HEENT Flashcards
Monocular vs Binocular vs Cerebral/Polyopial diplopia?
Monocular - diplopia when good eye is covered
Binocular - no diplopia when either eye covered
Cerebral - diplopia no matter what eye is covered
Causes of monocular diplopia (6)
- Dry eyes
- Corneal irregularity
- Cataract
- Lens dislocation
- Retinal wrinkles
- Conversion disorder
Differential for Binocular Diplopia:
- Structural (3)
- Orbital myositis (8)
- Isolated cranial nerve palsy (6)
- Multiple nerve palsy (2)
- Neuroaxial involving the brainstem and cranial nerves (10)
- NMSK disorder (2)
- Trauma
Infection
Craniofacial mass - Thyroid eye disease
Wegener granulomatosis
GCA
SLE
RA
Dermatomyositis
Sarcoidosis
Idiopathic orbital infl syndrome - Hypertensive vasculopathy
Idiopathic intracranial HTN
Diabetic vasculopathy
MS
Compression
Trauma - Cavernous sinus infection
Orbital plex syndrome - MS
Tumor
Stroke
Hemorrhage
Bilateral artery thrombosis
Vertebral artery dissection
Ophtalmoplegic migraine
Infectious ie basilar meningioe
Autoimmune ie Guillan Barre
Metabolic ie Wernicke - Myasthenia gravis
Botulism
Cranial nerve 3 palsy:
- Corresponding muscle?
- Symptoms?
- Exam finding?
- Superior, Medial, Inferior rectii muscle + Levator Palpebrae + Inferior oblique + ciliary and constrictor muscle (pupil)
- Multidirectional, horizontal and vertical diplopia + eyelid droop (excluding lateral gaze)
- Ptosis + pupil dilation + eye down and out
Cranial nerve 4 palsy:
- Corresponding muscle?
- Symptoms?
- Exam finding?
- Superior oblique
- Diplopia that worsens on looking down and towards the nose
- Extorsion on downward gaze
Cranial nerve 6 palsy:
- Corresponding muscle?
- Symptoms?
- Exam finding?
- Lateral rectus muscle
- Horizontal diplopia that worsens on lateral gaze of effected eye
- Lateral gaze palsy
4 Critical causes of diplopia
- Aneurism
- Basilar artery thrombosis
- Basilar meningitis
- Botulism
4 Emergent causes of diplopia
- Vertebral artery dissection
- Cavernous sinus process
- Werneckie encephalopathy
- Myasthania Gravis
8 urgent causes of diplopia
- Brainstem tumor
- Orbital myositis, pseudotumor
- Orbital apex mass
- Ophthalmoplegic migraine
- Miller-Fisher syndrome
- MS
- Ischemic neuropathy
- Grave’s disease
- Vital sign of the eye?
- Who can skip it?
- Visual acuity exam
- Those with acid, base or other toxins in eye
- Significant trauma
- Sudden complete vision loss
A test that can detect if there is decreased visual acuity due to abnormal refraction?
Pinhole testing
7 signs and symptoms associated with serious diagnosis in patients with red and painful eye? (Rosen’s Box)
- Severe ocular pain
- Proptosis
- Persistant blurred vision
- Corneal defect or opacity
- Pupil unreactive to light
- Reduced ocular light reflection
- Ciliary flush
What is a common, benign diagnosis of red eye without pain?
Subconjunctival hemorrhage
Who does not need antibiotics for bacterial conjunctivitis? (4)
Mild case, not wearing contact lens, no traumatic injury, not immunocompromised
Components of a complete eye exam? (VVEEPP + 2 more) (Rosen’s box)
Visual acuity
Visual field testing
External exam
Extraocular muscle movement
Pupillary eval
Pressure
+ Slit lamp
+ Fundoscopy for those w vision loss or vision change
corneal abrasion sign on fluorescene exam?
Seidel’s sign
7 causes of not seeing a red light reflex? (Box)
- Opacification of corneas
- Hyphema
- Cataract
- Blood in the vitreous or posterior eye wall
- Retinal detachment
- Intraocular mass
- Extremely miotic pupil
Acid vs Base caustic injury:
- What do they do to the eye?
- How much irrigation for each until pH = 7?
- Complications of liquefactive necrosis?
