HEENT Flashcards
ectropion vs entropion
ectropion: eyelid and lashed turned outwards
* MC in elderly due to relaxation of orbicular oculi muscle
entropion: eyelid and lashed turned inwards
* Mc due to orbicularis oculi spasm
what is dacrocystitis, and what is the MC organism?
-lacrimal gland infection MC due to S. Aureus
Treatment for dacrocystitis
-Clindamycin,
OR vancomycin + ceftriaxone
Causes of anterior blepharitis
Where skin and eyelid meet:
1) Infection (staph MC)
2) Seborrheic
Causes of Posterior Blepharitis
Caused by a Meibomian gland dysfunction
*associated with rosacea, allergic dermatitis
What is blepharitis?
Inflammation of both eyelids
Patients with blephritis commonly have what other conditions?
1) down syndrome
2) eczema
Blephritis treatment
-Eyelid hygiene, warm compress, meibomian gland expression if a posterior cause, azithromycin solution
What is a hordeolum and what organism MC causes it?
Local access of the eyelid margin (stye)
MC caused by staph aureus
What is the treatment of a hordeolum ?
- Warm compress is the mainstay
- topical erythromycin or bacitracin ointments
**if it does not spontaneously drain in 48 hrs, I&D may be indicated!
What is a chalazion?
PAINLESS granuloma of the meibomian gland
-presents as non-tender eyelid swelling that heals with warm compress
What is a Pterygium?
Fleshy, triangle shaped GROWING fibrovascular mass growing into eye, BEGINNING AT NASAL SIDE OF EYE
-associated with UV exposure, sand, wind, dust,
What is a pinguecula?
Yellow nodule on the NASAL SIDE OF SCLERA,
-DOES NOT GROW
What part of vision is the macula responsible for?
Central Vision
Color Vision
What is the MC cause of macular degeneration?
Age
Two types of macular degeneration
1) DRY: caused by atrophy of the macula, blurring of central vision with DRUSEN spots found on physical exam
2) WET: caused by neovascularization or exudates, new abnormal vessels grow under retina which leak and bleed leading to retinal scaring , diagnose with fluorescein angiography
Vision changes in a patient with macular degeneration
Central vision loss, scotomas, metamorphopsia (straight lines appear bent)
Treatment of dry macular degeneration
- Amsler grid to monitor (grid of lines to see if metamorphopsia is present)
- Zinc, Vit A, C, E can slow progression
Treatment of wet macular degeneration
Intravitreal anti-angiogenics: (VEGF inhibitors) such as Bevacizumab, these inhibit neovascularization
Pathophysiology of diabetic retinopathy
excess sugar attaches to the cologne of retinal blood vessels leading to ischemia and breakdown
3 types of diabetic retinopathy
1) Nonproliferative: microaneurysm;
- cotton wool spots (soft exudates)
- Hard exudates from lipid deposits
- Blot & dot hemorrhages
* NO VISION CHANGE
2) Proliferative: neovascularization
* VITREOUS HEMORRHAGE CAUSES BLOTTED VISON
3) Maculopathy: macular edema or exudates, blurred CENTRAL VISION LOSS
3 types of retinal detachment
1) Rhegmatogenous (MC type): direct tear of the retinal inner sensory layer from choroid plexus
2) Traction: adhesions separate retina from base
3) Exudative: serous fluid collects beneath the retina
MC predisposing factors to a phegmatogenous retinal detachment
- myopia (nearsighted)
- cataracts
Clinical Manifestations
- Photopsia (flashing lights)
- Floaters
- Progressive unilateral vision loss of central vision field
- Curtain coming down from periphery (amaurosis fugax will resolve, this will not)
What is Shafer’s sign?
