HEENT Flashcards
Acute Otitis Media definition, sx, dx, tx
Infection of middle ear, temporal bone, & mastoid air cells
*rapid onset + s/sxs of inflammation
Risk Factors: peak age 6-18mo, day care, pacifier or bottle use, second-hand smoke, not being breastfed
4 MC bugs: S. pneumoniae (MC), H. flu, M. catarrhalis
PATHO: MC preceded by viral URI, leading to blockage of the Eustachian tube
sx
Fever, otalgia (ear pain), ear tugging in infants, stuffiness, conductive hearing loss
TM rupture: relief of pain + otorrhea (heals 1-2d)
PE:
*bulging & erythematous TM w/ effusion, loss of landmarks
Acute: <3wks, chronic: >3mo
dx
Pneumatic otoscopy: ↓ TM mobility (most sensitive)
Tympanocentesis for a sample of fluid for culture – definitive (for recurrent cases)
tx
TOC: amoxicillin 80-90mg/kg/d x10-14d
*second line: Augmentin, cefuroxime, cefdinir, cefpodoxime
*PCN allergy: azithromycin, clarithromycin
Severe/recurrent: myringotomy (surgical drainage) w/ tympanostomy tube insertion
*3x/6mo or 4x/12mo
Recurrent: workup for iron-deficiency anemia
Otitis Externa definition, sx, dx, tx
Inflammation of the external auditory canal
Risk Factors:
*water immersion aka “swimmer’s ear” – rise in pH allows bacterial overgrowth
*local mechanical trauma (use of Q-tips), age 7-12, aberrant ear wax
Etiologies: pseudomonas aeruginosa MC
*staph aureus & epidermis, GABHS, proteus, anaerobes, aspergillus, fungi
sx
Ear pain, pruritis in the ear canal (may have recent hx of swimming)
Auricular discharge, ear pressure or fullness, hearing loss
PE: pain on traction of the ear canal or tragus, purulent auricular discharge
dx
Clinical + otoscopy: edema of external auditory canal w/ erythema, debris, or discharge
Rinne: BC > AC
tx
Protect ear from moisture (isopropyl alc & acetic acid drying agents) + removal or debris/cerumen + topical abx
*ciprofloxacin-dexamethasone, ofloxacin
*neomycin/polymyxin B/hydrocortisone – do not use if perf suspected (ototoxic)
Perf: cipro/dexamethasone or ofloxacin
Malignant (Necrotizing) Otitis Externa definiton, sx, dx, tx
Invasive infection of the external auditory canal & skull base (temporal bone, soft tissue, & cartilage) – complication of acute otitis externa
Etiologies: pseudomonas aeruginosa >95%
Risk Factors: immunocompromised (DM MC), high-dose glucocorticoid therapy, chemo, advanced HIV
sx
Severe auricular pain, otorrhea – cranial nerve palsies (CN 7) if osteomyelitis occurs
*may radiate to TMJ joint (pain w/ chewing)
PE: severe auricular pain on traction of the ear canal or tragus
dx
Otoscopy: edema of the external auditory canal w/ erythema, discharge, granulation tissue at the bony cartilaginous junction of the ear canal floor, frank necrosis of the ear canal skin
CT/MRI – confirms dx; bx most accurate
tx
ADMIT + IV ciprofloxacin
*piperacillin-tazobactam, ceftazidime, cefepime
Mastoiditis definition, sx, dx, tx
Infection of the mastoid air cells of the temporal bone
Largely a disease of childhood (esp. <2yrs)
Etiologies: usually a complication of acute otitis media
Bugs: S. pneumoniae, H. flu, M. catarrhalis, S. aureus, S. pyogenes
sx
*deep ear pain (usually worse @ night)
*fever, lethargy, malaise
PE:
*otalgia, fever, s/sxs of otitis media (bulging & erythematous TM)
*mastoid tenderness, edema & erythema
*forward protrusion of ear; narrowed auditory canal
dx
CT w/ contrast of temporal bone
Alt: MRI
tx
IV abx + middle ear or mastoid drainage (myringotomy) +/- tympanostomy tube placement
*IV vancomycin or clindamycin x4wks
Refractory/complicated: mastoidectomy
Tympanic Membrane Perforation definition, sx, dx, tx
Rupture of the TM
May lead to cholesteatoma
Etiologies: MC occur due to penetrating or noise trauma (MC occurs at the pars tensa) or otitis media
sx
