Week 3 - Neuro Diseases / Disorders Flashcards
Graves disease (hyperthyroid)
eyes bulging out of head
Horner Syndrome
sympathetic superior cervical ganglion compressed, miosis (constricted pupil), ptosis (drooping eyelid), anhidrosis (no sweat), if present for a long time there will be less pigment in effected iris/eye
Cranial Nerve III palsy / compression
always associated with ptosis (drooping of eyelid), nonreactive pupil to light (will not constrict), and/or extraocular muscle palsy - often caused by vascular problems like aneurysms
Adie’s Tonic pupil
benign lesion of ciliary ganglion, young women, pupil reacts slightly to light and slowly to convergence - pupil nonreactive to light
pharmacological
pupil nonreactive to light, mydriatics (pupil dilators), scopalamine patch, farm chemicals, sympathetic stimulators (pseudoephedrine)
trauma
can cause pupil unreactive to light
physiologic
1mm difference is pupil dilation in light and dark is found in 20% of people
nonreactive pupil to light
dilated pupil, will not constrict
drugs, narcotics
cause constricted pupil - miotics (pupil constrictors)
Argyll Robertson Pupil
constricts poorly to light, but reacts with constriction to convergence, syphilis
iritis
eye pain, redness, anterior chamber inflammation, constricted pupils
Horner’s syndrome - first order neuron disorder
central lesion on hypothalamospinal tract, ex: transection of cervical spinal cord
Horner’s syndrome - second order neuron disorder
most common, preganglionic lesion, ex: compression along sympathetic chain by lung tumor
Horner’s syndrome - third order neuron disorder
postganlionic lesion at level of internal carotid artery, ex: tumor of cavernous sinus or carotid artery dissection
causes of CN III palsy with dilated pupils
vascular disorders (diabetes, heart disease, atherosclerosis, aneurysm of posterior communicating artery), space occupying lesion or tumor, inflammation, infection, physical trauma, demyelinating disease (MS), autoimmune disease (myasthenia gravis), post operative neurosurgery complication, cavernous sinus thrombosis
pupil-sparing CN III palsy
commonly microvascular
pupil-involving CN III palsy
serious / urgent differential
CN III, CN IV, CN V1, CN VI, CN V2, internal carotid artery
pass through cavernous sinus
CN III palsy
down (superior oblique still working) and out (lateral rectus still working) position of affected eye, ptosis (drooped eyelid), mydriasis (pupil dilation)
CN III palsy - parasympathetic fibers
run on outside of nerve (motor on inside of nerve), parasympathetic symptoms before motor symptoms, ptosis (drooping eyelid) and mydriasis (dilated pupil) before down and out eye position
testing CN III function
movement of eye in 6 cardinal fields (H), look for limitation of movement in either eye (-ductions), look for limited gaxe (-versions), nystagmus (uncontrolled movement of the eye), strabismus (ocular misalignment)
causes of isolated ocular muscle weakness / palsy
cranial nerve palsy (VI, IV, III), grave’s disease (hyperthyroid), trauma, giant cell arteritis (inflammation of blood vessels), MS, stroke, mass, myasthenia, sarcoidosis, meningeal infection, meningeal inflammation (lymes) - often adult presenting with double vision
microvascular ocular muscle abnormality
diabetes screen, blood pressure, sed rate for temporal arteritis
thyroid ocular muscle abnormality
weight loss, hair loss, heart palpitations, proptosis, lid lag, red eyes - middle aged with eyes that stick out (proptosis)
neuroimaging ocular muscle abnormality
CT - for muscle size / entrapment / boney abnoramlity / sinus disease; MRI - brain abnormalities / tumors; MRA - angiography for vascular
other causes of ocular muscle abnormality
tensilon test (myasthenia gravis), CBC, lymes, rheumatologic work up (eyes tired with double vision by end of day)
orbital floor fracture
trauma / hydraulic force, fracture in orbital floor/medial orbit, swelling and hemorrhage in orbit affect eye movement, entrapped inferior rectus restricts upward gaze - often shows orbital bone flap with blood in sinus or air in orbit and trapped inferior rectus on CT, Tx surgery (2 wk window) and antibiotics
visual field evaluation
pt sitting in front of you, test eyes individually, pt looks at you, compare their field to yours, if detected - not horizontal or vertical midline - 1/2 or 1/4 of field missing
scotoma
area of abnormal / absent vision within otherwise intact vision field
hemianopia
loss of right or left half of visual field in either eye
homonymous hemianopia
loss of right or left half of vision field in both eyes, lesion on right or left optic tract
bitemporal hemianopia
loss of right half of field in right eye and left half of field in left eye, lesion at optic chiasm
altitudinal defect
loss of superior or inferior half of field
monocular vision loss
lesion on one optic nerve blocking afferent and efferent paths
lower homonymous quadrantopia
lesion on left or right parietal radiation - meyer’s loop
upper homonymous quadrantopia
lesion on left or right temporal radiation
complete vision loss in one eye
compressive tumor, inflammation, neuritis, anterior ischemia, optic neuropathy, vasculitis, idiopathic intracranial hypertension
vision loss in left 1/2 left eye and right 1/2 right eye
parasellar mass - aneurysm, pituitary, adenoma, meningioma, craniopharyngioma
vision loss in left or right halves of both eyes
neoplasm, inflammatory, ischemia, infections - encephalitis, arteriovenous malformation
vision loss in upper right or left quadrant or both eyes
neoplasm, inflammation, ischemia, infection
vision loss in lower right or left quadrant of both eyes
neoplasm, inflammation, ischemia, infection
junctional scotoma (chiasm)
loss of central vision in one eye and temporal field in other eye
visual hallucinations
repeated, formed, faces, animals, people, in color, stereotyped - pt know images aren’t real, elderly, with vision loss, possible early dementia
tunnel vision
loss or peripheral vision, late stage glaucoma, central retinal degeneration, retinal photocoagulation, nonphysiological
retinitis pigmentosa
hereditary degeneration of rods and then cones, bone spicule appearance on retina, restricted to 10-20% of field of vision
panretinal photocoagulation
laser spots, diabetic
examination of optic disc
ophthalmoscope, close to pt, pt looks up, use right eye for right and left eye for left, focus on nerve
optic nerve appearance
disc with central depression (cup), veins - larger / darker, arteries - smaller / lighter
glaucoma
increasing pressure from accumulating aqueous humor, physiologic cup in optic disc gets larger
optic neuritis
vision loss over hours / days, worst in one week, unilateral, 18-45, pain with eye movement, loss of color vision (intensity), decreased light intensity, focal neurological symptoms, flu-like - marcus gunn pupil (RAPD), decreased color vision, visual field defects, swollen disc (1/3 cases) that bulges outward into eye, blurred disc edges
causes of optic neuritis
idiopathic, MS (initial), measles, mumps, chickenpox, mono, zoster, lymes, orbital infection, granulomatous disease (TB, lues, scaroid)
optic neuritis labs
BP, visual field test, sed rate, MRI (shows enlarged optic nerve, inflammed areas on brain - demylination), CBC, RPR, FTA-ABS, CRP
optic neuritis Tx
IV methylprednisolone (1 gm for 3 days) -> oral prednisone (1mg/kg/day for 11 days) -> taper over 4 days -> antiulcer meds, consult
optic neuritis relation to MS
negative MRI = risk of MS low 20% over 10 years - give pulsed IV steroids, pt with 1+ positive MRI spots 50% change of MS over 10 years
ischemic optic neuropathy
sudden, painless, nonprogressive vision loss, over 60, unilateral, RAPD, disc swelling, flame hemorrhages, differentiate between arteritic and non-arteritic -> check sed rate and CRP, headache, jaw claudication, scalp tenderness, joint aches, anorexia, weight loss, fever, biopsy of temporal artery, caused by vascular occlusion
papilledema
optic nerve swelling due to increased intracranial pressure, transient vision loss after rising up, headache, diplopia, nausea, vomiting - optic disc bugles out
bilateral papilledema
intracranial mass, pseudo tumor cerebri, intracranial bleed, hypertensive crisis, hyrocephalus, meningitis
