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Speciality Medicine > Lecture 9: HEENT > Flashcards

Lecture 9: HEENT Flashcards

1
Q

Basic Eye Exam:
* What is first?
* What do you stain the eye with?
* Look for what type of sign?
* Why do you do slit lamp exam?
* _ Testing

A
  • Visual acuity first
  • Stained exam with fluorescein and tetracaine
  • Look for Seidel sign – bleb leakage indicates perforation
  • Slit lamp exam-> look at posterior eye
  • Pressure testing
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2
Q

What findings will require eye consult and possibly transfer?

A

Any acute findings such as retinal artery occlusion, iritis or acute closed angle will require eye consult and possibly transfer

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3
Q

Eye
* What are questions you need to ask? (4)

A
  • Size of pupils, are they equal?
  • Do they react?
  • Is there a globe injury?
  • Are there lid injuries?
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4
Q

What is this? How do you manage it?

A

hyphema
* Immediately put them at 45 degree recline to absorb the blood and manage the BP

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5
Q

Swelling of eye. Awoke with symptoms. Hx of sinus infection
* What is going on with the patietn?
* What should you order?

A

Preseptal or orbital
* more likely to be orbiral due to sinus infection
* CT with (better for infection) or without (just sinus)

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6
Q

Preseptal/orbital cellulitis:
* What is preseptal?
* What is orbital? Secondary to what?

A

Preseptal-
* Infection of anterior tissues (lid, lacrimal glands)-> Does not pass muscle

Orbital-
* Infection of deep structures of orbit
* Secondary to rhinosinusitis(86 to 98% of cases) or trauma, surgery, dental infections

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7
Q

PRESEPTAL/ ORBITAL CELLULITIS
* How do you differentiate between the two?

A

CT scan is usually necessary to differentiate between the two

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8
Q

ORBITAL CELLULITIS: Etiology
* What are the MC organisms? (3)
* Consider what organisms in immunocomproised patients?

A
  • Staph aureus pyogenes, Streptococcus pneumoniae, anaerobic infections
  • Consider Aspergillus and Mucor (molds) in immunocompromised patients

Sinitis: viral-> cox, adenovirus, covid but sinus still has lot of bacteria in sinus (increases with smoking, COPD)

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9
Q

What is this?

A

Left: Orbital becuase eye is red
Right: Orbital (even though it looks like preorbital)
* GET A CT IF UNSURE

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10
Q

PRESEPTAL VS ORBITAL CELLULITIS
* When are you allow to treat as outpatient? (8)

A
  • No fever
  • No pain with full extraocular movements
  • No chemosis (swollen, red, edematous cornea) or ptosis
  • Compliant patient
  • No underlying immune problems (HIV, diabetes, Autoimmune stuff etc.)
  • Does not appear toxic
  • No decreased vision
  • No signs of sinusitis

ALL PRESEPTAL

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11
Q

Red flags for orbital? (2)

A
  • Painful movement, ptosis
  • Toxic-> systematic issues
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12
Q

PRESEPTAL VS ORBITAL CELLULITIS
* What is the imaging?
* When in doubt do what?
* If preseptal, what does the patient need to do?

A
  • CT Scan or MRI
  • When in doubt, admit.
  • If preseptal, daily follow up with ophthalmology
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13
Q

What is this?

A

ORBITAL

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14
Q

What is going on here?

A

Orbital
* right eye abscess pressing on the Rectus muscle (pain with EOM)

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15
Q

Inpatient treatment of oritbal
* What do you need to order and consult?
* How do you tx infection?

A

Need blood work, cultures, surgical (ENT/oculoplastics) consult

IV antibiotics:
* Vancomycin (MRSA) + ceftriaxone (typical gram - and + bugs) or ampicillin sulbactam (Dr. S does not like because it takes long time) or piperacillin tazobactam (Good choice because cover flagulets)
* Amphotericin B if fungal (immunocompromise state-> CD4 under 50)

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16
Q

Dacryoadenitis:
* What is it?
* Onset?
* What are the sxs?
* What type of region?