Acid: Coagulation necrosis, at least 2L and 20min
Base: Liquefactive necrosis; at least 4L and 40min ; Complications = cataract formation, damage to ciliary body, irreversible damage within 5-15 min of exposure
Orbital compartment syndrome:
- Causes?
- IOP > x?
- Treatment?
- Retrobulbar hematoma/emphasyma/abscess
- > 20 abnormal; >30 may necessitate lateral canthotomy
- Lateral canthotamy
Penetrating globe injury:
- S&S (4)
- Tx (3)
- Localized redness
Treatdrop pupil
Blood in anterior chamber
loss of red reflex - Prevent from further injury (antiemetics, analgesics)
Abx - systemic like Cefazolin or Vanco IV
Tetanus
Emergent ophthalmology consult
- IN RSI, avoid succinylcholine bc might elevate IOP (weak evidence)
Hyphema
- S&S
- What is the general treatment?
- Longterm complications? (2)
- Who should get admitted for hyphema treatment? (5)
- Pain
Decreased VA
Blood in anterior chamber
Dilated/fixed pupil if trauma - First rule out open globe
IOP if no globe rupture
If > 30
If > 20, may use cycloplegic to prevent iris motion
Also: Bedrest/ head of the bed elevated (limited evidence)
Gentle ambulation
Eye patch
Ophtho followup asap (next day recommended)
3.
Raised IOP
Permanent corneal damage
4.
1. Lost to follow up
2. Poor compliance
3. Hyphema > 50%
4. anticoagulants
5. Sickle cell traits
Subconjunctival hemorrhage
- What is it?
- What to rule out?
- Treatment?
- Blood beneath conjunctival membrane
- Rule out coagulopathy or thrombocytopenia
- None
Corneal abrasion
- Treatment
- Who gets abx? (4)
- Complications? (4)
- Antibiotic prophylaxis with polymyxin-B/trimethoprim solution 1 drop every 3 h while awake and erythromycin ointment while sleeping.
- Contact lens wearers
Contaminated object
Deep object
IC patient - Keratitis
Corneal ulcer
Traumatic iritis
Recurrent erosion syndrome
Corneal ulcer
- S&S (4)
- Etiology (2)
- Treatment (5)
- Complications (2)
- Pain
FB sensation
White corneal defect
Fluorescene uptake - Contact lens
Post infection - No contact lens
Cycloplegics
Topical abx hourly
PO analgesics
Urgent ophthalmology FU - Hypopion
Perforation
Traumatic mydriasis
- What is it?
- Tx?
- Nonreactive dilated pupil NYD and no other eye abnormalities after trauma
- None if all normal
Inflammatory pseudotumor
- S&S (9)
- Treatment? (3)
- Ophtho follow up?
- Nonspecific idiopathic Retrobulbar infl with:
- eyelid swelling
- palpebral injection of conjunctiva
- chemosis
- proptosis
- blurred vision
- painful ocular mobility
- binocular diplopia
- optic disk edema
- venous engorgement of retina - Measure IOP
Evaluate DM, infection, vasculitis
CT orbit - IOP > 20 may be surgical emergency
If IOP < 20 and all normal, may dc w steroid after discussing with ophthalmology
Orbital cellulitis
- S&S
- Tx (5)
- Ophtho follow up?
- Complications (5)
- Eyelid swelling, redness, warm
Tender skin overlying bone
Palpebral injection
Chemosis
+ systemic unwell
blurred vision
proptosis
painful ocular movement
binocular diplopia
edema of optic disk
venous engorgement of retina
- Measure IOP
- Start ABX including Vanco + Cftx
- Blood cultures, BW
- Axial CT
- Consider LP
- All get admitted!!!
- Vision loss
CNS infection
Abscess
Osteomyelitis
Cavernous sinus thrombosis
Periorbital cellulitis
- S&S
- Tx
- Ophtho follow up?
- Eyelid swelling, redness, warm
Tender skin overlying bone
Palpebral injection
Chemosis - Rule out orbital cellulitis
PO ABX - If concerns for orbital cellulitis
Dacrocystitis/Dacryoadenitis
- S&S
- Tx
- Ophtho follow up?
- Eye tearing and infl of lacrimal puncture
- Abx (amox/clav)
Warm compress
Rule out orbital cellulitis, pus, - No if no concerns
Orbital tumor
- S&S
- Tx
- Ophtho follow up?
