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Rosen's > HEENT > Flashcards

HEENT Flashcards

1
Q

Monocular vs Binocular vs Cerebral/Polyopial diplopia?

A

Monocular - diplopia when good eye is covered

Binocular - no diplopia when either eye covered

Cerebral - diplopia no matter what eye is covered

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2
Q

Causes of monocular diplopia (6)

A
  1. Dry eyes
  2. Corneal irregularity
  3. Cataract
  4. Lens dislocation
  5. Retinal wrinkles
  6. Conversion disorder
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3
Q

Differential for Binocular Diplopia:

  1. Structural (3)
  2. Orbital myositis (8)
  3. Isolated cranial nerve palsy (6)
  4. Multiple nerve palsy (2)
  5. Neuroaxial involving the brainstem and cranial nerves (10)
  6. NMSK disorder (2)
A
  1. Trauma
    Infection
    Craniofacial mass
  2. Thyroid eye disease
    Wegener granulomatosis
    GCA
    SLE
    RA
    Dermatomyositis
    Sarcoidosis
    Idiopathic orbital infl syndrome
  3. Hypertensive vasculopathy
    Idiopathic intracranial HTN
    Diabetic vasculopathy
    MS
    Compression
    Trauma
  4. Cavernous sinus infection
    Orbital plex syndrome
  5. MS
    Tumor
    Stroke
    Hemorrhage
    Bilateral artery thrombosis
    Vertebral artery dissection
    Ophtalmoplegic migraine
    Infectious ie basilar meningioe
    Autoimmune ie Guillan Barre
    Metabolic ie Wernicke
  6. Myasthenia gravis
    Botulism
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4
Q

Cranial nerve 3 palsy:

  1. Corresponding muscle?
  2. Symptoms?
  3. Exam finding?
A
  1. Superior, Medial, Inferior rectii muscle + Levator Palpebrae + Inferior oblique + ciliary and constrictor muscle (pupil)
  2. Multidirectional, horizontal and vertical diplopia + eyelid droop (excluding lateral gaze)
  3. Ptosis + pupil dilation + eye down and out
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5
Q

Cranial nerve 4 palsy:

  1. Corresponding muscle?
  2. Symptoms?
  3. Exam finding?
A
  1. Superior oblique
  2. Diplopia that worsens on looking down and towards the nose
  3. Extorsion on downward gaze
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6
Q

Cranial nerve 6 palsy:

  1. Corresponding muscle?
  2. Symptoms?
  3. Exam finding?
A
  1. Lateral rectus muscle
  2. Horizontal diplopia that worsens on lateral gaze of effected eye
  3. Lateral gaze palsy
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7
Q

4 Critical causes of diplopia

A
  1. Aneurism
  2. Basilar artery thrombosis
  3. Basilar meningitis
  4. Botulism
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8
Q

4 Emergent causes of diplopia

A
  1. Vertebral artery dissection
  2. Cavernous sinus process
  3. Werneckie encephalopathy
  4. Myasthania Gravis
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9
Q

8 urgent causes of diplopia

A
  1. Brainstem tumor
  2. Orbital myositis, pseudotumor
  3. Orbital apex mass
  4. Ophthalmoplegic migraine
  5. Miller-Fisher syndrome
  6. MS
  7. Ischemic neuropathy
  8. Grave’s disease
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10
Q
  1. Vital sign of the eye?
  2. Who can skip it?
A
  1. Visual acuity exam
    • Those with acid, base or other toxins in eye
    • Significant trauma
    • Sudden complete vision loss
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11
Q

A test that can detect if there is decreased visual acuity due to abnormal refraction?

A

Pinhole testing

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12
Q

7 signs and symptoms associated with serious diagnosis in patients with red and painful eye? (Rosen’s Box)

A
  1. Severe ocular pain
  2. Proptosis
  3. Persistant blurred vision
  4. Corneal defect or opacity
  5. Pupil unreactive to light
  6. Reduced ocular light reflection
  7. Ciliary flush
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13
Q

What is a common, benign diagnosis of red eye without pain?

A

Subconjunctival hemorrhage

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14
Q

Who does not need antibiotics for bacterial conjunctivitis? (4)

A

Mild case, not wearing contact lens, no traumatic injury, not immunocompromised

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15
Q

Components of a complete eye exam? (VVEEPP + 2 more) (Rosen’s box)

A

Visual acuity
Visual field testing
External exam
Extraocular muscle movement
Pupillary eval
Pressure

+ Slit lamp
+ Fundoscopy for those w vision loss or vision change

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16
Q

corneal abrasion sign on fluorescene exam?

