HEENT Flashcards
Hordeolum (“Stye”)
most common causative organism
Staphylococcus abscess
Hordeolum (“Stye”) - external vs. internal
external - glands in eyelash follicle or lid margin
internal - inflammation of Meibomian gland
Hordeolum (“Stye”) - symptomology
- localized edema (“bump”) and redness
- acutely tender
- pain proportional to amount of edema
Hordeolum (“Stye”) - exam findings
- erythema
- edema
- tender
Hordeolum (“Stye”) - management
- most resolve spontaneously without intervention over several days
- warm, moist compresses 5-10 min. 3-5x/day
- don’t wear eye makeup
- possibly refer to ophthalmology
Hordeolum (“Stye”) - why refer to ophthalmology
- no start to resolution in 1- weeks
- bacitracin or erythromycin eye drops
- incision and drainage
Chalazion - what is it?
granulomatous inflammation of Meibomian gland
Chalazion - symptomology
- may be asymptomatic
- itchy
- flesh-colored “bump”
- vision changes if “bump” is large
Chalazion - exam findings
- flesh-colored, hard, swollen/indurated area
- NON-tender
- adjacent conjunctival injection
Chalazion - management
- may resolve spontaneously over days or weeks
- warm compresses 10-15 min. few times/day
- possible referral to ophthalmology
Chalazion - why refer to ophthalmology
- if eyelid is swollen causing drooping or obstruction of vision
- corticosteroid injections
Cataracts - what are they?
- abnormal, uniform opacity
- leading cause of blindness
- chronic, progressive
Cataracts - symptomology
- may have increase in near-sightedeness before lens opacity starts to appear
- progressive loss of vision
- glare
- NO pain
Cataracts - exam findings
- loss of red reflex! (or darkening of red reflex)
- opacity on fundoscopic exam
Cataracts - management
- glasses/magnifying glass
- contact lenses
- home safety
- surgical tx to remove opacity
Age Related Macular Degeneration - what is it?
- acute/chronic deterioration of central vision
- older ages, white/Caucasian, female > male
- irreversible
Age Related Macular Degeneration - 2 types
- non-exudative (dry)
- exudative (wet)
Age Related Macular Degeneration - Nonexudative (dry) symptomology
- slow, progressive loss over span of years
- visual fluctuation
- difficulty with night vision
- distortion
Age Related Macular Degeneration - Exudative (dry) symptomology
- progressive loss over span of months
- acute or insidious
- painless
Age Related Macular Degeneration - management
- antioxidants (vit. A & E, copper, zinc, carotenoids) can help reduce speed of progression
- VEFT inhibitors (ophthalmology rx)
Conjunctivitis (“pink eye”) - most common causes
- bacterial or viral
- can also be allergic or contact (chemical irritants)
Conjunctivitis (“pink eye”) - general symptomology
- NO effect on vision
- diffuse conjunctival injection
- mild pain possible (more discomfort or annoying sensation)
- very itchy = allergic
Conjunctivitis (“pink eye”) - viral common cause
Adenovirus
Conjunctivitis (“pink eye”) - viral symptomology
- typically bilateral
- discharge = copious, watery
- marked foreign body sensation
- associated with UTI, pharyngitis, fever, malaise
Conjunctivitis (“pink eye”) - viral management
- symptomatic (cold compresses)
- artificial tears
- antihistamine/ decongestant drops
Conjunctivitis (“pink eye”) - viral exception!
Herpes Simplex Virus (HSV)
- unilateral
- lid vesicles
- possible acute hemorrhagic conjunctivitis
- tx = topical antiviral (ganciclovir) and/or systemic (acyclovir)
- REFER!
Conjunctivitis (“pink eye”) - bacterial symptomology
- uni- or bilateral
- discharge = copious, mucopurulent, possible eyelash matting
- self-limiting (10-14 days without tx)
Conjunctivitis (“pink eye”) - bacterial common cause
Staphylococci (MSSA, MRSA)
Conjunctivitis (“pink eye”) - bacterial management
- erythromycin ointment or trimethroprim- polymyxin B drops
Conjunctivitis (“pink eye”) - bacterial exception!
Gonoccocal Conjunctivitis
- EMERGENCY!