Acute ear pain, hearing loss
Pts w/ otalgia prior to rupture may develop sudden pain relief w/ bloody otorrhea
Tinnitus & vertigo
dx
Otoscopic exam: perforated TM – DO NOT PERFORM PNEUMATIC OTOSCOPY
+/- conductive hearing loss
tx
Most heal spontaneously – follow up to ensure resolution
Topical abx in some (ofloxacin)
Avoid water & topical aminoglycosides in the ear
Persists >2mo: surgery
Hearing impairment conductive vs sensoneurial
Hearing loss can be classified as conductive, sensorineural, or both (mixed loss); TX: treat underlying cause, hearing aids, cochlear implants, surgery
*MCC of conductive loss is otitis media; others include cerumen impaction, otitis externa, exostoses (bony outgrowths of external auditory canal related to cold water exposure), TM perforation, otosclerosis, neoplasms
*MCC of sensorineural loss is presbycusis (gradual, symmetrical loss associated w/ age); others include noise-induced, infection, drug-induced, congenital, Meniere disease, CNS lesions
Rinne vs Weber
Rinne & Weber Tests:
Weber Test: tuning fork placed on center of head to see which ear sound lateralizes to (normal result is equal lateralization)
Conductive hearing loss 🡪 sound lateralizes to affected ear
Sensorineural hearing loss 🡪 sound lateralizes to unaffected ear
Rinne Test: fork first placed on mastoid until patient says they cannot hear, then moved parallel to ear (should be able to hear again)
Conductive hearing loss 🡪 bone > air (abnormal result)
Sensorineural hearing loss 🡪 air > bone (normal result)
Acute Pharyngitis/Tonsillitis definition, sx, dx, tx
Etiologies: usually viral; adenovirus MC, rhino/entero, EBV, influenza, RSV, HZV; fungal in pts using inhaled steroids
sx
Sore throat, pain
Viral: cough, hoarseness, coryza, conjunctivitis, diarrhea
dx
Clinical
Rapid strep or throat culture to r/o strep
tx
Symptomatic therapy – fluids, warm saline gargles, topical anesthetics, lozenges
Fungal: clotrimazole, miconazole, nystatin
Streptococcal Pharyngitis “strep throat” definition, sx, dx, tx
Group A streptococcus (S. pyogenes)
Rare in children <3yrs
Highest incidence of rheumatic fever if untreated in children 5-15yrs
sx
Dysphagia, fever
Not usually associated w/ sxs of viral infection
PE:
*pharyngeal edema or exudate, tonsillar exudate &/or petechiae
*anterior cervical LAD
dx
Centor Criteria:
(1) absence of cough
(2) exudates
(3) fever (>100.4F)
(4) cervical LAD
3/4 🡪 rapid antigen detection test
(+): treat strep
(-): throat culture: gold standard
tx
Penicillin first line
Allergy: azithromycin
Complications:
*rheumatic fever
*acute glomerulonephritis
*peritonsillar abscess
Acute/Chronic Rhinosinusitis (Sinusitis) definition, sx, dx, tx
Acute: <4wks
Subacute: 4-12wks
Chronic: >12wks
Viral (Common Cold):
*rhinovirus, influenza, parainfluenza, adenovirus
Bacterial:
*S. pneumoniae, streptococci, H. influenzae, S. aureus, M. catarrhalis
Invasive Fungal:
*aspergillus, mucormycosis
*seen in immunocompromised pts (DM, HIV/AIDS)
sx
Viral:
*nasal congestion, clear rhinorrhea, hyposmia
*malaise, HA, cough
*erythematous, engorged nasal mucosa w/o intranasal purulence
Bacterial:
*purulent yellow-green nasal discharge
*facial pain or pressure worse w/ bending down & leaning forward
*cough, malaise, fever, HA
Fungal:
*facial pain that is more severe
*clear or straw-colored nasal drainage (not purulent)
*Mucormycosis: black eschar on middle turbinate
dx
Clinical dx
CT – gold standard
Fungal: nasal bx w/ silver stains
*broad non-septate hyphae
tx
*decongestants, NSAIDs, saline nasal sprays
*intranasal corticosteroids
Indications for abx:
*sxs >10d w/o improvement
*fever >102F &/or purulent nasal discharge
*rapid worsening of sxs after initial improvement
Choice: Augmentin x5-7d
Fungal: amphotericin B, surgical debridement
