Week 7 - HEENT (Head, Ears, Eyes, Nose, and Teeth) Flashcards
Show me the eyeball
Show me retenal detachment
Show me a corneal Ulcer
Show me the types of glacoma
Show me the structures involved with glacoma
Show me the Nose and the possible fracture sites
Show my what peritonsillar abscess looks like
Puss filled tissue
Show me the Ear
Show me the Inner Ear
Dizziness Differentials
Peripheral?
Central?
Meniere’s Disease
Acute Otitis Media
Perilymphatic Fistular CNS Trauma
Cholesteatoma
Viral Labyrinthitis
Bacterial Labyrinthitis
Vestibular Neuronitis Motion sickness
Ototoxicity
Otologic Surgery
Otologic Injury/Trauma
Otosyphilis
Benign ParoxysPPV
Acoustic Neuroma
Brainstem CVA
Carotid Stenosis
CNS Neoplams
Multiple Sclerosis
Vertebrobasilar Insufficiency
Medication Overdose
Presbystasis
Psychogenic Disorder
Arnold-Chiari Malformation
CNS Infection
Seizure Disorder
Migraine
Dizziness Differentials
Systemic?
Cardiac Arrhythmia
Cardiac Valvular Disease
Orthostatic Hypertension
Alcohol Intoxication
Sleep Deprivation
Toxin Exposure
Hypoglycemia
Autonomic Dysfunction
Hyperventilation
Pain/Anxiety
What is Vertigo?
What is Vestibular Neuritis?
an abnormal sensation that is described by a person as a feeling that they are spinning, or that the world is spinning around them, and may be accompanies by intense nausea and vomiting. This feeling may be associated with loss of balance to the point that the person walks unsteadily of falls. Vertigo itself is a symptom or indicator of an underlying balance problem, either involving the labyrinth of the inner ear, or the cerebellum of the brain
thought to be the result of inflammation of the vestibular portion of the eighth cranial nerve and classically presents with vertigo, nausea, and gait imbalance
The seventh cranial nerve sends information between the brain and the muscles used in facial expression (such as smiling and frowning), some muscles in the jaw and the muscles of a small bone in the middle ear
What is Bell’s Palsy?
What is BPPV? (Benign Paroxysmal Positional Vertigo)
the most common cause of facial weakness, whereas vestibular neuritis ranks second or third as the most frequent cause of sudden onset of dizziness and vertigo. The two conditions can occur either singly or in combination to cause facial weakness and debilitating dizziness
a brief, intense episode of vertigo that occurs because of a specific change in the position of the head. A person also may experience BPPV when he or she rolls over in bed. BPPV sometimes may result from a head injury or aging
What are the top 9 differentials for HEENT?
What are ototoxic agents?
Tinnitus
Ototoxic Agents
Mastitis
Tonsilitis
Otitis Media
Auricular Hematomas/Cauliflower (rugby, MMA, Soccer)
Perichondritis – Trauma/Piercings
Otic Barotrauma – TM Preformation (many tubes)
Ear drainage tubes – Tympanostomy tubes
more than 600 prescriptions and over the counter drugs that can trigger tinnitus, make existing tinnitus worse, or cause a new tinnitus-causing drugs sprinkled throughout.
For example, antibiotics, painkillers, anti-anxiety, and anti-depression drugs, antimalarial medications, anti-cancer drugs, and blood pressure controlling medications – to name a few – can trigger tinnitus
Special Considerations
Eye Trauma?
Suspect head injury
Loss og vision is traumatic
Great Anxiety
Contact Lenses
Transient S+S
What are the Priority diagnosis for eyes?
Sudden vision loss
chemical injury
vision - threatening trauma
What will you do for a focused assessment for the eye?
Visual acuity
External inspection: lids, lashes, conjunctiva, and cornea, symmetry of eyes, eye movement
Paplate orbital rim
pupils
What’s the eyes external examination?
What’s the physical exam?
Penlight examination
Eyelids
Conjunctiva
Corneal Clarity
Pupil Size (oculomotor)
Pupil Symmetry
Pupillary light reactions (consensual)
Accommodation
Visual Acuity
Cranial Nerve II – Optic Nerve
Palpate the orbital rim
What are the extraocular movements?
What’s the eye assessment?
Cranial Nerve III – Oculomotor
Cranial Nerve IV – Trochlear
Cranial Nerve VI – Abducens
Current History – Mechanism of Injury, New/Recurrent problem, Loss/Change of
vision
How does the eye feel?
How does the eye look?
What’s the differentials for red painful eye(s)?
Eyes - traumatic emergencies?