On fundoscopy:
Clumping of brown-colored pigment cells in the anterior vitreous humor, “tobacco dust” appearance; found in retinal detachment
Treatment of a retinal detachment
OPTHO emergency; NO MIOTIC DROPS
Steps to treating a corneal abrasion
1) Check visual acuity
2) Fluorescein staining to look for abrasion of foreign body (“ice rink abrasions”)
3) May patch the eye if larger than 5mm, for 24 hours
4) antibiotic drops (erythromycin, or ciprofloxacin)
Contraindications to giving a patient an eye patch
- contact lens wearer
- pseudomonas infection
Which topical antibiotics cover pseudomonas?
Floroquinolones
Aminoglycosides
Hallmarks of viral conjunctivitis
Red itchy eye, pre auricular lymphadenopathy, WATERY discharge; often bilateral
- Punctate staining on slit lamp
- Treat with supportive treatment
Hallmarks of allergic conjunctivitis
Red eyes with other allergy s/s
-COBBLESTONE mucosa on inner eyelid; often bilateral
-Treat with topical antihistamines:
Olopatdine, Naohcon A
Hallmarks of bacterial conjunctivitis
Purulent discharge with LID CRUST, absence of colliery injection; often unilateral
-Treat with topical antibiotics
Which type of chemical burn is worse on the eye, alkali or acid?
Alkali is worse! (these cause denaturing and liquefactive necrosis)
-Acid burns cause coagulative necrosis
Management of chemical burns to the eye
1) IRRIGATION: use lactated ringers as these have a similar pH to tears (7.1)
- irrigate at least 30 minutes with at least 2 Liters
2) Check pH and visual acuity after irrigation
3) Moxifloxacin antibiotics
What is the MC virus causing conjunctivitis?
Adenovirus; often caught by children in swimming pools
Hallmarks of Orbital (septal) cellulitis
- usual 2ry to an ethmoid sinus infection
- Decreased vision, pain with ocular movements, proptosis
- High resolution CT
- IV antibiotics (vancomycin, clindamycin)
Preseptal cellulitis
infection of the eyelid and periocular tissue , NO vision loss or pain with ocular movement
-treat with IV amoxicillin
Esotropia
convergent strabismus (deviated inward)
Exotropia
divergent strabismus (deviated outward)
What is cilliary injection
Redness concentrated right around the cornea; found in keratitis, or a corneal ulcer
What is the most common cause of keratitis?`
Bacteria (pseudomonas or acanthamoeba) in contact wearers
Physical exam findings of bacterial vs HSV keratitis
BACTERIAL: hazy cornea, give fluoroquinolone drops and do not patch eye
HSV: dendritic lesions on flurescein stain
What are the two MC risk factors for cataract development?
Smoking, corticosteroids
Cataract= progressive lens thickening
Pathophysiology of papilledema
swelling of the OPTIC NERVE (disc) 2ry to increased intracranial pressure
Management of papilledema
decrease intracranial pressure with acetazolamide (decreased production of aqueous humor & CSF)
demyelination of the optic nerve is called
optic neuritis
What medication causes optic neuritis
Ethambutol
Physical exam findings in optic neuritis
- Loss of color vision
- central scotoma/blind spots
- ocular pain worse with eye movements
- Marcus-Gunn pupil
What is a Marcus-Gunn pupil?
- relative afferent pupillary defect; when the light is swung into the affected eye the pupil dilates instead of constricts.
- delayed response of the optic nerve seen in optic neuritis
What is a Argyll-Robertson Pupil?
Pupil constricts on accommodation, but does not react to bright light
-causes by neurosyphilis MC, midbrain lesions, or diabetic neuropathy
What are precipitating factors to acute angle closure glaucoma?
Mydriasis (pupillary dilation)
-dim lights, sympathomimetics, anticholinergics
Clinical manifestations of acute angle closure glaucoma
- Acute unilateral painful PERIPHERAL vision loss with halos
- tunnel vision +/- n/v, headache
- steamy cornea, mid-dilated, fixed, non-restive pupil
What is the treatment for acute angle closure glaucoma?