A

Seidel’s sign

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17
Q

7 causes of not seeing a red light reflex? (Box)

A
  1. Opacification of corneas
  2. Hyphema
  3. Cataract
  4. Blood in the vitreous or posterior eye wall
  5. Retinal detachment
  6. Intraocular mass
  7. Extremely miotic pupil
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18
Q

Acid vs Base caustic injury:

  • What do they do to the eye?
  • How much irrigation for each until pH = 7?
  • Complications of liquefactive necrosis?
A

Acid: Coagulation necrosis, at least 2L and 20min

Base: Liquefactive necrosis; at least 4L and 40min ; Complications = cataract formation, damage to ciliary body, irreversible damage within 5-15 min of exposure

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19
Q

Orbital compartment syndrome:

  • Causes?
  • IOP > x?
  • Treatment?
A
  1. Retrobulbar hematoma/emphasyma/abscess
  2. > 20 abnormal; >30 may necessitate lateral canthotomy
  3. Lateral canthotamy
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20
Q

Penetrating globe injury:

  • S&S (4)
  • Tx (3)
A
  1. Localized redness
    Treatdrop pupil
    Blood in anterior chamber
    loss of red reflex
  2. Prevent from further injury (antiemetics, analgesics)
    Abx - systemic like Cefazolin or Vanco IV
    Tetanus
    Emergent ophthalmology consult
  • IN RSI, avoid succinylcholine bc might elevate IOP (weak evidence)
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21
Q

Hyphema

  1. S&S
  2. What is the general treatment?
  3. Longterm complications? (2)
  4. Who should get admitted for hyphema treatment? (5)
A
  1. Pain
    Decreased VA
    Blood in anterior chamber
    Dilated/fixed pupil if trauma
  2. First rule out open globe
    IOP if no globe rupture
    If > 30
    If > 20, may use cycloplegic to prevent iris motion
    Also: Bedrest/ head of the bed elevated (limited evidence)
    Gentle ambulation
    Eye patch
    Ophtho followup asap (next day recommended)

3.
Raised IOP
Permanent corneal damage

4.
1. Lost to follow up
2. Poor compliance
3. Hyphema > 50%
4. anticoagulants
5. Sickle cell traits

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22
Q

Subconjunctival hemorrhage

  1. What is it?
  2. What to rule out?
  3. Treatment?
A
  1. Blood beneath conjunctival membrane
  2. Rule out coagulopathy or thrombocytopenia
  3. None
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23
Q

Corneal abrasion

  1. Treatment
  2. Who gets abx? (4)
  3. Complications? (4)
A
  1. Antibiotic prophylaxis with polymyxin-B/trimethoprim solution 1 drop every 3 h while awake and erythromycin ointment while sleeping.
  2. Contact lens wearers
    Contaminated object
    Deep object
    IC patient
  3. Keratitis
    Corneal ulcer
    Traumatic iritis
    Recurrent erosion syndrome
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24
Q

Corneal ulcer

  1. S&S (4)
  2. Etiology (2)
  3. Treatment (5)
  4. Complications (2)
A
  1. Pain
    FB sensation
    White corneal defect
    Fluorescene uptake
  2. Contact lens
    Post infection
  3. No contact lens
    Cycloplegics
    Topical abx hourly
    PO analgesics
    Urgent ophthalmology FU
  4. Hypopion
    Perforation
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25
Q

Traumatic mydriasis

  1. What is it?
  2. Tx?
A
  1. Nonreactive dilated pupil NYD and no other eye abnormalities after trauma
  2. None if all normal
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26
Q

Inflammatory pseudotumor

  1. S&S (9)
  2. Treatment? (3)
  3. Ophtho follow up?
A
  1. Nonspecific idiopathic Retrobulbar infl with:
    - eyelid swelling
    - palpebral injection of conjunctiva
    - chemosis
    - proptosis
    - blurred vision
    - painful ocular mobility
    - binocular diplopia
    - optic disk edema
    - venous engorgement of retina
  2. Measure IOP
    Evaluate DM, infection, vasculitis
    CT orbit
  3. IOP > 20 may be surgical emergency
    If IOP < 20 and all normal, may dc w steroid after discussing with ophthalmology
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27
Q

Orbital cellulitis

  1. S&S
  2. Tx (5)
  3. Ophtho follow up?
  4. Complications (5)
A
  1. Eyelid swelling, redness, warm
    Tender skin overlying bone
    Palpebral injection
    Chemosis

+ systemic unwell
blurred vision
proptosis
painful ocular movement
binocular diplopia
edema of optic disk
venous engorgement of retina

    • Measure IOP
    • Start ABX including Vanco + Cftx
    • Blood cultures, BW
    • Axial CT
    • Consider LP
  2. All get admitted!!!
  3. Vision loss
    CNS infection
    Abscess
    Osteomyelitis
    Cavernous sinus thrombosis
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28
Q

