (black lamp) in darkened room
- Contact lens-associated abrasions are usually in center and round
- Herpes keratitis: fernlike or branching curved lines (in contrast, corneal abrasions usually appear round or linear) - Always check visual acuity and pupils with penlight
- Rule out penetrating trauma, retained foreign body, and contact lens-associated eye infections
- If suspect bacterial infection, obtain C&S of eye discharge
- Flush eye with sterile normal saline to remove foreign body; ever eyelid to lok for foreign body. If unable to remove → refer
- Use topical ophthalmic antibiotic with pseudomonal coverage (especially if contact lens user); ciprofloxacin (Ciloxan), ofloxacin (Ocuflox), or trimethoprim-polymyxin B (Polytrim); apply to affect eye x 3-5 days
- Do not patch eye.
- Follow up in 24 hours. If not improve → Refer to ED or ophthalmologist STAT!
- Zovriax or Valtrex BID
- Avoid steroid ophthalmic drops for herpes keratitis
- Consider eye pain prescription (hydrocodone with acetaminophen; prescribe enough for 48 hours of use)
- Topical pain medication Acular 1 gtt QID
*Contraindication: allergy to NSAIDs
- Always check visual acuity and pupils with penlight
Hordeolum
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
- Stye – An external hordeolum is an abscess of a hair follicle and sebaceous gland in the upper or lower eyelid. An internal hordeolum involves inflammation of the meibomian gland. May have history of blephritis
- Acute onset of a swollen, red, and warm abscess on upper or lower eyelid involving one hair follicle that gradually enlarges
- May spontaneously rupture and drain purulent exudate
- Infection may spread to adjoining tissue (preseptal cellulitis)
- Acute onset of a swollen, red, and warm abscess on upper or lower eyelid involving one hair follicle that gradually enlarges
- Clinical diagnosis
- Hot compresses x 5-10 mins BID-TID until it drains
- If infection spread (preseptal cellulitis), systemic antibiotics such as dicloxacillin or erythromycin PO QID → Refer to ophthalmologist for I&D
- Hot compresses x 5-10 mins BID-TID until it drains
Chalazion
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
- A chronic inflammation fo the meibomian gland (specialized sweat gland ) of the ey lids. May resolve spontaneously in 2-8 weeks
- Gradual onset of a small superficial module on upper eyelid
- Feels like a bead, discrete and mobile/moveable
- Painless
- Can slowly enlarge over time
- If large, can press on cornea and cause blurred vision
- Gradual onset of a small superficial module on upper eyelid
- Clinical diagnosis
- I&D, surgical removal, or intrachalazion corticosteroid injections by ophthalmologist
Pinguecula
A raised, yellow-to-white, small round growth in the bulbar conjunctiva (skin covering eyeball) next to the cornea. Located on the nasal and temporal side of the eye. Caused by chronic sun exposure.
Pterygium
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
1 & 2. A yellow triangular (wedge-shaped) thickening of the conjunctiva that extends across the cornea on the nasal side. Results from chronic sun exposure.
- Sometimes called surfer’s eye
- Can be red or inflamed at times
- May complain of foreign body sensation on the eye
- Clinical diagnosis
- In inflamed → Refer to ophthalmologist for prescription of weak steroid eye drops only during exacerbations; use artificial tears PRN for irritation
- Use good-quality sunglasses (100% against UVA and UVB)
- Remove surgically if growth encroaches on cornea and affects vision
- In inflamed → Refer to ophthalmologist for prescription of weak steroid eye drops only during exacerbations; use artificial tears PRN for irritation
Subconjunctival Hemorrhage
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
- Blood trapped underneath conjunctiva and sclera 2º to broken arterioles. Can be caused by coughing, sneezing, heavy lifting, vomiting, or local trauma, or occur spontaneously.
- Resolves within 1-3 weeks (blood reabsorbed) like a bruise, with color changes from red to green to yellow
- Increased risk if patient is on aspirin or anticoagulants or has HTN - Sudden onset of bright-red blood in one eye after an incident of severe coughing, sneezing, or straining
- May also be d/t trauma such as a fall
- Denies visual loss and pain
- Sudden onset of bright-red blood in one eye after an incident of severe coughing, sneezing, or straining
- Clinical diagnosis
- Watchful waiting and reassurance of patient. Follow up until resolution
Primary Open-Angle Glaucoma
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
- Graduate onset of ↑ IOP >22 mmHg d/t blockage of drainage of aqueous humor inside eye. Retina (CN II) undergoes ischemic changes and, if untreated, become permanently damaged.