unilateral papilledema
optic neuritis, central retinal vein occulsion, ischemic optic neuropathy, orbital mass, juvenile diabetes, thyroid
spina bifida with meningocele
cyst-like protrusion of dura and arachnoid, detected inutero with ultrasound, failure of caudal end of neural tube to close and induce formation of neural arches in lumbar vertebra
multiple sclerosis
demyelinating disease, decreases axonal transmission due to increased capacitance and loss of saltatory conduction from node to node where Na / K channels are concentrated
closed angle glaucoma
acute, sudden, blockage of aqueous humor outflow
open angle glaucoma
chronic, gradual, overproduction of aqueous humor, more common
hyperopia
far sighted, axial length < focal length = image behind retina, convex lens (+D) correction brings image forward, axial hyperopia = eyeball too short, refractive hyperopia = cornea / lens weak
myopia
near sighted, axial length > focal length, image in front of retina, concave lens (-D) correction pushes image back, axila myopia = eyeball too long, refractive myopia = cornea / lens too strong
presbyopia
aging, decreased malleability of lens -> decreased accommodation, like hyperopia, correct with reading glasses (+D)
astigmatism
uneven lens/cornea, part of visual field out of focus
cataracts
opacity of lens, trauma/radiation/high glucose (diabetes)/age, Tx surgery to replace lens
glaucoma
IOP > 30mmHg, aqueous humor flow problem, loss of vision, 1. cornea with halos, edema, decreased transparency; 2. loss of photoreceptors from periphery to fovea; 3. optic nerve; 4. loss of arterial supply -> necrosis
retinitis pigmentosa
decreased response of photoreceptors, rods first (night blindness), tunnel vision, central color vision, variable age / progression
retinopathy
damage to retina, often from lack of blood supply
vit A deficiency
vit a = retinol (fat soluble vit), affects retinal pigment epithelium, night blindness because rod photopigment can’t be recycled, also immune / bone or skin growth and repair / embryonic development problems
macular degeneration
age, yellow drusen pigments between retinal pigment epithelium and choroid, 2 forms -> dry and wet
dry macular degeneration
atrophy of RPE, loss of photoreceptors, blurry vision, bad night vision, Tx slo with vit A sup, can progress to wet
wet macular degeneration
abnormal growth of blood vessels in choroid, loss of photoreceptors in central vision, Tx angiogenesis inhibitor (anti-VEGF antibodies)
noise induced hearing loss
primarily from damage to hair cells
benign paraphysinal positional vertigo
usually posterior canals of vestibular apparatus effected, can tell which canal and which side, determines therapy given
homonymous defect
visual defect in either right or left visual field, post-chiasmatic defect
heteronymous defect
visual defect of parts of both left and right visual field
hemianopsia
defective vision in 1/2 of a visual field
quadrantanopsia
defective vision in 1/4 of visual field
blindness in right eye
right eye optic nerve
blindness in left eye
left eye optic nerve
bitemporal heteronymous hemianopsia (loss of left and right lateral fields)
lesion on optic chiasm
left homonymous hemianopsia (loss of vision in lateral left and medial right fields)
lesion on right optic tract
left upper homonymous quadrantanopsia (loss of vision in left upper quadrant of both fields)
lesion on lateral right Meyer’s loop
left homonymous hemianopsia with macular sparing (loss of left half of both fields with center spared)
lesion (often of posterior cerebral artery) in medial calcarine cortex, excluding most caudal portion which may have some middle cerebral artery supply
damage anterior to optic chiasm
only affects ipsilateral eye
damage at optic chiasm
produces heteronymous defects because nasal optic fibers can’t cross over
damage posterior to chiasm
produces homonymous defects in visual field opposite to side of lesion
strabismus (squint)
failed coordination of extraocular muscles, deviation of affected eye and diplopia
diplopia
double vision, failure of image to be alinged on same point on each retina
amblyopia (lazy eye)
decreased visual acuity secondary to strabismus, brain avoids diplopia by suppressing vision of one eye in cortex, can occur in kids 3-8, Tx with therapy to train less dominant eye to operate by putting patch over dominant eye
scotoma
island of vision loss, ex: stroke effecting specific part of visual pathway
case - tumor in right visual cortex
loss of left half of visual field, with calcifications on pineal gland and choroid plexus
common causes of red eyes
conjunctivitis (bacterial, viral, allergic), corneal abrasion, foreign body, dry eye
five red eye symptoms that need ophthalmologic consultation
vision change, sluggish pupillary reflex, dendritic corneal lesion (herpes - newborn with HSV mother), pain, vesicular lesions around eye (zoster)
signs of narrow angle glaucoma
diminished / blurred vision, halo, tunnel vision, sudden onset, acute, light shine shows increased ant chamber, globe feels rock hard, KEY - tenometer measures IOP >30mmHg
risk factors of narrow angle glaucoma
40+, African American / Asian / Mexican American, family Hx, diabetes, hypothyroid, heart disease, high BP, other eye conditions, longterm corticosteroid use (esp as eye drops)
viral conjunctivitis
unilateral, tearing, less itch and exudate, possible upper respiratory infection, preauricular adenopathy common, adenovirus common, enterovirus, HSV, zoster
bacterial conjunctivitis
unilateral becoming unilateral, some tear, little itch, lots of purulent discharge, preauricular adenopathy uncommon, pneumococcus common cause, h. inf., staph aureus, N. gonorrhoeae
allergic conjunctivitis
bilateral, itching, tearing, watery
corneal abrasion
can see with blue scope lens and flurosine stain, check under lid for foreign body, heal 24 hours, if large antibiotic drops, no patch unless indicated, trauma, FB sensation, visible FB
foreign body
often under lens, may be imbedded in eye = x-ray, use lid eversion to look
dry eye
feels like foreign body, overuse of antihistamines, common in elderly, check meds, lack of tearing, Tx artificial tears
hyphema
blood in anterior chamber, trauma, need to drain, refer to ophthamologist
iritis
whole eye red, less swelling, abnormal vision, more pain, see ophthamologist
subconjunctival hemorrhage
patch of blood up top of white sclera, looks bad but harmless, common with labor strain / extreme pushing / weight lifting, spontaneous, will reabsorb
tonsilitis
large red palatine tonsils, can be in adults too, usually kids
black hairy tongue
benign, hypertrophy of papillae, smokers
malignant melanoma
dark asymmetrical spot on gums
cancer under tongue
tobacco chewers, hard as a rock
torus / tori
midline bump on palate, smooth, hard as bone, benign
minor salivary gland malignancy
off midline, roof of mouth, firm but spongy, more common than malignancy of larger salivary glands
localized plasmacytoma
lymphoma variant, on gums, fatigue, anemia, Tx radiation
pharyngeal cancer
progressive sore throat
unilateral vocal cord paralysis
poor voice on phonation with over compensation of intact side, good airway on inspiration
bilateral vocal cord paralysis
voice good on phonation because chords are similarly affect, airway poor on inspiration because neither side will spread
vocal cord nodule
benign, hoarseness
vocal cord polyps
swollen vocal cords
vocal cord cancer
warty looking, Tx success is stage dependent, Tx radiation
laryngeal cancer
hoarseness, can cause pain in ears
case - 69, progressive hoarseness, throat pain, no response to antibiotics, neg strep test, smoker, drinker, hemoptysis, dysphagia
vocal cord cancer
pack / years
packs per day x number of years smoked
cancer of the larynx
40+, drinker, smoker, chronic cough, weight loss, ear ache, neck lump, short of breath, hoarse, tickle, pain with swallow, hemoptysis
laryngectomy
removes larynx, preserve plane of platysmal (save nerves/vessels), remove muscles, split thyroid, lay nerves laterally, cut away from pharynx and close pharynx, ***if person with stoma from laryngectomy needs air it must go through stoma - no connection between airway and mouth