- Blurred vision
Binocular diplopia
Painful/limited mobility
Proptosis - Measure IOP
CT axial brain and orbital
3.
As required
Hordeolum (Stye)
- S&S
- Tx
- Ophtho follow up?
- Abscess on lid margin, can be internal or external
- External = warm compress x 4/d
Internal = Abx (Amox/clav) + warm compress - If tx failure after 2 weeks
Blepharitis
- S&S
- Tx
- Ophtho follow up?
1.
Inflammation of eyelid margins
Associated with crusts on awakening
FB sensation
Tearing
- Warm compress
Dry eye drops - If tx failure after 2 weeks
Chalazion
- S&S
- Tx
- Ophtho follow up?
1.
Infl of meibomian gland
Subcutaneous nodule within the eyelid
- Warm compress x 4/day
- No unless tx failure for 2 weeks
Narrow angle (ie acute angle-closure) glaucoma
- S&S
- Tx (meds in another flash card)
- Ophtho follow up?
- Fundoscopy findings?
1.
occurs when fluid cannot drain from the eye as it should, causing it to suddenly build up behind the iris
Severe unilateral eye pain, blurred vision and “halos” around the eye
Maybe: frontal headache, nausea, and vomiting; Puupil maybe fixed at midsize,
Limbal injection of conjunctiva
Symptoms may be precipitated in low light because pupils dilate causing pain
- EMERGENT ophthalmology consult
Elevate head of the bed
Patient in well lit room
Recheck IOP hourly
Medications in ED if IOP >30 (another flashcard) - Any IOP > 20 yes
- “Cupped” optic nerve
Poor vascular supply
Glaucoma medications
Decrease production of aqueous humor:
* Timolol 0.5% 1 drop (beta blocker)
* Acetazolamide (carbonic anhydride inhibitor)
* Apraclonidine 1% 1 drop
* Dorzolamide 2% 1 drops or
if sickle cell disease or trait, then methazolamide 50 mg PO
Decrease inflammation:
* Prednisolone 1% 1 drop every 15 min four times
Constrict pupil/facilitate vitrous humour outflow:
* Pilocarpine 1%–2% 1 drop
Establish osmotic gradient/ absorb fluid:
* Mannitol 2 g/kg IV
Keratitis (abrasion) ie corneal abrasion!
- S&S
- Tx
- Ophtho follow up?
- Pain
FB sensation
Fluorescene pooling
If neglected may ulcer - Fluorescene exam
Rule out corneal penetration/siedel sign
Anesthesize eye
Inspect eye for FB - Rule out globe rupture
Topical Abx/Anesthetics
NSAIDs
Keratitis (herpetic)
- S&S
- Tx
- Ophtho follow up?
- Same signs as other keratitis + dendritic pattern
- Topical anesthetic
Acyclovir 5% ointment (5drops x day for 1 week + taper for 2 weeks)
Trifluridine 1% solution (1 drop q2h x 7 days + taper for 2 weeks)
Varicella-zoster and CMV no antivirals if immunocompetent. - Yes esp if needing debridement or culture before abx
Scleritis
- S&S
- Tx
- Etiology? (7)
1.
Severe inc eye pain, usually unilateral
Decreasing vision
Phototopia
Tearing
Pain w eye motion
- PO NSAIDs
Discuss with ophthalmology about PO/Topical steroids - RA
Vasculitis
Gout
HSV/EBV
Malignancy
HIV/TB
Surgery
Anterior Uveitis & Hypopyon
- S&S
- Tx
- Ophtho follow up?
Uveitis = inflammation of uvea of eye, which includes iris, ciliary body, choroid.
1.
Pain
Photophobia
Tearing
Limbal injection of conjunctiva
Hypopyon is layering of white cells (pus) in anterior chamber
- IOP measurement.
Otherwise okay to dilate pupil with 2 drops of cyclopentolate 1%
3.
prednisolone acetate 1% discuss with ophthalmology
prob admit if hypopyon
Endophthalmitis
- S&S
- Tx
- Ophtho follow up?
- Causes?