Rhinitis definition, sx, tx
Types:
*Allergic: IgE mediated mast cell histamine release due to allergens (pollen, dust, mold)
*Infectious: Rhinovirus MCC (common cold)
*Vasomotor: nonallergic & noninfectious dilation of the blood vessels (temperature change, strong smells, humidity)
sx
*sneezing, nasal congestion, itching,
*clear, watery rhinorrhea
Allergic: +/- bluish discoloration around the eyes
PE:
*Allergic: pale or violaceous boggy turbinates, nasal polyps w/ cobblestone mucosa of the conjunctiva; may develop “allergic shiner” purple discoloration around the eyes or a nasal bridge crease from constant rubbing
*Viral: erythematous turbinates
tx
Allergic:
- intranasal corticosteroids first line for allergic or nasal polyps
- antihistamines, mast cell stabilizers (cromolyn), short-term decongestants
- anticholinergics can be used for rhinorrhea
- avoidance & environmental control, exposure reduction
Intranasal Steroids: mometasone, fluticasone
*indications: most effective med for allergic rhinitis esp. w/ nasal polyps
Decongestants:
*MOA: improve congestion
*Intranasal: oxymetazoline, phenylephrine, naphazoline
-use >3-5d 🡪 rhinitis medicamentosa (rebound congestion)
*PO: pseudoephedrine
Epistaxis causes, locations, sx, dx, tx
Anterior: Kiesselbach’s venous plexus MC site
Etiologies: trauma MC (nose picking), low humidity, hot environments, rhinitis, ETOH, cocaine, antiplatelets, FB
Posterior: sphenopalatine artery branches & Woodruff’s plexus MC site
Etiologies: HTN, older pts, nasal neoplasms
*may cause bleeding in both nares & posterior pharynx
*recurrent epistaxis requires r/o of HTN & hypercoagulable disorder
tx
Anterior: direct pressure x10-15min, seating, leaning forward
*short-acting topical decongestants (Afrin, phenylephrine, cocaine)
*nasal packing: requires abx (cephalosporin) to prevent toxic shock syndrome
*petroleum jelly or abx ointment inside nostril BID x4-5d; cauterization
Posterior: balloon catheter tamponade
*high risk for complications; requires specialist eval & inpatient monitoring
Bacterial Conjunctivitis definition, sx, dx, tx
MC due to staph aureus
*S. pneumoniae
*H. influenzae
*M. catarrhalis
Transmitted by direct contact & autoinoculation
sx
Purulent discharge, lid crusting (eye “stuck shut” in the morning), conjunctival erythema w/ no ciliary injection (limbal flush); usually no significant visual changes
dx
Clinical – fluorescein staining to look for keratitis or corneal abrasions
Culture & gram stain of discharge
tx
Topical abx:
*gentamicin/tobramycin (Tobrex)
*trimethoprim & polymyxin B (Polytrim)
*erythromycin – chlamydia for newborns
Contact lens: cover pseudomonas (topical ciprofloxacin or ofloxacin)
Viral Conjunctivitis definition, sx, dx, tx
Inflammation of the conjunctiva
MC caused by adenovirus; MC in children
Transmission: highly contagious from direct contact
*swimming pool MC source during outbreaks
sx
Foreign body or gritty sensation, ocular erythema, itching; normal vision
Often starts unilateral 🡪 bilateral after 1-2d
+/- viral sxs
PE:
*ipsilateral preauricular LAD, copious watery tearing
*punctate staining on slit lamp exam
tx
Supportive (self-limited) – warm to cool compresses, artificial tears, antihistamines, decongestants
Allergic Conjunctivitis definition, sx, dx, tx
Inflammation of the conjunctiva in response to an allergen
PATHO: contact of allergen w/ eye causes mast cell degranulation & histamine release
sx
Conjunctival erythema (red eyes) w/ normal vision
Other allergic sxs: nasal congestion, sneezing, marked pruritis
May have atopic hx (Hay fever)
PE: cobblestone mucosa appearance to inner upper eyelid, erythema, watery or mucoid discharge, chemosis (conjunctival edema)
tx
*Naphcon-A
*Ocuhist
*azelastine