case - 57, progressive hoarseness, no meds, healthy, nonsmoker, nondrinker, small paramedian neck mass
invasive thyroid cancer the is compressing recurrent laryngeal nerve to the larynx -> vocal cord paralyzed on one side, thyroid masses are mostly benign, workup -> ultrasound and needle biopsy, in surgical removal must take care to leave parathyroid glands and recurrent laryngeal nerve
case - 42, teacher, past smoker, nondrinker, variable hoarseness
vocal cord nodule, common in singers / speakers / teachers / lawyers, speech therapy, voice hygeine
signs of airway obstruction
stridor, respiratory effort, chest retraction, tracheal tug, intercostal retraction - little positive pressure will help breathing
stridor
laryngeal sound with airway obstruction, high pitch, inspiratory, then inspiratory and expiratory, 90% compromised airway, drop chest and raise abdomen = airway gone
sturdor
upper pharyngeal, gurgling, caused by swollen tonsils, pneumonia
croup
acute infection of larynx, slow onset 24-48 hrs, subglottic inflammation, viral / parainfluenza / RSV, inspiratory stridor, seal bark cough, rarely need intubation, Tx humidified air and steroids, steeple sign on PA film due to extended narrowing of airway below vocal cords
epiglottotis
WBC, blood culture, urine antigens, abrupt onset (hours), endoscopy with intubation, sit upright, hurts to swallow, intercostal and suprasternal retraction, lateral film shows thumbprint sign inflammed epiglotis, Tx antibiotics and intubation
vocal cord nodule
benign, hoarseness
vocal cord polyps
swollen vocal cords
vocal cord cancer
warty looking, Tx success is stage dependent, Tx radiation
laryngeal cancer
hoarseness, can cause pain in ears
case - 69, progressive hoarseness, throat pain, no response to antibiotics, neg strep test, smoker, drinker, hemoptysis, dysphagia
vocal cord cancer
pack / years
packs per day x number of years smoked
cancer of the larynx
40+, drinker, smoker, chronic cough, weight loss, ear ache, neck lump, short of breath, hoarse, tickle, pain with swallow, hemoptysis
laryngectomy
removes larynx, preserve plane of platysmal (save nerves/vessels), remove muscles, split thyroid, lay nerves laterally, cut away from pharynx and close pharynx, ***if person with stoma from laryngectomy needs air it must go through stoma - no connection between airway and mouth
case - 57, progressive hoarseness, no meds, healthy, nonsmoker, nondrinker, small paramedian neck mass
invasive thyroid cancer the is compressing recurrent laryngeal nerve to the larynx -> vocal cord paralyzed on one side, thyroid masses are mostly benign, workup -> ultrasound and needle biopsy, in surgical removal must take care to leave parathyroid glands and recurrent laryngeal nerve
case - 42, teacher, past smoker, nondrinker, variable hoarseness
vocal cord nodule, common in singers / speakers / teachers / lawyers, speech therapy, voice hygeine
signs of airway obstruction
stridor, respiratory effort, chest retraction, tracheal tug, intercostal retraction - little positive pressure will help breathing
stridor
laryngeal sound with airway obstruction, high pitch, inspiratory, then inspiratory and expiratory, 90% compromised airway, drop chest and raise abdomen = airway gone
sturdor
upper pharyngeal, gurgling, caused by swollen tonsils, pneumonia
croup
acute infection of larynx, slow onset 24-48 hrs, subglottic inflammation, viral / parainfluenza / RSV, inspiratory stridor, seal bark cough, rarely need intubation, Tx humidified air and steroids, steeple sign on PA film due to extended narrowing of airway below vocal cords
epiglottotis
WBC, blood culture, urine antigens, abrupt onset (hours), endoscopy with intubation, sit upright, hurts to swallow, intercostal and suprasternal retraction, lateral film shows thumbprint sign inflammed epiglotis, Tx antibiotics and intubation
ophthalamic zoster
prodrome, vesicular rash of C1 dermatome
subconjunctival hemorrhage
blood between conjunctiva and sclera, benign, trauma, coughing, labor, vomiting, valsalva, hypertension, diabetes mellitus, anticoagulants
eye globe pain
problem inside eye, iritis, uveitis, glaucoma, ophthalmologic consult
decreased visual acuity
risk of permanent vision loss, ophthalmologic consult
sluggish pupillary reflex
retinal or CNS problem, ophthalmologic consult
dendritic corneal lesion
HSV keratitis, ophthalmologic consult
vesicular lesions around eye
herpes zoster, ophthalmologic consult
signs of narrow angle glaucoma
sudden, pain, blurred vision, halos, subconjunctival hyperemia, corneal clouding, pupil dilation with absent / sluggish light response, increased IOP, risk factors: family hx, hyperopia, older, female, Asian / Inuit, pupil dilation with meds
correct use of ophthalmoscope
dark room, lens at 0 D, R hand/eye for R eye, L hand/eye for L eye, brace against your eye brow, pt looks over shoulder distantly, start 15 inches away and at 15 degrees off middle, look for red reflex, hand on pt forehead, advance toward pt
nose bleeds
most from ant nasal septum, called Kiesselbach’s area, terminal branches of sphenopalatine, ethmoidal, and superior labial arteries, posterior nose bleeds on septum or lateral wall supplies by sphenopalatine artery
Treacher Collins syndrome
first arch syndrome, deficient neural crest cell migration into arch, mandibulofacial dysostosis, abnormal dev of 1st arch structures - hypoplasia of upper and lower jaw, ext and middle ear deformation, palate and eyelid defects, conductive hearing loss, autosomal dominant or teratogenic, normal cognitive ability, mutation of TCOF1 gene on chromosome 5
Pierre Robin Syndrome
1st arch syndrome, deficient neural crest cell migration into arch, micrognathia, posterior tongue (airway obstruction - glossoptosis), U shaped palate, genetic/environmental, Tx tracheostomy and mandibular distraction
DiGeorge Syndrome
genetic / environmental, no thymus and parathyroid glands, causing diminished immunity and hypocalcemia, failure of neural crest cell migration causes failure of 3rd and 4th pouches and hypoplsia of 1st arch - cleft palate, low ears, poor feeding, delayed speech, heart defects, poor circulation, poor muscle tone
accessory or ectopic parathyroid glands
variable # and location, inferior may fail to descend or may be found in thorax with thymus
accessory or ectopic thymic tissue
found embedded in thyroid, near inferior parathyroid glands, or in isolated nests
lateral cervical or branchial cyst
ant edge of SCM, below angle of jaw, due to incomplete overgrowth of pharyngeal clefts by 2nd pharyngeal arch, epi inside may produce secretions causing cyst between 10-20 years old, may have a draining fistula
thyroglossal dust cyst of fistula
midline near hyoid, migrating thyroid that got caught up, epi secretions form cyst, infection likely
ectopic or accessory thyroid tissue
pieces of thyroid found anywhere along path of migration of thyroid
lingual thyroid
thyroid fails to descend from the base of the tongue, gland still works even though it is not in the right spot
blepharitis
infection of eye lid, stye
conjunctivitis
infection of conjunctiva
kerititis
infection of cornea
keratoconjunctivitis
infection of conjunctiva and cornea
uveitis
infection of iris, ciliary body, and choroid
chorioretinitis
infection of choroid and retina
endophthalmitis
infection of aqueous and vitreous humor
eye infections
outer surface protects, trauma, immunocompromised, dry eye, warm/moist under eyelid, deep layers invaded from brain/blood
eye defenses
sclera / cornea = physical barrier, tears with IgA and lysozyme, conjunctiva with lymphocytes/plasma cells/neutrophils/mast cells, blinking blocks attachment
conjunctivitis
discharge, red eye, irritation, sensitivity, no pain, no blurred vision, dilation of subepithelial vessels, can be viral, bacterial, allergic
bacterial conjunctivitis
mostly bilateral (spreads), thick discharge, red in older kids, occur with otitis media, no itchy
viral conjunctivitis
mostly unilateral, watery discharge, redness, little co-occurrance with otitis media, not itchy
allergic conjunctivitis
bilateral, little discharge, redness, no otitis media, very itchy
causes of neonatal viral conjunctivitis
herpes simplex virus, tx or will spread to cornea and affect vision
causes of post-natal viral conjunctivitis