- Most common type of glaucoma (60-70%). → Refer to ophthalmology
- Most seen in elderly patients esp African or Caucasian ancestry, or diabetics - Usually asymptomatic in early stages
- Gradual changes in peripheral vision (lost first)
- Then central vision
- May complain of missing portions of words when reading
- Usually asymptomatic in early stages
- Funduscopic exam → cupping, IOP is too high → Refer to Ophthalmology
- Check IOP (use tonometer) - Normal range: 8-21 mmHg
* IOP >30 mmHg is considered very high. Urgent referral within </= 24 hours to ophthalmologist or refer to ED - Betimol 0.5% (timolol): Beta-blocker eye drops (↓ aqueous production)
- Latanoprost (Xalatan): Topical prostaglandin eye drops (↑ aqueous outflow)
- SE: Same as oral form; includes bronchospasm, fatigue, depression, heart failure, bradycardia
- Contraindications: Asthma, emphysema, COPD, second- or third-degree heart block, HF
- Betimol 0.5% (timolol): Beta-blocker eye drops (↓ aqueous production)
Complication: Blindness d/t ischemic damage to retina (CN II)
Primary Angle-Closure Glaucoma
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
- Sudden blockage of aqueous humor causes marked ↑ of the IOP → ischemia and permanent damage to optic nerve (CN II)
- Older patient c/o acute onset of ↓/blurred
- Severe eye pain
- Front headache
- Accompanied by nausea and vomiting
- Older patient c/o acute onset of ↓/blurred
Objective findings:
- Fixed and mid-dilated, cloudy pupil (4-6 mm)
- Looks more oval than round
- Reacts slowly to light
- Conjunctival infection with ↑ lacrimation
- Clinical diagnosis
- Tonometry for IOP - Refer to ED!
Anterior Uveitis
Iritis
Insidious onset of eye pain with conjunctival injection
Refer to ophthalmologist for management ASAP wi th 24 hours!
- can result in blindness!
Conjunctival injection
Injection of the eye means the superficial blood vessels of the conjunctiva are prominent (red eyes) located mainly on the limbus (junction between cornea and sclera) that is a complication of autoimmune disorders (RA, Lupus, ankylosing spondylitis, sarcoidosis, syphilis, etc); no purulent discharge (as in bacterial conjunctivitis)
Sjogren’s Syndrome
1. Definition/Population
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
- Chronic autoimmune disorder characterized by ↓ function of lacrimal and salivary glands; can occur alone or with another autoimmune disorder (e.g., with RA)
- Persistent daily symptoms of dry eyes and dry mouth (xerostomia) for >3 months
- “dry eyes” or sandy/gritty sensation
- has used OTC artificial tears > TID
- Marked increase in dental caries
- oral exam → swollen and inflamed salivary glands
- Persistent daily symptoms of dry eyes and dry mouth (xerostomia) for >3 months
- Clinical diagnosis
- OTC tear-substitute eye drops TID
- keratoconjunctivitis sicca → Refer to ophthalmology
- dental caries → dentist
- Refer to rheumatologist for management
- OTC tear-substitute eye drops TID
Xerostomia
Dry mouth
keratoconjunctivitis sicca
Dry eyes or sandy/gritty sensation
chronic, bilateral desiccation of the conjunctiva and cornea caused by too little tear production or accelerated tear evaporation. Typical symptoms include intermittent itching; burning; blurring, a gritty, pulling, or foreign body sensation; and photosensitivity
Entropion
The eyelid (usually lower eyelid) is turned inward; eyelashes continuously rub against cornea → irritation, watery eyes, redness, pain, and/or foreign body sensation
- More common in elderly
Ectropion
Eyelid is turned outward of sags away from eye → irritation and eye dryness
- More common in elderly
Rhinitis Medicamentosa
1. Definition
2. Clinical presentation
3. Treatment
- Prolonged use of topical nasal decongestants (>3 days) causes rebound effects → severe and chronic nasal congestion
- Presents with daily severe nasal congestion and nasal discharge (clear, watery mucus)
- Stop the use of nasal decongestants
- Encourage use of nasal saline spray to control symptoms
- Stop the use of nasal decongestants
Epistaxis
1. Anterior vs posterior
2. Clinical presentations
3. Treatment
- Nosebleeds - most are self-limiting
Anterior - located anteriorly on lower 1/3 of nose
- milder and more common
- result of bleeding from Kiesselbach’s plexus (vascular area)
Posterior
- can lead to severe hemorrhage
- Aspirin use, NSAIDs, cocaine abuse, severe HTN, anticoagulants (warfarin; place patients at higher risk); intranasal cocaine use can cause nosebleeds and nasal septum perforation
- acute onset of nasal bleeding 2º trauma (e.g., nose picking)
- bright-red blood may drop externally through nasal passage and/or posterior pharynx
- profuse bleeding can result in vomiting of blood
- acute onset of nasal bleeding 2º trauma (e.g., nose picking)
- Apply direct pressure on front of nose for several minutes
- use nasal decongestants (Afrin) to shrink tissue helps to stop bleeding
- Apply triple antibiotic ointment or petroleum jelly in front of nose using cotton swab for a few days
- If recurrent anterior nasal bleeds → Refer ENT for cauterization
- Apply direct pressure on front of nose for several minutes
Posterior nasal bleeds may hemorrage → Refer to ED!
