ENT and Eye

Question 1

Causes of acute otitis externa

Answer 1

If there is copious purulent or serous drainage (crusty) - likely a bacterial cause (Pseudomonas or Staph) - Swimmer’s Ear

If gray/black plaques with a fuzzy cotton appearance - likely fungal - diabetics get this

Question 2

Treatment of Acute Otitis Externa

Answer 2

Cleaning the ear is just as affective as antibx treatment
–1:1 dilution of 3% hydrogen peroxide

If bacterial AOE is suspected can also give Cipro/hydrocortison gtts or Floxin gtts

Question 3

Diagnostic features of acute otitis media

Answer 3

Ear pain with some URI sxs
Real diagnosis comes from TM bulging, not just erythema

AOM with effusion - crackling sound in ear caused by blocked eustation tube - will be able to see the fluid behind the TM, no bulging

Perforated TM - severe AOM or trauma
–Severe pain, vertigo, tinnitus, markedly decreased hearing
–Start antibx, call ENT

Question 4

Treatment of Acute Otitis Media

Answer 4

Usually caused by Streptoccocus sp.

Treat with Amoxicillin
–Can use Erythromycin if penicillin allergy

Question 5

Treatment of perforated tympanic membrane

Answer 5

Remove debris with gentle suction
Insert a sterile cotton ball into the ear canal to protect it and have patient use wax ear plugs when showering
ENT should be the ones to remove the cotton ball

Treat with Floxin gtts

Question 6

Mastoiditis and how it is diagnosed and treated

Answer 6

Presents with sxs of AOM but also has fever, headache, possible signs of sepsis.
Tender mastoid process

Diagnosed with MRI

Treat with Ceftriaxone IV given that it is usually caused by Staph, Strep or H influenzae
Consult ENT

Question 7

Working someone up for dizziness, specifically vertigo

Answer 7

Hintz exam can diagnose vertigo

If sxs are severe (vomiting, falling, spinning) - likely peripheral (disorder of the inner ear)

CNS problems usually cause more mild sxs

Monitor for nystagmus - horizontal nystagmus usually suggests peripheral cause. Other types of nystagmus are caused by central.

Can perform the Dix-Hallpike test to provoke sxs on a patient that is not currently experiencing vertigo

Treatment can be with meclizine for a few days

If the response is poor, should receive MRI to rule out CNS lesion

Question 8

Epistaxis Treatment

Answer 8

-Clamp or pinch nose closed
-Put cotton ball with lidocaine and vasoconstrictor (oxymetalozine) into nose
-Look for bleeding in nose with nasal speculum
-Use bayonet foceps to insert medicated pledget to vasoconstrict
-Then reapply pressure for 15 minutes
-Could also consider silver nitrate or Merocel sponge
-Have patient walk around for a few minutes to increase intracranial pressure and reassess for bleeding
-If you are leaving packing in, start patient on cephalexin or clindamycin to prevent sinusitis.

Question 9

Clinical features of Ludwig’s Angina

Answer 9

Type of severe cellulitis involving the floor of the mouth with rapid onset over hours

Early on, the floor of the mouth is thrust upward and there is difficulty swallowing saliva

Usually has trismus (pain with opening mouth) and hot potato voice, febrile

As the condition worsens, the airway may be compromised

Obtain CT neck and soft tissues with contrast to find the abscess

Question 10

Difference between bacterial and viral pharyngitis

Answer 10

Centor Criteria for bacterial pharyngitis (3 or more indicate high risk for bacterial):
-Rapid onset fever
-Tonsillar exudates
-Tender anterior cervical adenopathy
-Absence of cough

Viral:
-Slower onset of sore throat
-Nasal congestion
-Cough
-Aphthous ulcers on the palate
-Conjuctivitis
-Other symptoms usually precede the onset of the sore throat

Question 11

Treatment of bacterial pharyngitis

Answer 11

Penicillin V 500mg PO BID x10 days

Question 12

Clinical features of peritonsillar abscess

Answer 12

The patient complaints of usual sxs of bacterial pharyngitis plus:
-Hot potato voice
-Drooling or dysphagia
-Trismus
-Putrid breath
-Trouble breathing

Only one tonsil will be affected - no such thing as bilateral peritonsillar abcess

Question 13

Treatment of Peritonsillar abscess

Answer 13

Obtain a CT of the neck with contrast if abscess is difficult to see
Consult ENT

Treated with ampicillin sulbactam 3mg IV every 8 hours
Clindamycin for PCN allergy

Question 14

Retropharyngeal abscess and what can go wrong

Answer 14

Typically, pt complains of sore throat, difficulty swallowing and dysphagia
Obtain neck CT soft tissues with contrast and consider CT chest as well given concern for mediastinitis
Likely will need intubation given threat to airway but endotrachial intubation might be impossible because it could rupture the abscess, might need surgical airway
Consult ENT
Surgery will be needed to drain the abscess.

Question 15

What is blepharitis and how is it treated?