adenovirus (common), coxsackie, HSV, VSV, EBV, rubella, mumps, influenza
causes of neonatal bacterial conjunctivitis
Niesseria gonorrhea
causes of child bacterial conjunctivitis
Staph aureus, Strep pneumonia, Heamophilus influenzae, Moraxella
causes of adult bacterial conjunctivitis
Staph aureus, Strep pneumonia, Corynebacterium, E.coli, Pseudomonas aeroginosa and Moraxella
cause of neonatal and adult inclusion conjunctivitis
Chlamydia trachomatis (serotypes D-K)
cause of trachoma
Chlamydia trachomatis (serotypes A-C)
causes of allergic conjunctivitis
IgE mediated sensitivity from allergens, chemicals, ocular medications (prolonged use), neoplasm, foreign body, contact lens
viral conjunctivitis (pink eye)
90% adenovirus, upper respiratory tract infection, preauricular adenopathy, contagious, benign, self limiting, Tx cold compress and topical vasoconstrictors, test with AdenoPlus that detects hexon protein in viral capsid
adenovirus
naked, d.s., infects epi cells, can cause necrosis, can integrate into host genome and have latent infection
herpes simplex virus
can cause keratoconjunctivitis, looks like adenovirus, lesion is painful, can scar cornea with recurrent infections, avoid corticosteroids that help corneal penetration, Tx topical trifluridine and systemic acyclovir and proph erythromycin
action of acyclovir and ganciclovir
prodrugs, inhibit viral DNA synthesis, competitive substrate for DNA polymerase, causes chain termination, viral thymadine kinase phosphorylates but has no sugar, guanine analogue
action of trifluridine
pyrimidine analogue, DNA chain termination and competitive inhibition of DNA polymerase, good for acyclovir resistant viruses, host kinases phosphorylate making more toxic
hyperacute bacterial conjunctivitis
Neisseria gonorrhoeae (meningitidis less often), copious green discharge, preauricular adenopathy, gram - intercellular diplococci on choclate agar, Tx systemic ceftriaxone and topical antibiotic/irrigation - ca progress to corneal ulceration and systemic level
action of ceftriaxone (3rd gen cephalosporin)
cell wall inhibitor, binds penicillin binding proteins, CNS penetration, Tx for N. gonorrhoeae conjunctivitis, empiric for bacterial meningitis with vancomycin, definitive and prophylactic for N. meningitis, empiric for brain abscess with metronidazole
acute bacterial conjunctivitis
kids - staph aureus, strep pneumoniae, haemophilus influenza; adults - staph aureus; tx decreases spread, broad empiric tx of moxifloxacin solution / bacitracin-polymyxin B ointment / trimethoprim-polymyxin B, if recurrent culture
action of moxifloxacin
DNA synthesis inhibitor, binds DNA gyrase and topoisomerase, broad Tx for conjunctivitis
action of polymyxin B
cationic molecules disrupt cell membranes of gram -, with trimethoprim for conjunctivitis, with neomycin and hydrocortisone for otitis externa
opthalmia neonatorum
conjunctivitis or keratoconjunctivitis in the week of life, N. gon / C. trachomatis / staph / strep / E. coli / H. inf / H simplex, proph tx erythromycin ointment, culture
action of erythromycin
protein synthesis inhibitor, binds 50S ribosomal subunit, proph tx for ophthalmia neonatorum
vertical transmission
mother to fetus, through placenta via blood, during vaginal birth in cervix (group B strep, C. trachomatis, N. gon, HSV2), through breast milk
perinatal
infections around birth, can include CMV spread in nurseries
chronic bacterial conjunctivitis
> 3 wks, Chlamydia trachomatis, inclusion serotypes D-K in US, trachoma serotypes A-C worldwide, basophilic inclusion bodies / EIA dipstick / PCR, coinfection with N. gon, Tx azithromycin, Tx sexual partners
action of azithromycin
protein synthesis inhibitor, binds 50S ribosomal subunit, tx Chlamydia trachomatis conjunctivitis
macrolides - erythromycin and azithromycin
inhibit protein synthesis, bind rRNS subunits, broad tx, resistance via increased efflux, drug hydrolysis by esterases, methylation of drug, adverse effects - GI, hepatic failure, prolonged QT, inhibits cytochrome p450
Chlamydia trachomatis
elementary body - small, spreads, taken up b epi of uterus and eye, reticular body - forms inclusion body, multiplies inside cell and releases elementary body, interferon-gamma can create a persistent form
chronic conjunctivitis associated with blepharitis
staph aureus, stye - in eyelid, chalazion - below eyelid in meibomian gland, tx - lid clean, warm compress, massage gland, erythromycin ointment
keratitis
vision defects, photophobia, pain in cornea, foreign body like sensation, with trauma / drying / hypoxia, viral - HSV1, bacterial - Staph a and e / Pseudo aeurgrunosa / B cereus; acanthamoeba (contact lens case/fluid), tx - bacterial moxifloxacin drops, viral trifluridine and acyclovir
pseudomonas aeroginsoa
gram -, aerobic, rod, flagella, water, soil, contact lens wearers, opportunistic with trauma, resistance with biofilms, tx pepercillian and ticarcillin, adherence factors, secretes cytoxins elastase and alklaine protease to destroy corneal epi -> immune response further scars cornea = loss of vision
rubella
deep eye infection in utero, cataracts, microphthalmia
CMV - cyclomegalovirus
in utero or with HIV, causes chorioretinitis in deep eye
toxoplasma gondii
in utero, chorioretinitis deep eye infection
uveitis
inflammed uveal, blurred vision, vision loss, anterior and posterior types
anterior uveitis (iritis)
not infectious, photophobia, pain, decreased vision, Treponema pallidum, HSV, VZV
posterior uveitis (chorioretinitis)
common, floaters, no pain
posterior uveitis (chorioretinitis)
blood to retina, systemic disease, toxoplasma and CMV in neonates and HIV, parasitic worms (Toxocara canis, Onchocerca volvulus), begins in periphery and spread with CMV
river blindness
parasitic worm, spread by sand flies, causes chorioretinitis
endophthalmitis
infection of vitreous and aqueous humor, rare, pain, red, vision loss, bacterial/fungal, exogenous from cataract surgery (Staph or Candida), endogenous - blood, tx vancomycin or -floxacin (fluoroquinolones)
action of vancomycin
cell wall inhibitor, binds D-ala-D-ala shielding it from transpeptidation reaction, good for gram + including MRSA, proph for meningitis with ceftriaxone
otitis media
most common, middle ear infection
otitis externa
fairly common, external ear infection, swimmers ear
labrinthitis
inner ear infection, vestibular defects, rare
otitis media
otalgia, erythema of TM, fluid in middle ear, can be acute / effusion / chronic / serous
acute otitis media
often with upper resp infection or allergies, narrowing of eustachian tubes preventing ventilation and drainage, enlarged adenoids, secretions accumulate and pathogen grows, e tubes in young kids narrower and flatter, males, native americans
causes of acute bacterial otitis media
strep pneumo, H. influ, Moraxella catarrhalis
causes of acute viral otitis media
RSV, rhinovirus
otitis media - strep pneumo
gram +, diplococci, alpha-hemolysis, secretion transmission, colonize naso-oropharynx, spread to middle ear, seen with alcoholism / diabetes mellitus / renal disease, 91 serotypes, unique surface capsule (oval), vaccine
strep pneumo virulence factors
capsule blocks phagocytosis, choline-binding proteins bind epi carbs, neuraminidases cleave mucin sialic acid, autolysin A degrades peptidoglycan -> alpha hemolysis of RBC and bacteria, pneumolysin pore forming that disrupts cilia, iron acquisition A and uptake A
Haemophilus influenzae
small, gram -, coccobacillus, nonmotile, biofilm, only humans, X and V chocolate agar, nonencapsulated, colonize nasopharynx, possible betalactamases, genital tract and conjunctivitis, vaccine does not cover because it is for encapsulated kind (has increased with Hib vaccine)
Moraxella catarrhalis
gram -, aerobic, diplococcus, oxidase, nonmotile, pili, chocolate agar, upper resp tract in infants, betalactamases, hockey puck test
acute otitis media dx
pneumatic otoscopy for TM, tympanometry to detect fluid in middle ear, aspirate and culture if not responding to Tx - recurrent can lead to hearing loss
empiric tx acute otitis media
amoxicillin (strep p and h infl), if not improvement in 48 hrs add clavulanate, if pen allergy azithromycin, pain management with acetominophen and ibu, resp viral vaccine?