Periorbital cellulitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Eyelid swelling, redness, warm
    Tender skin overlying bone
    Palpebral injection
    Chemosis
  2. Rule out orbital cellulitis
    PO ABX
  3. If concerns for orbital cellulitis
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29
Q

Dacrocystitis/Dacryoadenitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Eye tearing and infl of lacrimal puncture
  2. Abx (amox/clav)
    Warm compress
    Rule out orbital cellulitis, pus,
  3. No if no concerns
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30
Q

Orbital tumor

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Blurred vision
    Binocular diplopia
    Painful/limited mobility
    Proptosis
  2. Measure IOP
    CT axial brain and orbital

3.
As required

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31
Q

Hordeolum (Stye)

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Abscess on lid margin, can be internal or external
  2. External = warm compress x 4/d
    Internal = Abx (Amox/clav) + warm compress
  3. If tx failure after 2 weeks
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32
Q

Blepharitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A

1.
Inflammation of eyelid margins
Associated with crusts on awakening
FB sensation
Tearing

  1. Warm compress
    Dry eye drops
  2. If tx failure after 2 weeks
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33
Q

Chalazion

  1. S&S
  2. Tx
  3. Ophtho follow up?
A

1.
Infl of meibomian gland
Subcutaneous nodule within the eyelid

  1. Warm compress x 4/day
  2. No unless tx failure for 2 weeks
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34
Q

Narrow angle (ie acute angle-closure) glaucoma

  1. S&S
  2. Tx (meds in another flash card)
  3. Ophtho follow up?
  4. Fundoscopy findings?
A

1.
occurs when fluid cannot drain from the eye as it should, causing it to suddenly build up behind the iris
Severe unilateral eye pain, blurred vision and “halos” around the eye
Maybe: frontal headache, nausea, and vomiting; Puupil maybe fixed at midsize,
Limbal injection of conjunctiva
Symptoms may be precipitated in low light because pupils dilate causing pain

  1. EMERGENT ophthalmology consult
    Elevate head of the bed
    Patient in well lit room
    Recheck IOP hourly
    Medications in ED if IOP >30 (another flashcard)
  2. Any IOP > 20 yes
  3. “Cupped” optic nerve
    Poor vascular supply
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35
Q

Glaucoma medications

A

Decrease production of aqueous humor:
* Timolol 0.5% 1 drop (beta blocker)
* Acetazolamide (carbonic anhydride inhibitor)
* Apraclonidine 1% 1 drop
* Dorzolamide 2% 1 drops or
if sickle cell disease or trait, then methazolamide 50 mg PO

Decrease inflammation:
* Prednisolone 1% 1 drop every 15 min four times

Constrict pupil/facilitate vitrous humour outflow:
* Pilocarpine 1%–2% 1 drop

Establish osmotic gradient/ absorb fluid:
* Mannitol 2 g/kg IV

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36
Q

Keratitis (abrasion) ie corneal abrasion!

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Pain
    FB sensation
    Fluorescene pooling
    If neglected may ulcer
  2. Fluorescene exam
    Rule out corneal penetration/siedel sign
    Anesthesize eye
    Inspect eye for FB
  3. Rule out globe rupture
    Topical Abx/Anesthetics
    NSAIDs
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37
Q

Keratitis (herpetic)

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Same signs as other keratitis + dendritic pattern
  2. Topical anesthetic
    Acyclovir 5% ointment (5drops x day for 1 week + taper for 2 weeks)
    Trifluridine 1% solution (1 drop q2h x 7 days + taper for 2 weeks)
    Varicella-zoster and CMV no antivirals if immunocompetent.
  3. Yes esp if needing debridement or culture before abx
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38
Q

Scleritis

  1. S&S
  2. Tx
  3. Etiology? (7)
A

1.
Severe inc eye pain, usually unilateral
Decreasing vision
Phototopia
Tearing
Pain w eye motion

  1. PO NSAIDs
    Discuss with ophthalmology about PO/Topical steroids
  2. RA
    Vasculitis
    Gout
    HSV/EBV
    Malignancy
    HIV/TB
    Surgery
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39
Q

Anterior Uveitis & Hypopyon

  1. S&S
  2. Tx
  3. Ophtho follow up?
A

Uveitis = inflammation of uvea of eye, which includes iris, ciliary body, choroid.

