HEENT Flashcards

Question

Diabetic Retinopathy (con't)

Answer 1

• Ophthalmologist must do yearly retinal eye exam on all diabetics • Visual changes as the disease progresses. • Through ophthalmoscope microaneurysms, intraretinal hemorrhage, macular edema and lipid deposits

Answer 2

•First goal for patients at risk for microvascular complications, including diabetic retinopathy, is prevention •The only pharmacologic agent found to slow the progression of diabetic retinopathy is Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor •Laser surgery for patients with proliferative diabetic retinopathy or clinically significant macular edema

Answer 3

•Leading cause of blindness in patients older than 60 •“Dry”: a slow progressive atrophy and degeneration of the retina •“Wet”: age-related; new blood vessels develop under the retina in the macula, causing a sudden distortion or loss of central vision • Refer immediately to an ophthalmologist • Objective: If vision is less than 20/20, do “pinhole” test • Vision that corrects with the pinhole test implies an uncorrected refractive error • Possible unreactive pupil if acute angle-closure glaucoma • Funduscopic exam is normal in patients with refractive errors • Yellow round spots (drusen): indicative of early macular degeneration • Clumps of pigment irregularly interspersed with depigmented areas of atrophy in the macula: later phase of the disorder

Answer 4

A quick way to differentiate between the two is by performing the "Pinhole Test". • Take a piece of card and perforate it with a pen tip, creating a pinhole about 2mm in diameter. • Checking one eye at a time, look at an object that appears slightly blurred. • Then look at the same object through the pinhole. If it appears sharper through the pinhole, you probably have a focusing problem. • If it does not appear sharper, or looks even more blurred, you should refer this patient to an ophthalmologist immediately

Answer 5

•No proven strategies for preventing AMD •No treatments for the initial stage of early disease •In the intermediate stage of the disease, high-dose antioxidant vitamins and zinc supplements possibly help •Thermal laser photocoagulation for certain forms of wet AMD but of limited value for lesions in the central macula area

Answer 6

Lesion in the organ of Corti or in the central pathways (including the 8th cranial nerve. •Forms of sensorineural loss: • Age related (presbycusis) is a form • Meniere’s Disease • Tumors • Ototoxicity

Answer 7

• Involves the outer and middle ear. • Causes: • Cerumen impaction • Perforation of the tympanic membrane • Middle ear fluid • Trauma or infection • Cholesteatoma (a type of skin cyst in the middle ear.

Answer 8

Rinne Test: Normal AC twice as long as BC • Conductive hearing loss: BC is heard longer than or equal to AC • Sensorineural: AC is heard longer than BC in affected ear but less than 2:1 ratio Weber Test: Normal = Symmetrical • Sound localizes toward the poor ear with a conductive loss • Sound localizes toward the good ear with a sensorineural loss

Answer 9

Person hears noise when there isn’t any • Intermittent, continuous, or pulsatile (synchronous with heartbeat); may be bilateral or unilateral Risk factors: • Hearing loss, labyrinthitis, Ménière’s disease, otitis media or externa, otosclerosis, ear-canal blockage (from ear wax or a foreign body) • History of high or low blood pressure, head trauma, anemia, hypothyroidism, hyperthyroidism, or allergies • Chronic exposure to noise • Medications with reversible effects: salicylates, quinine, alcohol, and indomethacin [Indocin]) with reversible effects • Medications with irreversible effects: kanamycin, streptomycin, gentamicin, and vancomycin

Answer 10

• Elimination of possible offending medications (such as aspirin-containing products and NSAIDs) is a priority • Learning to cope with tinnitus is necessary • Avoidance of risk factors • Possible supplementation with vitamin A, vitamin C, cyanocobalamin, and nicotinic acid or with magnesium or copper • Protective earplugs • Tinnitus-masking devices • Oral antidepressants may be effective (Elavil) • Referral to an audiologist or if vertigo, N & V to an otorhinolaryngologist

Answer 11

Inner ear problem with excess fluid and pressure • Tinnitis, vertigo, and progressive hearing loss • Attacks can be disabling • Must exclude other causes of vertigo • Weber’s test will lateralize to the unaffected ear • Basic diagnostic testing: audiogram, MRI (R/O CNS lesions), TSH

Answer 12

• Referral to otolaryngologist • Low salt diet and a diuretic • Avoid alcohol, caffeine, stress, and nicotine • Identify and avoid triggers