action of amoxicillin
cell wall inhibitor, binds penicillin binding proteins, tx for otitis media
action of clavulanate
inactivates betalactamase enzymes that would degrade drug, added to amoxicillin to include moraxella catarrhalis and H. influ coverage
ear tube or incision
in TM, with recurrent ear infections, allows ear to drain
complications of otitis media
conductive hearing loss/delayed speech due to perforation of TM and degraded ossicles, cholesteatoma epi cyst due to pressure change, spread to mastoid, inner ear, temporal bone, meninges
otitis externa
inflammed canal, pain, ear drainage, risk factor - maceration of tissue/excessive moisture/middle ear infection, cerumen is acidic and has lysozymes (= no q tips)
acute localized otitis externa
staph, pustule or furuncle of hair follicle
acute diffuse otitis externa
pseudomonas aeroginosa, swimmers ear, itch, red, pain, tx ofloxacin
chronic otitis externa
drainage from perforated TM form otitis media, tx polymyxin B and neomycin
malignant otitis externa
pseudomonas aeroginosa, invades bone and cartilage, to CN, death, elderly with diabetes, tx imipenem
fungal otitis externa
aspergillus and candida, gray fuzzy canal
staphylcoccus aureus
cluster, gram +, cocci, anterior nares, protein A binds Fc on IgG preventing opsinization, coagulase binds prothrombin slowing migration of phagocytes, alpha toxin forms transmembrane pores lysing cells, resistant for MRSA
general tx otitis externa
topical cleansing with low pH (acetic acid) kills gram - bac, flush if TM intact
action imipenem
tx malignant pseudamonas chronic otitis externa
action -ofloxacin
fluoroquinolones, DNA syn inhibitor, binds DNA gyrase / topoisomerase, tx acute pseudamonas otitis externa
action polymyxin B
tx chronic otitis externa, with neomycin, cationic disruption of cell membrane in gram -
action neomycin
tx chronic otitis externa, with polymyxin B
stenosis (narrowing) /atresia (closure) problems
ear canal, nasal passage, larynx, esophagus, trachea
clefts (opening, fissure, indentation)
ear pit, nasal masses, face, lip, palate, larynx, tracheal-esophageal
persistent structures (that should have gone away)
thyroglossal duct, branchial clefts
preauricular pits / tags / cysts
tx observation, antibiotics, excision, rule out sensorineuronal hearing loss
prominent ears
tx otoplasty, cosmetic, creates antihelical fold, remove excess conchal cartilage
microtia
small, malformed ear, functional and cosmetic problem, pinna small / cut off, canal small / cut off, tx surgery to put in bone anchored hearing aid or repair atresia, soft band hearing aid
choanal atresia
problems breathing or breast feeding, nose running, can’t breathe, can be membranous, mostly bony
bilateral choanal atresia neonatal
babies are obligate nasal breathers, resp distress improved with crying, difficulty feeding, can’t pass 8fr catheter, neonatal presentation, rule out CHARGE syndrome (coloboma eye, heart defect, retarded dev, urogen defect, ear problems)
unilateral choanal atresia
delayed presentation, newborn - trisomy 21 or laryngomalacia, kid - chronic rhintis and adenoidectomy
tx choanal atresia
bilateral - secure airway (oral, tracheotomy), endoscopic / transpalatal surgery, postop stents, high recurrence in infants (restenosis)
congenital nasal masses
failure of foramen cecum closure, dermoid cyst along sinus tract, dimple in nasal skin with hair, dx imaging neurosurgery consult, tx excision of entire tract
nasal glioma
type of congenital nasal mass, failure of dural regression through foramen cecum, possible intracranial connection, dx imaging and neurosurgery consult, tx excision
frontanasal encephalocele
type of congenital nasal mass, does not involve foramen cecum, patent fonticulus frontalis, dx imaging and neurosurgery consult, tx resection
nasoethmoidal encephalocele
type of congenital nasal mass, intranasal/prenasal, nasal obstruction, dx imaging and neurosurgery consult, tx excision
ankyloglossia
ant tongue attached to floor of mouth, can’t latch to suck, neonatal, dysarthria, dental issues, cut it
cleft lip and palate
show on ultrasound, cleft lip -/+ palate more common than cleft palate alone, palate and lip form at separate times during embryo development, risk factors - heredity, nutritional def (folate), drugs (valium, dilantin, cortisone), primary palate = alveolar ridge, secondary palate = hard / soft palate
cleft lip surgery
10 wks old, Hb of 10, weighs 10 pounds
cleft palate surgery
18 months, speech, facial growth
cleft lip/palate secondary surgery
pharyngeal flap (4-8), cleft rhinoplasty (14-18), revisions
cleft lip / palate surgery
id vermillion, measure, incise flaps, suture lin near philtral ridge, close palate based on palatine arteries and growing palatine flaps
branchial cleft cyst / sinus / fistula
lateral on neck where 2nd pharyngeal arch overgrew pharyngeal clefts, preceding upper resp infection, if in 1st arch get external auditory canal duplication, 2nd arch fistula - starts ant SCM (deep to facial nerve and platysma, superficial to 3rd arch) opens into tonsil fossa
thyroglassal duct cyst
midline on neck, preceding upper resp infection, elevates with tongue protrusion / swallowing, CT with contrast
branchial and thyroglossal duct cyst tx
tx infection first, avoid incision/drainage, excision of entire tract/cyst, remember nerves, with thyroglossal resect part of hyoid and follow tract to base of tongue
goldenhar syndrome
1st/2nd arch, vascular insult?, hypoplastic maxilla/mandible/temporal bone, ear may be absent, vertebra abnor, dermoid eye tumor, one side of face
Treacher Collins
eyelid malform, hypoplastic cheek / jaw, low set and malform external ear, “fishmouth”
branchiootorenal syndrome
autosomal dominant on 8th chromosome, branchial cycts, renal abnorm, ear malform and hearing loss (conductive, sensorineuronal, both)
micrognathia
small lower jaw and mouth, seen with Pierre-Robin Sequence
glossoptosis
tongue at back of mouth, seen with Pierre Robin Sequence
anterior palate defects (cleft lip and incomplete cleft palate)
failed fusion of maxillary prominences with fused medial nasal prominences, upper lip, alveolar part of maxilla, primary palate
posterior palate defects
failed fusion of palatine shelves and nasal septum and primary palate, palatine shelves are from maxillary prominence, involves hard and soft palate
choanal atresia
narrowed choanae, babies are obligate nasal breathers, only breathe through mouth when crying, cycles of cyanosis with crying that re-oxygenates the blood - failed oronasal membrane rupture
FAS facial development
disrupted migration of cells-neurons in CNS and neural crest cells in head, short palpebral fissures, flat midface, short nose, flat philtrum, thin upper lip, microagnathia, ear abnorm, low nasal bridge, epicanthal folds
hyaloid artery
runs in optic fissure to supply optic cup and lens placode, hyaloid artery usually regresses by 8 mnths, if it persists in adult eye it might interfere with vision
congenital coloboma
defective closure of optic fissure, pupil is positioned in infero-nasal quadrant where fissure was and pupil has odd shape, usually only affect iris but can involve all eye structures behind iris
retinal detachment
separation of neural and pigmented retina, recreating intraretinal space, usually from trauma, medical emergency, floaters, flashes of light, can also be congenital from failed fusion of retinal layers