Progressively increasing eye pain & decreasing vision
Diminished red reflex
Cells/ flare (possibly hypopyon) in anterior chamber
Chemosis
Eyelid swelling
- Empirical parenteral antibiotic (vancomycin and ceftazidime) to cover Bacillus, enterococcus, and Staphylococcus
Ciprofloxacin or levofloxacin if above contraindictated - Always admit
Intravitreal abx - Penetrating trauma
FB
Surgery
Keratoconjunctivitis
- S&S
- Tx
- Ophtho follow up?
1.
Conjunctivitis with subepithelial infiltrates in cornea
Pain
Decreased vision
Possibly halos
- Treat conjunctivitis
- Ask about prednisone
FU in 2-3 days
Episcleritis
- S&S
- Tx
- Ophtho follow up?
- Focal redness
Pain (but less severe than scleritis)
Pain with eye movement - Artificial tears
PO NSAIDs - If no improvement in 2 weeks
Inflamed pingueceula
- S&S
- Tx
- Ophtho follow up?
- Infl of soft yellow patches in temporal and nasal edges of limbal margin
2.
Decrease inflammation w naphazoline or ketorolac drops
- Only if no improvement in 2 weeks
Inflamed pterygium
- S&S
- Tx
- Ophtho follow up?
Inflammation of firmer white nodules extending from limbal conjunctiva onto cornea
^ all rosens had
Bacterial conjunctivitis
- S&S
- Tx
- Ophtho follow up?
- Purulent discharge usually unilateral
Eyelid infl
Chemosis
Maybe subconjunctival hemorrhage - Polymyxin-B/trimethoprim in infants and children, bc more Staphylococcus
Topical sulfacetamide or gentamicin in most adult
Use topical fluoroquinolone if Pseudomonas
3,
All infants
All with sepsis
Chlamydia conjunctivitis
- S&S
- Tx
- Ophtho follow up?
1.
Bilateral palpebral injection of conjunctiva
2.
Empirical PO azithromycin for Chlamydia
Consider ceftriaxone for gonorrhoea
- Not if uncomplicated - 3 days of azithro is fine
If infant or complicated yes
Contact Dermatoconjunctivitis
- S&S
- Tx
- Ophtho follow up?
- Redness
Swelling
2.
Irrigate with tapa water/ normal saline
naphazoline drops to dec inf
- Only in 2 weeks if not better
Toxic Conjunctivitis
- S&S
- Tx
- Ophtho follow up?
1.
Diffuse conjunctivitis
Chemisis
Lip edema
2.
Irrigate with tapa water/ normal saline
naphazoline drops to dec inf
- Only in 2 weeks if not better
Allergic conjunctivitis
- S&S
- Tx
- Ophtho follow up?
- ..
- Antihistamines consider topical
naphazoline drops - Only in 2 weeks if not better
Viral conjunctivitis
- S&S
- Tx
- Ophtho follow up?
- ..
- Decrease irritation with artificial tears, naphazoline, or ketorolac drops.
- Yes for neonates
Ask about pregnant mothers, infants, and IC pts Education
Signs of open globe injury (6)
Loss of anterior chamber depth
Blood in anterior chamber
Prolapsed iris
Irregular/teardrop iris
360 degree subconjunctival hemorrhage
Positive Seidel’s test on fluorescein
*IF any of the above, stop the investigations immediately and ophtho consult STAT
Who gets anti-pseudomonas abx for eyes?
What are the abx?
- Contact wearers
- Deep or contaminated objects
- IC patients
Examples of abx:
1. Tobramyecin
2. Ciprofloxacin
3. Moxifloxacin
4. Gentamycin
Causes of RAPD (7)
- Optic neuritis
- Optic tumors
- CRAO
- CRVO
- Retinal detachment
- Retinal infections
- Severe glaucoma
IOP lowering agents?
Procedure in ED to lower IOP?
- Carbonic anhydrase inhibitor
- Topical beta blocker
- Alpha agonist
- IV Mannitol
Procedure = Lateral canthotamy
Hyphema vs Hypopyon
Hyphema = blood in anterior chamber
Hypopion = pus in anterior chamber, associated with keratitis or endophthalmitis
Clinical exam to differentiate “anterior uveitis” to “scleritis”
Anterior uveitis will lead to consensual phototopia!
Normal Angle VS Close angle glaucoma differences:
- Lens?
- Anterior chamber?
- Eye pain?
- IOP?
