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
Signs of diabetic retinopathy
Non-proliferative diabetic retinopathy:
sx: macular edema, hard exudates, ischemia, microaneurysms, retinal hemorrhages, retinal edema
Proliferative diabetic retinopathy:
Sx: more severe: new retinal vessels +/- vitreous hemorrhage, tractional retinal detachment
Tx: optimal preventive glucose/lipid/BP control and renal function
Hypertensive retinochoriodopathy
Results from systemic HTN
Chronic sxs: abnormal red-reflex (“silver or copper wiring”), AV nicking, flame hemorrhages
Acute sxs: cotton wool spots, retinal hemorrhages/edem/exudates, choroidal pigmentation from infarcts, optic disc swelling
Blood dycrasias
Fundoscopic findings
Leukemia: roth spots (white centered retinal hemorrhages)
Sick cell: salmon-patch preretiinal intraretinal hemorrhages, “black sunbursts”
HIV retinopathy
cotton-wools spots, retinal hemorrhages, microaneursyms
CMV retinitis
(complication of HIV/Aids
- progressively enlarging yellowish-white patches of retinal opacification with retinal hemorrhages
Macular degeneration (Atrophic or dry)
Atrophy and degeneration of outer retina and retinal pigment epithelium
- Gradual deterioration of central vision (typically bilaterally but can be unilateral)
- No pain or redness
- Peripheral fields and navigational vision maintained
- Fundoscopy: Drusen (Hard= discrete yellow deposits)
Macular degeneration (wet or exudative)
New growth of vessels seperate retinal epithelium from underlying membrane: leakage of serous fluid, hemorrhage and fibrosis
- Rapidly progressive visual loss, greater severity
- Large, confluent, soft drusen bilaterally
Leukoplakia
Eti: Hyperkeratoses from chronic irritation (dentures, tobacco, lichen planus)
- EtOH and tobacco use are major risk factors
- Hairy lekoplakia common early finding HIV
Sx: White lesion that cannot be rubbed off
Sialadenitis/ parotitis
Eti: acute bacterial infection of parotid or submandibular gland: S. aureus most common
Sx: Acute swelling of the gland, increase pain with meals, tenderness and erythema of the duct opening, purulent discharge when massage
Tx: Abx for s. aureus (clinda + cipro)
Severe: IV nafcillin
Peritonsillar abcess aka quinsy
Eti: pharyngeal infection: cellulitis: abscess
Most common bact: GABHS
Sx: severe sore throat, odynophagia, trismus, medial deviation of the soft palate, “hot potato voice”
Dx: aspiration of pus from peritonsillar fold
Tx: amox, augmentin, or clindamycin
Infectious mononucleosis
Eti: epstein-barr virus (10-35 yo most common)
Sx: malaise, fever, sore throat, uvular edema, tonsillitis, palatal petechiae
- LAD (posterior cervical chain), splenomegaly, maculopapular rash
Hoagland sign : transient bilateral upper eyelid edema
Dx: monospot: possitive 4 weeks after onset of sxs
- CBC: eval for hemolytic anemia and thrombocytopenia
- Blood smear: lymphocytosis, atypica large lymphocytes
Tx: acyclovir reduces viral load but does not cure.
Labyrinthitis
Eti: usually following a viral syndrome.
Acute onset of continuous, usually severe vertigo lasting several days to a week, accompanied by hearing loss and tinnitus.
Basicly: neuronitis plus hearing symptoms
Meniere syndrome
endolymphatic hydrops
Eti: unknown cause. distention of endolymphatic compartment of inner ear.
- Episodic vertigo: discrete spells lasting 20 minutes to several hours.
- Fluctuating low-freqency sensorineural hearing loss, tinnitus, and sense of aural pressure.
Tx: low salt diet, diuretics
Vestibular neuronitis
Paroxysmal, usually single attack without accompanying impariement of auditory function, several days to a week.
Dx: acute phase exam reveals nystagmus and absent responses to caloric stimulation on one or both sides.
Cause thought to be viral
BPPV
Benign paroxysmal positioning vertigo
Sx: recurrent spells of vertigo, lasting a few minutes per spell, associated with changes in head position (often rolling over in bed).
- Occurs in clusters, persist for several days.
- Brief latency period following head movement before sx,
- Acute vertigo subsides within 10-60 seconds
Perilymphatic fistula
Leakage of perilymphatic fluid from inner ear into tympanic cavity.
- Rare cause of vertigo and sensory hearing loss
- Due to: physical injury; extreme barotrauma, vigorous valsalva maneuvers
Vestibular schwannoma
Acoustic neuroma
(Eighth cranial nerve schwannomas are among the most common intracranial tumors)
- Unitlateral hearing loss with a deterioration of speech
- Often more disequilibrium than episodic vertigo
What antibody is seen in allergic disorders?
IgE antibodies
- atopic derm
- asthma
- parasitic infection
Type 1 hypersensitivity immune response
Anaphylactic or immediate hypersensitivity reaction (IgE mediated)
- Anaphylaxis, allergic rhinitis, allergic drug reactions
- Common allergies are Type 1
IgE antibodies bind to antigen and then attach to the surface of a mast cell causing inflammatory mediators to be released which produce clinical manifestation of allergies
Type 2 hypersensitivity
Cytotoxic reactions (IgG/IgM-mediated) - ex: Autoimmune hemolytic anemia
Antibody binding to antigen: opsinisation and compliment activation, and activation of NK cells
Type 3 hypersensitivity
Immune complex-mediated reactions
(Antigen-antibody immune complex formation)
- Complex may not be adequately cleared from circulation, tissue damage occurs, compliment activation… more needed here
Type 4 hypersensitivity
delayed hypersensitivity reactions (T cell mediated)
ex: contact dermatitis
- Does not involve antibodies
- Mediated by T-cells, which have been previously primed and clonally expanded