Glaucoma
Corneal Abrasion
Foreign body
Corneal ulcer
Conjunctivitis
Iritis
Scleritis
Episcleritis
Eyes: Traumatic Emergencies
Corneal Abrasions and lacerations
Corneal foreign bodies
Penetrating eye injuries
Retinal detachment (traumatic)
Burns
Acute vitreous hemorrhage & hyphema
Tell me about corneal abrasions and lacerations?
Common
Causes partial or complete removal of corneal epithelium
Prognosis – Depends on depth or injury
C/O severe pain, tearing and blepharospasm (lid spasm)
Management: Irrigate with normal saline, dry light pressure dressing over both
eyes with eyelids closed (do not tape eyelids closed)
Corneal Foreign Bodies
What are the clinical features?
What’s the physical exam?
Something in my eye
History of object being propelled into the eye
Tearing, conjunctival reddening blepharospasm
Dull non-localizing ocular ache and decreased vision
Complete Inspection of the eye
Note presence of absence of material
Note presence of rust ring
Visual Acuity
Multiple foreign bodies
Corneal Foreign Bodies
What’s the management?
What do you need to do for penetrating eye injuries?
ABCs
Avoid external pressure on the globe
Superficial conjunctival or corneal foreign bodies may be irrigated
Cover both eyes if injury/ pain is severe
Be prepared for emesis
Massive trauma only a brief look should be attempted
May have penetrated the globe
Control bleeding using minimal pressure
Do NOT manipulate, palpate, irrigate or apply cold packs
Acute Iritis/ Anterior Uveitis
Tell me about it
Anterior Uveitis – Inflammation of the anterior segment of the eye
Acute iritis – Mild inflammatory reaction of the iris – seen after blunt trauma
Clinical Features: Pain (Deep ache), Headache above eyebrow, photophobia,
excessive tearing
Retinal Detachment (traumatic)
Tell me about it
What’s the physical exam?
Blunt trauma may caused violent shifting of the vitreous body – causing renal
tears
Tears may ‘dissect’ the retina for the choroid (vascular layer) as blood enters
this space and hematoma develops
In acute injury, if patient reports seeing a flash of light, consider detachment
May be a latent period between injury and detachment (up to months)
Not painful – only symptom is VISUAL
Perceived as a curtain descending over the visual field (progressive loss of vision)
Loss of vision may also be sudden
Reports of light flashes and cloudy vision
Nothing visible (blood) on inspection
Retinal Detachment (non-traumatic)
Tell me about it
Spontaneous retinal detachment occurs most frequently in the elderly
Results from fluid or blood leakage from vessels within the retina
Causes: Hypertension, toxemia of pregnancy, papilledema (optic disc swelling)
Retinal damage can progress slowly or enlarge quickly resulting in complete
detachment
Burns to the Eyes
Tell me about akali burns
Tell me about acid burns
True ocular emergency
Alkaline exposure dissolves tissues until it is removed
Immediate Irrigation – minimum 20 minutes
Remove any particles
Severity can be judged by corneal cloudiness and scleral whitening
Tend to be less devastating
The body is better able to deal with acids
Treatment is same as for alkali exposure
Burns to the Eyes
Tell me about thermal burns
Tell me about radiation/ultraviolet burns
Affect the eye lids more than the globe
Determine if vision is decreased/blurred
Limit assessment to inspection
Cover affected eyes with moist dressing
Hot liquid splashes and cigarette ashes to the cornea usually results in a
superficial corneal epithealial injury – treat as corneal abrasion
Results in direct corneal epithelial damage
Latent period of 6-10 hours
Patient develops foreign body sensation, intense pain, tearing, photophobia and
blepharospasms
Cover the affected eyes for p
Hyphema and Acute Vitreous Hemorrhage
What is that?
What are the clinical features and physical exam?
Hyphema is blood in the anterior chamber resulting from rupture of one or more
iris vessels
Extent varies from microscopic to ‘8 ball’ hyphemas in which the entire anterior
chamber fills with blood
Clinical Features
Principle cause is traumatic, retinopathies in diabetic patients may also be
causative
Physical Exam
C/O pain and cloudy vision (floaters/spots)
Visible reddish tint in anterior chamber
What’s Enucleation?
Surgical management of malignancy
Severe Infection
Trauma
A ball implant is then inserted
What is the physical exam for enucleation?
Orbital edema and ecchymosis
Localized facial swelling
Pain
Tingling/Loss of sensation
Diplopia
Inability to elevate eye/restricted extraocular movements
Subconjunctival hemorrhage
Enophthalmos or exophthalmos
Subcutaneous emphysema
Eyes - what are the medical emergencies?
Central retinal artery occlusion
keratitis
Corneal ulcers
Acute glaucoma
Acute iritis
Conjunctivitis (bacterial/viral)
Tell me about central retinal artery occlusion?