Normal Angle:
1. Lens normal
2. Anterior chamber normal
3. Minimal eye pain
4. IOP mildly elevated
Close angle:
1. Lens bulging
2. AC tense
3. Eye painful (esp in low light setting)
4. IOP elevated > 30 usually
Glaucoma risk factors IMPORTANT!! (6)
- Age 40-50
- F > M
- Positive fmhx
- Hyperopia (far sighted)
- Thin cornea
- Medication use:
- Anticholingergics
- Antihistamines
- Salbutamol
- Septra
- Stimulants
- SSRIs
- TCA
Signs of glaucoma?
At least 3 of:
IOP > 21
Decreased VA
Ciliary flush
Dilated non reactive pupil
Shallow anterior chamber
Corneal edema/cloudiness
Symptoms of glaucoma?
At least 2 of:
Occular pain
Blurred vision
Halos
N/V
DDX elevated IOP (7)
Open angle glaucoma
Acute close angle glaucoma
Retrobulbular hematoma
Chemical burns
Ketamine
TCAs
Atropine
DDX Painless vision loss? (5)
CRAO
CRVO
Retinal detachment
Vitrous detachment
Vitrous hemorrhage
DDX Painful vision loss? (4)
Optic neuritis
Glaucoma
Traumatic
Inflammatory/Infectious
Ocular trauma delayed complications? (4)
Glaucoma
Retinal detachment
Corneal Ulcer
Endophthalmitis
Retinal detachment
- S&S
- Risk factors
- Treatment
- Flashes and floaters
Curtain like loss of vision
Decreased VA
Painless
2.
Trauma
Surgery
PVD
Diabetic retinopathy
CRVO
Vasculitis
Eclampsia
Neoplasm
3.
Urgent referral to ophthalmology ; no ED tx
Retrobulbar hemorrhage triad?
- Proptosis
- Ophthalmoplegia
- Altered vision
Difference between treatment of HSV vs Herpes Zorster Keratits?
HSV:
TOPICAL antivirals
AVOID steroids bc worsens infection
Topical abx and cycoplegic only if iritis
HZV:
SYSTEMIC antivirals
STEROIDS and topical abx can be used
*Look for Hutchinson’s sign
What is Amaurosis Fugax?
TIA of the eye!
Transient loss of vision of the eye
Central Retinal Artery Occlusion (CRAO)
- Causes?
- Who is at risk?
- Fundoscopy findings?
- Treatment?
- TIA of retinal artery
Occlusion of retinal artery
Inflammatory cause ie temporal arteritis - Ages 50-70
Vascular RFs
Increased IOP RFs (glaucoma, retrobulbar hemorrhage etc) - Cherry red spot
Whitening of the retina - Occular emergency!!!
No good evidence but some include:
- Occular massage
- Carbon
- Hyperbaric O2
- tPA?
- Can just observe
Central Retinal Vein Occlusion (CRVO)
- Causes?
- Risk factors?
- Fundoscopy findings
- Treatment
- Pooling of fluid and blood causing ischemia
- HTN, Hyperlipid, DM, Smoking, Obesity, Glaucoma
- Disk edema, dilated veins, “Blood and Thunder”
- Ophtho consult, very little ED treatment
Optic Neuritis
- S&S
- Risk factors?
- Tx
Inflammatory, demyelination of optic nerve, associated with MS
- Eye pain, vision loss unilateral
Colour loss > VA
Retroorbital headache
painful EOM
+ RAPD - MS
ages 20-50
Caucasian and female dominant - IV STEROIDS!
- Name of teeth
- Numerical?
Central incisor
Lateral incisor
Canine
1st Premolar
2nd Premolar
1st - 3rd Molar
Start at UR (#1) –> UL (#16) –> LL (#17) –> LR (#32)
* Essentially starts at Upper right and goes counterclockwise
Block for single tooth?
Block for multiple teeth?
Supraperiosteal nerve block
Alveolar nerve block
Gingivitis vs Periodontitis vs Pericoronitis
Treatment?
Gingivitis = infl of gum
Periodontitis = infl of gum and surrounding structure of tooth
- can see recession of gum, inc tooth mobility, bone loss, tooth loss
Pericoronitis = infl of gingiva and surrounding soft tissue
Treatment
- Proper oral hygiene
- NSAIDS
- Topical infiltrate
- Smoking cessation
- Dental FU
- Abx if really bad (amox clav, Pen V, clinda, flagyl, Nystatin - ROSENS BOX)
Acute Necrotizing Ulcerative Gingivitis
- What is it?
