HEENT Flashcards

Question

Ocular Foreign Body definition, sx, dx, tx

Answer 1

Any object embedded in or adhering to the conjunctiva or cornea sx Metallic FB 🡪 rust ring Trapped under lid 🡪 corneal abrasions (worsen w/ blinking) dx *slit-lamp exam w/ fluorescein staining w/ cobalt light illumination Globe penetration 🡪 x-ray or CT tx *first 🡪 install topical anesthetic *then 🡪 removal attempt w/ irrigation *can attempt to remove w/ swab after visual Intraocular FB 🡪 immediate surgical removal by ophthalmologist *systemic & topical abx indicated Rust ring 🡪 treat as corneal abrasion *ring will resorb gradually on its own

Answer 2

Angle-closure glaucoma: closure of the anterior angle chamber at the junction of the iris & cornea (iridocorneal angle) physically blocks drainage of aqueous, elevating IOP which damages the optic nerve ➀ Acute angle-closure glaucoma (AACG): sudden angle obstruction causes rapid, acutely-symptomatic, vision-threatening IOP elevation Acute angle-closure glaucoma (AACG): ▪︎S/SXS: sudden onset severe, unilateral ocular pain, blurry vision, halos around lights, HA, N/V ▪︎PE: unilateral conjunctival erythema, cloudy cornea, mid-dilated fixed pupil, eye hard on palpation dx ▪︎tonometry: ⇡ IOP >30mmHg ▪︎slit-lamp/gonioscopy: narrowing/closure of iridocorneal angle tx TX (acute): emergency ophthalmology consult, place patient supine ➀ Topical drops: ▪︎pilocarpine (cholinergic/miotic) + ▪︎apraclonidine (⍺2 agonist) + ▪︎timolol (BB) plus ➁ PO acetazolamide (CAI) Definitive: laser peripheral iridotomy (LPI) within 24-48h after attack resolution

Answer 3

Vestibular Neuritis: inflammation of the vestibular portion of CN 8 Labyrinthitis: inflammation of the vestibular & cochlear portion of CN 8 *Etiologies: idiopathic – may be associated w/ viral or post-viral inflammation sx Vestibular sxs (both): continuous peripheral vertigo, dizziness, N/V, gait disturbances *nystagmus – usually horizontal & rotary Cochlear sxs (labyrinthitis only): unilateral hearing loss, tinnitus dx: clinical tx: Glucocorticoids first line

Answer 4

acute inflammatory demyelination of the optic nerve sx *painful loss of vision *decrease in color vision (desaturation) *visual field defects (scotoma – blind spot) over hrs-days *unilateral PE: *ocular pain worse w/ eye movement *Marcus-Gunn pupil: eye dilates when light enters dx Fundoscopy: optic disc swelling/blurring (papillitis) tx IV methylprednisolone

Answer 5

Infection of the orbit (fat & ocular muscles) posterior to the orbital system Polymicrobial: S. aureus, streptococci, GABHS, H. flu sx *ocular pain esp. w/ eye movements *ophthalmoplegia (extraocular muscle weakness) *proptosis (bulging) *eyelid edema & erythema dx: clinical CT – confirmatory tx: ADMIT + IV abx (vancomycin + ceftriaxone/cefotaxim

Answer 6

Abscess between the palatine tonsil & the pharyngeal muscles resulting from a complication of tonsillitis or pharyngitis – MC in adolescent & young adults 15-30yrs Dysphagia, severe unilateral pharyngitis, high fever Muffled “hot potato” voice, drooling, trismus PE: *swollen or fluctuant tonsil causing uvula deviation to the contralateral side *bulging of the posterior soft palate *anterior cervical LAD dx Primarily clinical; U/S CT imaging of choice to differentiate between abscess and cellulitis tx Drainage (aspiration or I&D) + abx *drainage: needle aspiration preferred *abx: PO Augmentin, clindamycin Tonsillectomy – reserved for pts who fail to respond to drainage, complications, recurrent, or severe

Answer 7

*deep neck space infection located behind the posterior pharyngeal wall *MC in children 2-4yrs sx Neck: *torticollis (unwilling to move the neck secondary to pain & spasms) *neck stiffness esp. w/ extension *fever, drooling, dysphagia, odynophagia, chest pain, trismus *muffled “hot potato” voice PE: *midline or unilateral posterior pharyngeal wall edema (MC) *anterior cervical LAD, lateral neck mass or swelling dx Lateral neck x-ray: *low suspicion *increased prevertebral space >50% of the width of adjacent vertebral body CT w/ contrast *preferred if high suspicion tx *surgical incision & drainage w/ abx for large & mature abscesses in the OR -ampicillin-sulbactam or clindamycin *abscess <2.5cm2 may be observed for 24-48hrs w/ antibiotic therapy

Answer 8

Rhegmatogenous (MC): retinal tears cause fluid to seep into subretinal space ▪︎RF: prior eye surgery, posterior vitreous detachment, myopia Non-Rhegmatogenous: ➀ Tractional: formation of vitreoretinal bands ▪︎RF: proliferative diabetic retinopathy, sickle cell ➁ Exudative: subretinal fluid accumulation ▪︎RF: HTN, central serous retinopathy