A
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17
Q

Dacryocystitis
* What is it?
* Onset?
* What are the sxs?
* Where is it?

A

Worst than dacryoadentitis

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18
Q

Dacryoadenitis
* Infection of what?
* What are the common bugs or issues that cause this? (3)

A
  • Infection of the lacrimal gland
  • Viral (mumps), bacterial (staphylococus, gonorrhea), tumor or mass (sarcoid)

Viral MC

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19
Q

Dacryoadenitis
* What are the sxs?

A

Symptoms include swelling of lid, redness, pain, discharge and/or tearing, preauricular node

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20
Q

Treatment of Dacryoadenitis/cystitis
* What is the supportive care?
* What do you do if fluctuant?
* Refer for what?

A
  • Hot compresses for viral/ bacterial infection
  • I & D if fluctuant, likely done by plastics (MORE IN Dacryocystitis)
  • Refer for follow up or admit/transfer
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21
Q

Treatment of Dacryoadenitis/cystitis
* What anx needed?
* What if pen allergic?
* What do children need?

A
  • Cephalexin (Keflex) or Cefaclor (Ceclor)
  • Erythromycin for penicillin allergic
  • Children need IV antibiotics
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22
Q

Shotgun injury to eye, presents to the trauma bay.
* What do you need to do for this patient?

A

Consult ophthalmologist because they need to go to OR because if patients does not go to OR they will get septal invasion and having eye problems-> VISION LOST

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23
Q

PENETRATING EYE INJURIES (OPEN GLOBE)-
* What hx questions do you need to take on patient? (5)
* What do you place on eye? Do not remove what?

A
  • Allergies
  • Significant past medical history
  • Medications
  • Eye shield- DO NOT REMOVE OBJECT!
  • Tetanus toxoid up to date
  • Last food and drink/ LMP

IMPORTANT FOR SURGERY

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24
Q

PENETRATING EYE INJURIES (OPEN GLOBE)
* What do you need get hx of before injury? What should if give if eye is painful?

A

Vision and history of vision before injury – if painful give topical analgesic
* Painful in even conjunctivitis or septal cellulits-> document that you cannot do vision

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25
Q

PENETRATING EYE INJURIES (OPEN GLOBE)
* What anx do you give?
* What do you need to do for surgery?
* Order what?

A

IV antibiotics: variable (caused by something like animal/human bite)
* Ceftriaxone or cephalon
* Vancomycin and (ceftazidine OR fluoroquinalone)-> allergy profile

NPO+ Blood type (type and screen)

Order CT Orbit scan, without contrast (because looking for FB)

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26
Q

Patient hit in the eye with a racket ball. Not wearing eye protection
* What is going on with the patient?

A

Infraorbital fracture
* inferior rectus m. is trap

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27
Q

BLOWOUT FRACTURE
* What is the mc area?
* Can have entrapment of what?
* What may be present?

A
  • Most common area: fracture of the inferior orbit (floor)
  • Can have entrapment of inferior rectus or inferior oblique muscles
  • Diplopia may be present
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28
Q

BLOWOUT FRACTURE
* What is the txt? (4)

A
  • Needs surgery and ophthalmology referral
  • Augmentin/ Azithromycin (need this because inferior floow connects to maxillary sinus-> dirty so this helps prevent orbital cellulitis
  • HOB elevated
  • Avoid nose blowing
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29
Q

What is going on with this patient?

A

Temporal arteritis

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30
Q

TEMPORAL ARTERITIS (Giant Cell Arteritis)
* Typically a hx of what?
* Common in what ages?
* What are sxs?(5)

A
  • History of autoimmune disease
  • Older patients- RARE before age 50
  • Temple pain (palpable), headache, loss of vision, jaw claudication
  • Ear pain can also be a symptom
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31
Q

TEMPORAL ARTERITIS (Giant Cell Arteritis)
* What can you get to eval aneurysm?
* Causes what?
* Increase risk of what?
* Double risk of what?

A
  • Get US to eval aneurism
  • Causes blindness due to ischemia
  • ↑Risk of thoracic aneurysms x17 times.
  • Double risk of abdominal aneurysms
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32
Q

TA Lab Evaluation and Treatment
* Elevated what?
* What is definitive test?
* Should not delay what?