What are the causes?
Blood supply to the retina is obstructed producing a painless, total or near total
black out of vision
Re-establishment of retinal circulation MUST be accomplished within 90 minutes to regain vision
Predisposing factors
Atherosclerosis of carotid artery (clot formation)
Atrial Fibrillation
Prolonged pressure on eye with swelling/tight dressing
Central Retinal Artery Occlusion
What’s the physical exams?
What’s the management?
What’s the clinical progression?
Patient presents without pain
Sudden loss of unilateral vision
No history of trauma
Associated with history of hypertension or hypercoagulable states
Emotional Support
Transport
Immediate recognition
In 90-120 minutes, retina becomes necrotic and edematous – irreversible
blindness
What is Keratitis/what does it look like?
What are corneal ulcers?
Inflammation of the cornea
Caused by infections, hypersensitivity reactions, ischemia, defects in tears,
trauma
Presents as moderate to severe pain depending on the amount of epithelial
disruption present
Scar tissue formation is the leading cause of blindness
Divided into non-ulcerative and ulcerative
Integrity of the corneal epithelium is disrupted
Symptoms include pain, increased tearing, photophobia, ocular irritation
What is glaucoma?
What are cataracts?
Defined as a group of conditions characterized by increased intraocular
pressure
Caused by alterations in the circulation and resorption of aqueous humor
Classified as open angle or closed angle
Opacity of the lens of the eye or the capsule or both leading to a painless loss of vision
Due to aging process, but can be caused by infection, injury, exposure to radiation or chemicals, UV radiation or metabolic disorders
Presents with a distortion of the visual image especially at night or in bright light
Management is surgical
The iris may appear distorted in post-op surgery patients
What is Conjunctivitis (Viral)?
What is Conjunctivitis (Bacterial)?
Infections and accounts for the majority of “pink eye”
Frequently occurs in conjunction with an URI
Redness & tearing are common
Treatment is symptomatic
Presents with a mucopurulent discharge of varying colors (gray, yellow, green).
Typically there is matting of the lashes in the morning, but minimal, if any pain.
Treatment consists of topical antibiotic drops for one week
Warm soaks should be used to keep the lids/lashes free
What is Macular Degeneration?
Degeneration of the macular area of the retina in the eye (the macula is in the
center of the retina)
Causes: Age related unknown, injury, inflammation, nutritional and hereditary factors implicated
S/S: loss of central vision, visual distortion
Orbital Cellulitis
Periorbital?
The S+S
Orbital?
Fever
Periorbital edema
Eye tenderness
No proptosis (bulging eye)
Visual Changes
Pain with EOM
Decreased visual acuity
Ophthalmoplegias
Spreads from adjacent infections
Can extend into dural sinuses and meninges
What are the top 3 emergencies for traumatic ear injuries?
What are potential ear trauma injuries?
Ear trauma
Foreign body in ear
Ruptured tympanic membrane
Lacerations & contusions
Thermal Injuries
Chemical Injuries
Traumatic perforations
Barotitis (ears ‘pop’ from flying at high altitudes, scuba)
Foreign Body in Ear clinical features?
Patient usually state something is in ear
Quite often an insect (adult), bead (peds)
Patient may present with pain and purulent drainage and not be aware of foreign body
Important: Is there a history of tympanic membrane rupture
What is a ruptered typmpanic membrane?
What are more Ear medical emergencies?
Perforations of TM result from: acute changes in air or water pressure (blast injury), direct trauma (foreign body, Q-tips), caustics, lightning strike, otitis media, or associated temporal bone fractures.
The patient may complain of slight hearing loss or pain
The presence of concurrent vertigo or acute deafness suggests associated injuries to the semicircular canals
Otitis media & otitis externa
Meniere’s disease
Tinnitus
Labyrinthitis
Vertigo
What is Otitis Externa?
What is the etiology?
Defined as an inflammation of the outer ear
The limited form of otitis externa is common to swimmers
Physical findings may be limited to erythema
Water-facilitates infection
Bacteria – usually pseudomonas
Fungal – aspergillosis and candida (immuno-compromised, chronic users of steroid drops)
Malignant otitis externa: Osteomyelitis of the skull, begins as typical OE, nonresolving, OE defaults to this for diabetic, HIV, Ca pts
What is Otitis Media?
What is Menere’s disease?
Otitis media includes the initial acute infection, otitis media with effusion, and
chronic otitis media
Acute Otitis Media (AOM) presents with the rapid onset of ear discomfort
Typically follows URI
Pain associated is not aggravated by movement
Defined as a chronic disorder of the inner ear. Triad of symptoms: vertigo,
tinnitus and sensorineural hearing loss
Overaccumulation of fluid in the membranous labyrinth of the inner ear
Onset of symptoms may be gradual or sudden
What are the S+S of Meniere’s disease?