Answer 9

Prodromal: floaters, flashes of light (photopsia) S/SXS: sudden onset unilateral, painless visual loss, “curtain coming down” ⊕relative afferent pupillary defect (RAPD), also called Marcus Gunn pupil » defect in consensual light reflex i.e., affected eye constricts less Fundoscopy: retinal tear (dark red), detached tissue floats freely/moves w/ eye movements ⊕Shafer’s sign: pigment cells in vitreous tx TX: keep patient supine w/ head turned towards side of detachment, emergency ophthalmology consult ▪︎laser photocoagulation, cryoretinopexy

Answer 10

CRAO: retinal artery thrombus or embolus causing ischemia ▪︎onset >60yo, more common in males MCC: embolus resulting from carotid artery atherosclerosis ▪︎cardiogenic emboli (e.g., AFIB), temporal arteritis (rare) S/SXS: sudden onset unilateral, painless vision loss; may be preceded by amaurosis fugax ⊕RAPD Fundoscopy: pale, opaque fundus (retina) w/ cherry-red spot (fovea/macula); attenuated arteries (boxcar appearance) TX: ⇣ IOP; immediate TX indicated if onset within 24h* ▪︎ocular massage, anterior chamber paracentesis ▪︎ocular hypotensive drugs (timolol 0.5%, acetazolamide) ▪︎catheterization, thrombolytics **irreversible retinal damage after 90m

Answer 11

CRVO: non-ischemic (venous stasis retinopathy) or ischemic (hemorrhagic retinopathy) vein occlusion causing ischemia ▪︎onset >80yo, exact cause known SXS: sudden onset unilateral, painless vision loss; ⊕RAPD Fundoscopy: blood & thunder retina (i.e., dilated, tortuous veins; hemorrhages; cotton wool spots) ▪︎macular edema, papilledema (optic disc swelling) DX: fluorescein angiography (differentiates ischemic vs non-ischemic) ▪︎optical coherence tomography: determines degree of macular edema & its response to TX TX: panretinal photocoagulation (minimizes neovascularization) Macular edema: intravitreal anti-VEGF injection

Answer 12

Infection due to EBV characterized by fever, LAD, & tonsillar pharyngitis PATHO: EBV infects B cells Transmission: saliva (known as the kissing disease) esp. ages 15-25 sx *fever, LAD (esp. posterior cervical) *tonsillar pharyngitis (may be exudative) +/- petechiae on hard palate +/- fatigue, HA, malaise PE: *splenomegaly *rash – seen in ~5% esp. if given ampicillin dx Heterophile antibody (Monospot) Rapid viral capsid antigen test; ↑ LFTs Peripheral smear: lymphocytosis >5% w/ >10% atypical lymphocytes tx Supportive - rest - analgesics (acetaminophen, NSAIDs) - antipyretics Steroids ONLY if: - airway obstruction d/t LAD - hemolytic anemia - severe thrombocytopenia AVOID TRAUMA & CONTACT SPORTS 3-4WKS IF SPLENOMEGALY TO PREVENT RUPTURE

Answer 13

*blunt trauma to the pinna may cause a subperichondrial hematoma & accumulation of large amounts of blood between the perichondrium & cartilage *this can interrupt the blood supply to the cartilage & render all or part of the pinna a shapeless, reddish-purple mass *avascular necrosis of the cartilage may follow *characteristic “cauliflower ear” of wrestlers/boxers dx Cauliflower ear: clinical appearance + hx of blunt trauma to the auricle tx Cauliflower ear: *immediate referral for I&D by an ENT specialist *PO abx effective against staph (cephalexin 500mg TID) x5d

Answer 14

Collection of blood inside the anterior chamber of the eye (the space between the cornea and the iris); blood may cover most or all of iris/pupil, blocking vision partially or completely; usually painful. ▪︎MCC: trauma S/SXS: visible blood in front of eye, photophobia, pain, blurry/clouded vision dx: clinical tx: monitor IOP, limit activity, eye shield ▪︎cycloplegic drops (cyclopentolate, scopolamine) ▪︎steroid drops (prednisolone, dexamethasone)

Answer 15

Optic nerve (disc) swelling 2° to ⇡ ICP (usually bilateral) S/SXS: HA, N/V *vision is often preserved Fundoscopy: swollen optic disc w/ blurred margins DX: MRI/CT (r/o mass effect) ⇢ LP (⇡ CSF pressure) TX: acetazolamide, treat the underlying cause

Answer 16

MC cause of permanent legal blindness & vision loss in older adults (esp. >75) Types: *dry (atrophic): MC type; progressive (over decades) *wet (neovascular or exudative): more aggressive (within months) sx Bilateral, progressive central vision loss (including detailed & colored vision) *central scotomas *metamorphopsia (strait lines appear bent) *micropsia (objects seem smaller in affected eye) Wet occurs more rapidly & is more severe dx Fundoscopic exam: - dry: drusen bodies – small, round, yellow-white spots on the outer retina (represent local deposits of extracellular material) - wet: new, abnormal vessels that can cause retinal hemorrhaging & scarring Fluorescein staining, Amsler grid tx Dry: *zinc + antioxidant vitamins (C, E) may slow progression but do not reverse changes *amsler grid at home to monitor stability Wet: *intravitreal VEGF inhibitors (bevacizumab) ↓ new, abnormal vessel formation *laser photocoagulation