- Risk factors?
- Name for infection that involves gingiva but also tonsils and pharynx?
- Most severe end of dz name?
- Treatment?
- Polymicrobial bacteria invading tissue and causing pain, bleeding, destruction
- Poor oral hygiene, smoking, DM, IC
- Vincent Angina
- Noma
- Oral ABX , Mouthwash, OMFS for debridement
- 3 causes of gingival hyperplasia?
- Medication classes and risk of gingival hyperplasia (3 classes) ; most common?
- Medications
Poor oral hygiene
Leukemia
2.
Anticonvulsants:
- Phenytoin MOST COMMON
- Valproic acid
- Carbemazapine
Immunosuprassants
- Cyclosporine (2nd most common, common in kids)
Calcium channel blockers:
- Nifedipine
- Amlodapine
- Verapamil
- Diltiazam
- Felodipine
Alveolar Osteitis
- Lay name?
- Cause?
- Treatment?
- Dry socket
- Dislodgement of clot in fossa where root was, exposing bone. Usually after wisdom tooth extraction
- R/o infection
Analgesics (NSAIDs, topical, nerve block)
Iodoform gauze with eugenol
Dentist appointment next day
Infection of maxillary canine root:
- What space will get infected?
- Sign?
- Complication?
- Maxillary canine space
- Flattening of the nasolabial fold
- Cavernous sinus thrombosis
3 spaces in the mandible that can get infected?
When all 3 are infected, what is it called? Feared complication?
Submandibular, sublingual, submental
= Ludwig’s angina ; airway compromise
6 RFs for deep space neck infections?
- Poor oral hygiene/dental infections
- Recurrent pharyngitis
- Sinusitis
- AOM
- IC patient
- IVDU
Teeth injuries:
- Subluxed vs Luxed vs Avulsed?
- Avulsion: Medium to leave tooth in to save periodontal ligaments from dying?
- ED management of Avulsion? abx?
- Tooth #, what solution used to tape back together?
- Subluxed = mobile but in anatomical position
Luxed = out of anatomical position but not fully out .. can be Extrinsic, Intrinsic, Lateral
Avulsed = fully out
- Milk is good, can last 3-8 hours
Hank’s balanced salt solution can last 24h
If nothing else, saliva!
Avoid water bc hypotonic and cells die - Ensure no aspiration –> Dental block –> Hold teeth at crown –> irrigate w NS –> irrigate socket w saline –> re-implement! –> if no immediate dentist FU, use Resin to make splint –> FU within 24/48h + soft diet + abx
Abx adults = doxy x 7d
Abx kids = penicillin x 7 days
- Calcium hydroxide
The Ellis Classification of tooth #:
Class 1 vs II vs III
What solution is used to adhere teeth back together in ED?
Class I - Enamel only
Class II - Enamel + Dentin
Class III - Enamel + Dentin + Pulp
Calcium Hydroxide
*Tooth must be bone dry!
TMJ dislocation:
- What bones in TMJ?
- How does it happen?
- Causes?
- Treatment?
- Temporal bone and mandible bone condyle
- When mandible condyle moves anteriorly (instead of inferiorly)
- Teeth grinding, jaw clenching and open wide mouth , muscle spasms (ie due to seizure or dystonia) and trauma
- Reduce with procedural analgesia
Acute otitis media (AOM) vs Otitis Media with effusion (OME)
AOM - Middle ear effusion with infection
OME - Middle ear effusion w/o infection
2 Criteria to diagnose AOM
- Middle ear effusion
- Infection
2 Criteria to dx chronic AOM?
- > 3 or more in 6 months
- 4 in 1 year
Common AOM pathogens (4)
- S. Pneumoniae
- H. Influenzae
- Catarrhalis
- Group A strep
Also could be viral!
Risk factors for AOM (8)
- Non hispanic white race
- Male
- Daycare
- Parents smoking
- Bottle fed
- Pacifiers
- Family hx of AOMs
- Anatomical variety ie cleft plate
3-intertemportal and 2-intracranial complications of AOM?
