HEENT Flashcards
(67 cards)
1
Q
Chalazion is chronic inflammation of ___________
More common in (age)
A
meibomian gland
adults 30-50 (androgen hormones cause sebaceous secretion)
2
Q
Physical findings of chalazion:
how to differentiate between stye and chalazion?
A
non-tender palpable nodule inside eyelid margin
Styes tend to be painful and angry-looking
3
Q
Differential diagnoses of chalazion
A
- hordeolum (stye)
- blepharitis
- if recurrent: consider SCC, sebaceous carcinoma, meibomian cancer (esp in elderly)
4
Q
What is recommended for treatment of chalazion?
A
- antibiotics not indicated (it is a granulomatous inflammation)
- warm compress QID
- frequent handwashing
5
Q
Hordeolum is infection of _______ or _______ usually caused by (pathogen) ________
A
infection of meibomian gland or eyelash follicle
Staph aureus
6
Q
What are some predisposing conditions to development of hordeolum? (5)
A
- recurrent blepharitis
- seborrheic dermatitis
- rosacea
- poorly controlled diabetes
- hyperlipidemia
7
Q
Hordeolum: assessment should rule out cellulitis
What are signs of
- preseptal cellulitis
- periorbital cellulitis
A
Preseptal: ocular pain, eyelid swelling, erythema, fever
Orbital: symptoms of preseptal AND swelling causes pain with extraocular movement, diplopia or blurred vision, proptosis, fever
**need to refer to ER for CT
8
Q
Patient education points for hordeolum
A
- will resolve without rx
- warm compresses QID
- handwashing
- lid hygiene
- discard all eye makeup
9
Q
Blepharitis
predisposing risk factors?
A
- diabetes
- candida
- seborrheic dermatitis
- psoriasis
- rosacea
- demodex mites
- use of isotretinoin for cystic acne
- contact lens use
10
Q
Blepharitis
3 pathophysiological causes
A
most common:
-meibomian gland dysfunction: inadequate flow of oil/mucous into tear duct
- staph aureus
- seborrheic: shedding of skin cells block glands
11
Q
Blepharitis
Common recurrent symptoms? Associated symptoms with -seborrheic -staph -meibomian gland?
A
Burning and itching, tearing, photophobia, dry flaky lids, dry eyes
Transient blurred vision (better with blinking)
all 3 will have lid swelling and erythema
Seborrheic: flaking, nasolabial erythema, scaling
Staph aureus: burning/tearing/itching, recurrent stye/chalazion
Meibomian gland dysfunction: frothy thick discharge and chalazion, may have rosacea or seb dermatitis
12
Q
Blepharitis
- specific questions to ask on history?
- pertinent positive findings on exam
A
History
- itching/burning/pain
- change in facial products
- visual change/pain
-hallmark characteristic findings: redness and irritation of eyelids with crusting/flakes on eyelids or eyelashes
may have ectropion/entropion if recurrent
13
Q
Blepharitis
First line treatment?
Patient education points?
A
Symptomatic management for mild-mod symptoms
- warm compresses QID x 10 min
- lid massage (immed after compress)
- lid hygiene (baby shampoo)
- artificial tears
- handwashing
- avoid triggers (smoking, allergens, contact lens, old makeup)
14
Q
Blepharitis
What is the next step if blepharitis does not respond to symptomatic tx?
When is a referral to ophtho warranted?
A
-topical abx (bacitracin or erythro ointment) at bedtime x 2 weeks
- severe or refractory symptoms not responding to topical abx
- severe eye pain/visual change/photophobia
- suspicious for malignancy (recurrent unilateral)
15
Q
Corneal epithelium is innervated by CN _____
A
CN V (trigeminal)
16
Q
Corneal abrasions from contaminated material eg farming equipment is at high risk for ________
A
bacterial keratitis
17
Q
What are symptoms associated with corneal abrasion?
