HEENT Flashcards by Lauren Cunningham

Q

False sense of motion (or exaggerated sense of motion)

A

Vertigo

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Q

2 types of vertigo

A

Peripheral and central

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Q

Horizontal nystagmus indicates

A

Peripheral vertigo - due to labyrinth or vestibular issues

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Q

Episodic vertigo, no hearing loss

A

BPPV or

Vestibular neuritis

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Q

Episodic vertigo, hearing loss

A

Meniere or

Labyrinthitis

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Q

Management of N/V in pts with vertigo

A

Antihistamines (Meclizine, cyclizine, dimenhydramine, diphenhydramine)
Metoclopramide, prochlorperazine
Scopolamine
Lorazepam, diazepam

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Q

Inflammation of both eyelids. Common in pts with _________ and ________

A

Blepharitis
Down syndrome
Eczema

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Q

Two types of blepharitis

A

Infectious (staph aureus or staph epidermidis)

2. Seborrheic

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Q

Signs/symptoms of blepharitis

A

Eye irritation/itching

2. Eyelid burning, erythema, crusting, scaling, red-rimming and eyelash flaking

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Q

Management of blepharitis

A

Warm compresses, eyelid scrubbing/washing with baby shampoo

May give azithromycin ointment/solution

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Q

Most common etiology of conjunctivitis

A

Adenovirus

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Q

Most common cause of viral conjunctivitis

A

Swimming pools

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Q

Signs/symptoms of viral conjunctivitis

A

Foreign body sensation
Erythema
Itching
Normal vision

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Q

Preauricular lymphadenopathy, copious watery discharge from eyes, scanty mucoid discharge.
Often bilateral

A

Viral conjunctivitis

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Q

Management of viral conjunctivitis

A

Supportive - cool compresses, artificial tears

Antihistamines for itching/redness

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Q

Signs/symptoms of allergic conjunctivitis

A

Conjunctival erythema paired with other allergic symptoms

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Q

Cobblestone mucosa appearance to the inner/upper eyelid, itching, tearing, redness, stringy discharge. Usually bilateral, +/- conjunctival swelling

A

Allergic conjunctivitis

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Q

Treatment for allergic conjunctivitis

A

Topical antihistamine: olopatadine

Topical NSAID: ketorolac

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Q

Most common causes of bacterial conjunctivitis

A

S. aureus
Strep pneumoniae
H. influenzae

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Q

Purulent discharge from eye, lid crusting, usually no vision changes

A

Bacterial conjunctivitis

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Q

Management of bacterial conjunctivitis

A

Topical abx - erythromycin, fluoroquinolones (moxi), sulfonamides, aminoglycosides

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Q

Management of bacterial conjunctivitis if contact lens wearer

A

Cover pseudomonas

Fluoroquinolones or aminoglycoside

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Q

Blowout fracture:

A

Fracture to the orbital floor as result of trauma. May lead to trapping of eye structures

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Q

Signs/symptoms of blowout fracture

A

Decreased visual acuity (trapped orbital tissue)
Diplopia especially with upward gaze (if inferior rectus muscle entrapment)
Orbital emphysema (eyelid swelling after blowing nose - air from maxillary sinus)
Epistaxis, anesthesia to the anteromedial cheek

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Diagnosis of blowout fracture

CT - may show teardrop sign

Management of blowout fracture

1. Initial: nasal decongestants, avoid blowing nose, corticosteroids, antibiotics 2. Surgical repair - severe cases, patients with enophthalmos

Foreign body sensation in the eye, tearing, red and pain that is relieved with instillation of ophthalmic analgesic drops

Ocular Foreign body | Corneal abrasion

Diagnosis of ocular foreign body /corneal abrasion

Pain relieved with instillation of ophthalmic analgesic drops Fluorescein staining- abrasions

Management of ocular foreign body

Check visual acuity first Remove foreign bodies with sterile irrigation Avoid sending pts home with topical anesthetics Antibiotic drops - erythro, polymyxin/trimethoprim

Management of corneal abrasion

Check visual acuity first Patching not indicated for small abrasions and no longer than 24 hrs Ciprofloxacin, erythromycin