- copious purulent drainage
- corneal involvement may lead to perforation
- tx: ceftriaxone 1g IM, topical (erythromycin, bacitracin)
- REFER to ophthalmology
Corneal Abrasion - symptomology
- tearing
- blephorospasm
- severe pain, foreign body sensation
- watery or purulent discharge
- blurry vision common
Corneal Abrasion - exam findings
- Fluorescein stain - dye uptake at site of corneal defect (using slit-lamp)
- circumcorneal injection
- consider retained foreign body
Corneal Abrasion - managment
- cycloplegic drops (1%) for exam only
- simple/clean - topical erythromycin
- dirty/contacts - ophthalmic ciprofloxacin
- tetanus booster
- patching and steroid preps contraindicated
- ophthalmology follow-up within 24 hours
Corneal Foreign Body - symptomology
- foreign body sensation
- pain
- tearing
- redness
- photophobia
Corneal Foreign Body - exam findings
- normal or decreased visual acuity
- conjunctival injection
- visible foreign body
- rust ring
- epithelial defect with fluorescein stain
- corneal edema
Corneal Foreign Body - management
- cycloplegia drops (1%) for exam
- remove foreign body
- antibiotic drops (tobramycin, polymyxin B)
- ophthalmology follow-up
Diabetic Retinopathy - 2 types
- non-proliferative
- proliferative (less common, more severe)
Diabetic Retinopathy - non-proliferative phases
- mild: at least 1 microaneurysm
- moderate: microaneurysms and hemorrhages
- severe (4-2-1): hemorrhages and microaneurysms in 4 quadrants, venous bleeding in 2+ quadrants, and intraretinal abnormalities in 1+ quadrants
Diabetic Retinopathy - proliferative hallmark sign
Neovascularization
Diabetic Retinopathy - symptomology
- early/initial: asymptomatic
- advanced: floaters, blurry vision, progressive visual acuity loss
- visual acuity and symptoms are poor guides to presence of diabetic retinopathy
Diabetic Retinopathy - exam findings
- microaneurysm: earliest, sign, looks like small dots
- dot/blot hemorrhages: look similar to microaneurysms but in deeper layers
- flame-shaped hemorrhage
- cotton-wool spots
- venous looping/ beading: significant predictor of proliferative from non-proliferative
Diabetic Retinopathy - workup/ diagnostics
- lab: diabetes workup
Diabetic Retinopathy - management
- control diabetes #1 (control sugar, BP, lipids)
- REFER to ophthalmology (retina specialist)
- annual screenings
Retinal Detachment - what is it?
- separation of inner layers of retina from underlying retinal epithelium
- can be spontaneous or penetrating/ blunt trauma
- spontaneous generally affects > 50 years
Retinal Detachment - symptomology
- photopsia: perceived flashes of light
- rapid loss of vision in curtain-like fashion
- may describe vision loss as a shadow
- floaters
- NO pain or redness
Retinal Detachment - workup / exam findings
- ask about previous eye trauma, surgeries, conditions
- visual acuity
- external signs of trauma
- assess pupil reaction
- intraocular pressure (tonometry)
- ophthalmoloscopic exam
Retinal Detachment - management
- emergent referral to ophthalmology
- NPO
- protect globe if traumatic
- avoid pressure on eye, limit activity
Central/Branch Retinal Artery Obstruction - most common cause
Embolus (cholesterol)
Central/Branch Retinal Artery Obstruction - risk factors
- same as CVD
- smoking, HTN, CAD, high cholesterol, hx of TIA
Central/Branch Retinal Artery Obstruction - symptomology
- acute, painLESS partial loss of vision
- “descending nightshade”
- monocular
- central or sectoral visual deficits
- may be asymptomatic
- may c/o amaurosis fugax (transient loss of vision in one eye)
Central/Branch Retinal Artery Obstruction - workup / exam findings
- ESR
- consider coag panel: PTT, fibrinogen, CBC, lipid
- ophthalmoscopic exam: box cars (segmented or narrowed flow) or cherry spots
- CV work-up
Central/Branch Retinal Artery Obstruction - treatment
- acute/rapid presentation: supine/ HOB flat
- ocular massage
- acetazolamide 500 mg IV (lower s intraocular pressure)
- long-term antiplatelet therapy for stroke prevention
Chronic (Angle-Closure) Glaucoma - symptomology
- initially asymptomatic
- loss of peripheral fields (slow and insidious)
Chronic (Angle-Closure) Glaucoma - exam finding
- optic disk cupping! - looks at cup to disc ratio