Septal Perforation
A hole on the nasal septum (cartilage_ can range in size from small to large
- Shine a light on one nostril will transilluminate both sides
- One of most common cause: snorting or inhaling cocaine (potent vasoconstrictor; causes ischemia)
Other causes:
- trauma
- prior septal surgery
- untreated septal hematomas
- self-induced lesions
Streptococcal Pharyngitis/Tonsillopharyngitis
1. Definition/Population
2. Clinical Presentation
3. Labs/Diagnostics
4. Treatment
“Strep” throat
1. An acute infection of the pharynx and/or palatine tonsils caused by group A streptococcal bacteria (streptococcus pyogenes)
- Most common: viral (e.g., rhinovirus, adenovirus, respiratory syncytial virus [RSV]_
- Suspect viral etiology (or coinfection) if cough and symptoms such as stuffy nose, rhinitis with clear mucus, and water eyes (coryza)
- All ages are affected, but most common in children
- Abrupt onset of fever
- Sore throat
- pain on swallowing
- mildly enlarged submandibular nodes
- may have purulent exudate on tonsils
- anterior cervical nodes mildly enlarged and tender (anterior cervical adenitis)
- Adult may report that child goes to preschool
- Abrupt onset of fever
- Centor Criteria – clinical decision tool used to help diagnose “strep” throat, including:
- tonsillar exudate
- tender anterior cervical adenopathy
- history of fever
- absence of cough - Rapid antigen detection testing (RADT) is a rapid “strep” test or throat C&S
- First line: PO penicillin V 500 mg BID-TID x 10 days
- Alternative: amoxicillin 500 mg BID x 10 days
- PCN or beta-lactam allergy: azithromycin (Z-Pak) x 5 days
- Throat pain and fever: ibuprofen (advil) or acetaminophen (Tylenol)
- Symptomatic treatment: Saltwater gargles, throat lozenges, drink more fluids
- Repeat C&S after antibiotic treatment (test of cure): Hx of mitral valve prolapse or heart valve surgery
- Rapid antigen detection testing (RADT) is a rapid “strep” test or throat C&S
coryza
an acute inflammatory contagious disease involving the upper respiratory tract: : common cold
Acute Otitis Media
1. Definition
2. Common pathogens
3. Clinical Presentation
4. Labs/Diagnostics
5. Treatment
- An acute infection of the middle ear cavity with bacterial pathogens d/t mucus that becomes trapped in the middle ear; 2º to temporary eustachian tube dysfunction; usually unilateral but may involve both ears. Most have middle ear effusion (MEE).
- Most cases occur in childhood - Adult infections usually d/t Streptococcus pneumoniae; high rates of beta-lactamase resistance.
