Throat, Eyes Flashcards
Define trismus.
Spasm of facial and jaw muscles, unable to fully open mouth. Drooling and muffled voice.
Quinsy/peritonsillar abscess presentation?
Sore throat, trismus, does not want to open mouth, uvula displaced by very swollen tonsils. Hot potato voice. Tender cervical LA.
Gold standard for diagnosis of peritonsillar abscess (quinsy)?
Needle aspiration.
Treatment for peritonsillar abscess?
Incision and drainage or aspiration of abscess.
IV abx. ER referral necessary.
Peritonsillar abscess complications?
Airway obstruction, meningitis, peritonsillar cellulitis.
Aspiration pneumonia, septicemia.
What are the suppurative complications of poorly or untreated pharyngitis?
Peritonsillar abscess (quinsy) Retropharyngeal abscess
What is Ludwig’s angina?
Infection of the submental space.
Pt has severe trismus, drooling, airway compromise.
“Collar of brawny” edema (neck).
EMERGENCY
Presentation of retropharyngeal abscess?
Dyspnea, stridor and “hot potato voice.”
Stiff neck with high fever, pain may refer to posterior neck.
Usually secondary to dental infection, foreign body insult or other trauma.
Presenting history in epiglottitis?
Sore throat High fever (over 102) Weak voice; hot potato voice Marked drooling **Sit very upright with head forward and neck extended** Stridor is a late and ominous sign.
Tx of epiglottitis?
DO NOT put anything in mouth or try to visualize.
Immediate referral to ER.
What is the “thumbprint sign”?
An indication of epiglottitis on x-ray. It’s caused by the thickened free edge of the epiglottis.
Giveaway sign for diphtheria?
Blue-white membrane adhered to posterior pharynx.
Ddx for irritative cause of chronic sore throat:
- Reflux pharyngitis
- Post nasal drip
- Toxins
- Improper vocal cord hygiene
- Vocal abuse
- Chronic cough
Ddx for neoplastic cause of chronic sore throat:
Nasopharyngeal, oropharyngeal, laryngeal, upper esophageal carcinomas.
Possible tumor under the sternum.
What is Kawasaki disease?
Acute, self-limited vasculitis that occurs in children of all ages. Clinical features reflect widespread inflammation of medium- and small-sized blood vessels.
Clinical presentation and diagnosis of Kawasaki?
Must have a fever of unknown origin x5 days, and four of the following criteria:
- Bilateral conjunctival injection
- Oral mucous membrane changes (injected or fissured lips, injected pharynx, or strawberry tongue)
- Peripheral extremity changes (e.g. erythema of palms or soles, edema of hands or feet)
- Polymorphous rash
- Cervical lymphadenopathy (at least one lymph node >1.5 cm in diameter)
What is globus?
Subjective sensation of a lump or mass in the throat unrelated to swallowing. There is usually a physical cause.
What are some causes of globus?
- Mucosal edema or inflammation. (GERD can cause this and is the cause of globus in 25-68% of cases).
- Thyroglossal cyst (will move with tongue).
- Ulceration or granulation of vocal cords (CT or barium).
- Barrett’s metaplasia or esophageal malignancy (laryngoscopy).
Globus management:
Take a careful history and refer for nasolarygoscopy.
In high-risk patients (abnormal nasolarygoscopy), work up for malignancy.
In low-risk patients, empirically treat for GERD.
Work-up for hoarseness?
Targeted history
PE (look for lymphadenopathy and signs of rhinitis with cobble stoning and postnasal drip)
Laryngoscopy (if hoarseness lasts longer than 2 weeks and has no clear benign cause)
Common causes of hoarseness?
Inflammatory or irritant (e.g. allergies, infections)
Neoplastic
Neuromuscular (e.g. MS, Parkinson’s)
Systemic dz (e.g. RA, hypothyroid)
What are some ways to treat/prevent hoarseness?
Treat underlying condition
Vocal training/therapy
Vocal hygiene:
-Environmental changes and dietary changes
-Behavioral/vocal habit changes (avoidance of frequent coughing or throat clearing, avoidance of shouting or speaking loudly)
Surgical treatment is sometimes indicated.
What are the common findings in a patient with sleep apnea?
Overweight Snoring Daytime fatigue Chronic rinitis Nasal polyps Septal deviation
What is the morbidity of sleep apnea?
The risk of long-term mortality increases when patients have two or more respirator events per hour during sleep.