Infection of the lacrimal sac

Dacryocystitis

Tearing, tenderness, edema and redness to the nasal side of lower eyelid

Dacryocystitis

Management of dacryocystitis

Antibiotics - clindamycin | Dacryocystorhinostomy

Signs/symptoms of foreign body in the ear

Ear pain, drainage, conductive hearing loss. May be asymptomatic

Management of foreign body in ear

1. Lidocaine drops if insect (to paralyze) 2. Foreign body removal 3. Assess for tympanic membrane rupture or complications

Signs/symptoms of foreign body in nose

``` Mucopurulent discharge Foul odor Epistaxis Nasal obstruction (mouth breathing) ```

Management of foreign body in nose

Positive pressure technique (have pt close other nostril and blow) Oral positive pressure (parent blows into mouth while occluding other nostril - small children) Instrument removal

Increased intraocular pressure leads to optic nerve damage, leading to decreased visual acuity

Acute narrow angle-closure glaucoma

Decreased drainage of aqueous humor via trabecular meshwork and canal of schlemm in pts with preexisting narrow angle or large lens

Acute narrow angle-closure glaucoma

Leading cause of preventable blindness in US

Acute narrow angle-closure glaucoma

Precipitating factors for acute narrow angle-closure glaucoma

Mydriasis - pupillary dilation further closes the angle | Dim lights, sympathomimetics and anticholinergics

Severe, sudden onset of unilateral ocular pain +/- nausea, vomiting, headache. Vision changes, blurring, halos around lights, peripheral vision loss (tunnel)

Acute narrow angle-closure glaucoma

Conjunctival erythema, steamy cornea, mid-dilated, fixed, nonreactive pupil, eye may feel hard to palpation

Acute narrow angle-closure glaucoma

Diagnosis of acute narrow angle-closure glaucoma

Increased IOP by tonometry (> 21 mmHg) | Cupping of optic nerve on fundoscopy

Management of acute angle glaucoma

Ophthalmic emergency Step 1: lower IOP (acetazolamide, BB, mannitol) Step 2: open the angle (cholinergics -pilocarpine, carbachol) Peripheral iridotomy definitive treatment

Medications to avoid with acute angle glaucoma

Anticholinergics | Sympathomimetics

Visible blood in the anterior chamber of the ey

Hyphema

Complication of hyphema

Can lead to blindness if not properly attended to - leads to ocular hypertension

Diagnostic testing for hyphema

1. Screen for sickle cell disease | 2. If serious injury, CT scan for further evaluation

Treatment of hyphema

Eye shield, elevated head to 30 degrees Give adequate analgesia (topical cycloplegics) and antiemetics to prevent increased ocular pressure Topical steroids Topical BB if increased pressure

Surgery indications of hyphema

Early corneal blood staining > 1/2 of anterior chamber involved Uncontrolled intraocular pressure

Risk factors for macular degeneration

1. Age > 50 2. Caucasian 3. Females 4. Smokers

Most common cause of permanent legal blindness and visual loss in the elderly

Macular degeneration

Small, round, yellow-white spots on the outer retina (scattered, diffuse). Accumulation of waste products

Drusen - seen in macular degeneration

New, abnormal vessels grow under the central retina which leak and bleed, leading to retinal scarring - rarer than dry

Wet (neovascular or exudative) macular degeneration

Bilateral blurred or loss of central vision (including detailed and colored vision), scotomas (blind spots, shadows)

Macular degeneration

Straight lines appear bent

Metamorphopsia | Macular degeneration

Object seen by the affected eye looks smaller than in the unaffected eye

Micropsia | Macular degeneration

Diagnosis of macular degeneration

Amsler grid | Wet: fluorescein angiography

Management of wet macular degeneration

1. Bevacizumab - VEGF 2. Laser photocoagulation 3. Optical tomography done to monitor treatment response

Acute inflammatory demyelination of the optic nerve

Optic Neuritis (Optic Nerve/CN II Inflammation)

Etiologies of optic neuritis

1. Multiple Sclerosis (MC) | 2. Medications (ethambutol, chloramphenicol, autoimmune)

Signs/symptoms of otpic neuritis

1. Loss of color vision, visual field defects, loss of vision over a few days 2. Usually unilateral 3. Associated with ocular pain that is worse with eye movement

During swinging-flashlight test from the unaffected eye into the affected eye, the pupils appear to dilate (delayed response from affected optic nerve)

Marcus-Gunn Pupil | Optic Neuritis

Diagnosis of optic neuritis

1. Marcus-Gunn pupil 2. Fundoscopy - 2/3 normal disc/cup ratio OR 1/3 optic disc swelling/blurring 3. May use MRI in some cases

Management of optic neuritis

IV methylprednisolone followed by oral corticosteroids | Vision usually returns with tx

Usually secondary to sinus infections (ethmoid 90%)

Orbital cellulitis

Orbital cellulitis most commonly occurs in ___________

children

Signs/Symptoms of orbital cellulitis