Acetazolamide to decrease aqueous humor production
Timolol to decrease IOP
Avoid sympathomimetics and anticholinergics
What causes an acute angle closure glaucoma?
Decreased drainage of aqueous humor
Chronic, open angle, glaucoma hallmarks
- Gradual, Bilateral, Painless, Peripheral vision loss (tunnel vision)
- Due to chronic reduced aqueous humor drainage
- Cupping of optic disc on exam
- Prostaglandin analogs 1st line tx (Latanoprost)
Hallmarks of a central retinal artery occlusion
- Often have atherosclerosis
- acute, sudden, monocular vision loss often proceed my amaurosis fugal
- PALE RETINA, CHERY RED MACULA
- acetazolamide tx
Hallmarks of central retinal vein occlusion
- fluid backup to due occlusion
- acute sudden monocular vision loss
- extensive retinal hemorrhages with “BLOOD AND THUNDER” APPEARANCE
- no tx
MC organism causing otitis externa
Pseudomonas,
*AKA swimmers ear, often the increased water exposure weakens the ears normal acidic pH allowing for bacterial overgrowth
Presentation of otitis externa
Pain, pruritus, discharge, fullness, hearing usually preserved.
Treatment of otitis externa
- Cipofloxacin/dexamethazone topical agents
- You can use aminoglycosides as long as there is no TM perforation as they are ototoxic
What is malignant otitis externa?
Osteomyelitis at skull base 2ry to Pseudomonas
- Often seen in DM, or immunocompromised patients
- Tx with IV antipseudomonal
Mc organisms causing acute otitis media
1) S. pneumo
2) H. Flu
3) Moroxella catarrhalis
4) Strep Pyogenes
5) If Bullae on TM = mycoplasma pneumonia
**MC proceeded by viral URI
Pathophysiology of acute otitis media
URI causes edema of eustachian tube (or congenital tube dysfunction) which leads to transudation of fluid & mucus in the middle ear, leading to bacterial colonization
Clinical manifestations of acute otitis media
bulging Tm with erythema, otalgia, ear tugging in infants,
-Pain with DECREASE with TM rupture, and otorrhea will begin (2 days to heal)
Treatment of acute otitis media
Amoxicillin x10-14 days
Cefixime in children
*erythromycin-sulfisoxazole if allergic
Hallmarks of chronic otitis media
Complication of actor otitis media
- MC pseudomonas, S. aureus
- Perforated TM + persistant recurrent purulent otorrhea
_Topical antibiotic treatment with oflaxacin or cipro
What is a cholesteatoma?
Abnormal keratinized collection of squamous epithelium that erodes the ossicles and mastoid bone over time
-Leads to a conductive hearing loss
Clinical manifestions/PE of cholesteatoma
- Painless otorrhea (brown/yellow discharge with odor)
- Granulation tissue with conductive hearing loss
- Treat with surgical excision
Hallmarks of Benign positional vertigo
- Episodic, peripheral vertigo with changes to head positioning.
- DX with DIX-Hallpike : lay patient with head 30 degrees lower than body, watch for delayed horizontal nystagmus when head is quickly tuned.
- Treat with Epley maneuver: canalith reposition, no medical treatment needed
What is the labyrinth and what is it made up of?
The bony & membranous part of the inner ear that is made up of:
1) Cochlea: converts impulses to allow for HEARING
2) Vestibular system: 3 semicircle canals responsible for BALANCE
What is the difference between vestibular neuritis & Labyrinthitis?
Vestibular neuritis: inflammation of the vestibular nerve (CN 8); this will present as continuous dizziness with gait/balance disturbances, NO HEARING LOSS
Labyrinthitis: Inflammation of vestibular nerve PLUS the cochlea; this will present as vestibular s/s PLUS hearing loss continuously
**treatment is with steroids
What cranial nerve is responsible for balance?
CN VIII (vestibular nerve)
What is Meniere’s Disease?