Answer 13

• Inflamed external ear canal usually unilateral • Objective findings: Pain when pulling on the tragus • May culture drainage • NSAIDS and cleaning and drying the ear canal • Staph (yellow, crust exudate) may be treated with antibiotic-hydrocortisone compound such as polymyxin B sulfate, neomycin, hydrocortisone) Cortisporin Otic Suspension • If aquatic sports consider coverage against Pseudomonas aeruginosa and Staphylococcus aureus • Ciprofloxacin-hydrocortisone or ofloxacin otic solution

Answer 14

• Severe disease (preauricular or auricular cellulitis and/or fever) • Consider dual therapy with both topical and systemic antibiotics. • Systemic treatment with a fluoroquinolone (levofloxacin 500 mg orally once daily for seven days) for coverage of S. aureus and P. aeruginosa is preferred. • Malignant Otitis Externa usually in diabetics or immunocompromised patients: severe pain, necrosis and osteomyelitis • REFER and admit!! Life Threatening

Answer 15

• Otitis media with effusion (OME): transudation of plasma from middle ear blood vessels, leading to chronic effusion in the absence of the signs and symptoms of acute infection. The most significant precipitating event leading to OM with effusion is a viral upper respiratory infection • Acute otitis media (AOM): suppurative OM or purulent OM • Recurrent OM: the clearance of middle ear effusions between acute episodes of otic inflammation • Chronic OM: inflammation persists more than 3 months, typically related to tympanic membrane perforation with either intermittent or persistent otic discharge

Answer 16

• Marked “deep” ear pain and fever • Unilateral hearing loss • Otic discharge • Recent history of upper respiratory infection • Possible dizziness (space disorientation), vertigo, tinnitus (ringing in the ears), vomiting, or nausea

Answer 17

• History of repeated bouts of acute otitis media, followed by a period of continuous or intermittent otorrhea lasting for more than three months • Pain is seldom a complaint, as hearing loss (related to tympanic membrane perforation) is the primary concern

Answer 18

OME: • Mucous membranes of nasal and oral cavities may be injected or edematous • Eardrum may be dull but usually is not bulging but fluid is in the middle ear, and eardrum mobility typically decreases on pneumatic otoscopy AOM: • Tympanic membrane may be amber or yellow-orange, or may be injected and pinkish gray to fiery red in color. • Tympanic membrane typically full or bulging in acute cases, with absent or obscured bony landmarks and cone light reflex

Answer 19

Chronic OM: • A perforated, draining tympanic membrane and possibly invasive granulation tissue • Chronic, foul-smelling otorrhea—anaerobic bacterial infection • Chronic, grayish-yellow suppuration—cholesteatoma from the degenerative products of invasive epithelialization • Bullae formed between layers of the tympanic membrane (bullous myringitis) caused by certain viruses or Mycoplasma pneumoniae • Multiple perforations of the tympanic membrane are characteristic of tuberculous otitis

Answer 20

• Uncomplicated cases of OM: self-limited and require no specific intervention • May need pain relief (Table 23.2) • Pain from OM: Ibuprofen or Acetaminophen • The preferred antibacterial drug for the patient with AOM must be active against S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis. • Treatment of complicated or recurrent OM needed to prevent permanent anatomic changes of the middle ear and subsequent hearing loss. AOM: Amoxicillin: 500 mg every 8 hours OR 875 mg two times daily for 10 days β-Lactamase–resistant: Amoxicillin-clavulanate (Augmentin): 875 mg two times daily for 10 days; Cefixime (Suprax): 400 mg daily for 7 days Penicillin-allergic patients: Macrolides Azithromycin (Zithromax): 500 mg on day 1, then 250 mg daily for 4 days; Clarithromycin (Biaxin): 500 mg every 12 hours for 7 days

Answer 21

• Watchful waiting with symptomatic treatment • In OME, the majority of effusions will resolve over the course of 12 weeks, and most patients can be observed over this time period. • In patients with substantial symptoms, offer treatment with antihistamines (for OME due to allergic rhinitis), oral decongestants, and/or nasal corticosteroids. • If effusion persists past several months • Referred for full nasopharyngeal evaluation to rule out obstructive pathology.

Answer 22

• Concurrent vertigo or ataxia • Failed closure of a ruptured tympanic membrane • If symptoms worsen after 3 or 4 days of treatment Consider: Eustachian tube dysfunction: commonly related to seasonal allergic rhinitis or upper respiratory tract infection, is the most important factor in the pathogenesis of middle ear infections in adults.

Answer 23

•A suppurative infection of the mastoid cells that may occur with AOM or follow an AOM Clinical findings: •Concurrent or recurrent AOM •Fever and otalgia •Persistent otitis media unresponsive to antibiotic therapy •Postauricular swelling •Tenderness over mastoid bone •REFER TO ER!