1.
Pain
Photophobia
Tearing
Limbal injection of conjunctiva
Hypopyon is layering of white cells (pus) in anterior chamber

  1. IOP measurement.
    Otherwise okay to dilate pupil with 2 drops of cyclopentolate 1%

3.
prednisolone acetate 1% discuss with ophthalmology
prob admit if hypopyon

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40
Q

Endophthalmitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
  4. Causes?
A

Progressively increasing eye pain & decreasing vision
Diminished red reflex
Cells/ flare (possibly hypopyon) in anterior chamber
Chemosis
Eyelid swelling

  1. Empirical parenteral antibiotic (vancomycin and ceftazidime) to cover Bacillus, enterococcus, and Staphylococcus
    Ciprofloxacin or levofloxacin if above contraindictated
  2. Always admit
    Intravitreal abx
  3. Penetrating trauma
    FB
    Surgery
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41
Q

Keratoconjunctivitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A

1.
Conjunctivitis with subepithelial infiltrates in cornea
Pain
Decreased vision
Possibly halos

  1. Treat conjunctivitis
  2. Ask about prednisone
    FU in 2-3 days
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42
Q

Episcleritis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Focal redness
    Pain (but less severe than scleritis)
    Pain with eye movement
  2. Artificial tears
    PO NSAIDs
  3. If no improvement in 2 weeks
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43
Q

Inflamed pingueceula

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Infl of soft yellow patches in temporal and nasal edges of limbal margin

2.
Decrease inflammation w naphazoline or ketorolac drops

  1. Only if no improvement in 2 weeks
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44
Q

Inflamed pterygium

  1. S&S
  2. Tx
  3. Ophtho follow up?
A

Inflammation of firmer white nodules extending from limbal conjunctiva onto cornea

^ all rosens had

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45
Q

Bacterial conjunctivitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Purulent discharge usually unilateral
    Eyelid infl
    Chemosis
    Maybe subconjunctival hemorrhage
  2. Polymyxin-B/trimethoprim in infants and children, bc more Staphylococcus
    Topical sulfacetamide or gentamicin in most adult
    Use topical fluoroquinolone if Pseudomonas

3,
All infants
All with sepsis

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46
Q

Chlamydia conjunctivitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A

1.
Bilateral palpebral injection of conjunctiva

2.
Empirical PO azithromycin for Chlamydia
Consider ceftriaxone for gonorrhoea

  1. Not if uncomplicated - 3 days of azithro is fine
    If infant or complicated yes
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47
Q

Contact Dermatoconjunctivitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. Redness
    Swelling

2.
Irrigate with tapa water/ normal saline
naphazoline drops to dec inf

  1. Only in 2 weeks if not better
48
Q

Toxic Conjunctivitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A

1.
Diffuse conjunctivitis
Chemisis
Lip edema

2.
Irrigate with tapa water/ normal saline
naphazoline drops to dec inf

  1. Only in 2 weeks if not better
49
Q

Allergic conjunctivitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. ..
  2. Antihistamines consider topical
    naphazoline drops
  3. Only in 2 weeks if not better
50
Q

Viral conjunctivitis

  1. S&S
  2. Tx
  3. Ophtho follow up?
A
  1. ..
  2. Decrease irritation with artificial tears, naphazoline, or ketorolac drops.
  3. Yes for neonates
    Ask about pregnant mothers, infants, and IC pts Education
51
Q

Signs of open globe injury (6)

A

Loss of anterior chamber depth
Blood in anterior chamber
Prolapsed iris
Irregular/teardrop iris
360 degree subconjunctival hemorrhage
Positive Seidel’s test on fluorescein

*IF any of the above, stop the investigations immediately and ophtho consult STAT

52
Q

Who gets anti-pseudomonas abx for eyes?

What are the abx?

A
  1. Contact wearers
  2. Deep or contaminated objects
  3. IC patients

Examples of abx:
1. Tobramyecin
2. Ciprofloxacin
3. Moxifloxacin
4. Gentamycin

53
Q

Causes of RAPD (7)

A
  1. Optic neuritis
  2. Optic tumors
  3. CRAO
  4. CRVO
  5. Retinal detachment
  6. Retinal infections
  7. Severe glaucoma
54
Q

IOP lowering agents?

Procedure in ED to lower IOP?

A
  1. Carbonic anhydrase inhibitor
  2. Topical beta blocker
  3. Alpha agonist
  4. IV Mannitol

Procedure = Lateral canthotamy

55
Q

Hyphema vs Hypopyon

A

Hyphema = blood in anterior chamber

Hypopion = pus in anterior chamber, associated with keratitis or endophthalmitis

56
Q

Clinical exam to differentiate “anterior uveitis” to “scleritis”

A

Anterior uveitis will lead to consensual phototopia!

57
Q

Normal Angle VS Close angle glaucoma differences:

  1. Lens?
  2. Anterior chamber?
  3. Eye pain?
  4. IOP?
A

Normal Angle:
1. Lens normal
2. Anterior chamber normal
3. Minimal eye pain
4. IOP mildly elevated

Close angle:
1. Lens bulging
2. AC tense
3. Eye painful (esp in low light setting)
4. IOP elevated > 30 usually

58
Q

Glaucoma risk factors IMPORTANT!! (6)

A
  1. Age 40-50
  2. F > M
  3. Positive fmhx
  4. Hyperopia (far sighted)
  5. Thin cornea
  6. Medication use:
    • Anticholingergics
    • Antihistamines
    • Salbutamol
    • Septra
    • Stimulants
    • SSRIs
    • TCA
59
Q

Signs of glaucoma?