A
  • Elevated ESR and CRP
  • TA biopsy is definitive test for diagnosis but can be negative.
  • Do not delay steroid therapy until biopsy results
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33
Q

TA Lab Evaluation and Treatment
* What is the medication?
* Start meds when?
* Admit for what?

A
  • Early high IV dose steroids (methylprednisolone 1 Gram IV)
  • Start before biopsy
  • Admit for Neuro-ophthalmologist/ Neurologist/ Rheumatologist evaluation
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34
Q

What does a retinal artery occlusion show? Retinal detachment show?
* Who should you call for both of these?

A
  • Retinal artery occlusion: Cherry red spot
  • Retinal detachment: Start with floaters and reduced vision (can use US to look for it)
  • Call ophthalmology
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35
Q

Conjunctivitis
* Usually result of what?
* MCC?
* Consider bacterial when?

A
  • Usually as a result of direct inoculation
  • MCC is viral (typically adenovirus)
  • Consider bacterial if <2yo (S. aureus) and most will have purulent exudate

Differential: STI, chronic conjunctivitis, autoimmune,contact lenses use, allergies, episcleritis

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36
Q

Conjunctivitis
* Always do what?
* What is first line?

A
  • Always stain all eye complaints and document pressures
  • Baby shampoo scrubbing and warm compresses are first-line
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37
Q

Conjunctivitis
* Typically therapy is what? (anx)

A

Typical therapy is antibiotics (ointment preferred) and ophthalmology referral
* Erythromycin or Tobramycin
* Cipro for contact lenses keratitis(pseudomonas coverage)

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38
Q
  • You see a 24yo WM welder for evaluation of right eye pain, tearing and blurry vision. He was grinding metal and is here for further evaluation.
  • After you get visual acuity and stain his eye, you see this:
A

metal FB
* Early on because no rust ring
* Get imaging + tetanus update

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39
Q

Corneal FB
* What are three ways to remove it?

A
  • Cotton swab
  • Tip of needle (at least 22ga)
  • Burr tool
40
Q

Corneal FB
* If you suspect metal FB by history but cannot see it, what do you do?
* After eye consult, cover with what?
* Always do what?

A
  • If you suspect metal FB by history but cannot see it -> order Orbital CT
  • After eye consult, cover with ABX (ointment!)
    * Need a follow up for full stain to make sure the patient is not getting worst
  • Always evert eyelids
41
Q

Corneal abrasion:
* What should you do for every signal eye complaint?
* How do you tx

A
  • Stain the eye
  • Ointment of erythromycin, tobromycin or cipro if allergic
42
Q

Chalazion and Hordeolum
* both technically what?
* Advise what?

A
  • Both are technically “styes”
  • Advise to discontinue make-up use
43
Q

Chalazion
* What is it?
* May require what?
* Treat with what?

A

Chalazion (less of a stye)
* Noninfectious (granuloma) Meibomian/Zeis gland occlusion (generally painless)
* May require incision
* Treat with warm compresses & steroids

44
Q

Hordeolum
* What are they?
* usually what?
* May lead to what?
* Treat with what?

A

Hordeolum (more of a stye)
* Most are Infectious from eyelash follicle obstruction (few can be sterile)
* Usually painful
* May lead to blepharitis or preseptal cellulitis
* Treat with warm compresses, massage and if not better -> topical ABX

horrible hordeolum

45
Q

Pinguecula and Pterygium
* both are what?
* Develop due to what?
* What is the difference?

A
  • Both are protein and fat deposits in the conjunctiva
  • Develop due to UV exposure
  • Pinguecula: Does not cross corneal limbus
  • Pterygium: Crosses the corneal limbus

Trick: Y (pterYgium) would you cross the line

46
Q

Nose Injuries
* If there are fractures, what do you need to look for? What do you need to do with them?
* Any clear drainage that could be what?

A

Fracture-> look for Septal hematoma
* These need to be aspirated or will cause septal necrosis.

Any clear drainage that could be CSF fluid (Filter paper halo or glucose)

47
Q

How do you txt?