congenital cataracts
lens opaque in utero, can be balloon like or central, causes: rubella, hereditary, malnutrition, chromosomal, radiation, galactosemia
rubella congenital defects
eye (blindness), ear (deafness), cardiac defects
congenital ptosis
autosomal dominant, surgically corrected, does not affect vision, unilateral, appears in first year, from birth trauma, abnormal CN III, or dysgenesis of levator palpebrae superioris
congenital external ear malformation
often with 1st arch syndromes and chromosomal abnorm
minor appendages / preauricular tags
from supernumerary hillocks or bits of tissue left behind, congenital malformation of external ear
preauricular cysts
from incomplete fusion of hillocks, congenital malformation of external ear
microtia
abnormal shape or size of external ear, unilateral more common, congenital malformation of external ear
anotia
agenesis of the external ear, inner ear may be normal and hearing may be close to normal, congenital malformation of external ear
reconstruction of external ear
uses rib cartilage placed under the skin
rubella and hearing loss
1st trimester infection has high rate of defects, hearing loss, hearing defects, neurologic problems
neurosensory deafness
abnormal development of cochlea, CN VIII, or brainstem, damage to organ of Corti in 30% of 1st trimester rubella
conductive deafness
persisting meatal plug (1st arch syndromes), poor fixation of footplate of stapes, malleus and incus problems (1st arch syndrome) - hereditary and environmental causes
tongue cancer lymphatic spread
bilateral from tongue down neck, ant tongue drains to submental nodes
epiglottic valleculae
indentation in hyoepiglottic ligament between lateral and median glossoepiglottic folds - area where cancer can hide
median glossoepiglottic fold
fold on midline superior hyoid bone, from epiglottis to tongue
lateral glossoepiglottic folds
folds on lateral superior hyoid bone, from epiglottis to tongue
epiglottis
cartilage extension off thyroid cartilage that extends superior to hyoid, covers larynx when swallowing
thyroid cartilage
large cartilage inferior to hyoid and superior to cricoid
cricoid cartilage
thinner cartilage inferior to thyroid cartilage
arytenoid cartilage
small cartilages that sit on superior cricoid lamina, muscular process extends posterior laterally and vocal process extends anteriorly to thyroid cartilage, vocal processes connect vocal ligament with lamina of thyroid cartilage
aryepiglottic folds
connects arytenoid cartilages with epiglottis
piriform fossa
fossa created on either side of larynx, thryoid cartilage is lateral to it and cricoid cartilage is medial, pierced by the superior laryngeal artery and the internal branch of the superior laryngeal nerve (vagus) with sensory to larynx above vocal folds
vestibular folds
false vocal cords, superior to true vocal cords, vestibule between aryepiglottic fold and vestibular fold
vocal folds
true vocal cords, inferior to vestibular fold, middle part is the space between the vestibular fold and vocal fold
vestibule
space between aryepiglottic fold and vestibular fold
ventricle
space between vestibular and vocal folds
infraglottic region
space inferior to vocal folds down to inferior edge of cricoid cartilage
Rima glottidis
space between the vocal folds,
glottis
vocal folds and rima glottidis
vocal ligament
from vocal process of arytenoid cartilage to back of thyroid lamina
posterior cricoarytenoid muscle
wraps around cricoid lamina, adbucts rima glottidis, swings vocal process of arytenoid cartilage laterally, from posterior cricoid to muscular process of arytenoid cartilage, recurrent branch of the laryngeal nerve (vagus)
recurrent branch of the laryngeal nerve
all muscles of larynx, runs superiorly along trachea, dives under constrictor muscles, branch of vagus
referred pain from middle ear infection to tonsilar fossa
glossopharyngeal nerve
tongue deviation
hypoglossal nerve, tongue will deviate toward the side of the lesion due to unopposed normal side, ipsilateral muscles will atrophy and fasciculate
512 tuning fork
for Weber and Rinne test
Rinne test
tuning fork on mastoid and in air by ear, AC > BC is normal, BC > AC conductive hearing loss
Weber test
tuning fork on midline of skull, symmetrical is normal, lateralizes - to conductive hearing loss side, away from sensorineuronal side
audiogram
freq increases l-r, higher on the graph is better
speech discrimination score
50%+ is ok, 80% is normal, how well are they hearing speech
tympanometry
finds impedence of the middle ear (normal = 0), would tell you if there is fluid, tumor, or other behind ear drum making it stiffer
otoacoustic emission test
for newborn, outerhair cell noise, good for kids <2yrs
auditory brainstem response
sound into ear, follow through brainstem into teomporal bone, electrodes
sensorineural hearing loss
old, progressive, 50% of >75, infectious (peds), trauma, ototoxic drugs, autoimmune, congenital, meurolgic, neoplastic
conductive hearing loss
ear wax, otitis media, TM perforation, cholesteatoma
aging of inner ear
high freq, progressive, symmetric, multifactorial, hearing aid, assistive device, cochlea implants, rehab - pharmthereapy, PT, surgery
otosclerosis
autosomal dominant, bone deposistion at foot plate of stapes, fluoride prevents, family Hx, tx - hearing aids or stapedectomy
noise induced hearing loss
exposure of life, audiogram with normal and then drop off at high freq
temporal bone fracture
head trauma, headache, vertigo, SNHL, CHL, facial nerve para, CSF leak, tx - neurosurgical, reconstruction - is facial nerve working hardest to fix - it facial nerve is out immediately and you can fix it you should - if facial nerve goes away gradually will probably come back
acoustic neuroma
unilateral SNHL, vertigo, facial nerve para, aural fullness, trigeminal numbness, diplopia, MRI with contrast, obs / surg
tinnitus
subjective - perceived sound without sound, objective - perceived sound of internal body, more men, >50, 15% of pop
subjective tinnitus
SNHL, pt perceives sound when there is none outside body, NSAIDS, aminoglycosides, antidep, anticancers, trauma, systemic disease (HTN,depression, anxiety, MS, stroke, meningitis), metabolic (hyper-hypothyroid, hyperlipidemia, vit A, vit B, zinc def)
objective tinnitus
pt hears sound produced inside the body, doc can hear it too, vascular (bruits, hums, tumors), eustachian tube, myoclonus, tensor tympani/stapedius, spont otoacoustic emission
vertigo
vestibular, illusion of movement
dysequilibrium
vestibular, poor coordination,
dizziness
vestibular, all encompassing
imbalance
vestibular, orthopedic or neuro
vestibular work up
HP, MRI/CT, LP?, electronystagmography, rotary chair, comp dynamic posturography, vest evoked myogenic potential
ddx for peripheral vertigo
inner ear, benign paroxysmal positional vertigo - dizzy when head in certain position/repeatable, Meniere’s disease, neuronitis, labyrinithitis, ototoxicity, otitis media, fistula
ddx for central vertigo
inner ear, MS, stroke, cerebellar lesions, daibetes, migraines
benign paroxysmal positional vertigo
peripheral vertigo, post trauma/viral, brief positional vertigo with latency and fatigability, Dix-Hallpike manuver, hormal hearing
Meniere’s disease
