Module 2 - HEENT Flashcards
Occurs naturally in older adults; prevalence increases with age
Associated w/ decreased QOL, functional ability, increase in safety issues (falls, MVA), some cognitive impairment r/t decreased vision
Progressive and irreversible → surgical removal safe and effective
-> Increasing age, DM, smoking, fam hx, long term corticosteroid use, HTN, trauma, UV light exposure without protection
Cataracts
Opacity of lens
Patient ℅ glare or halo around lights (esp at night), difficulty night driving, polyopia (multiple images), difficulty reading newspaper
Cataracts
PE for cataracts
What to expect?
Visual exam (decreased visual acuity), normal pupillary response, haziness during fundoscopic exam Evaluate red reflex 1 ft away from patient→ if yellowish/whitish tint present inside pupil, refer
Tx for cataracts
Watchful waiting if early
Slow progression by: decreasing sun exposure (sunglasses, hats), smoking cessation
Refer if
-> Main cause of vision loss; functioning and ability to perform ADLs affected; pt understands surgery is needed and is agreeable
Main tx: surgical correction
Leading cause of blindness worldwide
Pressure buildup in eye where too much pressure on optic nerve r/t fluid buildup → causes irreversible damage to optic nerve and permanently changes sight
Glaucoma
“silent stealer of sight” (MOST COMMON)
Triad—> tearing, photophobia, excessive blinking (blepharospasm)
Open angle glaucoma
Vision damage irreversible; significant progression by time central vision affected
> 50 y/o, fam hx, African Americans, thin central cornea, myopia, DM2, corticosteroid use (long term)
Most do not complain of sx; some may ℅ peripheral vision loss
Triad—> tearing, photophobia, excessive blinking (blepharospasm)
Open angle glaucoma
PE for open-angle glaucoma
diagnostics?
Fundoscopic exam → optic disk cupping
Tonometer (measures intraocular pressure) → ophthalmology
Tx for open-angle glaucoma?
goals?
Topicals (drops to lower eye pressure: beta adrenergic antagonists, cholinergic eye drops) → expensive!
Book: BB- Timolol
Carbonic anhydride- Dorzolamide/ Brinzolamide
Surgery for severe cases
Goal= Decrease IOP & stop damage
education for open-angle glaucoma?
All members needs to get IOP checked
Med compliance
No excessive physical/ emotional stress, no straining
F/U is for LIFE- q3-6mo
True angular abnormality
Usually found when pt ℅ unilateral HA, visual blurring/cloudiness, rings around lights, n/v, photophobia
- Females, older age, asian descent
Ophthalmologic emergency → REFER
closed angle glaucoma
May see hazy cornea, nonreactive pupils that are semi dilated, scleral injection
tx= surgery
Ophthalmologic emergency → REFER
closed-angle glaucoma
Leading cause of blindness in those over 50 y.o in the US
Macular degeneration/ ARMD (age-related MD)
Two types of Macular degeneration/ ARMD
Dry (better prognosis) and wet
Early, intermediate and advanced sx of Macular degeneration/ ARMD
Early (dry): Asx
Intermediate (dry): vision changes, blurred in one or both eyes, difficulty with fine motor(reading, driving)
Advanced (wet/bad prognosis): Acute onset, metamorphosis (wavy—> straight lines)
PE for Macular degeneration/ ARMD
diagnostics?
Fundoscopic exam- dilation needed
Visual acuity. Confrontation
External/lids
Dx= Amsler grid (test each eye)
Tx for Macular degeneration/ ARMD diagnostics?
