HEENT Flashcards
Laryngitis
Eti: typically viral, vocal cords become stiff and vibrate irregularly
Risk factors: URI risk factors, smoking
Sx: hoarseness persisting about a week after other URI symptoms have resolved
Tx: rest voice, hoarseness greater than 2 weeks, refer to ENT
Vocal cord paralysis
Eti: trauma to recurrent laryngeal n. or vagus nerves, can be surgical, viral, tumor, neuro
Sx: Hoarseness, aspiration, high pitched stridor,
Dx: Laryngoscopy, EMG (electromyography)
- bilateral paralysis - trachestomy
Benign tumor of the larynx
Eti: repetitive trauma to the vocal cords
Risk f: Professional voice use (nodules), hx of voice abuse, frequent intubation (granulomas)
Sx: Dysphonia (difficulty speaking), odynophagia and cough.
- nodules, polyps, cysts, reinke edema
Dx: endoscopy
Tx: Surgery
SCC of larynx
Eti: Almost exculsively with major tobacco use, most common malignancy of larynx. HPV 16/18 associated.
Sx: hoarseness for greater than 2 weeks in a smoker.
- Persistant throat or ear pain, especially with swallowing
- Neck mass, hemoptysis, stridor, dysphagia, weightloss
Tx: Refer to ENT, radiation, generally good prognosis
What are floaters
Eti: Most commonly benign vitreous opacities
Ddx: benign opacities, posterior vitreous detachment, vitreous hemorrhage, posterior uveitis, retinal tear/detachment
WU: Urgent referral especially with flashing lights or subjective vision reduction
Diplopia
Eti: ocular misalignment
DDx: Central disorders or CN palsies due to head injuries.
- Intracranial disease (vascular, neoplastic, infammatory)
- Wernicke syndrome, myasthenia gravis
- Orbital disease
l- Monocular diplopia usually due to refractive error or lens opacities
WU: urgent ophth referal
- If recent onset of CNIII palsy: CT or MR for intracranial aneuysm
Altered visual acuity
Eti: disease of retina or optic nerve typically is monocular
DDx: Refractive error, corneal opacities, cataract, intraocular inflammation (uveitis), vitreous hemorrhage, retinal detachment, macular degeneration, diabetic retinopathy, central retinal artery or vein occlusion, optic nerve disorder
Initial WU: Emergent referral if vision loss associated with pain or marked redness
Visual field defects
Eti: Bitemoral: tumor or lesion of the optic chiasm.
- Contralateral homonymous hemianopic: retrochiasmal lesions, usually cerebrovascular disease or tumor.
WU: complete neuro exam
- visual fields by confrontation
- Rule out stroke: CBC, PTT/INR, ECG
- CT rule out bleeds
Dacryocystitis
Infection, tumor, trauma or other of the lacrimal sac
Acute: S. aureus and Beta-hem strep most common
Sx: Eyeball not red, but eyelid is
- pain, swelling, tenderness
Comp: Orbital cellulitis
Keratoconjunctivities sicca
Kerato: cornea, conjunctivities: inflam of conjunctiva, Sicca: dry
Eti: hypofunction of lacrimal glands due to aging, hereditary d., systemic (Sjogren s.)
Sx: dry eyes, redness, foreign body sensation.
Severe sx: photophobia, conjunctival injection.
Dx: Gross inspection often not helpful.
- Slit-lamp
- Schirmer test (how much tear production)
Ptosis
Drooping of the upper eye lid
Eti: Muscular, trauma/injury
- neuro: horner syndrome (pupil constriction), CN III palsy (abnor of eye movement and pupil dilation and poorly reactive to light), myasthenia gravis (pupils are normal and ptosis is fatigable, stroke
Tx: surgical or manage underlying condition if applicable
Entropion/ectropion
Entropion: Inward turning of the eyelids
Ectropion: outward turning of the eyelids
Dx: clinical
Tx: Surgery if lashes rub on cornea
Uveitis/iritis: Eti?