``` Decreased vision Pain with EOM Proptosis (bulging eye) Eyelid erythema Edema ```

Diagnosis of orbital cellulitis

High resolution CT scan Infection of the fat and ocular muscles MRI

Management of orbital cellulitis

IV antibiotics - vancomycin, clindamycin, cefotaxime, ampicillin/sulbactam

Management of preseptal cellulitis

Amoxicillin (no admit needed)

Infection of the eyelid and periocular tissue - may have ocular pain and swelling but no visual changes and no pain with ocular movement

Preseptal cellulitis

Optic nerve (disc) swelling secondary to increased intracranial pressure (classically bilateral)

Papilledema

Etiologies of papilledema (4)

1. Idiopathic intracranial HTN (pseudotumor cerebri) 2. Space-occupying lesion (cerebral tumor, abscess) 3. Increased CSF production 4. Cerebral edema, severe HTN (malignant)

Signs/symptoms of papilledema

1. Headache 2. Nausea/vomiting 3. Vision usually well preserved, but may have changes

Diagnosis of papilledema

1. Fundoscopy 2. MRI or CT scan to r/o mass 3. LP for increased CSF pressure

Management of papilledema

Diuretics (acetazolamide)

Most common type of retinal detachment

Rhegmatogenous | Retinal inner sensory layer detaches from choroid plexus

Most common predisposing factors for retinal detachment

Myopia (nearsightedness) | Cataracts

Photopsia (flashing lights), floaters, progressive unilateral vision loss

Retinal detachment

Shadow "curtain coming down" in peripheral initially, leading to loss of central visual field. No pain or redness of eye

Retinal detachment

Diagnosis of retinal detachment

Fundoscopy: detached tissue flapping in vitreous humor

Clumping of brown-colored pigment cells in anterior vitreous humor resembling tobacco dust

+ Shafer's Sign | Retinal detachment

Management of retinal detachment

Ortho emergency Keep patient supine Don't use miotic drops Laser, cryotherapy

Central retinal thrombus, fluid backup in retina, acute sudden monocular vision loss

Central retinal vein occlusion (CRVO)

Risk factors for CRVO

1. HTN 2. DM 3. Glaucoma 4. Hypercoagulable states

Extensive retinal hemorrhages (blood and thunder appearance), retinal vein dilation, macular edema, optic disc swelling

Central retinal vein occlusion

Management of CRVO

No known effective tx +/- anti-inflammatories, steroids, laser photocoagulation May resolve spontaneously or progress to permanent vision loss

Excess H2O or local trauma changes the normal acidic pH of the ear, causing bacterial overgrowth

otitis externa

Most common eteiology of otitis externa

Pseudomonas (MC) | Proteus, S. aureus

1--2 days of ear pain, pruritus in the ear canal May have had recent activity of swimming Auricular discharge, pressure/fullness. hearing usually preserved

Otitis externa

Management of otitis externa

Protect ear against moisture Ciprofloxacin/dexamethasone Ofloxacin safe Aminoglycoside combination

Management of malignant otitis externa

Seen in DM and immunocompromised | IV Ceftazidime or Piperacillin + fluoroquinolones

Infection of middle ear, temporal bone, and mastoid air cells. Most commonly preceded by viral URI