- visual field abnormalities
- elevated IOP: > 20 mmHg
Chronic (Angle-Closure) Glaucoma - management
- aimed at lowering IOP
- prostaglandin analogues (-prost)
- beta blockers (-lol)
Acute (Angle-Closure) Glaucoma - symptomology
- cloudy/blurry vision or vision loss
- extreme orbital pain
- headache
- halos around lights
- GI symptoms (nausea, abdominal pain)
Acute (Angle-Closure) Glaucoma - exam findings
- ocular injections
- corneal haziness
- minimally reactive pupil
- elevated IOP: 40-90 mmHg
Acute (Angle-Closure) Glaucoma - management
- LOWER IOP
- refer to ophthalmology
- carbonic anhydrase inhibitor (acetazolamide 500 mg IV x1)
- once IOP decreases: cholinergic agonists (Pilocarpine 1 drop q15min for 1 hour)
- definitive tx: laser peripheral iridotomy
Bell’s Palsy - symptomology
- acute onset of unilateral upper/lower facial paralysis with no other neuro symptoms (except those listed)
- posterior auricular pain
- decreased tearing
- otalgia (aching of ear or mastoid)
- weakness of facial muscles
- poor eyelid closure
- paresthesias of cheek/mouth
- blurry vision
Bell’s Palsy - exam findings
- flattening of forehead/ nasolabial folds
- lateralization with neuro exam (ex: when pt. smiles)
- varying degree of neuro deficits
Bell’s Palsy - House Brackman Facial Nerve Grading System
Grade 1: normal function
Grade 2: mild dysfunction, normal symmetry at rest
Grade 3: mod. dysfunction, can close eye with effort
Grade 4: mod-severe dysfunction, incomplete eye closure
Grade 5: sev. dysfunction, only barely perceptible motion
Grade 6: no movement
Bell’s Palsy - Acute management
- 4 day window to treat
- corticosteroids (prednisone 60-80 mg x 5-7 days) for grade 1-3
- antivirals (valcyclovir 1g TID x 7 days) + corticosteroid for grades 4-6
- lubricating eye drops and protective measures
Bell’s Palsy - long term management
- refer to facial nerve specialist if symptoms persist or recurrent problems
Vertigo - symptomology
- intermittent/episodic dizziness
- nausea (typically no vomiting)
Vertigo - work-up
- Head impulse test (HIT)
- Dix-Hallpike Test
- Epley maneuvers
- refer if not BPPV
- antihistamine antiemetic (promethazine)
- anticholinergics (scopolamine patch)
Vertigo - Head impulse test (HIT)
- sit face to face with provider holding patient’s head from the front
- ask patient to fix their gaze on target (examiner’s nose)
- turn the head rapidly to one side and then the other watching for presence or absence of corrective movement
- normal: eyes continue to fixate on target
- abnormal: eyes have to make corrective movement to re-fixate
Vertigo - Dix-Hallpike Test
- tests for BPPV
- rapidly moving patient from sitting to supine position with head turned 45 degrees to right
- after waiting 20-30 seconds, patient returned to sitting position
- nystagmus = BPPV
Vertigo - Epley maneuvers
- series of maneuvers used to treat BPPV
- turn head toward size that causes vertigo
- quickly lay down on back, keeping head in same position and just off edge of table
- slowly move head toward opposite side
- turn body so that it is now in line with head
- sit upright
- may have to repeat
Trigeminal Neuralgia - symptomology
- brief/paroxysmal episodes of stabbing unilateral facial pain
- usually one side of mouth and shoots towards ears or eyes
- typically 2nd/3rd division of trigeminal nerve
- exacerbated by touch, movement, eating
Trigeminal Neuralgia - exam findings
- normal neuro exam
Trigeminal Neuralgia - diagnosis of exclusion
A. recurrent paroxsymal attacks of unilateral facial pain (plus B & C)
B. pain characteristics- seconds to 2 minutes, electric-like shock, stabbing, shooting
C. precipitated by innocuous stimuli within trigeminal distribution
D. not attributed to other causes
Trigeminal Neuralgia - management
- antiepileptic (carbamazepine)
Hearing Loss - Conductive, what is it?
- dysfunction of external/middle ear
- mechanism: obstruction (cerumen), mass loading (effusion), stiffness (otosclerosis), discontinuity (ossicular dissruption)
- persistent loss
Hearing Loss - sensory, what is it?
deterioration of chochlea
Hearing Loss - Neural, what is it?
lesions of CN VIII, auditory nuclei, ascending tracts, or auditory cortex)
Hearing Loss - sensorineural, what is it?