A
  • Topical lidocaine then aspirate

OR

  • Inject lidocaine and cut
48
Q

Septal Hematoma In Nasal Fracture
* Usually related?
* Risk of what within 3 days?
* Risk of what? (2)

A
  • Usually trauma related
  • Risk of hematoma infection within 3 days
  • Risk of septal perforation
  • Risk of saddle nose
49
Q

Septal Hematoma:
* How do you txt it?
* What is the expection?

A
  • Needle aspiration (or #15 scalpel) under topical anesthesia with 18 or 20 gauge needle.
  • Except in patients who present immediately, specimens should be sent for gram stain and aerobic/ anaerobic cultures.
50
Q

Septal Hematoma
* What meds should you give?
* Incise/ aspirate what?
* Bilateral staggered incisions should be made what?

A
  • Antibiotics (cover typical respiratory pathogens)
  • Incise/ aspirate the mucosa over the area of greatest fluctuance without incising cartilage.
  • Bilateral staggered incisions should be made for bilateral hematomas to avoid a through-and-through perforation

  • cephalexin 250-500 mg QID and
  • amoxicillin/clavulanate 250-500 mg TID.
  • clindamycin 150-300 mg QID
  • trimethoprim/sulfamethoxazole DS BID
51
Q

Epistaxis
* What are some causes?

A
  • Traumatic: Blunt force
  • Spontaneous: URI, anticoagulants, HTN

Anterior: Commonly seen in winter months dt thinner nasal walls
Posterior: Anticog problems

52
Q

Epistaxis txt of unilateral and bilateral?

A
  • Unilateral: Requires packing and likely dc
  • Bilateral: Likely requires admission and ENT consult
53
Q

Epistaxis
* Always cover for what with nasal rockets?
* What is alternative
* Good idea to check what on a patient on anticoagulation?
* Imaging for what?

A

CT brain: for canadian head CT rules or C-spain clearnance

54
Q

Mouth
* What are common issues?

A
  • Dental trauma
  • Bleeding
  • Secretions
  • Foreign bodies must identify and remove
  • Jaw dislocations
  • Tongue and mucosa injuries
  • Injuries to the palate or floor of the mouth
55
Q

If you have tongue frenulum issue then what do you need to look for?

A

Tongue frenulum = Fx Mandible

Mandibular fracture if torn frenulum.

56
Q

What is going on? What do you do?

A

Mandible fracture -> look for second fx
* Need IV ABX ASAP and call MaxFace Sx.

57
Q

Dental injuries
* Seen with what?
* R/O what?

A
  • Assaults
  • Dental caries
  • R/O abcess, ludwig angina (into submanibular space) -> see drooling, trismis and unable to handle secreations
    * EMERGENCY
58
Q

Dental injuries
* What are two ways of describing locations?

A
  • Numbers
  • Names
59
Q

What do you do if the tooth completely knocked out? (3 options)

A
  • First, try to put it back in its socket.
  • The next best option is putting it in a glass of milk.
  • If milk isn’t available, hold the tooth in your cheek pouch (saliva is better than tap water).
60
Q

Tooth knockout:
* Do not let what? Why?
* When should reimplantation occur?

A

Don’t let it dry (periodontal cells will die)

Reimplantation should occur within 20-30 minutes for best results, most studies suggest to be within 18hours.
* Up to 2 weeks from trauma can happen

61
Q

Dental Pain Management
* usually includes what?
* What is difficult to control? Why?
* Can over avulsion with what?
* _ block

A
  • Usually includes antibiotics
  • Pain difficult to control long term due to nerve exposure or pulpitis
  • Can cover avulsion with wax
  • Dental block
62
Q

Fill in for how to do these

A
63
Q

Fill in for how to do this block

A
64
Q

Fill in how to do for regional block

A
65
Q

What is going on here? When do you need to fix it?

A

Tongue lacerations (common trauma, and seizures)
* Suture if over the size of piece of corn

66
Q

Tongue Lacerations
* Look for what?
* Excessive bleeding can cause what?
* How do you tx the pain?