tinnitus, fluctuating SNHL, episodic vertigo, unilateral, progressive, tx - salt restriction, spaced meals, H2O, diuretics, steroids, vestibular suppressants, allergy, surgery - r/o stroke, tumor, infection, trauma
vestibular neuronitis
viral infect of vestibular nerve, hours to days, no hearing loss, prodrome viral URI, weeks - months, tx - meclizine, benzos, antiemetics
labyrinthitis
viral, bacterial, sudden hearing loss and vertigo, tinnitis, from middle ear through round or oval window, audiogram (SNHL), tx - IV antibiotics, vestibular suppressants, surgery, steriods
facial nerve para
birth, mobious syndrome, herpes zoster, tumor, stroke, surgery, Guillain-Barre, myesthenia gravis
anotia
more unilateral, canal atresia and middle ear, reconstruction, bone anchored hearing aid
microtia grade I
slightly smaller, conchal bowl cupped, all parts present, no surgery
microtia grade II
1/2 size auricle, all structures present, soft tissue def, surgery sometimes
microtia grade III
small cartilage piece, ant deflected lobule, surgery 5-6yrs, prostheses, use rib cartilage
lop ear
common, ears stick out, absent antihelical fold, royal lineages, teasing, low self esteem, surgery - otoplasty
preauricular pits / fistulas
infected, antibiotics, incision, drain, excise after infection, bilateral
auricular appendages
arrested hillock fusion, xxxx47
relapsing polychondritis
autoimmune, episodic, nose/joints/airway/heart valves, ESR, IgG high, tx - steroids and NSAIDs, entire upper cartilage inflammed
xxxx 50
xxxx 50
keloids
scar, avoid peircing, steroids, pressure dressing, excision
auricular hemotoma
trauma, wrestlers, incision and drain, then bolster that pushes skin to cartilage, causes cauliflower ear
cellulitis of pinna
pain, swollen, red entire ear, staph, strep, pseudomonas, tx - antibiotic and pain meds, risk - diabetes, foreign body, piercing, trauma
ear canal osteoma / exostosis
benign into canal, norwegians, cold water exposure, no surgery, looks like cholesteatoma, observe
carcinoma of ear canal
pain, bleeding, soft tissue mass in canal, biopsy, excision and radiation, can metastasize, fatal
otitis externa
painful red canal, swimmers, diabetics, immunosupressed, tx - antibiotic drops / systemic, cheesy, wet moist canal, suctioning, pseudomonas, e coli, staph, hearing may be affected - put sponge in to pull meds into canal and absorb secretions
herpes zoster oticus
vesicular purulent ulcers, around ear, low hearing, pain, facial nerve para, tx - antiviral and pain meds, immunocompromised
otorrhea (ear drainage)
pain, hearing loss, vertigo, trauma, previous surgery / infection, otitis media / externa, allergy, trauma, CSF, culture if recurrent, beta 2 transferrin for CSF
psoriasis of external ear
red, itchy, flakes, no Q tips, in other places, tx - topic steriod and antibiotic for secondary otitis externa
canal stenosis
congenital, trauma, xxxxx62
otomycosis
fungal, pain, itch, hearing low, prior antibiotic, antifungal drops and pain meds, debride, alcohol, vinegar, peroxide tx - underlying immunocompromised?, fruiting bodies
ear canal foreign body
flies, cerumen - in canal
cerumen
protective against viruses/fungus/bacteria, can plug canal, canal sensitive, can cause vertigo or temp hearing loss, removal tricky
cerumenectomy
removes ear wax, irrigation with syringe / water pick / suctioning / curetting / alligators, complication - pain, lacerates canal, perforation of TM, perilymph fistula, vertigo, deafness
TM perforation
cause?, hearing loss, otorrhea, tinnitis, keep dry, tympanoplasty for large hearing loss, often heal with time if not chronic
bullous myringitis
TM with serous bullae, virus, mycoplasma, URI, otalgia, otorrhea, hearing loss, tx - pain meds, antibiotics, decompression of vesicle, steroids
tympanosclerosis
white plaque on TM, hyalin or calcium, otitis media or trauma, normal hearing, if middle ear - then conductive hearing loss
cholesteatoma
ball of keratin from skin in the middle ear, bone erosion, surgery to prevent destruction of ear, can get to brain, must operate!!!
middle ear choesteatoma
squ epi, bone and soft tissue destruction, then infection, no pain, otorrhea, pearly mass, hearing loss, vertigo, tympanomastoidectomy
acute otitis media
middle ear, <3wks, kids, ear tube neg middle ear pressure causing retracted ear drum and fluid collection, strep pneumo, H. influenza, mor. catarrhalis, irritable, ear tugging, hearing loss, tinnitis, fever, red/yellow TM that bulges, TM turns red with crying, tx - resolve, antibiotics, topical drops if TM perforated, pain meds, proph antibiotics,
serous otitis media
dark amber TM, serous fluid behind TM, use tympanogram
otitis media - risk factors
day care, smoke, bottle feeding, food/nasal allergies, URIs, skull base ab, adenoid hypertrophy, GI reflux, immune disorder, ciliary dysfuction, nasal intubation, nasopharyngeal tumor, cholesteatoma, genetics
myringotom and tubes for AOM
recurrent om, >3 in 3 mnths / >4 in 12 mnths, chronic effusion, poor response to antibiotics, cleft palate, TM retraction, immunocompromised, barotitis media, ear tube dysfunction
mastoidectomy
irradicates infection, removing cholesteatoma, keep hearing and vestibular function
complications of AOM
mastoiditis, abscess, petrous apiculitis, labyrinthine fistula, facial nerve para, meningitis, sinus thrombosis, hydrocephalus
ddx for otalgia
infection, inflammatory, trauma, tumor, TMJ, dental, tonsil, cancer, post herpetic, cervical arthritis
Q tips
promote infection, push wax deeper, makes ear itch, promotes stenosis, perforates TM
case - 23, male, 6wks red eyes, discharge, tearing, blurred, swollen, already tx with polymyxin B/neomycin, started unilateral to bilateral, preauricular lymph nodes, multiple sexual partners
labs - chlamydia DNA probe positive = chlamydia trachomatis
allergic conjunctivitis
itches, bilateral from start, serous / mucoid discharge, hay fever, itch / red / eyelid swelling, seasonal, Tx - vasoconstrictors and topical antihistamine drops
viral conjunctivitis
unilateral at start, serous discharge, preauricular lymph nodes, contageous, eyes red / watery / foreign body sense, recent URI, adenovirus / herpes / zoster, Tx - cold compress and topical vasoconstrictors
bacterial conjunctivitis
unilateral at start, mucopurulent discharge
not conjunctivitis
pain, photophobia, blurred vision
chlamydial conjunctivitis
mucoid / mucopurulent discharge, preauricular lymph nodes
hyperacute bacterial conjunctivitis
severe, sight threatening, abrupt, lots of yellow discharge, red, tender, lid swelling, adenopathy, N/ gonorrhoeae or N. meninigitidis, neonates and sexually active young adults, Tx - ceftriaxone IM/topical antibiotic/irrigation
acute bacterial conjunctivitis
tearing, mucopurulent / purulent, matted eyelid on waking, slower onset, less severe, Tx - topical antibiotic
causes of acute bacterial conjunctivitis in kids
strep pneumo, H. influ, staph
causes of acute bacterial conjuctivitis in adults
staph, strep, e. coli, pseudomonas, morazella
chronic bacterial conjunctivitis
staph, eyelid findings swelling, debris, eyelash loss, Tx - warm compresses and topical antibiotic
ocular chlamydial bacterial conjunctivitis
trachoma - serotyples A-C (worldwide), inclusion - serotypes D-K (US), Tx - oral tetracycline/doxycycline/erythromycin for 2-3 wks
trachoma conjunctivitis