- most common form
- gradual, progressive
- presbycusis - high-frequency loss
- others - excessive noise, head trauma, systemic disease
Hearing Loss - evaluation/ work-up
- Weber Test
- Rinne Test
- Formal audiometric studies (REFER)
- screening (> 65 or exposure populations)
Hearing Loss - Weber test
- tuning fork on forehead
- conductive: sound is louder in poorer-hearing hear
- sensorineural: sound radiates to better ear
Hearing Loss - Rinne test
- tuning fork on mastoid
- normal: air conduction > bone conduction
- conductive: bone conduction > air conduction
- sensorineural: air conduction > bone conduction (but less than normal hearing)
Hearing Loss - management
- REFER
- treat cause when possible
- hearing amplification
Otitis Externa - common cause
pseudomonas or staph. aureus
Otitis Externa - symptomology
- otalgia/hearing loss
- fullness or pressure
- tinnitus
- itching
- severe deep pain
- discharge
Otitis Externa - exam findings
- pain with palpation or traction of pinna (hallmark)
- erythema, edema
- narrowing of EAC
- TM likely difficult to visualize
Otitis Externa - management
- antibiotics (antibiotic + glucocorticoid) (ex: cipro + hydrocortisone)
- ear wick to penetrate if edema severe
- analgesics
- refer if concern for TM rupture
Otitis Media - common causes
- streptoccocus
- viral (when prescpitated by URI)
Otitis Media - symptomology
- decreased hearing
- otalgia
- fever
- aural pressure
- vertigo
- n/v
Otitis Media - exam findings
- erythematous TM
- possible bulla on TM
Otitis Media - management
- antibiotics: amoxicillin/clavulanate (augmentin)
- duration 5-7 days, will notice improvement 48 hours after start of tx
- refer if recurrent or chronic
Allergic Rhinitis (“hay fever”) - symptomology
- sneezing, itching
- rhinorrhea +/- post-nasal drip
- congestion, headache
- earache
- eye swelling
- fatigue, drowsiness, malaise
Allergic Rhinitis (“hay fever”) - exam findings
- allergic shiners
- nasal crease/ allergic salute
- nasal turbinates boggy, swollen, pale/grey/blue
- secretions thin/watery
Allergic Rhinitis (“hay fever”) - management
- anthistamines (2nd gen = non-drowsy) +/- decongestants
- refer to ENT it don’t or are not longer responding to first-line
Acute Sinusitis/ Rhinosinusitis - causes
VIRAL or bacterial
Acute Sinusitis/ Rhinosinusitis - symptomology
- pain in cheeks, facial pressure
- redness of nose, cheeks, eyes
- postnasal drainage
- stuffy nose
- cough or sore throat
- fever (bacterial)
- duration > 7 days
Acute Sinusitis/ Rhinosinusitis - exam findings
- tenderness to palpation of sinuses
- facial erythema
- periorbital edema
- purulent secretions
Acute Sinusitis/ Rhinosinusitis - workup
- viral: usually < 10 days that are consistent and not worsening
- bacterial: persistent symptoms > 10 days without improvement or biphasic pattern, onset of severe illness like high fever, nasal drainage, facial pain or at least 3-4 consecutive days at beginning
- severity of illness alone is not sufficient evidence to start antibiotics
Acute Sinusitis/ Rhinosinusitis - complications
- orbital cellulitis/ abscess = most common bacterial complication
Acute Sinusitis/ Rhinosinusitis - management
- analgesics (NSAIDs)
- oral/nasal decongestants
- bacterial also: if not getting better after 7 days, can start antimicrobial therapy (amoxicillin or augmentin)
Epistaxis - posterior vs. anterior
Anterior - usually venous, oozing, most common
Posterior - usually arterial, problematic because of airway compromise and difficult to control
Epistaxis - physical exam
- have equipment ready: illumination, suction, topical meds, cautery, packing materials
- if already packed, remove packing
- vasoconstrictor: helps reduce bleeding making it easier to visualize
- topical analgesic (lidocaine)
- nasal speculum - spread vertically
Epistaxis - management
- manual hemostasis with pressure
- vasoconstrictor, cautery
- packing if not responsive to cautery
- avoid strenuous activity 7-10 days, hot showers
Oral Cancer - leukoplakia
- very small plaque that occurs from chronic irritation
- looks like white patches
- some will go on to develop squamous carcinoma
Oral Cancer - Erythroplakia
- erythematous component
- very high malignant rate
- tobacco and heavy drinkers
- looks like red velvety asymptomatic patch
- almost always on floor of mouth, ventral tongue, or soft palate
Oral Cancer - Oral Lichen Planus
- potentially malignant
- lacy pattern
- buccal mucosa
Oral Cancer - workup
- incisional biospy
- exfoliative cytologic exam
- REFER to head and neck surgeon, specialist, or ENT
Oral Candidiasis - what is it?