A

Look for retained FB (teeth)

Excessive bleeding can cause swelling, so protect airway

Don’t be cruel, treat the pain
* Topical lidocaine soaked 2x2~5mins
* Infiltrate wound with lidocaine
* May have to sedate a child

67
Q

Tongue Lacerations
* Generally close if laceration is what? What suture do you use?
* Prophylax with what?

A
  • Generally close if laceration hole fits a piece of corn or its gaping
  • Use absorbable suture (Chromic gut, vicryl)
  • Prophylax with ABX (augmentin or 2nd/3rd cephlo-> ceftriaxone
68
Q

Pinna Hematoma
* What is the cause?
* Results in what?

A
  • Blunt trauma shears the perichondrium from the underlying cartilage and tears adjoining blood vessels
  • Result: tissue necrosis and asymmetrical formation of new cartilage->“cauliflower ear”
69
Q

Treatment of pinna hematoma:
* If up to 24-48 hours old and, <2 cm:
* If >24-48 hours:
* Place what?
* Suture with what?

A
  • If up to 24-48 hours old and, <2 cm: aspiration with 18 gauge needle and syringe (after topical anesthesia)
  • If >24-48 hours, I & D of hematoma or aspiration
  • Place drain/ leave space to drain, 18 gauge catheter 1cm left in place
  • Suture with mattress suture
70
Q

Treatment of pinna hematoma
* Common bacteria?
* What meds do you give (adults vs peds)
* What do you need to cover the ear with?
* Refer to who?

A

Give oral antibiotics to cover Staph, Strep, and Pseudomonas species
* Adult: levofloxacin IV, Cipro PO or clindamycin
* Peds: amoxicillin/clavulanate

Pressure dressing

Refer to ENT for daily F/U.

71
Q

How do you do a needle aspiration of an auricular hematoma?

A
72
Q

What is the process of covering the ear from ear hematoma?

A
73
Q

What is going on?

A

Mastoiditis

74
Q

Mastoiditis
* How do you dx?
* Call who?
* Usually a dx of what?
* Will require what?

A
  • Clinical diagnosis, can confirm with CT
  • Call ENT
  • Usually a diagnosis of admission/transfer
  • Will require IV ABX (ceftriaxone or clindamycin) and likely surgical drainage->Need to clean out area because if not then higher risk of encephalitis
75
Q

Foreign Bodies
* What do you do with bugs?
* What can you do to decrease dicomfort and anxiety when trying to get FB?
* What is the alt?

A
  • Kill whatever if it is still alive->Insects can be drowned in lidocaine
  • Use otoscope tip to pass instruments to orifice to avoid contact to wall which will cause discomfort or anxiety
  • Can use suction, lavage (calorics) or refer to ENT

Lavage: can cause vertigo

76
Q

Pharyngitis Differential
* What are 5 ddx?

A
  • Viral
  • Group A streptococcus
  • Mononucleosis
  • Gonorrhea
  • CMV
77
Q

Diagnosis pharynitis
* PE is not always what?
* False negative in what?
* How long does it take for culture?

A
  • Physical exam is not always reliable, although few findings are very specific
  • Rapid strep test- 10 % false negative
  • Culture- 48 hours
78
Q

Diagnosis pharynitis
* When can mono spot test be negative? What are other abnormal lab values?
* What NAAT?
* What do you order for CMV

A
  • Mono spot test- can be negative early, lymphocytosis and atypical lymphocytes
  • GC NAAT
  • IgM, IgG for CMV (CD4 under 50)
79
Q

When to treat with antibiotics for pharygitis? (5)

A
  • Fever
  • Pus on tonsils
  • Adenopathy
  • Hyperemia – increased blood flow to tissue
  • High WBC count
80
Q

What is the centor criteria?

A

1)age 3-14 years
2)tonsillar exudates or swelling
3)tender anterior cervical adenopathy
4)absence of cough
5)history of fever

81
Q

Mononucleosis
* What causes it? (organism)
* What is high?
* What is txt?
* Avoid what? (2)

A
  • Epstein- Barr virus
  • lymphocytosis
  • Treatment: supportive therapy, +/- oral/ IV prednisolone
  • Avoid contact sports for 4-6 months (can rupture spleen)
  • Avoid amoxicillin (cause rash)
82
Q

Cytomegalovirus (CMV)
* Like what?
* What is the txt?