There is no cure
STOP smoking
Dry (better prognosis): High dose antioxidant vitamins/ Beta carotene + zinc: reduce risk and slow progression
Wet MD: intravitreal vascular endothelial growth factor (VEGF) injections: slow down progression + improve vision
Laser surgery
Localized bacterial infection of the skin and subq tissues anterior to the orbital septum (outside of bony orbit)
AKA: affects soft tissues in front of orbital septum
Typically seen in children
More common in winter r/t increase in sinus infections
(Hib, staph aureus, MRSA, strep)
Periorbital (preseptal) cellulitis
Swelling around eyelid and eye (periorbital), erythema and warmth in area, painful (but not painful to move eye), conjunctivitis may be present or the cause, blurred vision possible BUT pupillary response should be normal
Periorbital (preseptal) cellulitis
Tx for Periorbital (preseptal) cellulitis
Try to identify source of infection
If mild (no fever, mild erythema, patient stable) outpt with abx -> Amox-clav (augmentin) OR 3rd gen cephalosporin
If MRSA suspected
Double strength trimeth-sulfa (bactrim), clindamycin, or doxy (no doxy <9 y/o)
Requires CLOSE followup, check back in 24 hours, if no improvement or worsens → refer for IV abx
If questioning preseptal vs orbital → refer for CT
More serious than periorbital; must differentiate btw the two; refer if you can’t!
Infection located posterior to orbital septum
Frequently preceded by a sinus infection (ethmoid sinuses)
Can have serious complications (blindness, death)
Can put pressure on optic nerve if the infection spreads which can lead to brain abscess and sepsis
(roup A beta-hem strep, s aureus, s pneumoniae, Hib, other strep, anaerobic microorganisms)
Orbital cellulitis
Pain, vision loss, restricted motility/EOM, eye erythema and edema, exophthalmos (bulging of eye), proptosis and diplopia, fever (usually >102), systemic malaise, pain with mvmt of eye
Orbital cellulitis
Group 1: preseptal cellulitis Group 2: orbital cellulitis Group 3: subperiosteal abscess Group 4: intraorbital abscess Group 5: cavernous sinus thrombosis
Chandler Classification for Acute Sinusitis
Tx for Orbital cellulitis
Refer to ED or ENT (if fast) → EMERGENCY
CT to confirm dx, IV abx, surgical intervention common
NP role in Orbital cellulitis
Take complete hx, assess visual acuity and ocular ROM, full HEENT exam and inspect nares, check neck flexibility (r/o meningitis), determine preseptal vs orbital (if considering orbital → refer)
Understand complications: meningitis or progression down grade scale
Occurs when the sensory portion of the retina is separated from the underlying epithelium
Result of: vitreous fluid moving through a small hole in the retina, inflammation, tumor, trauma, adhesions mechanically pulling on retina
Retinal detachment
PE for possible retinal detachment
Visual acuity, visual field testing, fundoscopic exam
Optometry: slit lamp, dilated exam
Can use US
REFER immediately if RD is suspected → most require surgery
NP role for retinal detachment
Identify high risk, complete hx of vision and changes, fundoscopic exam (dilated is better), know s/s and know how to refer
an intraocular tumor that develops in the retina, more common in childhood (<15y.o)
The majority unilateral, but can be bilateral (hereditary) white pupil (leukocoria) “ cat eye reflex”
Strabismus (most common), decreased visual acuity
Orbital cellulitis, photophobia, hyphema, hypopyon (pus)
retinoblastoma
Screening for retinoblastoma
All infants red light reflex screening before discharge from nursery + every visit
High-risk retinoblastoma screening rules?
High risk: Dilated exam 0-3 months: monthly 3–12 months:Q2mo 12-36months: Q3mo 36-60month: Q4-6mo
High-risk retinoblastoma screening rules?
High risk: Dilated exam 0-3 months: monthly 3–12 months:Q2mo 12-36months: Q3mo 36-60month: Q4-6mo
Symptom, NOT a diagnosis
Varying degrees, may have a benign cause (typically) or may be more serious
Most episodes acute and limited
RF= Viral infection, vocal abuse (yelling, screaming, singing), smoking, inhaling an irritant, recent intubation, allergies, GERD
Serious causes: allergic reactions (anaphylaxis), epiglottitis, trauma, neoplastic lesions
Hoarseness/Dysphonia
tx for Hoarseness/Dysphonia caused by acute laryngitis
(most viral): supportive care, lozenges, cool drinks, vocal rest, steroids occasionally
Tx for Hoarseness/Dysphonia caused by GERD?