- S. pneumoniae (Gram+; up to 40% of cases)
- Haemophilus influenzae (Gram-; up to 50% of cases)
- Moraxella catarrhalise (Gram-; up to 20% of cases) - ear pain (otalgia)
- popping noises
- muffled hearing
- Recent hx of cold or flare-up of allergic rhinitis
- ear pain (otalgia)
Adults
- develop more slowly than children
- afebrile to low-grade fever
- May be accompanied by TM rupture (reports blood and pus seen on pillowcase with relief of ear pain)
- Bullous Myringitis
PE:
- Weber exam shows lateralization to the “bad”/affected ear (conductive hearing loss)
- Rinne test: BC > AC (conductive hearing loss)
- TM: buldging or retraction with displaced light reflex (displaced landmarks); may look opaque
- Erythematous TM
- ↓ mobility with flat-line tracing on tympanogram (most objective finding)
- If TM is ruptured, purulent discharge from affected ear (and relief of ear pain)
- Clinical diagnosis
- First line: Amoxicillin (any age group if no abx in prior month) 500 mg PO TID x 5-7 days
- Mild-to-mod disease: treat 5-7 days
- Severe disease: treat 10 days
- Most patients will respond in 48 - 72 hours. If no response → second-line drug such as amoxicillin-clavulanate (Augmentin) TID OR cefdinir (Omnicef) OR cefprozil (Ceftin BID), or levofloxacin (Levaquin) or moxifloxacin (Avelox) daily x 5 days
- Treat symptoms of otalgia and eustachian tube dysfunction (becomes swollen d/t inflammation and cannot drain); pt will c/o “plugged-up” ear (MEE) and ↑ hearing in affected ear (temporary). When fluid in middle ear drains, hearing will return to normal
Otalgia
ear pain
Bullous Myringitis
Type of AOM infection that is more painful d/t presence of blisters (bullae) on a reddened and bulging TM.
- Conductive hearing loss
- Caused by different types of pathogens (e.g., mycoplasma, virus, bacteria)
Treat the same as bacterial AOM
Middle Ear effusions (MEE)
1. How long can MEEs persist for after treatment of AOM?
2. What are some nonpharmacological considerations for treating MEE?
- MEEs can persist for 8 weeks or longer after treatment of AOM
- Recommended for allergic rhinitis:
*Many are allergic to dust mites (an indoor allergen)
- Allergy pillow covers
- Allergy mattresses
- HEPA allergy filters for air conditioners
Transillumination
Turn off the light (darkened room)
Place a bright light source directly on the surface of the cheek (on maxillary sinus). Instruct patient to open mouth and look at the roof of the mouth (hard palate) for a round glow of light). Compare both sides.
The “affected” sinus has no glow or duller glow compared with the normal sinus. For frontal sinusitis, place the light under the supraorbital ridge at the medial aspect and compare glow of light
cacosmia
Bad odor in nose
Otitis Media with Effusion
1. Definition
2. Clinical Presentation
3. Treatment
Serous Otitis Media
1. May follow AOM; can also be caused by chronic allergic rhinitis. sterile serous fluid is trapped inside middle ear.
- C/o ear pressure
- popping noises
- muffled hearing in affected ear
- C/o ear pressure
PE/Objective findings:
- TM may bulge or retract. Tympanogram abnormal (flat line or no peak)
- TM should not be red
- A fluid level and/or bubbles may be visible inside the TM
- Oral decongestants (pseudoephedrine or phenylalanine)
- Steroid nasal spray BID - TID x few weeks or saline nasal spray (Ocean spray) PRN
- Allergic rhinitis: Steroid nasal sprays with long-acting oral antihistamine (Zyrtec)
- Oral decongestants (pseudoephedrine or phenylalanine)
Otitis Externa (Swimmer’s Ear)
1. Definition
2. Common pathogens
3. Clinical Presentation
4. Treatment
- Bacterial infection of the skin of the external ear canal (rarely fungal). More common during warm and humid weather (e.g, summer)
- Pseudomonas aeruginosa (gram-)
S. aureus (gram+) - External ear pain
- Swelling
- discharge
- pruritis
- hearing loss (if ear canal is blocked with pus)
- hx of recent activities that involve swimming or getting ears wet
- External ear pain
PE/Objective findings:
- Ear pain with manipulation of the external ear or tragus
- Purulent green discharge
- Erythematous and swollen ear canal that is very tender to the touch
- Polymyxin B-neomycin-hydrocortisone (Cortisporin Otic) suspension 4 gtt QID x 7 days; Ofloxacin otic or ciprofloxacin (Cipro HC) otic ear drops BID x 7days