chronic keratoconjunctivitis, preventable blindness, Africa, Asia, Middle East, immigrants to US
inclusion conjunctivitis in newborn
chlamydia, STD, to newborn via infected cervix, tearing, discharge, eyelid swelling 5-12 days after birth
inclusion conjunctivitis in adult
chlamydia, STD, sexually active 18-30, infected genital secretion to the eye, subacute/chronic, red, mucopurulent, FB sense, adenopathy
conjunctivitis test
hyperacute/chronic - culture, DNA probe, ELISA, PCR
conjunctivitis
discharge and no pain
steroid eye drops
do not use in eye drops alone or with antibiotic/antiviral
case - 17 mnth boy, clear nasal discharge, cough, fever, fussy, not sleeping, father smokes, bottle fed, bulging TM, red TM, ear tugging, nodes on neck, nasal cold prior, mom chronic ear infections, TM no cone of light and can’t see malleus
acute otitis media not viral very often, labs - none needed, possible causes strep pneumo, staph, H. influ non-typable, Moraxella catterhalis
acute otitis media article
strep pneumo, H influ, moraxella catarrhalis, fever, otalgia, headache, irritability, cough, listless, anorexia, vomiting, diarrhea, pulling ears, middle ear effusion detected with pneumatic otoscopy, tx amoxicillin with macrolides(erythro/azythro)/clindamycin/cephalosporin to penicillin allergy, hearing and language testing if hearing loss or effusion >3 mnths, sure signs - bulging TM, nonmobile TM, and red TM, smooth tympanogram = effusion, pointed neg pres tympanogram = retracted TM, tx - pain (aceto/ibu), spont resolution common, antibiotics if <6mnths, certain, or serious over 2yrs, tubes if recurrent
if resistant otitis media
add clavulanate to amoxicillin
chlamydial conjunctivitis, serotypes A-C
trachoma, conjunctival scarring, decreased tear adherence, corneal ulceration, blindness
chlamydial conjunctivitis, serotypes D-K
genital infection, conjunctivitis, conjunctival scarring - not blindness, cervical cell inclusion body
chlaymdial conjunctivitis
follicles, scarring, corneal opacity (serotypes A-C), cervical cell inclusion body (serotypes D-K)
PBL - 15, male, peripheral vision loss, bad night vision, bad balance, pat grandpa blind and deaf, pallor in optic disc, attentuated retinal blood vessels, drusen, no vestibular reflexes
Usher syndrome - retinosis pigmentosa and congenital deafness, progressive blindness, MYO7A mutation, tx - vit A, docosaheaenoic acid (enhances vit A), field-expanding lenses
conductive hearing loss audiogram
bone conduction greater than air conduction
sensorineural hearing loss audiogram
air and bone conduction are the same, there is a drop off in hearing at higher freq
cochlear implant
controversy because are deaf normal and can function with ASL, microphone -> speech processor -> transmitter -> receiver/stimulator -> electrode array in cochlea into nerve, very successful, not like normal hearing, good to implant during critical speech learning period, therapy to learn sounds
retinal implant
camera -> transmitter -> wire -> chip in retina, new, narrow applications (must have healthy retinal cells - retinitis pigementosa and macular degeneration), low resolution image, newly approved
risk factors for vision loss
African American, Hispanic, 40+, family Hx, nearsighted, longterm steriods, diabetes, eye trauma, hypertension, high IOP
risk factors for hearing loss
babies - infection during pregnancy (CMV, rubella, toxo), ototoxic meds during pregnancy, neonatal infections (CMV, herpes, rubella, toxo), premature, genetics, malformation
nystagmus
fast, uncontrolled eye movements side to side or up and down or circular, slow and fest phases, named for direction of fast phase
vestibulo-cochlear reflex
head moves in one direction and eyes move in opposite direction, lateral semicircular canal -> vestibular nucleus -> interneuron -> abducens and oculomotor nucleus -> reticular formation (medial fibers only) -> lateral and medial recti (inhibited or excited to moves eye oppisite head), slow phase = smooth pursuit, fast phase = saccadic
caloric testing
irritate external auditory canal with warm/cold water or air, stimulates lateral semicircular canals, causes nystagmus
rotational testing
turning chair intended to induce nystagmus
Usher syndrome Type I
3-6% of kids who are deaf or hard of hearing, 4/100,000 babies, MYO7A mutation, autosomal recessive
why vit A for retinitis pigmentosa
combines with opsin to form rhodopsin - a light absorbing molecule
papilledema
optic nerve - bulging / blurred, blood vessels - engorged
macular degeneration
optic nerve - pits, blood vessels - lacey, drusen speckling in macula
glaucoma
optic nerve - cupped inward, blood vessels - baring makes them look larger
drusen diseases
optic exam - looks like light and dark speckling on the retina, found with macular degeneration, retinitis pigmentosa, Usher syndrome
normal ear drum
white, clear, cone of light, malleus
tympanosclerosis
calcium plaques from old infections, bumpy white spots on TM
serous otitis media
neg pressure, clear fluid behind TM, from eustachian tube obstruction, ear drum still looks pretty clear, eventually erosion of osicles, retracted TM
cholesteatoma
skin cyst, retraction pocket of TM into middle ear, erodes bone, possible facial paralysis, hearing loss, dizziness, Tx mastoid operation
ear drum perforation
watch, may heal, tympanoplasty
otitis media
bulging TM, red, inflamed
hemotypanium
blood in middle ear, looks dark
abrasion of ear drum
Q tips, can lead to otitis externa
cause of primary otalgia
otitis media or otitis externa
cause of secondary otalgia
referred pain from TMJ, pharyngitis, dental disease, cervical spine arthritis
ear pain that needs further evaluation
hx or px of smoking, drinking, >50, diabetes
evaluation of continuing ear pain after Tx
MRI, fiberoptic nasolaryngoscopy, ESR
ear pain exam
traction on auricle, press on tragus, palpate TMJ
epistaxis (nose bleed)
most often from anterior nasal cavity, compression usually stops bleeding
if compression does not stop epitaxis
topical vasoconstriction, chemical cautery (silver nitrate), electrocautery, nasal packing, posterior gauze packing, balloon system, artierial ligation
amicyasin (aminoglycosides)
antiobiotic that can be ototoxic in utero
rubella
can cause deafness in utero
defect of MYO7a
not all defects of myosin 7a cause usher syndrome, some just cause deafness
neg pressure tympanogram
retracted TM, eustachian tube obstruction
lower peak at normal pressure tympanogram
otitis serous (otitis media would have obvious other symptoms), often with URI
epistaxis
unilateral = anterior (Kisselbach’s), bilateral = posterior, pressure 15 min (clamp), lean forward, pack if can’t see/stop bleeding, pack more post bleeds than ant, use lidocaine with vasoconstrictor (epi)
DiGoerge Syndrome
failure of 3rd and 4th pharyngeal pouch formation, no thymus or parathyroid glands, immunosuppressed and hypocalcemic
narrow angle glaucoma
sudden, pain, blurred vision, Asian, halo around light, anisocoria, sluggish pupil light reaction
optic neuritis
loss of vision for hour-few hours, pain with eye movement, loss of color vision, altered pupil reaction to bright light, associated with future MS diagnosis
trochlear nerve dysfunction
eye can’t look down and inward (intortion) on convergence, superior oblique not working
base of cochlear membrane not working
can’t hear high frequencies as well