A

At least 3 of:

IOP > 21
Decreased VA
Ciliary flush
Dilated non reactive pupil
Shallow anterior chamber
Corneal edema/cloudiness

60
Q

Symptoms of glaucoma?

A

At least 2 of:

Occular pain
Blurred vision
Halos
N/V

61
Q

DDX elevated IOP (7)

A

Open angle glaucoma
Acute close angle glaucoma
Retrobulbular hematoma
Chemical burns
Ketamine
TCAs
Atropine

62
Q

DDX Painless vision loss? (5)

A

CRAO
CRVO
Retinal detachment
Vitrous detachment
Vitrous hemorrhage

63
Q

DDX Painful vision loss? (4)

A

Optic neuritis
Glaucoma
Traumatic
Inflammatory/Infectious

64
Q

Ocular trauma delayed complications? (4)

A

Glaucoma
Retinal detachment
Corneal Ulcer
Endophthalmitis

65
Q

Retinal detachment

  1. S&S
  2. Risk factors
  3. Treatment
A
  1. Flashes and floaters
    Curtain like loss of vision
    Decreased VA
    Painless

2.
Trauma
Surgery
PVD
Diabetic retinopathy
CRVO
Vasculitis
Eclampsia
Neoplasm

3.
Urgent referral to ophthalmology ; no ED tx

66
Q

Retrobulbar hemorrhage triad?

A
  1. Proptosis
  2. Ophthalmoplegia
  3. Altered vision
67
Q

Difference between treatment of HSV vs Herpes Zorster Keratits?

A

HSV:
TOPICAL antivirals
AVOID steroids bc worsens infection
Topical abx and cycoplegic only if iritis

HZV:
SYSTEMIC antivirals
STEROIDS and topical abx can be used
*Look for Hutchinson’s sign

68
Q

What is Amaurosis Fugax?

A

TIA of the eye!

Transient loss of vision of the eye

69
Q

Central Retinal Artery Occlusion (CRAO)

  1. Causes?
  2. Who is at risk?
  3. Fundoscopy findings?
  4. Treatment?
A
  1. TIA of retinal artery
    Occlusion of retinal artery
    Inflammatory cause ie temporal arteritis
  2. Ages 50-70
    Vascular RFs
    Increased IOP RFs (glaucoma, retrobulbar hemorrhage etc)
  3. Cherry red spot
    Whitening of the retina
  4. Occular emergency!!!
    No good evidence but some include:
    - Occular massage
    - Carbon
    - Hyperbaric O2
    - tPA?
  • Can just observe
70
Q

Central Retinal Vein Occlusion (CRVO)

  1. Causes?
  2. Risk factors?
  3. Fundoscopy findings
  4. Treatment
A
  1. Pooling of fluid and blood causing ischemia
  2. HTN, Hyperlipid, DM, Smoking, Obesity, Glaucoma
  3. Disk edema, dilated veins, “Blood and Thunder”
  4. Ophtho consult, very little ED treatment
71
Q

Optic Neuritis

  1. S&S
  2. Risk factors?
  3. Tx
A

Inflammatory, demyelination of optic nerve, associated with MS

  1. Eye pain, vision loss unilateral
    Colour loss > VA
    Retroorbital headache
    painful EOM
    + RAPD
  2. MS
    ages 20-50
    Caucasian and female dominant
  3. IV STEROIDS!
72
Q
  1. Name of teeth
  2. Numerical?
A

Central incisor
Lateral incisor
Canine
1st Premolar
2nd Premolar
1st - 3rd Molar

Start at UR (#1) –> UL (#16) –> LL (#17) –> LR (#32)
* Essentially starts at Upper right and goes counterclockwise

73
Q

Block for single tooth?

Block for multiple teeth?

A

Supraperiosteal nerve block

Alveolar nerve block

74
Q

Gingivitis vs Periodontitis vs Pericoronitis

Treatment?