H2 blocker or PPI
What to do if Hoarseness/Dysphonia persisits > 2-3 weeks?
refer to ENT
Benign tumor found in middle ear made of of keratinized epithelial cells that can grow, causing damage to middle ear structures, or even extend into external ear canal
Can be congenital or acquired
Serous OM + hearing loss → 🚩 red flag
Although benign, becomes a prob when grows and causes damage
Cholesteatoma
Congenital vs. Acquired Cholesteatoma
Congenital: whitish or pearl-like mass behind translucent TM
Acquired: found on the TM and can be associated with a defect
Dx and Tx for Cholesteatoma
TM exam with otoscope; audiograph to assess hearing (ENT), CT to verify
Surgery for removal; early identification associated with better outcomes
how does labyrinthitis differ from benign paroxysmal positional vertigo (BPPV)
BPPV attacks are shorter, caused by debris, WORSE with lying down
: vertigo AND hearing loss in one ear; acute onset lasts days to couple weeks; n/v; fullness or tinnitus in affected ear; URI sx; Sx IMPROVE while pt is laying down with eyes closed
labyrinthitis
how to manage labyrinthitis
Bed rest, antiemetics for nausea, meds to suppress vertigo (meclizine/antivert, dramamine, low dose ativan/diazepam)
If no improvement in 2 weeks or worsens in any way → ENT
Chronic ringing in one or both ears, COMMON
is a symptom, NOT a disease → find the cause if possible
>6 mos considered chronic
Tinnitus
What is important to differentiate in pts with tinnitus?
ringing in one or both ears
Ask pt to describe sound (can be high pitched, roaring, pulsating, rushing)
Audiogram → will demonstrate high-frequency hearing loss
test for syphilis and lyme dx if unilateral
Meds that can cause tinnitus
Loop diuretics, salicylates (ASA), NSAIDS, quinine, abx (aminoglycosides, erythro, vanc, polymyxin B, neomycin), some chemo, topical agents, antiseptics
Typically they damage the cochlea and auditory nerve, vestibular system
If caught early, typically reversible
How to dx tinnitus
Hearing tests (Weber/Rinne, audiogram) test for acuity or loss Labs for suspected etiology
How to manage tinnitus
Refer unilateral or pulsatile to specialist
Find cause to manage or reduce further damage
Counseling if depressed or severely affected
Stop any ototoxic drugs, decrease caffeine and nicotine, no loud noises, ear protection, white noise for sleeping
Triad: vertigo, tinnitus, hearing loss
Meniere Disease
dx of exclusion
Chronic condition of inner ear (recurrent vertigo and hearing loss)
Excess fluid and pressure in the labrinth of the inner ear that distends the structures and damages the vestibular system (balance) and cochlear hair cells (hearing)
Meniere Disease
Intermittent attacks of vertigo lasting minutes - hours, n/v, pressure in ear
HEENT- exclude AOM/ infection, Neuro
Weber: sound to unaffected ear; rinne: A>B
Nystagmus during attacks
Meniere Disease
Dx for Meniere Disease
Clinical or response to tx
Criteria: 2 episodes spontaneous vertigo at least 20 mins, audiogram hearing loss, tinnitus/ fullness, and exclusion of other causes
MRI- r/o CNS lesion
Labs: TSH, RPR (syphillis), BS, Lyme serologies
Mgmt for Meniere Disease
No cure Refer to otolaryngologist for testing and mgmt Viral: anti-virals Mgmt vertigo Autoimmune: + response to steroid
How to manage sx of Meniere Disease
Anti-emetics + antihistamines w/ anti-cholingeric effects suppress the vestibular system while improving antiemetics relief
-> Meclizine (least sedating), promethazine, dimenhydrinate
Vertigo
-> Benzos ( GABA agonist effect)- daily not d/t ADDICTION and W/D
Quick onset with duration for vertigo attack (ok if infrequent)
Lower Na intake- decreases build up of pressure