A
- sudden onset eye pain
- FB sensation
- watery red eye
- photophobia
- blurred vision
18
Q
Risk factors for stomatitis / recurrent aphthous ulcers
A
- Oral trauma
- history of RAS
- ?deficiency in iron/folic acid/zinc
- Hormonal changes
- stress
- food/chemical sensitivity
possible link to SLS in toothpaste
19
Q
Stomatitis: what systems to assess during physical exam?
A
- oral
- cervical lymphadenopathy
- derm: r/o hand foot mouth (look at palms and soles)
20
Q
Define difference between minor and major aphthous ulcers:
- size
- pain
- duration
A
Minor aphthous ulcers: <1 cm, mildly painful, last 7-14 days
Major aphthous ulcers: >1 cm, very painful, last 4-6 weeks
21
Q
Name 4 differential dx for stomatitis:
A
- oral HSV
- hand foot mouth (coxsakievirus)
- Kawasaki (red tongue)
- side effect of medication (eg chemo)
22
Q
Use of viscous lidocaine for stomatitis:
2 precautions with prescribing:
A
• 2% viscous lidocaine: applied directly to surface or ulcer OR as swish/spit
* Not for use in children <3 (seizures, cardiopulm arrest, death) * Do not chew/eat gum for 60 min after use
23
Q
Stomatitis:
-when to refer?
A
To oral surgeon/ENT if ulcers >1-5 mm deep OR last longer than 3 weeks
Cardiology if suspected Kawasaki
24
Q
Subconjunctival hemorrhage:
-commonly caused by:
-chronic diseases:
A
-increased intrathoracic pressure with exertion (coughing, vomiting, labour)
- HTN
- diabetes
- long term hemodialysis
25
Signs and symptoms of subconjunctival hemorrhage?
Components of physical exam:
visual acuity is _____
-check _____
- painless red eye, often unilateral
- blood between conjunctiva and sclera
normal visual acuity
-check BP to r/o systemic HTN
26
Subconjunctival hemorrhage:
Treatment?
Education?
- no rx needed
- will resolve over weeks
- if recurrent: work up for HTN or blood dyscrasia
27
Dry eyes
What are the 3 layers that comprises a tear film?
What can cause dry eyes?
- outer lipid layer (Meibomian)
- middle aqueous (lacrimal)
- inner mucinous (goblet cells)
Causes:
- systemic illness (eg Sjogren's, rheumatoid)
- aging
- dry environment
- medications: TCA, anti-histamines, diuretics, isotretinoins
28
Dry eyes
Components of physical exam?
Exam of both eyes
- fundoscopy
- mouth (dry?)
- check skin, thyroid and joints (r/o systemic cause)
29
What are red flag signs of acute angle glaucoma?
rainbow halos, red painful eye, pupil dilation
30
What are the 3 classic hallmarks of Sjogren's triad?
- chronic dry mouth
- dry eyes
- arthritis
31
What class of medication may REDUCE the risk of dry eyes in adults?
ACE-I
*consider in use for pts who have concurrent HTN
32
The majority of nose bleeds come from: ________
Posterior bleeds originate from ______
- 90% anterior
- Kiesselbach's plexus
Posterior bleed:
-sphenopalatine artery
33
What are some risk factors for recurrent or severe epistaxis?
- Anticoagulation
- foreign body
- chronic use of nasal steroids
- systemic causes: bleeding disorders, HTN
- Trauma
- Tumors
- pregnancy
- cocaine use
34
Signs and symptoms differentiating anterior and posterior bleed
Anterior: bleeding from one nare, may be able to visualize source at the septum
Posterior: "brisk" arterial hemorrhage, patient reports swallowing blood
35
Components of physical assessment for epistaxis
Exam:
- vitals
- airway patency (sit and lean forward)
- use topical lidocaine before nasal exam
- nares: unilateral bleeding + purulent discharge = foreign body; bilat purulent discharge = sinusitis
- look at pharynx: blood flowing down throat = sign of posterior bleed
- derm: mucous membranes, pallor, purpura/petechiae/ecchymosis
36
What is the main cause of rhinosinusitis?
What are the main organisms in:
- acute rhinosinusitis?
- chronic rhinosinusitis?