Answer 24

• Posterior bleeds are more common in the elderly • Predisposing factors: fragile mucous membranes, nasal trauma, rhinitis, drying of the nasal mucosa, deviated septum, alcohol use, and antiplatelet meds

Answer 25

• Look for underlying conditions • If lots of bleeding reported - CBC • Management: Application of direct pressure to the anterior portion of the nose for a minimum of 10 min if source is anterior. • Sit up leaning forward • Nasal decongestants • Phenylephrine 0.125% (Afrin, Neo-Synephrine, Sinex)

Answer 26

Nasal Congestion: (2 Types) Allergic & Nonallergic Nonallergic Rhinitis: 1. Infectious 2. Irritant-related (often in the workplace) 3. Vasomotor (noninfectious without eosinophilia) 4. Hormone-related 5. Associated with medication use or overuse (rhinitis medicamentosum) 6. Atrophic (mostly in geriatric patients) Allergic: Seasonal or perennial (recurrent)

Answer 27

Viral rhinitis (usually acute and self-limiting) • Accompanied by malaise, headache, sore throat, and occasionally fever . • If hoarseness, cough, diarrhea, conjunctivitis or viral rash. highly suggestive of viral Allergic rhinitis: IgE mediated response • Itching in the nasal passages, conjunctivae, and roof of the mouth • Epiphoria (stringy, watery ocular discharge) • Sneezing, coughing, and a sore or burning throat • Consider pharyngitis

Answer 28

Noninfectious rhinitis without eosinophilia • Watery rhinorrhea, nasal congestion, “nasal” speech, and forced mouth-breathing • Onset of congestion is rapid in vasomotor rhinitis; patients typically complain of a pronounced, watery postnasal drip, as well as persistent nasal obstruction that may switch sides with each attack • Fluctuations and reductions in estrogen contribute to this type (menses, BCP, pregnancy, menopause)

Answer 29

• Avoidance or reduced exposure to offending allergens • Oral antihistamines: short-term treatment • Intranasal corticosteroids: long-term management • Flonase • Leukotriene receptor antagonists

Answer 30

Treat symptomatically • Fever and headache may be treated with acetaminophen • Rhinorrhea may be treated with oral decongestants • Topical preparations • Intranasal ipratropium (Atrovent) nasal spray • Dextromethorphan for persistent coughs

Answer 31

1. Acute: abrupt onset of infection and post-therapeutic resolution of symptoms lasting no more than 4 weeks 2. Subacute: a purulent nasal discharge persists despite therapy, lasting from 4 to 12 weeks 3. Chronic: episodes of prolonged inflammation with repeated or inadequately treated acute infection lasting greater than 12 consecutive weeks

Answer 32

• Gradual onset of symptoms • Recurrent or chronic dull, constant pain over the affected sinuses • Criteria for treatment is that it has lasted for >7 days. • Worsening after getting better • Pain increases and becomes characteristically throbbing • Sinusitis Subjective Symptom • Maxillary : pain over the cheeks and upper teeth—may worsen when standing erect • Frontal : pain over the eyebrows—may worsen when recumbent • Ethmoid : pain over or behind the eyes associated with retro-orbital pain

Answer 33

• Purulent nasal secretions • Total opacification of affected sinuses on transillumination • A swollen pale mucosa with watery secretions, points to allergic sinusitis or rhinitis • Black or necrotic material—mucormycosis-related rhinorrhea in immunocompromised patients • Ethmoid sinus involvement may result in chemosis (eyelid mucous membrane edema), proptosis, conjunctival injection, extraocular muscle palsy, or orbital fixation • Tenderness on palpation over the sinuses

Answer 34

• Since a vast majority of acute sinusitis cases are caused by viruses, antibiotics are largely unhelpful • Antimicrobial therapy indicated for acute uncomplicated BACTERIAL sinusitis • TREATMENT: Saline nasal spray; decongestant nasal spray, NSAIDS, corticosteroids • Dedicated sinus irrigation two or more times a day • Referral to a specialist if the patient has recurrent sinusitis, allergic sinusitis or if it is refractory to antibiotic therapy

Answer 35

• A cool-mist, ultrasonic humidifier • Avoid smoke and other environmental pollutants • Increase fluid intake • Use a heated mist from a facial sauna, steam bath, shower, or hot, moist towels wrapped around the face

