The Ear and Eye

Question 1

Types of hearing loss (2)

Answer 1

1. Conductive hearing loss - from (physical/mechanical) problems that limit the movement of the sound wave through the external and middle ear.
2. Sensorineural hearing loss - damage in the inner ear or nerves that sense sound.

Question 2

What can cause conductive hearing loss?

Answer 2

1. Obstructed external ear canal
2. Perforated tympanic membrane
3. Dislocated ossicle
4. Otitis media
5. Otitis externa
6. Osteosclerosis
7. Congenital
8. Cholesteatoma - squamous epithelial overgrowth

Question 3

What can cause sensorineural hearing loss?

Answer 3

1. Acoustic trauma - exposure to loud noises
2. Barotrauma - pressure trauma
3. Head trauma
4. Ototoxic drugs
5. Infection
6. Aging
7. Acoustic neuroma
8. SSNHL - unilateral hear loss over 72hrs
9. Meniere dz - hearing loss, vertigo and tinnitus
10. Vascular dz
11. MS

Question 4

What are the two types of tinnitus?

Answer 4

Subjective - most common, audible only to pt, due to damage of fine hair cells.
Objective - rare, can be heard with stethoscope over pt’s ear due to vascular issues.

Question 5

What are the two types of vertigo?

Answer 5

Subjective - pt has the impression they are moving

Objective - pt feels that objects are moving around them

Question 6

True vertigo

Answer 6

Sensation of movement caused by asymmetry in the vestibular system.

Peripheral vertigo - labyrinth or CN VIII
Central vertigo - cerebellum, vestibular cortex in temporal lobe

Question 7

Non-vertigo

Answer 7

Lightheadedness - hypoperfusion of the brain

Disequilibrium - only feel unsteady when they are walking

Question 8

Work-up for vertigo

Answer 8

Hx: Onset (sudden or gradual), Duration (episodic or long-lasting)
PE: general exam, otological exam, extraocular movements (H in space test), hearing tests, proprioception, vestibular imbalance

RED FLAG: head or neck pain, ataxia, loss of consciousness, focal neurological deficit

Question 9

Ear pain

Answer 9

Otalgia
Causes: external (impacted cerumen or foreign body, local trauma, otitis externa), middle (eustacian tube obstruction, OM, neoplasms), referred pain from TMJ, wisdom teeth, local infection, tumors, neuralgia

RED FLAG: DM, immunocompromised, red or pain over mastoid, severe swelling, chronic pain

Question 10

Ear discharge

Answer 10

Otorrhea
Acute d/c causes: otitis media with TM perforation, post-tympanostomy tube, otitis externa
Chronic d/c causes: cancer, cholesteatoma, chronic purulent OM, foreign body, mastoiditis

RED FLAG: same as otalgia

Question 11

Acute otitis externa (AOE)

Answer 11

Etiology: infections, swimmer’s ear, forceful cleaning of the ear, trauma
S/Sx: itching, pain, ,discharge possible, loss of hearing
PE: pinna and tragus painful when pressed or tugged on, TM is normal, fever, LA

Question 12

Chronic otitis externa (COE)

Answer 12

Etiology: often follows psoriasis, seborrheic dermatitis, eczema, allergy, fungus
S/Sx: same as AOE
PE: same as AOE but tragus and pinna may be less painful

Question 13

Perichondritis

Answer 13

Etiology: trauma, insect bites

Question 14

Tumors

Answer 14

Etiology: sebaceous cysts, gouty deposits, BCC, SCC

Question 15

Acute otitis media (AOM)

Answer 15

Etiology: infection
S/Sx: pain, fever, dec hearing, moodiness, irritability
PE: bulging red TM, no visual of bony landmarks
Complications: progresses to OME, bilateral infection can lead to hearing loss and speech development issues, mastoiditis, rupture of the TM

Question 16

Otitis media with effusion (OME)

Answer 16

fluid behind TM, may be unresolved AOM or inflammation

Question 17

Chronic OM with effusion (COME)

Answer 17

S/Sx: hearing impairment, mild otalgia, overlapping sx of common cold
PE: amber or gray, TM is intact bubbles or air/fluid level may be seen, chronic cervical LA

Question 18

Chronic suppurative otitis media (CSOM)

Answer 18

Chronic inflammation of the middle ear that persists at least 6 wks with TM perforation and otorrhea
Etiology: AOM, trauma
S/Sx: hearing loss, chronic purulent d/c, painless

Question 19

Cholesteatoma

Answer 19

Growth of keratinizing squamous cell epithelium that invades the inner ear
Etiology: congenital, primary acquired, secondary acquired
S/Sx: painless otorrhea, either unremitting or frequently recurrent, conductive hearing loss