Heart failure
Depression
How do you diagnose sleep apnea?
Sleep study
What are the treatment options for mild sleep apnea?
Sufficient sleep
Abstain from alcohol and sedatives
Lose weight
Avoid supine sleeping
What are the treatment options for clinically significant sleep apnea?
Best = CPAP (continuous positive airway pressure) Oral appliances (inconsistent) Palatal surgery (may not help the apnea, helps snoring) More invasive surgery if severe
What is amblyopia?
When a child doesn’t use one eye so the retina doesn’t fully develop. (“Lazy eye”)
What are the three main causes of amblyopia?
Strabismus
Congenital cataracts
Refractive errors
What are a couple of screening tests for amblyopia?
Hirschberg corneal reflection
Cover/uncover testing
What should you definitely not do when evaluating eye trauma?
DO NOT PRESS ON EYE!
When should you refer eye trauma?
Diminished vision (visual change of more than one line on the Snellen chart suggests corneal abrasion, retinal detachment, and lens dislocation)
Asymmetric pupils
Evidence of retinal damage
Ocular misalignment
Hyphema (can lead to angle-closure glaucoma)
What are some eye trauma ND treatments?
Ice on day 1, heat day 2-3. Bromelain, curcumain, boswellia, zingiber. Homeopathy: -Aconite (abrasions) -Symphytum (esp. blunt trauma) -Arnica
What is a subconjunctival hemorrhage?
Hemorrhage over the sclera. Painless Normal vision DT minor trauma: cough, sneeze Tx: reassure
What are two commonly involved structures with painful eye?
Cornea and iris (highly innervated).
What should you consider with a painful eye that isn’t red?
Referred pain from sinuses, orbit, or nose.
Neuropathy: Trigeminal, zoster, CNS disorder.
DDx for painful red eye? (8)
Corneal abrasion Foreign body Ulcer or infection Keratitis Scleritis/episcleritis Acute angle closure glaucoma Iritis Uveitis
DDx for red eye that isn’t painful? (2)
Subconjunctival hemorrhage
Conjunctivitis
DDx for red eye with impaired vision? (4)
Allergic
Acute glaucoma - REFER
Iritis
Corneal Disease
DDx for red eye with abrupt onset? (4)
Trauma
Foreign body
Chemical irritation
UV exposure
DDx for red eye with subacute onset?
Conjunctivitis, unless it’s gonococcal conjunctivitis.
DDx for chronic or persistent red eye? (3)
Staph (blepharitis)
Chlamydia
Moraxella (genus confused with neiseeria)
DDx for recurrent red eye? (2)
Allergic conjunctivitis
Recurrent iritis - reactive arthritis
What are some PE findings for iritis (anterior uveitis)?
Small, irregular pupil (muddy)
Pupil is poorly reflective to light
Sign of iritis (anterior uveitis)?
The presence of cells and flare in the anterior chamber as seen with a slit lamp exam.
How is injection different in conjunctivitis vs iritis?
Conjunctivitis will have injection more towards the periphery, little injection around the iris.
Iritis will have ciliary injection (right around the iris), though may also extend into periphery.
What is hyperacute conjunctivitis?
- Gonococcal infection of the eye; because people try hard.
- VERY fast onset.
- Red, swollen, purulent DC.
- Dx with gram stain
- Tx: Refer to ophthalmologist for ABX.
How are corneal abrasions visualized?
Use fluorescein dye to look for the characteristic apple-green areas of abrasion (under a cobalt blue light).
Make sure to evert the upper and lower lids to check for an occult foreign object.
What is in Geller’s conjunctivitis formula? For bacterial and viral.
Berberis Hydrastis Hamamelis Fennel Calendula
What are some general treatments for bacterial conjunctivitis?
Breast milk ABX (erythromycin ointment) Hydro/eye washes Treat the terrain Homeopathy
Homeopathic:
Much burning in the eye, edema around the eye with hot, excoriating intense photophobia and discharge; > external heat
Arsenicum album
Homeopathic:
Streaming eyes and nose associated with much sneezing, discharge makes nose sore
Allium cepa
Homeopathic:
Catarrhal conjunctivitis, eyes water al the time, DC burning and acrid, burning and swelling of lids, constant blinking
Euphrasia
Homeopathic:
Profuse yellow DC, no excoriation, itching and burning in eyes
Pulsatilla
Localized infection of the margin of the lid. Painful and red lower. May involve glands of zeiss or moll. More painful. Staph.