A

Gingivitis = infl of gum

Periodontitis = infl of gum and surrounding structure of tooth
- can see recession of gum, inc tooth mobility, bone loss, tooth loss

Pericoronitis = infl of gingiva and surrounding soft tissue

Treatment
- Proper oral hygiene
- NSAIDS
- Topical infiltrate
- Smoking cessation
- Dental FU
- Abx if really bad (amox clav, Pen V, clinda, flagyl, Nystatin - ROSENS BOX)

75
Q

Acute Necrotizing Ulcerative Gingivitis

  1. What is it?
  2. Risk factors?
  3. Name for infection that involves gingiva but also tonsils and pharynx?
  4. Most severe end of dz name?
  5. Treatment?
A
  1. Polymicrobial bacteria invading tissue and causing pain, bleeding, destruction
  2. Poor oral hygiene, smoking, DM, IC
  3. Vincent Angina
  4. Noma
  5. Oral ABX , Mouthwash, OMFS for debridement
76
Q
  1. 3 causes of gingival hyperplasia?
  2. Medication classes and risk of gingival hyperplasia (3 classes) ; most common?
A
  1. Medications
    Poor oral hygiene
    Leukemia

2.
Anticonvulsants:
- Phenytoin MOST COMMON
- Valproic acid
- Carbemazapine

Immunosuprassants
- Cyclosporine (2nd most common, common in kids)

Calcium channel blockers:
- Nifedipine
- Amlodapine
- Verapamil
- Diltiazam
- Felodipine

77
Q

Alveolar Osteitis

  1. Lay name?
  2. Cause?
  3. Treatment?
A
  1. Dry socket
  2. Dislodgement of clot in fossa where root was, exposing bone. Usually after wisdom tooth extraction
  3. R/o infection
    Analgesics (NSAIDs, topical, nerve block)
    Iodoform gauze with eugenol
    Dentist appointment next day
78
Q

Infection of maxillary canine root:

  1. What space will get infected?
  2. Sign?
  3. Complication?
A
  1. Maxillary canine space
  2. Flattening of the nasolabial fold
  3. Cavernous sinus thrombosis
79
Q

3 spaces in the mandible that can get infected?

When all 3 are infected, what is it called? Feared complication?

A

Submandibular, sublingual, submental

= Ludwig’s angina ; airway compromise

80
Q

6 RFs for deep space neck infections?

A
  1. Poor oral hygiene/dental infections
  2. Recurrent pharyngitis
  3. Sinusitis
  4. AOM
  5. IC patient
  6. IVDU
81
Q

Teeth injuries:

  1. Subluxed vs Luxed vs Avulsed?
  2. Avulsion: Medium to leave tooth in to save periodontal ligaments from dying?
  3. ED management of Avulsion? abx?
  4. Tooth #, what solution used to tape back together?
A
  1. Subluxed = mobile but in anatomical position

Luxed = out of anatomical position but not fully out .. can be Extrinsic, Intrinsic, Lateral

Avulsed = fully out

  1. Milk is good, can last 3-8 hours
    Hank’s balanced salt solution can last 24h
    If nothing else, saliva!
    Avoid water bc hypotonic and cells die
  2. Ensure no aspiration –> Dental block –> Hold teeth at crown –> irrigate w NS –> irrigate socket w saline –> re-implement! –> if no immediate dentist FU, use Resin to make splint –> FU within 24/48h + soft diet + abx

Abx adults = doxy x 7d
Abx kids = penicillin x 7 days

  1. Calcium hydroxide
82
Q

The Ellis Classification of tooth #:
Class 1 vs II vs III

What solution is used to adhere teeth back together in ED?

A

Class I - Enamel only
Class II - Enamel + Dentin
Class III - Enamel + Dentin + Pulp

Calcium Hydroxide
*Tooth must be bone dry!

83
Q

TMJ dislocation:

  1. What bones in TMJ?
  2. How does it happen?
  3. Causes?
  4. Treatment?
A
  1. Temporal bone and mandible bone condyle
  2. When mandible condyle moves anteriorly (instead of inferiorly)
  3. Teeth grinding, jaw clenching and open wide mouth , muscle spasms (ie due to seizure or dystonia) and trauma
  4. Reduce with procedural analgesia
84
Q

Acute otitis media (AOM) vs Otitis Media with effusion (OME)

A

AOM - Middle ear effusion with infection

OME - Middle ear effusion w/o infection

85
Q

2 Criteria to diagnose AOM

A
  1. Middle ear effusion
  2. Infection
86
Q

2 Criteria to dx chronic AOM?

A
  • > 3 or more in 6 months
  • 4 in 1 year
87
Q

Common AOM pathogens (4)

A
  1. S. Pneumoniae
  2. H. Influenzae
  3. Catarrhalis
  4. Group A strep

Also could be viral!

88
Q

Risk factors for AOM (8)

A
  1. Non hispanic white race
  2. Male
  3. Daycare
  4. Parents smoking
  5. Bottle fed
  6. Pacifiers
  7. Family hx of AOMs
  8. Anatomical variety ie cleft plate
89
Q

3-intertemportal and 2-intracranial complications of AOM?