Acute otitis media

4 most common organisms of acute otitis media

S. pneumo, H. influenzae, M. catarrhalis, strep pyogenes

Risk factors for otitis media

``` Eustachian tube dysfunction Young (ET is wider, shorter and more horizontal) Daycare Pacifier/bottle use Parental smoking Not being breastfed ```

Fever, otalgia, ear tugging in infants, conductive hearing loss, stuffiness

Otitis media

Rapid relief of ear pain + otorrhea

Tympanic membrane perforation

Management of otitis media

1. Amoxicillin 10-14 days 2. Augmentin or Cefixime 3. If PCN allergic, erythromycin, azithromycin, Bactrim

Management for severe, recurrent cases of otitis media

Myringotomy (surgical drainage) | Tympanostomy

Treatment for chronic otitis media - perforated TM + persistent or recurrent purulent otorrhea +/- pain

Topical ofloxacin or ciprofloxacin | Avoid water/moisture/topical aminoglycosides in ear with TM rupture

Treatment for tympanic membrane perforation without infection

Most heal spontaneously. Follow up to ensure resolution

Auricular hematoma occurs after ____________ to the ear, typically during spots (wrestling, rugby, boxing, etc)

Direct trauma

If an auricular hematoma is not drained, disruption of blood supply to the auricular cartilage causes necrosis and usually results in:

Cauliflower ear

Management of auricular hematoma

All should be drained ASAP after injury If > 7 days old, refer to otolaryngologist or plastic surgeon for debridement Regional auricular block using local anesthetic usually provides adequate anesthesias, then either needle aspiration or I&D is performed

Inflammation of the vestibular portion of CN 8 - most commonly after viral infection

Vestibular Neuritis

Vestibular neuritis plus hearing loss/tinnitus

Labyrinthitis

Signs/symptoms of vestibular neuritis/labyrinthitis

Peripheral vertigo (usually continuous), dizziness, N/V, gait disturbances

Management of vestibular neuritis/labyrinthitis

Corticosteroids first line | Meclizine, benzos for sx

Inflammation of the mastoid air cells of the temporal bone

Mastoiditis

Etiology of mastoiditis

Usually a complication of prolonged or inadequately treated otitis media

Signs/symptoms fo mastoiditis

1. Deep ear pain, fever | 2. Mastoid tenderness, may develop cutaneous abscess

Complications of mastoiditis

Hearing loss, labyrinthitis, vertigo, CN VII paralysis, brain abscess

Diagnosis of mastoiditis

CT scan

Management of mastoiditis

1. IV antibiotics + middle ear/mastoid drainage hallmark | 2. Mastoidectomy if refractory or complicated

Tonsillitis --> cellulitis --> _____________

Abscess formation | Peritonsillar abscess

Most common causes of peritonsillar abscess

``` Strep pyogenes (GABHS) Staph aureus ```

Signs/symptoms of peritonsillar abscess

Dysphagia, pharyngitis Muffled "hot potato voice" Difficulty handling oral secretions, trismus Uvula deviation to contralateral side Tonsillitis, anterior cervical lymphadenopathy

Diagnosis of peritonsillar abscess

CT scan first line to differentiate cellulitis vs abscess

Management of peritonsillar abscess

Antibiotics + aspiration or I&D Unasyn, clindamycin, penicillin G + metronidazole Tonsillectomy if recurrent

Treatment for dental abscess

Augmentin and abscess drainage

Inflammation of the larynx

Laryngitis

Most common etiology of laryngitis

Viral - adenovirus, rhinovirus, etc. | Trauma (vocal abuse)

Hallmark of laryngitis

Hoarseness

Management of laryngitis

Vocal rest, warm saline gargles, anesthetics, lozenges, increased fluid intake

Inflammation of the epiglottis that may interfere with breathing (medical emergency)

Epiglottitis

Most common cause of epiglottitis

Haemophilus influenzae type B - reduced incidence due to Hib vaccination

Signs/symptoms of epiglottitis

3 D's - dysphagia, drooling, distress | Fever, odynophagia, inspiratory stridor, dyspnea, hoarseness, muffled voice, tripoding

Suspect in pt with rapidly developing pharyngitis, muffled voice and odynophagia out of proportion to physical finddings

Epiglottitis

Diagnosis of epiglottitis

1. Laryngoscopy - direct visualization - cherry red epiglottis 2. Lateral cervical radiograph - thumb sign 3. If high suspicion, do not attempt to visualize the epiglottis with tongue depressor

Management of mild epiglottitis - no stridor at rest, no respiratory distress

Cool humidified air mist, hydration Dexamethasone provides significant relief as early as 6 hours after dose (oral or IM) Supplemental O2 in pts with sats < 92% Patients can be discharged home

Management of moderate epiglottitis - stridor at rest with mild to moderate retractions

Dexamethasone PO or IM + supportive treatment +/- nebulized epinephrine Should be observed for 3-4 hours after clinical intervnetion May be discharged home if improvement is seen

Management of severe epiglottitis - stridor at rest with marked retractions

Dexamethasone + nebulized epinephrine and hospitalization

Most common etiology of corneal ulcer? In contact lens wearers? With ocular trauma? Chronic topical steroid use?