Question 20

Myringitis

Answer 20

Inflammation or infection of the TM.
Etiology: primary and secondary causes
S/Sx: serosanguinous otorrhea, otalgia, hearing impairment, if acute: sudden onset of ear pain that lasts 24-48hrs

Question 21

Acute mastoiditis

Answer 21

Suppurative infection in the mastoid air cells
Etiology: complication of severe AOM
S/Sx: redness, swelling, tenderness behind ear, fever, hearing loss, profuse creamy ear d/c, throbbing pain
PE: bulging TM, tenderness, postauricular fluctuance
REFER!! Serious complication

Question 22

Ostosclerosis

Answer 22

Genetic metabolic bone dz affecting otic capsule and ossicles, leads to overgrowth of footplate in stapes/dysfunction
S/Sx: progressive bilateral, hearing loss and tinnitus

Question 23

Tympanosclerosis

Answer 23

Sclerosis of the TM from COM that leads to stiffening of the TM and impaired conductive hearing
S/Sx: progressive hearing loss
PE: whitish plaques on TM

Question 24

Viral labyrinthitis

Answer 24

URI precedes the onset of sx in up to 50% of cases, sudden unilateral hearing loss and severe vertigo, assoc. with nausea and vomiting. Age 30-60 most common
Etiology: potentially Herpes Zoster Oticus
PE: spontaneous nystagmus towards the normal side with diminished or absent caloric response.

Question 25

Bacterial labyrinthitis

Answer 25

Bacterial infection of the inner ear. Can further develop into meningitis. S/Sx: vertigo, ataxia, hearing loss, N/V

Question 26

Vestibular neuritis

Answer 26

Benign and temporary disorder of the vestibular nerve with vertigo but NO hearing loss. URI precedes. Self-limiting. S/Sx: sudden acute vertigo without hearing loss in an otherwise healthy patient.

Question 27

Benign paroxysmal positional vertigo (BPPV)

Answer 27

Sudden vertigo elicited by provocative positions, triggering nystagmus. 90% of the time it is due to posterior semicircular canal canalithiasis. Etiology: major surgery, caffeine, alcohol, CNS dz, etc. S/Sx: sudden onset, very sudden sx but usually dissipate within 20-30s. N/V. PE: Full work-up with Dix-Hallpike maneuver - considered pathognomonic

Question 28

Acoustic neuroma

Answer 28

Benign, slow-growing tumor derived from Schwann cells of CN VIII. S/Sx: Consider ANY unilateral sensorineural hearing loss an acoustic neuroma until proven otherwise. May present with vertigo, tinnitus, HA in 50-60%, facial numbness in 25%.

Question 29

Meniere disease

Answer 29

Increase in volume and pressure of the endolymph in the inner ear canals. Age: middle-aged S/Sx: Triad (SN hearing loss, tinnitus, vertigo), prodrome with a sense of fullness in one ear, tinnitus followed by a decrease in hearing, vertigo that lasts min to hours and possibly days (Tumarkin crises - severe vertigo attack that they fall to the ground), HA, gait unsteadiness. PE: complete neurological exam

Question 30

Toxic vestibulopathy

Answer 30

Toxic agent ingestion that is toxic to the vestibular structures of the ear.

Question 31

Errors of Refraction

Answer 31

Vision is becoming blurry Hyperopia (far-sightedness) - most common; distant objects are clear, and close-up objects are blurry Myopia (near-sightedness) - faraway objects will appear blurry Astigmatism - refraction is unequal in different meridians of the eye; cornea has a slightly different curvature. Presbyopia - slow loss of ability to see close objects or small print. With age, the lens becomes less pliable.

Question 32

Scotoma

Answer 32

Area of partial or complete blindness usually within the central 30-degree area. From damage to nerve fiber layer in retina. "Scintillating scotoma" - an irregular outline around a luminous patch in the visual field following mental or physical work, eyestrain, or a migraine prodrome.

Question 33

Hemianopsia

Answer 33

Blindness or decreased vision in half of visual field of one or both eyes. Homonymous - same side, both eyes. Usually optic tract problem Crossed - opposite side, often pituitary problem Quadrant - level of brain, pupil reflex present as optic tract not affected.

Question 34

Hemorrhage of conjunctival vessels

Answer 34

Sclera gets very red; due to minor trauma - straining, sneeze or cough; not painful, no vision change, not pathologically sig.

Question 35

Injection

Answer 35

Congestion of vessels Conjunctival - common, peripheral, brick-red, tortuous superficial vessels that fade toward the iris; move with conjunctiva; usually assoc. with allergies, etc. Blanches. Ciliary - less common, violet or rose colored; fine, straight, deep vessels that radiate out from iris and fade towards the periphery, doesn't blanch.