Intertemporal
○ Mastoiditis
○ Hearing loss
○ Facial nerve paralysis
Intracranial
○ Meningitis
Abscess
DDX AOM (6)
- FB
- Otitis externa
- Otitis media with effusion
- Trauma
- Mastoiditis
- Referred pain
AOM abx: who gets them? (3)
< 2 years
Bilateral AOM
Otorrhea
Who to consider “watch and wait” for 48-72h for AOM? (7)
- > 6 months
- Healthy
- Unilateral
- Temp < 39
- < 48h of symptoms
- Mild otalgia
- Responsive
AOM Abx:
- First choice + Dose/course?
- If allergic? (1)
- If failure to treatment? (2)
- Who gets 10-day course? (3)
- Amoxicillin 80-90mg/kg/day
2.
2nd/3rd gen cephalosporin
- Amox-clav or Cftx
- < 2 years
Chronic infection
TM perf
*Always abx if perf
* Adults ALWAYS abx cz almost always bacterial
RetroPharyngeal Abscess
- Causes (10)
- Dx: Gold standard + alternatives
- Tx
1 .
Pharyngitis
Tonsillitis
PTA
AOM
Dental infections
FB
Trauma
Ludwig Angina
Oral procedures
Endoscopy
- CT gold standard
XR and US also able - Tazo + Vanco (polymicrobial)
Airway management!
ICU/ENT dispo
Otitis externa:
- Common pathogens (3)
- RFs (4)
- S&S (6)
- Staph aureus
Pseudomonas
Aspergillus - Hot temp
Humidity
Repeated exposure to moisture
Trauma - Ear pain
Ear discharge
Hearing loss
Jaw pain
Tragus/auricle reproduces pain
Lymphadenitis
EOM DDX (6 - 3 inner ear, 3 outer ear)
- AOM
- Otomycosis
- Perichondritis
- Auricular cellulitis
- Skin condition (eczema etc)
- Herpes zoster optics
EOM management
- Mainstay
- Who gets systemic ABX (2)? Which one? how long?
1.
Ciprodex 4 drops BID x 7days
- If extending beyond middle ear, IC patient
Cipro 500mg PO BID x 7 days
Otomycosis
- Pathogens
- S&S
- RFs
- Tx
- Candida, Aspergillus
- Itching but NO PAIN
- Topical climate, DM, IC
- Locacorten Vioform
Perichondritis
- What is it?
- Pathogens?
- Treatment? (3)
- Infection of connective tissue covering cartilage - happens with rubbing hearing aid, piercing, trauma
- Pseudomonas (almost always)
- I&D if collection, Cipro, ENT if severe
Necrotizing (Malignant) External Otitis
- What is it?
- RFs (3)
- S&S (5)
- Dx (1)
- Treatment (3)
- Complications (5)
- OE spread through temporal bone –> osteomyelitis of bones, tissue, face
- DM, IC, Elderly
- Otorrhea, otalgia, headache, Periauricular pain, CN7 probs
- CT head
- Cipro 400mg IV q12h (for 6-8 weeks!) + Tazo if pseudomonas + ENT
- 5-10% mortality
Skull base osteomyelitis
Sigmoid sinus thrombosis
Meningitis
Brain abscess
Mastoiditis
- S&S (6)
- DDX (7)
- Dx
- Tx (3)
- Otalgia
Erythema
Postauricular pain
Protrusion of auricle
Fever
Headache - AOM
OE
Skull #
Malignant OE
Lymphadenopathy
Lymphadenitis
Deep space neck infection - Clinical but also can do CT
- IV Vanco + Ceftriaxone (pseudomonas)
ENT consult
Sudden hearing loss
- DDX (3 outer ear, 2 ME, 5 inner ear)
- Dx
- Tx (3)
- Outer ear:
- Cerumen impaction
- OE
- FB
Middle ear
- AOM
-TM perf
Inner ear
- Meds (amino glycoside, loop diuretics, ASA)
- Barotrauma
- Autoimune
- infection
- Neoplasm - Clinical
MRI if vertigo - Prednisone with taper (within 2 weeks onset of sx if able)
Steroid drop
ENT EMERGENCY!
Tinnitus
- Red flags (4)
- Primary vs Secondary - 1 vs 8 categories
- Pulsatile
Unilateral
Hearing loss
Focal neuro deficits
2.