A

Intertemporal
○ Mastoiditis
○ Hearing loss
○ Facial nerve paralysis
Intracranial
○ Meningitis
Abscess

90
Q

DDX AOM (6)

A
  • FB
  • Otitis externa
  • Otitis media with effusion
  • Trauma
  • Mastoiditis
  • Referred pain
91
Q

AOM abx: who gets them? (3)

A

< 2 years
Bilateral AOM
Otorrhea

92
Q

Who to consider “watch and wait” for 48-72h for AOM? (7)

A
  1. > 6 months
  2. Healthy
  3. Unilateral
  4. Temp < 39
  5. < 48h of symptoms
  6. Mild otalgia
  7. Responsive
93
Q

AOM Abx:

  1. First choice + Dose/course?
  2. If allergic? (1)
  3. If failure to treatment? (2)
  4. Who gets 10-day course? (3)
A
  1. Amoxicillin 80-90mg/kg/day

2.
2nd/3rd gen cephalosporin

  1. Amox-clav or Cftx
  2. < 2 years
    Chronic infection
    TM perf

*Always abx if perf
* Adults ALWAYS abx cz almost always bacterial

94
Q

RetroPharyngeal Abscess

  1. Causes (10)
  2. Dx: Gold standard + alternatives
  3. Tx
A

1 .
Pharyngitis
Tonsillitis
PTA
AOM
Dental infections
FB
Trauma
Ludwig Angina
Oral procedures
Endoscopy

  1. CT gold standard
    XR and US also able
  2. Tazo + Vanco (polymicrobial)
    Airway management!
    ICU/ENT dispo
95
Q

Otitis externa:

  1. Common pathogens (3)
  2. RFs (4)
  3. S&S (6)
A
  1. Staph aureus
    Pseudomonas
    Aspergillus
  2. Hot temp
    Humidity
    Repeated exposure to moisture
    Trauma
  3. Ear pain
    Ear discharge
    Hearing loss
    Jaw pain
    Tragus/auricle reproduces pain
    Lymphadenitis
96
Q

EOM DDX (6 - 3 inner ear, 3 outer ear)

A
  1. AOM
  2. Otomycosis
  3. Perichondritis
  4. Auricular cellulitis
  5. Skin condition (eczema etc)
  6. Herpes zoster optics
97
Q

EOM management

  1. Mainstay
  2. Who gets systemic ABX (2)? Which one? how long?
A

1.
Ciprodex 4 drops BID x 7days

  1. If extending beyond middle ear, IC patient
    Cipro 500mg PO BID x 7 days
98
Q

Otomycosis

  1. Pathogens
  2. S&S
  3. RFs
  4. Tx
A
  1. Candida, Aspergillus
  2. Itching but NO PAIN
  3. Topical climate, DM, IC
  4. Locacorten Vioform
99
Q

Perichondritis

  1. What is it?
  2. Pathogens?
  3. Treatment? (3)
A
  1. Infection of connective tissue covering cartilage - happens with rubbing hearing aid, piercing, trauma
  2. Pseudomonas (almost always)
  3. I&D if collection, Cipro, ENT if severe
100
Q

Necrotizing (Malignant) External Otitis

  1. What is it?
  2. RFs (3)
  3. S&S (5)
  4. Dx (1)
  5. Treatment (3)
  6. Complications (5)
A
  1. OE spread through temporal bone –> osteomyelitis of bones, tissue, face
  2. DM, IC, Elderly
  3. Otorrhea, otalgia, headache, Periauricular pain, CN7 probs
  4. CT head
  5. Cipro 400mg IV q12h (for 6-8 weeks!) + Tazo if pseudomonas + ENT
  6. 5-10% mortality
    Skull base osteomyelitis
    Sigmoid sinus thrombosis
    Meningitis
    Brain abscess
101
Q

Mastoiditis

  1. S&S (6)
  2. DDX (7)
  3. Dx
  4. Tx (3)
A
  1. Otalgia
    Erythema
    Postauricular pain
    Protrusion of auricle
    Fever
    Headache
  2. AOM
    OE
    Skull #
    Malignant OE
    Lymphadenopathy
    Lymphadenitis
    Deep space neck infection
  3. Clinical but also can do CT
  4. IV Vanco + Ceftriaxone (pseudomonas)
    ENT consult
102
Q

Sudden hearing loss

  1. DDX (3 outer ear, 2 ME, 5 inner ear)
  2. Dx
  3. Tx (3)
A
  1. Outer ear:
    - Cerumen impaction
    - OE
    - FB
    Middle ear
    - AOM
    -TM perf
    Inner ear
    - Meds (amino glycoside, loop diuretics, ASA)
    - Barotrauma
    - Autoimune
    - infection
    - Neoplasm
  2. Clinical
    MRI if vertigo
  3. Prednisone with taper (within 2 weeks onset of sx if able)
    Steroid drop
    ENT EMERGENCY!
103
Q

Tinnitus

  1. Red flags (4)
  2. Primary vs Secondary - 1 vs 8 categories
A
  1. Pulsatile
    Unilateral
    Hearing loss
    Focal neuro deficits

2.
Primary
- Idiopathic, associated w SNHL (Webbers test), multifactorial

Secondary
- Infectious (Lyme, fungal, viral)
- Metabolic (DM, HDL)
- Neurological
- Otolgic (Manners, AOM)
- Somatic (injury)
- Tox (meds/substance)
- Trauma
- Vascular (bruits, AV malformation, dissection)

104
Q

Epistaxis anterior, what vessel?