A
  • Mono like syndrome when negative for mono
  • Supportive treatment
83
Q

Treatment of GABHS
* What is the txt? PCN allergy?

A
  • Penicillin X 10 days for adults and peds
  • Cephalexin 500mg BID x 10 days
  • Increased resistance to PCN G
  • Azithromycin in PCN allergy
84
Q

Peritonsillar Abscess (PTA)
* Ages?
* What is it?
* What are the sxs?

A
  • Anyone aged 10-60 years
  • Infectious abscess of the soft palate
  • Soft palate erythematous, edematous, “Hot potato–sounding” voice
  • Dysphagia
  • Displaced uvula laterally

Bounded by the tonsillar pillars anteroposteriorly, the piriform fossa inferiorly, and the hard palate superiorly

85
Q

Peritonsillar Abscess (PTA)
* What is the txt?
* What imaging can you do?

A
  • CT with contrast
  • Txt: under 2cm-> steriod and anx and then over 2cm then steroids and drainage
    * Give steriods before drainage

anx (clindamycin, amox clav, vanco, linezolid)

86
Q

Peritonsillar abscess:
* What are the mc aerobic species?
* What are the most common anaerobic species?

A
  • most common aerobic species: Streptococcus species (especially Streptococcus pyogenes), Staphylococcal, H. Influenza
  • most common anaerobic species: Prevotella species and Peptostreptococcus species
87
Q

I think this is low yield

Treatment PTA with experienced Clinician or ENT
* Obtain what?
* Then How do you aspirate?

A
88
Q

Retropharyngeal abscess
* What is happening in the basic ER exam?
* What are late findings on exam?
* What is usually necessary?

A
  • Pain out of proportion to basic ER exam
    * Dysphasia, fever, but tonsil is midline and everything is okay
  • Late findings on exam: stridor and stiff neck
  • Look with laryngoscope or glidoscope
  • CT Soft Tissue Neck usually necessary (with contrast)
89
Q

Retropharyngeal abscess
* What is necessary to protect?
* Call who?
* What meds?

A
  • Protect airway is necessary
  • Call ENT for consult
  • IV ABX (Ceftriaxone or Clinda)
  • IV steroids
90
Q

Presenting Symptoms/Signs of Para”pharyngeal” Space (8)

A

Carotid artery erosion=> delay in txt

91
Q

Etiology of Retropharyngeal abscess
* Infected what? (4)

A
  • Infected MOLARS – most common
  • Infected tonsils
  • Infected sinuses
  • Lymphatic spread

Reason why every single dental pain gets anx

92
Q

What is this? How can you tell if there is submaniblar involvement

A
  • Parapharyngeal Space Abscess
  • Submandiblar: Pain Tounge Mvts (think ludwig’s with this)
93
Q

What is going on? Who does this happen in?

A

Buccal Space Abscess
* Inner check disease-> under the skin with the tissue itself
* Babies and adults with trauma to face (usually did not get txt)

94
Q

Ludwig’s Angina
* What is it?
* What happens to the tongue?
* It is usually caused by what?

A
  • Ludwig’s angina is a bilateral board-like swelling of the submandibular, submental and sublingual spaces.
  • The tongue is elevated/edematous
  • It is usually caused by infection of the second and third molar teeth.
95
Q

Ludwig’s Angina
* Typically occurs in who?
* There is what?
* On x-ray, there may be what?

A
  • Typically occurs in diabetics
  • There is a brawny induration of the area without palpable fluctuance.
  • On x-ray, there may be gas in the tissue.
    * CT is better though
96
Q

What are the sxs of ludwig angina?

A

Whole thing has to be excised. Intubate all!!!

97
Q

What is the txt of ludwig angina

A

This patient needs I&D, high doses of antibiotics, steriods and airway observation
* Anaerobic infection.

Speciality Medicine (12 decks)

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