Question 36

Acute allergic conjuctivitis

Answer 36

Recurs in spring and lasts through summer. | S/Sx: sudden, mild to moderate bilateral severe swelling of conjunctiva and lids, pruritus is common

Question 37

Chronic allergic conjunctivitis

Answer 37

Non-seasonal, little evidence of inflammation but itching, burning and photophobia are present.

Question 38

Giant papillary conjunctivitis

Answer 38

Allergy to soft contact lenses; may be slow to develop S/Sx: excessive pruritus, mucous production, increasing intolerance to contact use PE: inflamed conjunctiva, sticky discharge, worse in morning

Question 39

Viral conjunctivitis

Answer 39

Usually adenovirus, common lasts 1-2wks. S/Sx: pruritus, minimal pain; clear, thin, watery discharge is typical. Occasionally severe photophobia and foreign-body sensation occurs, usually caused by adenovirus when assoc. with keratitis.

Question 40

Herpes simplex virus conjunctivitis

Answer 40

Affects only 1 eye, most often occurs on the cornea which results in herpes kereatitis. Recurring infection takes form in dendritic keratitis. S/Sx: EARLY: foreign body sensation, lacrimation, photophobia. LATE: anesthesia of cornea and dendritic keratitis lesion. Assoc with immunocompromised pts

Question 41

Bacterial conjunctivitis

Answer 41

Staph and Strep are the most common. S/Sx: acute onset, minimal pain PE: preauricular adenopathy; chemosis is common

Question 42

Neisseria gonorrhea

Answer 42

Adult - rare, 12-48hr incubation, severe purulent discharge, usually unilateral, lids swollen Neonate - purulent discharge, 2-5 days after birth, may be severe lid edema

Question 43

Chlamydia trachomatis

Answer 43

Adult - swimming pool with infected individuals | Neonatal - exposure during birth

Question 44

Trachoma

Answer 44

Endemic to Africa, Asia, Middle East, Latin America, Pacific Islands, Australia S/Sx: often asymptomatic, bilateral, photophobia, lacrimation, pain 7-10d follicles develop in upper lid

Question 45

Pinguecula

Answer 45

Harmless slight raised bumps, fatty deposits under the conjunctiva on the nasal side

Question 46

Pterygium

Answer 46

Conjunctival thickening from chronic inflammation from wind, dust. Often distinct triangular lesion which may grow over cornea and affect vision.

Question 47

Corneal trauma

Answer 47

Etiology: foreign body and/or abrasion S/Sx: pain, photophobia, spasm PE: evert lid to inspect for foreign body, check cornea for damage, check PERRLA

Question 48

Corneal ulcer

Answer 48

Etiology: HSV most common, contact lens, trauma, VZV | S/Sx: erythema of eyelid and conjunctiva, foreign body sensation, photophobia, pain, blurred vision

Question 49

Band keratopathy

Answer 49

Hard, white calcified plaques at 2, 5, 7, 10 o'clock of limbus. May be secondary to kidney dz

Question 50

Arcus senilis

Answer 50

Whitish deposits around limbus, usually in the elderly. May be related to hyperlipoproteinemia

Question 51

UV Keratitis

Answer 51

Etiology: exposure to UV lights, welding arcs, radiation to the corneal epithelium is cumulative S/Sx: onset of foreign body sensation, irritation, pain, photophobia, tearing PE: diffuse staining with fluorescein dye

Question 52

Acute uveitis

Answer 52

Inflammation of the uveal tract most common in adults' Anatomically classified: 1) anterior, ciliary body, or both 2) intermediate 3) posterior, rare, serious Etiology: underlying systemic dz, may be idiopathic S/Sx: anterior uveitis - acute unilateral, painful ciliary flush, blurred vision, photophobia. Intermediate - painless, floaters, blurred vision Posterior - blurred vision, floaters, eye pain, RA, Sjorgren's PE: 360 peri-limbal injection which increases in intensity as it approaches the limbus

Question 53

Cataract

Answer 53

Opacity of the lens with painless, progressive, gradual visual loss. Etiology: developmental - juvenile, congenital or early life from poor diet. Degenerative - senile degeneration, DM, x-ray, cortisone S/Sx: decreased visual acuity, increased glare, no red reflex

Question 54

Acute closed angle glaucoma

Answer 54

EMERGENCY Etiology: mechanical blockage of outflow channels, drugs S/Sx: elderly, hyperopic, hx of glaucoma. Most commonly present with peri-orbital pain and visual deficits, ipsilateral HA, Halos PE: blurred vision, can see movement but not letters or numbers, increased IOP, pain upon movement