- Immunocompromised (e.g., poorly controlled diabetes, chemotherapy, immunosuppressive drugs, AIDs) → topical antibiotics + systemic/oral abx such as ciprofloxacin or ofloxacin BID x 7-10 days
- Keep ears out of water during treatment. If patient has recurrent episodes, prophylaxis is Otic Deomoboro (boric) or alcohol and vinegar (VoSol)
- Polymyxin B-neomycin-hydrocortisone (Cortisporin Otic) suspension 4 gtt QID x 7 days; Ofloxacin otic or ciprofloxacin (Cipro HC) otic ear drops BID x 7days
Infectious Mononucleosis
1. Definition
2. Clinical Presentation + Classic triad
3. Objective Findings
4. Treatment
5. Complications
- Infection by the EBC (herpesvirus family). Peak ages of acute infection is US are 15-24 years. After acute infection, EBC lies latent in oropharyngeal; can become reactivated and cause symptoms; virus is hed mainly through saliva
- Classic triad: fever, pharyngitis, lymphadenopathy (>50% cases)
- hx sore throat (usually teen)
- enlarged posterior cervical nodes
- symmetric lymphadenopahty
- fatigue (several weeks; can last weeks to months)
- Tonsillar exudate with color of exudate ranging from white to gray-green
- May have abdominal pain d/t hepatomegaly and/or splenomegaly
- Hx of intimate kissing
- Classic triad: fever, pharyngitis, lymphadenopathy (>50% cases)
- CBC: atypical lymphocytes and lymphocytosis (>50%); repeat CBC until resolves
- LFTs: abnormal for 80% for several weeks
- Heterophile antibody test (Monospot): Positive (80-90% of adults)
- Nodes: Large cervical nodes that may be tender to palpation
- Pharynx: Erythematous
- Tonsils: Inflamed, sometimes with cryptic exudate (off-white color)
- Hepatomegaly (20%) and splenomegaly (50%): avoid vigorous palpation of abdomen until resolves
- Skin: Occasionally a generalized red maculopapular rash is present
- CBC: atypical lymphocytes and lymphocytosis (>50%); repeat CBC until resolves
- Acute states: - Limit physical activity (exercise, contact sports, weightlifting) for 4 weeks to ↓ risk of splenic rupture
- Order abdominal US if splenomegaly/hepatomegaly is present, esp if pt is athlete or physically active, or athletic coach
- Repeat abdominal US in 4-6 weeks if abnormal to document resolution
- Treat symptoms
- Avoid using amoxicillin if patient has “strep” throat (drug rash from 70-90%).
- Avoid close contact; kissing, sharing toothbrush, fork, spoon, or knife; and using the same glass - Splenomegaly/splenic rupture: rare but serious
- If airway obstruction, hospitalize and give high-dose steroid to ↓ swelling
- Neuro complications: GBS, aseptic meningitis, optic neuritis, etc
- Blood dyscrasias (atypical lymphocytes): Repeat CBC until lymphocytes are normalized
- Splenomegaly/splenic rupture: rare but serious
Vertigo
1. Types
2. Clinical Presentation
3. Important assessment components
4. Treatment
- Two types:
- Peripheral vertigo: caused by disorders of the vestibular apparatus of inner ear or inflammation of vestibular nerve (CN VIII)
- Central vertigo: associated with serious to life-threatening conditions such as stroke (Cerebellar or brainstem bleeding), MS, infections, or tumor
- room spinning sensation
- rotational movement
- may be associated with nystagmus
- Person has vertigo or other types of dizziness such as near syncope, hypoglycemia, orthostatic hypotension, cerebrovascular disease, and arrhythmias
- room spinning sensation
- Antivertigo medications (meclizine)
* Be careful with geriatric patients as some of these meds are antihistamines and may cause dizziness and sedation (↑ risk of falls)
- Antivertigo medications (meclizine)
Vertigo: Dix-Hallpile Maneuver
GOLD STANDARD clinical test for benign paroxysmal positional vertigo disease (BPPV)
- Positive finding: rotary nystagmus with latency of limited duration
Direction: Assuming affected ear is on the right, with the patient sitting on the exam table (facing forward, with eyes open), turn the patient’s head 45º to the right. While standing behind the pt and supporting the pt’s head with one hand, rapidly move head from an upright to “head hanging” position, where the patient’s head is at least 10º below horizontal.
To achieve complete dependency of pt’s head during maneuver, pt should be positioned in such a way that their shoulders will meet the head of the table when they are reclined.