Primary
- Idiopathic, associated w SNHL (Webbers test), multifactorial
Secondary
- Infectious (Lyme, fungal, viral)
- Metabolic (DM, HDL)
- Neurological
- Otolgic (Manners, AOM)
- Somatic (injury)
- Tox (meds/substance)
- Trauma
- Vascular (bruits, AV malformation, dissection)
Epistaxis anterior, what vessel?
Kiesselbach’s plexus
15 causes of Epistaxis
Anatomical
- Polyps
- FB
Environmental
- Low humidity
- Nasal trauma
- Nose picking
- Irritants
- Cocaine
Diseases
- URTI
- Allergies
- Neoplasm
- Surgery
Bleeding disorder
- Hepatic disease
- Alcoholism
- Vitamin K deficiency
- Folic acid deficiency
6 steps to managing epistaxis
- Blow your nose/clip
- Apply 2% lidocaine with gauze
- Cauterize with silver nitrate UNILATERAL ONLY
- Anterior packing with rhino rocket
- Topical TXA
*If all above fail, prob posterior bleed
* ENT consult can be done to also embolism
Who gets prophylaxis ABX for nose packing? (2)
> 48hours
IC patient
Sialolithiasis
- What is it?
- RFs (6)
- S&S (3)
- DDX (5)
- Dx
- Tx (3)
- Tonsilar stones
- Dehydration
- Diuretic use
- Anticholinergic meds
- Smoking
- Trauma
- Gout
- Pain esp during eating or salivating
- Swelling
- Infection
4.
- Salivary gland pathology
- LN dz
- Granulomatous process
- Soft tissue mass
- Neoplasm
- CT
- Massage, sialogouges, analgesics
Neck masses rule of 80?
in children, 80% benign
in adults, 80% malignant
Neck masses DDX ROSENS BOX (5 categories)
- Inflammatory
○ Adenitis
○ Bacterial
○ Viral
○ Fungal
○ Parasitic
○ Cat scratch dz
○ Tularemia
○ Sialodenitis
○ Thyroditis - Congenital
○ Brachial cleft cyst
○ Dermoid cyst
○ Torticollis
○ Ranula - Masses benign
○ Lipoma, fibroma
○ Salivary gland masses
○ Hemangioma, aneurism - Masses malignant
○ Sarcoma
○ Salivary gland tumor
○ Thyroid tumor
○ Lymphoma
-Mets
GAS pharyngitis complications (12)
Rheumatic fever
Scarlet fever
Abscess
Ludwig’s Angina
AOM
Mastoiditis
Osteomyelitis
Sinusitis
Post strep GN
TSS
Meningitis
Bacteremia
Jones criteria for diagnosing acute rheumatic fever
- Major criteria (5)
- Minor criteria (4)
*JONES FACE
Major (JONES)
- Joints poly arthritis
- Carditis
- Nodules SubQ
- Erythema marginatum
- Sydenham Chorea
Minor (FACE)
- Fever > 38.5
- (Poly)Arthralgia
- CRP > 30 / ESR > 60
- ECG prolonged PR
*2 major
OR
1 major + 2 minor
GAS treatment:
- Mainstay dose?
- If allergic abx dose?
- If anaphylactic? (3)
Amoxicillin 50mg/kg/d x 10d
Cephalexin 20mg/kg PO x 10d
If anaphylactic:
Clinda
Azithro
Clarithromycin
Dysphagia: Oropharyngeal vs Esophageal
Oropharyngeal
- difficulty INITIATING swallow
- occurs RIGHT AWAY
- multiple swallowing attempts
- C pain
- coughing
- choking
- drooling
Esophageal
- difficulty transporting material down
- occurs 2-4s after swallowing
Oropharyngeal dysphagia DDX (10)
NMSK
- Stroke (most common)
- Myopathy
- Myasthania Gravis
- MS
- DM neuropathy
- Botulism
- Tetanus
- Diphtheria
Obstructive
- Tumor
Other
- Dry mouth
Esophageal dysphagia DDX (15)
Dysmotility
- Achalasia
- LES HTN
- Esophageal spasm
- Connective tissue disorder
Mechanical
- Stricture
- Rings
- Webs
- Post-op
- Tumor
- Esophagitis
- GERD
- FB
Extrinsic mechanical
- Goitre
- Aneurism compression
- Zenker’s diverticulum