- thrush
- immunosuppressed population
- common adults who wear dentures, poor dental hygiene, DM, anemia
- overgrowth of yeast on oral mucosa
Oral Candidiasis - common causative agent
C. albicans
Oral Candidiasis - symptomology
- pain
- white rash in mouth
Oral Candidiasis - exam findings
- creamy-white, curd-like, fluffy patches
- erythematous wound bed
- note recent antibiotic or steroid use
Oral Candidiasis - management
- antifungals: nystatin (not very palatable), clotrimazole
TMJ Syndrome - what is it?
- myofascial pain dysfunction (tension + spasm)
- internal derangement (often articulating discs)
- degenerative joint disease (arthritic changes)
- female > male
TMJ Syndrome - symptomology
- chronic pain in muscle of mastication
- locking of jaw
- ear clicking or popping
- headache or neck-ache
- bite that feels uncomfortable
- bruxism/ teeth clenching
TMJ Syndrome - exam findings
- ROM limitation
- palpable spasm of facial muscles
- clicking or popping of TMJ
- tenderness to palpation
- crepitus over joint
- lateral deviation of mandible
TMJ Syndrome - management
- analgesics (NSAIDs)
- muscle relaxants (benzos)
- moist heat and massage
- refer to ENT if persists
Pharyngitis - causes
- viral
- group A beta-hemolytic strep
Pharyngitis - symptomology
- sore throat
- dysphagia
- malaise
- rhinorrhea (viral)
- fever (bacterial)
Pharyngitis - exam findings
- erythematous pharynx
- exudate (bacteria)
- anterior cervical adenopathy (bacterial)
Pharyngitis - workup
- GABHS rapid test
- throat culture
Pharyngitis - Centor Criteria for GAS - don’t test until they meet criteria
- fever (1 pt)
- anterior cervical adenopathy (1 pt)
- tonsillar exudate (1 pt)
- absence of cough (1 pt)
score 0-1: treat supportively
score 4: can be treated with antibiotics with need for test, presumed positive
Pharyngitis - management
- viral: analgesics + supportive measures
- bacterial GAS: penicillin V (500 mg BID x 10 days) or amoxicillin
Epiglottis/ Supraglottitis - most common cause
- H. influenzae
Epiglottis/ Supraglottitis - symptomology
- rapid onset of sore throat
- odynophagia out of proportion
- muffled voice (hot potato voice)
- sepsis
Epiglottis/ Supraglottitis - exam findings
- tripod positioning
- tongue out
- drooling
- stridor (late finding)
- cervical adenopathy
- fever
- hypoxia
- respiratory distress
- severe pain on palpation
- toxic appearance
- swollen, erythematous epiglottis
Epiglottis/ Supraglottitis - workup
- nasopharyngoscopy/ laryngoscopy (specialist)
- XR = “thumb sign” - fat epiglottis that looks like a thumb
- cultures
Epiglottis/ Supraglottitis - managment
- ABCs!
- admit to ICU (potential intubation)
- antibiotics: ceftriaxone 1g PLUS vanco, clindamyin, or oxacillin
Peritonsillar Abscess - symptomology
- fever, malaise
- headache, neck pain
- throat pain
- dysphagia
- hot-potato voice
- odynophagia
- otaliga
Peritonsillar Abscess - exam findings
- mild-moderate distress
- tachycardia
- dehydration
- drooling
- trismus (trouble opening mouth)
- muffled voice
- rancid breath
- cervical lymphadenitis (anterior chain)
- asymmetric tonsillar hypertrophy
- displacement on tonsil
- contralateral deviation of uvula
Peritonsillar Abscess - workup
- CBC, monospot, cultures, rapid strep
- CT, intraoral ultrasound, XR
- fine needle aspiration
Peritonsillar Abscess - management
- ABCs
- analgesics
- drainage
- IV hydration
- empiric antibiotics
- antipyretics
- refer if necessary