HSV overall pseudomonas Bacterial fungal

Ulceration usually has regular borders and will have accompanying purulent exudate

Corneal ulcer

Blue/green discharge with corneal ulcer

pseudomonas

Dendrites on fluorescein staining with corneal ulcer

HSV

Satellite lesions around ulceration with corneal ulcer

Fungus

3 main types of rhinitis

Allergic Infectious Vasomotor

Nonallergic/noninfectious dilation of the blood vessels (ex temperature change)

Vasomotor rhinitis

MC infectious cause of rhinitis

Rhinovirus (common cold)

Sneezing, nasal congestion/itching, clear rhinorrhea. Eyes, ears, nose and throat may be involved. Allergic associated with nasal polyps and tends to be worse in the morning

Rhinitis

Pale/violaceous, boggy turbinates, nasal polyps with cobblestone mucosa of the conjunctiva

Allergic rhinitis

Erythematous turbinates indicates

Viral rhinitis

Management of viral rhinitis

1. Intranasal corticosteroids

Management of rhinitis

1. Oral antihistamines | 2. Decongestants - oral, intranasal

Acute sinusitis is defined as:

1-4 weeks

Etiologies of sinusitis

S. pneumo H. flu GABHS M. catarrhalis (same as otitis media)

Signs/symptoms of sinusitis

``` Sinus pain/pressure - worse with bending down and leaning forward Headache, malaise Purulent sputum or nasal discharge Fever Nasal congestion ```

Physical exam of sinusitis

Sinus tenderness on palpation | Opacification with transillumination

Diagnosis of sinusitis

Clinical diagnosis CT scan diagnostic test of choice Sinus radiographs- waters view

Symptomatic management of sinusitis

1. Decongestants, antihistamines, mucolytics, intranasal corticosteroids, analgesics, nasal lavage Indicated if sx < 7 days

Antibiotic treatment for sinusitis

Sx should be present for > 10-14 days or earlier if: febrile, facial swelling, etc Amoxicillin drug of choice x 10-14 days Doxycycline, Bactrim

Chronic sinusitis is defined as

> 12 consecutive weeks

Most common bacterial cause of chronic sinusitis

S. aureus

Most common epistaxis form

Anterior

Most common site of bleeding in anterior epistaxis

Kiesselbach's Plexus

Most common risk factors for posterior epistaxis

Hypertension and atherosclerosis

Most common site of bleeding in posterior epistaxis

Palatine artery

Management of epistaxis

1. Pressure while seated and leaning forward 2. Topical decongestants/vasoconstrictors 3. Cauterization if bleeding can be seen 4. Nasal packing

Most common causes of pharyngitis

Adenovirus, rhinovirus, enterovirus | GABHS for streptococcal pharyngitis

Signs/symptoms of pharyngitis

1. Sore throat | 2. Pain with swallowing

Management of viral pharyngitis

Fluids, warm saline gargles, topical anesthetics, lozenges, NSAIDs

Centor criteria for strep throat

1. Fever > 100.4 2. Pharyngotonsillar exudates 3. Tender anterior cervical lymphadenopathy 4. Absence of cough

Centor criteria interpretation

Score 0-4 0-1 no abx or culture needed 2-3 throat culture 4-5 give abx

Modified centor criteria

< 15 y/o add 1 point | > 44 y/o subtract 1 point

Diagnosis of strep throat

Rapid antigen detection test | Throat culture - definitive diagnosis (gold standard)

Management of strep throat

Penicillin G or VK first line, amoxicillin, augmentin | Macrolides if PCN allergic (azithromycin, clarithromycin, erythromycin)

Complications of strep throat

1. Rheumatic fever 2. Glomerulonephritis 3. Peritonsillar abscess, cellulitis