What is tinitus?
Severe rotary vertigo (may be associated with N/V)
Tinnitus
Nystagmus during acute attacks
Most common complaint with otologic conditions
Ranges from mild ringing to a loud roaring in the ear
Causes include: presbycusis, otosclerosis, Meniere’s, loud noise, certain drugs and a wide variety of pathological disorders
Treatment is resolving underlying disorder
What is Labyrinthitis?
What is vertigo and dizziness?
Infection of the labyrinth
Clinical Manifestations: hearing loss, tinnitus and spontaneous nystagmus to the
affected side
Causes include: nearby infections of ear, nose or throat. Otitis media or
meningitis; toxic effect of certain drugs
Common clinical manifestation of many ear disorders
Dizziness is described as a disturbed sense of the proper relationship to space
Three systems combine to give input regarding balance: visual, vestibular and the proprioceptive system
Associated symptoms of vertigo: Nausea/Vomiting, falling, nystagmus, hearing loss and tinnitus
What are the nose traumatic emergencies?
What is Epistaxis?
Epistaxis
Fractured nose
Foreign Body in nose
Highly vascular
Bleeding may originate in the anterior or posterior nose
Causes include medications, particularly antiplatelets or anticoagulants and:
* Anterior: drying, infection, blunt, trauma, manipulation, cocaine use and local infection
* Posterior: Blood dyscrasias, hypertension, diabetes and trauma
Fractured Nose
What are the mechanisms?
What’s the physical exam?
Trauma that produces a fracture of the nasal bones may come from frontal,
superior to inferior or lateral direction
Of these – laterally directed trauma most likely to fracture since no cartilage to
absorb or dissipate the force
Suspected in all patients with significant facial trauma
Swelling
Tenderness/Pain
Crepitus
Ecchymosis (bruising)
Deformity
Epistaxis
Tell me about foreign body in the nose?
What are the clinical features?
Most common for insertion of foreign bodies by children
Patient was seen inserting the object
Or presents with a purulent unilateral malodourous nasal discharge
Body Odor
What is sinusitis?
What are the acute symptoms?
Inflammation with resulting infection of the mucous membranes of one of more
paranasal sinuses
Commonly follows URTI or viral rhinitis
Causes include URI, nasal polyps, deviated septum, tooth abscess, abuse of nasal decongestants, swimming and diving, frequent changes in barometric pressure
Constant, often severe pain and tenderness
Maxillary sinus involvement may lead to teeth pain
Headache
Fever
Purulent nasal discharge
Sore Inflamed throat
Sinusitis
What are the subacute OR chronic symptoms?
Dull, intermittent or constant pain
Purulent nasal discharge
Chronic cough
Recurrent episodes
Loss of sense of smell
Throat
Traumatic Fractured Larynx - tell me about it
What’s the physical exam?
Blunt or penetrating trauma to the anterior neck can cause fracture or dislocation of laryngeal or tracheal cartilages
Need a high degree of suspicion for associated vascular injury
Injuries associated include fractures of hyoid bone, fractures of thyroid cartilage, fracture/dislocation of cricothyroid and fractures of trachea
History/Mechanism
Hoarseness or aphonia
Edema and bleeding (hemoptysis)
Throat
Medical Peritonsillar Abscess - tell me about it
What are the potential complicaitons?
What’s the physical exam?
Bacterial – streptococcus/staphylococcus
Infection spreads into tissue between the tonsils and underlying muscle and creates an abscess
Untreated – infection can spread deep into neck with the potential for eroding a large vessel or aspiration of purulent drainage if abscess ruptures when patient is asleep
Edema may threaten patency of the airway
Erosion into the carotid artery
Physical Exam/History
Sore throat x days with clinical progression to malaise and fever
Unilateral pain and difficulty swallowing
Patient may drool
Red edematous area above the tonsil between the soft palate and the tonsil often displacing the uvular
Throat
Medical Retropharyngeal Abscess - tell me about it
Retropharyngeal space extends from base of skull to tracheal bifurcation
Fever, dysphagia, neck pain, sore throat, muffled voice, respiratory distress, stridor in kids
Immediate ENT consult is required
Fatal complication: airway compromised
Dental trauma - tell me about it
How do you care for an avulsed tooth?
Normal adult mouth has 32 teeth
3 Sections – crown, neck, root
Can involve fractures alone or fractures in combination of jaw (mandibular #) or facial bones
With fractured teeth, oral cavity should be examined for tooth fragments
Cold, fresh milk or saline for tooth transport
Do not rinse tooth
Take care NOT to handle by the root