Question 55

Chronic open angle glaucoma

Answer 55

NO red eye 90% of all glaucoma; caused by a malfunction of the drainage system Etiology: decreased rate of flow, bilateral, genetic predisposition S/Sx: gradual loss of peripheral vision, can lead to blindness

Question 56

Hyphema

Answer 56

hemorrhage into anterior chamber from trauma, danger of recurrent bleeding which may cause glaucoma and visual loss

Question 57

Preseptal cellulitis

Answer 57

Inflammation/infection of eyelid and surrounding skin anterior to the orbital septum Etiology: trauma, infection S/Sx: tenderness, swelling warmth, redness of eyelid Typically mild condition. Difficult to distinguish from ???

Question 58

Orbital cellulitis

Answer 58

EMERGENCY Infection of the orbital tissues posterior to the orbital septum. Common in kids Etiology: infection from ethmoid sinus S/Sx: swelling, redness of eyelid and surrounding tissues, proptosis, extreme orbital pain, conjunctival hyperemia and chemosis, decreased visual acuity, fever, malaise, HA

Question 59

Exopthalomos

Answer 59

bulging of the eyes, also known as proptosis | Etiology: orbital inflammation, edema, injuries, hyperthyroid, leukemia, meningioma

Question 60

Retinal detachment

Answer 60

EMERGENCY Etiology: trauma, diabetes, inflammatory disorder, posterior vitreous detachment S/Sx: painless, dark irregular floaters, flashes of light, blurred vision, curtain over field of vision

Question 61

Posterior vitreous detachment

Answer 61

With age, the vitrious gel can collapse and pull forward | S/Sx: painless, floaters, flashes of light. Might see a "rice ring"

Question 62

Macular degeneration

Answer 62

Leading cause of visual loss in the elderly from a hemorrhagic disturbance in the macular region of the eye. S/Sx: slow or sudden, painless loss of central visual acuity

Question 63

Diabetic retinopathy

Answer 63

Major cause of blindness in diabetics S/Sx: early - venous dilation and small, red well demarcated lesions. Late - soft exudates caused by anoxia, or hard yellow exudates REFER if suddenly develops

Question 64

Hypertensive retinopathy

Answer 64

Vascular changes with extent and persistence of hypertension. 1) copper wire - brightening and widening of central strip artery 2) silver wire - central light reflex is entire width of arteriole from thickened walls 3) AV nicking - arteriole crossing venule, thickened arteriole walls compress and obscure the vein 4) Hemorrhages 5) Soft exudates - fuzzy, gray-white, irregular borders 6) Hard exudates - well defined yellow-white deposits 7) Papilledema

Question 65

Retinitis pigmentosa

Answer 65

Inherited, slowly progressive, bilateral, retinal degeneration. Loss of photoreceptors and blindness.

Question 66

Blepharitis

Answer 66

Inflammation of the lid margins causing irritation, itching, occasionally red eye S/Sx: eye irritation, itching and erythema of the lids, lacrimation, photophobia, blurred vision, crusting and matting of eyelashes PE: loss of lashes, whitening of lashes, scarring and misdirection of lashes, crusting of the lashes and meibornian orifices, lid irregularity

Question 67

Hordeolum (external)

Answer 67

A stye. Localized infection or inflammation of the eyelid margin involving a sebaceous gland S/Sx: begins with pain, redness, tenderness of lid margin followed by small, round, tender, induration. Lacrimation, photophobia, foreign body sensation, pustule on lid margin, ruptures and heals spontaneously

Question 68

Hordeolum (internal)

Answer 68

Acute inflammation of meibomian gland, usually more severe. | S/Sx: pain, redness, edema more localized, abscess can form.

Question 69

Entropion

Answer 69

Lid inversion, lid area atrophic or scarred, then lashes grow inward, causing irritation, blepharospasm, may lead to corneal ulceration and scarring

Question 70

Ectropion

Answer 70

Lid turns outward, tissue relaxation with aging, leads to poor drainage of tear, excess tearing, redness, irritation

Question 71

Dacryoadenitis

Answer 71

Enlarged lacrimal gland on upper lateral aspect of eye. Tender, red if acute; painless if chronic. Can abscess.

Question 72

Dacryocystitis

Answer 72

Inflammation of the lacrimal sac, usually secondary to obstruction of nasolacrimal duct, tenderness, swelling, redness; may express pus from sac

Question 73

Dacryostenosis

Answer 73

Congenital narrowed lacrimal duct in neonate; excess tearing, may be pus expresses, usually resolves in 6mo.