90-98% secondary to viral
0.5% will develop bacterial sinusitis after 10 days
Acute: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
Chronic: Staphylococcus aureus, Pseudomonas aeruginosa
37
What is the pathophysiology behind the transformation from viral to bacterial sinusitis?
Transition from viral --> bacterial due to decreased mucociliary clearance --> colonization of bacteria on retained mucous secretions --> proliferate as they are trapped in sinuses
38
What is the definition (time) of:
- acute sinusitis
- subacute sinusitis
- chronic sinusitis
- acute: up to 4 weeks
- subacute: 4-12 weeks
- chronic: 12+ weeks
39
What are some history questions to ask during assessment of rhinosinusitis?
- duration >10 days or >12 weeks
* "double sickening" symptoms: gradually feel better, then feel worse again
- recent URTI
- recent dental infection
- allergies
- home treatments
- for kids: look for FB
- hx of swimming/diving/flying
40
What systems should be assessed during a physical exam for rhinosinusitis?
- eyes: r/o periorbital cellulitis
- ENT: edema, discharge, patency, polyps, foreign body
* infected mucosa will look red and swollen, allergic will look boggy (purple/blue)
- dental: r/o abscess
- sinuses: frontal, maxillary, ethmoid
- lymphadenopathy
- neuro exam if suspected meningitis or intracranial abscess
41
What are some signs and symptoms of rhinosinusitis?
PODS
4 main symptoms PODS:
- pain and pressure (facial)
- obstruction
- discharge (mucopurulent)
- smell loss (anosmia)
Other:
- headache
- dental/ear pain
- fever (usu with acute sinusitis), fatigue, cough, mouth breathing
- sour bad taste (halitosis) is usually a sign of bacterial sinusitis
42
What are some potential complications (red flags) for rhinosinusitis?
Meningitis, pre-septal/orbital cellulitis, subperiosteal/intracranial abscess, epidural abscess, cavernous sinus thrombosis
43
What is the treatment approach for
- acute rhinosinusitis
- chronic rhinosinusitis
Acute viral: supportive, OTC analgesics and decongestants, saline irrigation
Acute and chronic bacterial: saline irritation and antibiotics
44
What is the first line antibiotic for acute bacterial rhinosinusitis?
What is the alternative first line if there is an allergy to PCN?
Amox-Clav or amoxicillin
alternative: doxycycline
45
What is the role of decongestants in rhinosinusitis?
- eg of decongestant?
- what should patients be taught?
Decongestants: to correct underlying mucosal edema
* must limit use to 3 days to prevent rebound congestion and rhinitis medicamentosa
* overuse of oxymetazoline can lead to body being dependent on its vasoconstricting properties
* caution with HTN or cardiac disorder
eg oxymetazoline (Afrin)
46
What is the role of intranasal corticosteroids in rhinosinusitis?
eg of INCS?
-what should patients be taught?
Nasal corticosteroid sprays: to reduce nasal inflammation
* lean forward, angle spray towards cheek, minimal sniffing
* never use with head back (in sniffing position) or pointing to septum
eg Flonase (fluticasone), Nasonex (mometasone), Rhinocort (budesonide)
47
What is the role of antihistamines in rhinosinusitis?
| -what should patients be taught?
only for use if allergic symptoms
consider allergy testing
removal of triggers
48
What are some co-morbidities associated with Tempomandibular Joint Dysfunction>
Comorbidities: mood disorders: anxiety, depression, PTSD, hx of abuse
- RA
- teeth grinding (bruxism)
- joint trauma
- poor head/cervical posture
49
TMJ
- what are the muscles involved?
- what nerve is involved?
Muscles: masseter, temporalis, pterygoid.
CN V (trigeminal) V3
50
Describe components of the physical exam for TMJ dysfunction
CN nerve exam is focused on which 2 nerves?
Exam: focus on TMJ, head and neck
- mandibular ROM
- alignment of teeth
- tenderness and crepitus
- pain with dynamic loading: bite down on cotton ball/tongue depressor between upper and lower canine --> compresses contralateral TMJ
- bruxism: sign of wear and tear to teeth
- posture: slouching, leaning
- neuromuscular exam of head, neck and face: palpate muscles of neck and shoulders
CN exam focused on CN V (trigeminal) and CN VII (facial) nerves
51
What are 4 categories of signs/symptoms of TMJ dysfunction?