A

Kiesselbach’s plexus

105
Q

15 causes of Epistaxis

A

Anatomical
- Polyps
- FB

Environmental
- Low humidity
- Nasal trauma
- Nose picking
- Irritants
- Cocaine

Diseases
- URTI
- Allergies
- Neoplasm
- Surgery

Bleeding disorder
- Hepatic disease
- Alcoholism
- Vitamin K deficiency
- Folic acid deficiency

106
Q

6 steps to managing epistaxis

A
  1. Blow your nose/clip
  2. Apply 2% lidocaine with gauze
  3. Cauterize with silver nitrate UNILATERAL ONLY
  4. Anterior packing with rhino rocket
  5. Topical TXA

*If all above fail, prob posterior bleed
* ENT consult can be done to also embolism

107
Q

Who gets prophylaxis ABX for nose packing? (2)

A

> 48hours
IC patient

108
Q

Sialolithiasis

  1. What is it?
  2. RFs (6)
  3. S&S (3)
  4. DDX (5)
  5. Dx
  6. Tx (3)
A
  1. Tonsilar stones
    • Dehydration
    • Diuretic use
    • Anticholinergic meds
    • Smoking
    • Trauma
    • Gout
    • Pain esp during eating or salivating
    • Swelling
    • Infection

4.
- Salivary gland pathology
- LN dz
- Granulomatous process
- Soft tissue mass
- Neoplasm

  1. CT
  2. Massage, sialogouges, analgesics
109
Q

Neck masses rule of 80?

A

in children, 80% benign
in adults, 80% malignant

110
Q

Neck masses DDX ROSENS BOX (5 categories)

A
  • Inflammatory
    ○ Adenitis
    ○ Bacterial
    ○ Viral
    ○ Fungal
    ○ Parasitic
    ○ Cat scratch dz
    ○ Tularemia
    ○ Sialodenitis
    ○ Thyroditis
  • Congenital
    ○ Brachial cleft cyst
    ○ Dermoid cyst
    ○ Torticollis
    ○ Ranula
  • Masses benign
    ○ Lipoma, fibroma
    ○ Salivary gland masses
    ○ Hemangioma, aneurism
  • Masses malignant
    ○ Sarcoma
    ○ Salivary gland tumor
    ○ Thyroid tumor
    ○ Lymphoma
    -Mets
111
Q

GAS pharyngitis complications (12)

A

Rheumatic fever
Scarlet fever
Abscess
Ludwig’s Angina
AOM
Mastoiditis
Osteomyelitis
Sinusitis
Post strep GN
TSS
Meningitis
Bacteremia

112
Q

Jones criteria for diagnosing acute rheumatic fever

  • Major criteria (5)
  • Minor criteria (4)

*JONES FACE

A

Major (JONES)
- Joints poly arthritis
- Carditis
- Nodules SubQ
- Erythema marginatum
- Sydenham Chorea

Minor (FACE)
- Fever > 38.5
- (Poly)Arthralgia
- CRP > 30 / ESR > 60
- ECG prolonged PR

*2 major
OR
1 major + 2 minor

113
Q

GAS treatment:

  1. Mainstay dose?
  2. If allergic abx dose?
  3. If anaphylactic? (3)
A

Amoxicillin 50mg/kg/d x 10d

Cephalexin 20mg/kg PO x 10d

If anaphylactic:
Clinda
Azithro
Clarithromycin

114
Q

Dysphagia: Oropharyngeal vs Esophageal

A

Oropharyngeal
- difficulty INITIATING swallow
- occurs RIGHT AWAY
- multiple swallowing attempts
- C pain
- coughing
- choking
- drooling

Esophageal
- difficulty transporting material down
- occurs 2-4s after swallowing

115
Q

Oropharyngeal dysphagia DDX (10)

A

NMSK
- Stroke (most common)
- Myopathy
- Myasthania Gravis
- MS
- DM neuropathy
- Botulism
- Tetanus
- Diphtheria

Obstructive
- Tumor

Other
- Dry mouth

116
Q

Esophageal dysphagia DDX (15)

A

Dysmotility
- Achalasia
- LES HTN
- Esophageal spasm
- Connective tissue disorder

Mechanical
- Stricture
- Rings
- Webs
- Post-op
- Tumor
- Esophagitis
- GERD
- FB

Extrinsic mechanical
- Goitre
- Aneurism compression
- Zenker’s diverticulum

Rosen's (3 decks)

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