IDIOPATHIC dissension of the inner ear by excess fluid
Presentation of Meniere’s Disease
1) episodic vertigo for minutes to hours
2) tinnitus
3) ear fullness
4) fluctuating hearing loss
5) nystagmus, n/v
Treatment of Meniere’s disease
Treat nausea s/s with antiemetics
- Prevent with diuretics (HCTZ)
- Avoid salt, caffeine, chocolate, ETOH
What is an acoustic neuroma and how does it present?
Tumor of the schwann cells that make up the myelin sheath of CN VIII
-It will present as UNILATERAL hearing loss with tinnitus
What is the MC location of acute sinusitis
maxillary>ethmoid>frontal>sphenoid
Clinical manifestations of acute sinusitis
Acute = 1-4 weeks
Sinus pressure, headache, purulent sputum, nasal discharge
*sinus transillumination on physical exam
Treatment of acute sinusitis
Amoxicillin *symptoms must be present for at least 1-14 days before you give antibiotics to rule out viral causes !!!
-2nd line is doxy or bactrim
Definition and common organisms causing chronic sinusitis
At least 12 weeks
- S. Aureus MC bacteria
- Aspergillus MC fungal cause
- Mucormycosis 2nd MC fungal cause
What does chronic sinusitis caused by mucormycosis present like?
- Often immunocompromised patient
- black eschar on palate or face
- IV amphotercin B for treatment
What are the 3 types of rhinitis?
1) Allergic (MC)
2) Viral: rhinovirus (common cold)
3) Vasomotor (blood vessel dilation from temp change)
Clinical manifestations of allergic rhinitis
-pale, violet boggy turbinates; clear rhinorrhea, nasal polyps*****, cobblestone mucosa of conjunctiva, worse in the morning
**treat with intranasal corticosteroids
Clinical manifestations of viral rhinitis
erythematous turbinates
What is Samter’s triad?
1) asthma
2) nasal polyps
3) ASA allergy
Where is the bleed coming from in anterior vs. posterior epistaxis?
Anterior: Kiesselbach’s plexus , one nostril
Posterior: Palantine artery, bleed from both nostrils (HTN and atherosclerosis predispose)
What is MC cause of pharyngitis?
Viral!
-If bacterial… GABHS
What is Centor Criteria ?
For the diagnosis of Bacterial (Strep) Throat
1) Fever
2) Anterior cervical lymphadenopathy
3) Pharyngotonsillar exudates
4) absence of cough
5) add a point if younger than 15
**if O-1; no culture needed
2-3; culture
4-5; go straight to antibiotics
What is the treatment for strep pharyngitis?
Pen G or VK
Macrolides if pen allergic
Signs of a peritonsilar access (Quincy)
- Uvula deviation
- Hot potato voice
- difficulty handling secretions
Diagnosis and treatment of a peritonsilar abcess
Dx: CT scan
Tx: I&D plus antibiotics
- Unasyn
- Pen G + Metronidazole
How does laryngitis present?
- It is inflammation of the larynx (vocal chords) :
- Hoarseness, aphonia
- MC viral cause so give supportive treatment
Presentation of oral leukoplakia
- White painless patchy lesions that cannot be scared off
* *precurser to cancer
Aphthous Ulcers (canker sore)
Painful ulcers with ulceration and erythematous ulcers,
-Associated with human herpes virus 6
What are the two salary gland ducts of the mouth?
Wharton’s duct-submandibular (MC place for stones)
Stensen’s duct (parotid gland duct)
Sialolithiasis
Salivary gland stones!
-MC in wharton’s duct
- Postparandial salivary gland pain and swelling
- fluids and sialogogues (tart hard candies)
Sialadenitis
salivary gland stones:
- INFECTION of salivary glands MC S. Aureus
- Pain, swelling, trismus, duct tenderness and drainage
- Give antibiotics (dicloxacillin or Nafcillin)