Answer 36

• Oral analgesics for pain • Avoid nonprescription medicated nose drops and sprays • Use prescription nasal sprays for no more than 3 to 4 days at a time (LIMIT AFRIN!!) • Expectorants such as guaifenesin to liquefy sinus secretions and facilitate drainage • Anti-inflammatory topical steroids in nasal spray preparations • Empiric antibiotic therapy for 7 to 10 days • Augmentin 875mg BID for 5-7 days • If PCN allergy: Doxycycline 100mg BID or Levofloxacin 750mg daily

Answer 37

• Oral candidiasis • Aphthous (canker sores) • Secondary herpetic stomatitis • Vincent’s stomatitis: acute necrotizing ulcerative gingivitis or trench mouth • Allergic stomatitis • Parasitic glossitis (black hairy tongue) • Hairy Leukoplakia: with no other symptoms of immune suppression is strongly suggestive of HIV.

Answer 38

• Infection/irritation of the pharynx/tonsils. • May be noninfectious or infections • Noninfectious: allergies, trauma (burns/foreign object), cancer, chemo, radiation, irritation • Infectious: viruses, bacteria, fungi or parasites (strep: A, C, and G beta hemolytic) Common causes: • Viruses -adenovirus, rhinovirus, coxsackie virus • Group A Beta Hemolytic Strep (GABHS) • Mycoplasma pneumoniae in ~10% of cases in adolescents

Answer 39

• Most important to identify (responsible for acute rheumatic fever and post-strep glomerulonephritis. • Group C is more common in college students an adolescents Signs and Symptoms • Viral: Most common. Sudden onset of sore throat, fever, malaise, cough, headache, myalgias and fatigue mild erythema (little or no exudate). No painful or tender lymph glands.

Answer 40

• More prevalent in kids less than 15: Sudden onset, painful swallowing, fever, chills, H/A, N & V. • Marked erythema, patchy, discrete, white or yellow exudate. Tender ANTERIOR lymph nodes • Use the Modified CENTOR Score • If score above 4, treat even if no rapid strep

Answer 41

• Rapid strep test for GABHS • If rapid strep test is negative, specimen should be sent for full culture • If symptoms suggest, consider a mono spot test • CBC rarely indicated

Answer 42

• Infectious mononucleosis (MONO): • H/A, malaise, fatigue, and anorexia before sore throat, tender POSTERIOR lymph nodes • Hepato-splenomegaly, and POSITIVE mono spot. • Allergies: teary eyes, pruritus, rhititis, postnasal drip, pale, boggy nasal mucosa and erythematous pharynx with mucus • Thrush: • Peritonsillar cellulitis/abscess • Pharyngeal abscess (need to send to ED or physician) • Deviated uvula • Reflux pharyngitis: • GABHS • Sinusitis

Answer 43

• No antibiotics unless strong evidence of GABHS recommended by the American College of Physicians. • Criteria for treatment: hx of fever, exudate, palpable anterior cervical tender glands, absence of cough • TREATMENT (10 days): • Penicillin VK oral 500 mg po BID • Amoxicillin 1000 mg Daily • Cephalexin 500 mg BID • If sever PCN allergy • Clindamycin: 300 mg TID • Azithromycin 500 mg Daily

Answer 44

• Rest, fluids, humidification, voice rest, and warm saline gargles • Acetaminophen or ibuprofen • Topical anesthetic sprays and lozenges • MONO: NO SPORTS FOR 6 WEEKS

Answer 45

• Contagious until 24 hours after start of antibiotic therapy • Adherence to prescribed therapy • Proper oral hygiene • Toothbrushes and orthodontic devices should be cleaned thoroughly • Misuse of antibiotic therapy (for viral infections)

Answer 46

• A cluster of related disorders in the masticatory system • The most common presenting symptom is PAIN in the muscles of mastication, the preauricular area, and/or the temporomandibular joint • Chewing, bruxism (clenching, grinding, or gnashing of the teeth during nonfunctional movements of the mandible), or other jaw functions tend to aggravate the pain

Answer 47

• Pain (89%) • Jaw noise (85%) • Limited jaw movement (40%) • Ear symptoms account for 28% of clinical presentations • Only 4% of patients present with obvious jaw dislocation

Answer 48

• Use a multidisciplinary approach • Goals for management: reduction or elimination of pain and restoration of acceptable mandibular function • Adjustment in diet consistency, education, and alteration of oral parafunctional habits • Application of ice (for acute symptomatology) or moist heat (for chronic symptomatology)

Answer 49

• Physical therapy • Electromodalities and therapeutic exercises • Behavioral therapy • Stress relief, pain control methods such as counseling, hypnosis, biofeedback, and guided imagery • Pharmacotherapy • NSAIDS

HEENT Flashcards

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