Vertigo: Epley Maneuver
This maneuver can be done in the clinic or at home by the pt.
Direction: Assuming affected ear is on the right, with the patient sitting on the exam table (facing forward, with eyes open), turn the patient’s head 45º to the right. While standing behind the pt and supporting the pt’s head with one hand, rapidly move head from an upright to “head hanging” position, where the patient’s head is at least 10º below horizontal.
Then, maintain for 30 seconds or until any nystagmus and vertiginous symptoms subsite. Reposition hands on either side of pt’s head and turn pt’s head 90 º away from the affected ear, placing it at 45º toward opposite shoulder. Ask pt to roll onto their shoulder on unaffected side (left). While pt rolls onto their shoulder, maintain pt’s head at its 45º oriented on shoulder. As pt rolls, their face will be directed to floor. Pt should keep this position until nystagmus/vertigo subside or 30 seconds have passed then sit up.
Differential diagnoses for vertigo
- Meniere’s disease
- BPPV
- Acoustic neuroma (vestibular schwannoma)
- Labyrinthitis
- Cerebellar infarction or hemorrhage (cerebellar stroke)
Vertigo Ddx: Meniere’s disease
1. Characteristics
2. Assessment
3. Treatment
- Tirad of recurrent vertigo, tinnitus, and unilateral hearing loss that is chronic
- may be nausea/vomiting with episodes
- usually affects only one ear, but in 15% will involve both
- no associated neuro symptoms
2 & 3. - Initial tx: lifestyle changes
- Salt restriction (203 g/day)
- avoid MSG and nicotine
- minimize intake of caffeine, alcohol (one serving/day)
- Vestibular suppressant PRN
- nausea/vomit mediations PRN
- Persistant attacks → Refer to ENT; consider vestibular rehabilitation
Vertigo Ddx: BPPV
1. Characteristics
2. Assessment
3. Treatment
- Abrupt onset with brief episodes of vertigo that last <1 min induced by sudden head movements and positions
- Due to calcium carbonate crystal s)otoconia) trapped in semicircular canals
- RF: head trauma, high intensity aerobics, bike riding in rough trails; most common cause of vertigo in US; ages 50-70
- Abrupt onset with brief episodes of vertigo that last <1 min induced by sudden head movements and positions
- GOLD STANDARD: Dix-Hallpile maneuver
- Epley maneuver/modified Epley done in clinic or at home - Meclizine PO Q4-8 H (vertigo)
- Prochlorperazine IM, rectal suppository, or PO (nausea/vomiting)
- Avoid sleeping on side of affected ear for several days
Vertigo Ddx: Acoustic neuroma (vestibular schwannoma)
1. Characteristics
2. Assessment
3. Treatment
- CN VIII (vestibular portion) tumor; Schwann cell-derived tumors; Symptoms are slow and insidious.
- Two major symptoms:
- chronic hearing loss (avg duration 4 years)_
- Chronic tinnitus
- If trigeminal nerve is compressed, symptoms are facial numbness and pain
→ leads to asymmetric sensorineural hearing loss
- CN VIII (vestibular portion) tumor; Schwann cell-derived tumors; Symptoms are slow and insidious.
- Weber and Rinne tests; hearing testing CN testing
- Refer to ENT; surgical removal, radiation
Vertigo Ddx: Labyrinthitis
1. Characteristics
2. Assessment
3. Treatment
- Sudden onset of severe vertigo
- Accompanied by sensorineural hearing loss and tinnitus
- Last from hours to days
- Due to inflammation of vestibular nerve caused by viral or bacterial infection
2 & 3. - Vestibular suppressants PRN for severe attacks of vertigo only. If mild symptoms, do not use, since delay recovery
- If suspect bacterial infection → broad-spectrum antibiotic and refer to ENT
Vertigo Ddx: Cerebellar infarction or hemorrhage (cerebellar stroke)
1. Characteristics
2. Assessment
3. Treatment
- Sudden onset of severe headache
- vertigo
- nausea/vomiting
- motor deficits
- impaired gait
- imbalance
- impaired control arm/leg movements
- slurred speech (dysarthria)
- <10% of strokes, higher mortality
- Sudden onset of severe headache
- GOLD STANDARD: MRI for diagnosing infarction on brain
- Call 911!
dysarthria
slurred speech