PEHT
Pain: dull constant unilateral facial ache, waxes and wanes
- may radiate to ear/temporal/posterior neck
- worse by jaw motion (after meals)
Ear symptoms: painful, fullness, tinnitus
Headache: frontal/temporal/occipital, radiates to jaw/temple/forehead, worse in morning
TMJ: clicking, decreased ROM, locking --> worse in morning
52
What are some differential diagnoses for TMJ dysfunction?
What is a red flag differential?
- dental abscess
- sinusitis
- ear disorders (AOM, OME, eustachian tube)
- trigeminal neuralgia
- headache
- post-herpetic neuralgia
RED FLAG:
-giant cell arteritis
*will have headache, jaw claudication, palpable tender temporal artery, visual symptoms
53
What is the treatment approach for TMJ dysfunction?
what is the first line rx?
- self care
- rx if persistent symptoms
first line:
NSAIDS (eg naproxen, ibuprofen)
*limit use to 10-14 days* OR topical diclofenac
54
Referrals for TMJ dysfunction?
PT for TMJ exercise, biofeedback, posture, massage
Dentist: bite guard / splint
Surgeon for trigger point/botox/injection or surgery
55
What are some predisposing risk factors for tinnitus?
-most common cause?
*anxiety, depression, high stress levels (common cause)
Ototoxic medications
Ear: cerumen, TM perforation, middle ear effusion, eustachian tube dysfunction
Anemia
HTN
TMJ syndrome
56
examples of medications that cause/exacerbate tinnitus?
- aminoglycosides
- ACE-I
- benzos
- fluoroquinolones
- loop diuretics
- furosemide
- PPIs
- antidepressants (sertraline, TCA)
57
What are the 3 types of hearing loss?
| -what anatomical part is involved?
-conductive: external or middle ear
-sensorineural:
inner ear or CN VIII
-mixed: combo of conductive and sensorineural hearing loss
58
What is presbycusis?
-age related damage to cranial nerve VIII
59
What are questions to ask during history taking for assessment of hearing loss?
- Exposure to noise?
- recent/chronic ear infections?
- Self care of ears?
- Discharge, pain, dizziness
- Medications
- Occupation/hobbies, use of ear protection
60
Describe NORMAL findings associated with Weber and Rinne test
Weber: sound comes from midline
Rinne:
AC>BC
ie air-conducted sound hear 2x longer than bone-conducted sound
61
What is the finding in CONDUCTIVE hearing loss with Weber and Rinne test?
CONDUCTIVE
Weber:
-sound comes from affected ear
Rinne:
-BC>AC on affected ear
62
What is the finding in SENSORINEURAL hearing loss with Weber and Rinne test?
SENSORINEURAL
Weber:
-sound comes from normal ear
Rinne:
AC>BC (same as normal finding)
63
most common cause of acute pharyngitis?
viral (20-45%)
*adenovirus, rhinovirus, coronavirus
64
what is the hallmark feature of diphtheria?
grey pseudomembrane covering pharynx
| adherent, bleeds when removed
65
What are the hallmark signs and symptoms of GAS?
Centor criteria
```
• Tonsillar exudate
• Tender ant cervical lymph nodes
• No cough
• Fever >38
*age (3-14)
```
May also have petechiae to palate, scarlatina rash, strawberry tongue
66
What are the hallmark signs and symptoms of mono?
sore throat (85%)
fatigue
mod to high fever
symmetrical posterior cervical LN
67
Red flag signs for pharyngitis?
Airway obstruction:
* hot potato/muffled voice
* drooling
* stridor
* sniffing/tripod position
* bulging edematous pharynx
Deep Space Neck Infection eg peritonsillar abscess
* unilateral severe sore throat
* drooling
* hot potato voice
* unilateral deviated uvula
* severe sore/stiff/swollen neck