Answer 15

Common chronic bilateral inflammatory condition of the lid margins

Can be caused by use of old make up or false lashes

Usually better hygiene resolves the problem however can treat with minocycline, tetracycline or docycycline

If no exudate then you don’t need antibx

Question 16

Dacrocystis: What is it and treatment

Answer 16

Infection of the lacrimal sac due to an obstruction of the nasolacrimal drainage system

Presents as painful, swelling, redness and tenderness to the lacrimal sac

Usually responds well to systemic, not topical antibx

Question 17

Treatment of bacterial conjuctivitis

Answer 17

Erythromycin ointment

If they wear contacts, higher risk for Pseudomonas so need to treat with Cipro

Question 18

Clinical features of uveitis

Answer 18

Almost always monocular
Usually complain of eye pain, blurriness of vision, photophobia and maybe some injection for the last few days

Instillation of anesthetic eye drops will usually have little to no effect

Look for limbal flush - red rim around the cornea as this is an early sign of uveitis

Look for irregular shape of the pupil

Consensual photophobia is also noted

Shining a light across the anterior chamber will show a “smokey room” which is the aqueous humor filling with exudate

Question 19

How to treat Uveitis

Answer 19

Measure intraocular pressure with a Tonopen
–Should be normal or low.
–If high, should consider acute glaucoma

Treatment is ophthalmology consult and treatment with Cyclopentolate 1% - paralyses the pupil and keeps iris away from the lens so that adhesions do not form
Also treat with prednisolone 1% 1gtt QID

Needs follow up in 24 hours

Question 20

Clinical progression of retinal detachment

Answer 20

-Flashes of light briefly on the periphery
-Sudden dramatic increase in the number of floaters
-A ring of floaters or hairs just to the temporal side of the central vision
-A dense shadow that starts in the peripheral vision and slowly progresses towards the central vision
-The impression that a veil or curtain was drawn over the field of vision
-Straight lines that suddenly appear curved (positive Amsler grid test)
-Central visual loss

Question 21

Vitreous hemorrhage: presentation, treatment

Answer 21

Rupture of a blood vessel within the choroid can result in hemorrhage spreading under the sensory retina

Pt reports flashes and floaters, blurry vision, reddish tint to vision (suggests blood as mixed into the vitreous) or a reddish spot in the field of vision (suggests a contained hemorrhage)

Refer to ophthalmologist immediately

Question 22

Glaucoma: Acute vs chronic

Answer 22

Chronic, open angle glaucoma is caused by the decrease in flow of aqueous humor through the trabecular meshwork due to degeneration and obstruction of the meshwork.

This causes chronic, painless buildup of pressure in the eye that can be measured with a Tonopen
Cupping of the disc
Constriction of visual fields

Acute, closed-angle glaucoma is caused by sudden forward displacement of the iris against the cornea (often caused by medications that dilate the pupil) that causes an acute build up of aqueous humor
This is very painful, causing vomiting, blurred vision, halos around lights

Question 23

Treatment of acute glaucoma

Answer 23

Chronic:
Prostaglandin analogs: end in -prost
Alpha 2-adrenergic agonists

Acute:
Single dose of Acetazolamide 500mg IV followed by 250mg PO QID

If no response, sometimes osmotic diuretics are needed such as Mannitol 1-2g/kg

Any medicine that has a mydriatic effect needs to be stopped at once (any medicine with anticholinergic effects)

Question 24

Risk factors for acute glaucoma

Answer 24

Diabetes
Can also be caused by medications that cause mydriasis - anticholinergics

Question 25

Difference between dry and wet macular degeneration

Answer 25

Dry form (nonexudative) is more common and less severe - chronic over years
–Cellular debris called drusen accumulates between the retina and the choroid, causing atrophy and scarring to the retina

Wet form (exudative) is less common and quite severe - acute change over weeks
–Blood vessels grow up from the choroid behind the retina which can leak exudate and fluid and also cause hemorrhaging

Question 26

Difference between central retinal vein occlusion and branch retinal vein occlusion

Answer 26

More common than artery occlusions and less severe

Central retinal vein occlusion - main vein of the eye is blocked, therefore causes hemorrhages in the retina - whole retina is bleeding

Brain retinal vein occlusion - a small branch of vessels attached to the main vein is blocked, causing bleeding in just parts of the retina - cotton wool exudates

Question 27

Orbital blowout fracture exam findings

Answer 27

Common symptoms include:
_Orbital pain
-Limitations of gaze, referred to as entrapment
-Diplopia
-Sunken ocular globes
-Loss of sensation of the cheek and upper gums due to infraorbital nerve injury

Question 28

What do cotton wool spots indicate

Answer 28

Diabetic retinopathy

Question 29

What causes arcus senilis

Answer 29

Old age and HLD

Question 30

What do you do with bright red eye that is irritated with hx of herpes simplex?

Answer 30

Refer to ophthalmologist - emergency!

Question 31

What do you do with an eye that is red with copious purulent drainage?

Answer 31

Could be Gonococcal/Chlamydial conjunctivitis

Ceftriaxone 250mg IM + Azithromycin

Question 32

How do you treat a corneal abraison

Answer 32

Anesthetize the eye for thorough exam to ensure no foreign body
Topical antibiotic ointment may be prescribed, especially in patients who wear contact lenses (pseudomonas)
Steroid drops and anesthetic drops are contraindicated after initial exam
Should be healed in 24 hours

Question 33

What is the pathophysiology of a cataract

Answer 33

Clouding and opacification of the normally clear lens of the eye
Highest cause of treatable blindness

Question 34

What are the symptoms of cataracts

Answer 34

Painless
Clouded, blurred or dim vision
Difficulty with vision at night
Sensitivity to light and glare
Fading/yellowing of colors
Halos around lights
No red reflex
Diplopia in a single eye