External hordeolum (sty)
Most commonly involves meibomian glands.
Internal hordeolum (called a chalazion when chronic)
Inflammation of the eyelids causing red, irritated, itchy eyelids and dandruf like scales. Not contagious, no permanent damage.
Blepharitis
Chronic internal hordeolum, sterile, nodular, lipogranulomatous inflammaiton of the meibomian gland.
Chalazion
Swelling and redness of the lacrimal sac from infection. Excess tears overflow, pressing on lacrimal sac and causing mucopurulent DC from lacrimal puncta.
Dacrocystitis
What are some risk factors for cataracts? (8)
Ocular disease, injury, surgery. Diabetes mellitus Galactosemia UV light Smoking Genetics and epigenetics Poor liver detox Statins
What are some general tx principles for cataracts?
Avoid UV light to decrease free radicals.
Increase antioxidants by various sources.
What kind of eyedrops are good for cataracts?
N-Acetylcarnosine
What botanicals might you use for cataracts?
- Chaparral (prevention)
- Cineraria maritime (increase circulation to intraocular tissue)
- Vaccinium (stops progression)
- Gingko (protects against oxidants)
What is the diagnostic criteria for glaucoma?
Loss of peripheral vision that progresses to central loss.
Increased cup to disc ratio.
Increased intra-ocular pressure.
How does acute closed-angle glaucoma present?
Severe eye pain.
Red eye, nausea, vomiting, diminished vision, colored halos, headache.
Perilimbal injection, cloudy cornea, narrow anterior angle.
Pupil is fixed and dilated.
EMERGENCY!
What are some mechanisms of glaucoma?
Mechanical: correlated with IOP but not causative.
Vascular: HTN and POAG can lead to poor optic nerve perfusion.
Glutamate toxicity: Retinal apoptosis after glutathione deficiency leading to high intraocular glutamate.
What is the allopathic treatment for glaucoma?
Beta-blockers
Cholinergic agents
Surgery to increase drainage
What can you give IV for glaucoma?
High dose vitamin C. Decreases IOP osmotically.
What are two botanical eyedrops for glaucoma?
Forskolin lowers IOP and increases flow rate.
Foeniculum has oculohypotensive activity.
What is the hypothetical mechanism by which cannabis can lower IOP?
It might decrease aqueous formation in the ciliary body.
What is the IOP in acute glaucoma?
40-80mm Hg
How does keratitis typically present?
Photophobia, pain, lacrimation, blurred vision.
Begins with patchy inflammation in mid-stroma that causes opacification.
Cornea develops a ground glass appearance, obscuring the iris.
Neovascularization of the limbus leads to orange-red salmon patches.
What STI can lead to keratitis?
Syphilis
What is a scotoma?
Partial loss of vision or blind spot in otherwise normal visual field.
What are the SSx of wet ARMD?
10% of cases.
New vessels form to improve the blood supply to oxygen-deprived retinal tissue, but are very delicate and break easily, causing bleeding and damage to surrounding tissue.
Vision loss that occurs acutely (over a period of days or weeks) may represent wet ARMD and requires urgent ophthalmic evaluation.
What are the SSx of dry ARMD?
Gradual loss of vision in one or both eyes with difficulty reading or driving. Scotomas, or increased reliance on brighter light or a magnifying lens for tasks that require fine visual acuity. Onset is slow and peripheral vision remains intact.
Presence of drusen bodies increases the likelihood of developing ARMD by 23%.
What are drusen bodies?
Buildup of extracellular materiel in the eye. Can be a normal finding but excessive quantities indicate ARMD.
What are a few treatments for ARMD?
Control atherosclerosis. STOP SMOKING Improve metabolic and vascular fxn Antioxidants Ozone therapy Exercise Reduce exposure to UV light Dark leafy greens (carotenoids)
What are some supplements for ARMD?
Bilberry Lutein and zeaxanthin Zinc + Copper Beta carotene Vit E Vit C ALA Omega 3 Folic acid Pyridoxine Vit B12
What supplements can you give specifically for high homocysteine in ARMD?
Folinic acid
Pyridoxal 5’-phosphate
Methylcobalamin
What are the components of the IV protocol for ARMD?
Every week for 1 month, then every 2 weeks.
Zinc Selenium Glutathione Test vision before and after each Tx Oral Taurine as well