Inflammation of the iris, choroid, retina.
Anterior Eti: Idiopathic, HLA-B27 (non-gramulomatous), autoimmune, infectious
Posterior Eti: Inflammatory lesion of retina or choroid
Panuveitis Eti: Idiopathic, sarcoid, …
Clinical presentation of anterior uveitis?
Non-granulomatous anterior:
- unilateral pain, redness, photophobia, visual loss
Granulomatous: indolent, blurred vision, mild inflammation, hypopyon if severe
Dx: Visualize anterior chamber cells with slit lamp:
- non-G: small mutton-fat keratic precipitates, no iris nodules
- granulomatous: large mutton-fat KPs and iris nodules
Pinguecula
Nodules on exterior of sclera
Eti: UV exposure
Sx: Yellow elevated ocnjunctival nodule, most commonly on nasal side
Tx usually unnecessary
Pterygium
Associated with prolonged exposure to wind, sun, sand and dust.
Sx: fleshy, triangular encroachment of the conjunctiva onto the nasal side of the cornea
Tx: excision if vision is compromised
Subconjunctival hemorrhage
Eti: Benign, rupture of small conjunctival vessel
Sx: Bright red flat conjunctiva, stops abruptly at the limbus
tx: reassurance, reabsorbs in 2-3 weeks
Allergic conjunctivitis
Eti: seasonal hay fever, an expression of atopy
Sx: itching, tearing, redness, stringy discharge, occasional photophobia and visual loss.
- Vernal keratoconjunctivits: large cobblestone papillae.
Cataracts
Opacity in the lens
Risk f: Age 50% in 65-74 yos
Sx: gradual development of blurred vision, lens opacities, glare from bright lights, notice while driving
- No pain or redness
Fundoscopy: impaired or absent red reflex
Open-angle glaucoma
Chronic: reduced drainage of aq fluid through the trabecular meshwork
Sx: bilateral tunnel vision, visual acuity preserved until advanced stage
- Increased intraocular pressure
- Fundoscopy: pale optic disc, optic disc cupping
Dx: requires 2 of 3:
- cup disc ratio
- visual field deficit
- increased intraocular pressure (normal is 10-21mmHg)
Tx: prostaglandin analogs
Angle-closure glaucoma
More common in farsighted individuals, inuits and asians
Eti: flow of aqueous fluid into anterior chamber is obstructed
- anterior uveitis, lens dislocation
Sx: rapid onset severe pain, profound visual loss with halos around lights
- Hard eye on palpation
- Preceded by pupillary dilation
Tx: Reduce IOP: IV acetazolamide, the PO QID, oral gylcerin if acetazolamide doesn’t work
Comp: untreated: severe and permanent vision loss within 2-5 days of onset of sx.
AVOID MYDRIATIC AGENTS (dialate eye)
Retinal detachement
Eti: development of tears or holes.
- nearsightedness and cataract extraction are two most common predisposing factors
- Usually in patients greater than 50
Sx: Visual field loss that starts inferiorly and moves upward.
- Sudden appearance of floaters and flashes and reduced vision
Dx: Ophthalmoscope exam
Tx: Refer urgently
Retinal vein occlusion
Eti: DM, HTN, hyperlip,... many more Sx: sudden monocular loss of vision - no pain or redness - widespread or sectoral hemorrhages Central: retinal venous dilations/tortuosity, cotton wools spots, optic disk swelling Branch: abnormalities confined to the area near the drainage. Dx: Check BP! - Fundoscopy - Lab screening Tx: refer urgently
Retinal artery occlusion
Eti: embolus, DM, HTN, HyperL…many more
Sx: - sudden monocular loss of vision, no pain or redness, widespread or sectoral retinal pallid swelling
- pallid swelling of retina w/ cherry red spots on fovea
- accentuated arteries and box-car veins
Tx: urgently look for source of emboli
- treat to prevent stroke
Screen of underlying cause
- Check BP
- Giant cell: CRP and sed rate
- ultra sound, ECG, echo
