HEENT Flashcards
(36 cards)
acute unilateral vision loss flowchart - painful vs painless
Painless: amaurosis fugax, CRAO, CRVO, optic neuritis (can be painful on movement), PRES, retinal detachment, vitreous hemorrhage, stroke, hyphema, wet age-related macular degeneration
Painful: Glaucoma, temporal arteritis, corneal ulcer/abrasion, uveitis, iritis , endopthalmitis, ischemic optic neuropathy, traumatic lens dislocation, optic neuritis
funduscopic and/or ultrasound findings in retinal detachment, vitreous hemorrhage
RETINAL DETACHMENT:
- Tear in the retina allowing vitreous to separate the retina from the choroid
- RF: male, History of RD, DM, sickle cell, family hx, near sighted, advanced age
-Fundoscopy- PALE GREY FOLDING retina, vitreous hemorrahge (cant r/o w/ fundoscopy)
-US- mobile hyperechoic membrane floating inside vitreous -> moves with eye movement
VITREOUS HEMORRHAGE:
- Poor fundus view due to diffuse red haze
-Fundoscopy- neovascularization, cobwebs, shadows; hard to visualize due to red haze
-US- snowstorm appearance- hyperechoic,
funduscopic and/or ultrasound findings in CRAO and CRVO?
CRAO:
-fundoscopy- cherry red spot, pale retina
-arteries are narrow
-US- wnl
CRVO:
-fundoscopy- blood and thunder -> diffuse retinal hemorrhage, dilated tortuous veins
-flame hemorrhages
-optic disc edema
-US- wnl
Acute angle glaucoma: overview, tx, painful vs painless
-!Red/painful eye, vomiting, HA, AMS
-!Precipitated by dark room, or using mydriatics
-Canal of Schlemm is narrowed, cannot drain fluid
-Vision threatening
-Systemically unwell
-Steamy hazy cornea
-!Mid-dilated, non-reactive pupil
-!Elevated IOP >40-70 (normal 10-21mmHg)
-May have a rock hard globe
Tx:
-Emergent ophthalmology consult
-Pain control
-↓ IOP: mnemonic STAMP
-Supine- lower head of bed
-Timolol: eye drops
-Acetazolamide 500mg IV (carbonic anhydrase inhibitor)
-Mannitol 1g/kg IV (osmotic decompression )
-Pilocarpine eyedrop
🔍 Clinical Presentation
Vision-threatening emergency
Red, painful eye
Headache, nausea, vomiting
Altered mental status (in severe cases)
Precipitating factors:
Entering dark rooms
Use of mydriatic agents (e.g., atropine)
Findings:
Steamy, hazy cornea
Mid-dilated, non-reactive pupil
Rock-hard globe on palpation
IOP elevated >40–70 mmHg (normal: 10–21)
⚠️ Pathophysiology
Narrowing or closure of the canal of Schlemm → impaired aqueous humor drainage
Rapid ↑ in intraocular pressure (IOP)
Can lead to permanent vision loss in hours
💊 Management Summary
🚨 1. Emergent Ophthalmology Consult
Do not delay while initiating medical therapy
🛏️ 2. Positioning
Supine position
Lower head of bed slightly to improve drainage
💊 3. Lower IOP – Mnemonic: STAMP
Letter Drug Mechanism
S Supine (Not a drug, but position to aid flow)
T Timolol (eye drop) β-blocker – ↓ aqueous humor production
A Acetazolamide 500 mg IV Carbonic anhydrase inhibitor – ↓ aqueous production
M Mannitol 1 g/kg IV Osmotic diuretic – ↓ vitreous volume
P Pilocarpine (eye drop) Miotic – opens trabecular meshwork via pupillary constriction
⚠️ Note: Pilocarpine is ineffective when IOP is extremely high — wait until pressure starts to decrease
➕ Supportive Measures
Pain control: antiemetics, analgesics
Avoid mydriatics (e.g., anticholinergics)
periorbital vs. orbital cellulitis
-PRESEPTAL:
-Staph, group A strep, strep pneumo
-injury (scratches, bug bites), local spread from URI, stye, blepharitis, conjunctivitis
-Fever, erythema, lid edema
-Young = do a septic workup
-PO Augmentin, clinda
-POST-SEPTAL:
-2ndary spread (sinusitis, dental infections, dacryocystitis, orbital surgery, endogenous sources)
-Staph, strep, pseudomonas, enterococcus, H. flu
-Proptosis, Ptosis
-Limited EOM (diplopia)
-Chemosis
-Suspect compression optic neuropathy if afferent pupillary defect, ↓ visual acuity, visual field deficit and ↑ IOP
-Clinical dx -> confirm w/ CT
-blood cultures
-Tx: IV clinda or cefuroxime, admission, ophtho consult for possible debridement
-Complications: Meningitis, abscesses, cavernous sinus thrombosis, CN deficits, orbital compartment syndrome
RETROBULBAR HEMATOMA
-
-Blunt trauma -> hematoma behind eye
-Proptosis
Limited EOM
Non-reactive pupil to light
IOP >40
Afferent pupillary defect
-Decrease visual acuity
-Non-reactive pupil
- DX: Ct scan orbits noncontrast; tonometry with raised IOP
-Tx- Lateral canthotomy, emergent (can cause permanent blindness)
red eye
-conjunctivits:
-spares the ring around the pupil
-episcleritis:
-self limited
-blanches with phenylephrine -> dx and differentiates from scleritis
-scleritis:
-rare but emergent -> vision threat
-pain, blurry vision, photophobia
-sclera edema, violet/blue globe
-underlying autoimmune ds
-tx- oral steroids, NSAIDs, emergent ophtho
-anterior uveitis/iritis:
-inflammation of internal structures
-Etiology: Infectious, post-traumatic, autoimmune (associated with HLA-B27)!!
-sudden, unilateral deep pain
-!direct and consensual photophobia -> painful constriction
-miosis
-ciliary flush
-slit lamp - cell and flare (WBC in anterior chamber (hypopyon) -> foggy)
-tx- topical cycloplegics (dilate pupil) and topical steroids
-anesthetics dont work bc its deep
-ophtho consult
-keratitis:
-inflammation of cornea
-vision blurry, red
-perilimbic flush - not as deep as ciliary flush
-UV keratitis- welders, fluorescein shows superficial punctate! keratitis) -> tx- no ophtho consult -> patch, cycloplegics, topical, antibx
-!!corneal ulcer- contact lens (pseudo) -> SOFT/HAZY white EDGES (unlike sharp abrasion) -> EMERGENCY / IV antibx
-tx- prophylactic antibx
-call ophtho
-NO steroids for HSV
Epistaxis: first line treatments, other treatment options, when is a posterior balloon indicated? (NOT ON TEST)
Step 1: !Hold pressure below nasal bridge -> ENTIRE fleshy part
-Should be uncomfortable
-Tongue depressor option
-Lean head slightly forward
-Ice on forehead or occiput
-Wait 10-20 mins
-LOOK in nose and throat
Tx options:
-!Afrin spray (oxymetazoline) + pressure + time = manages majority of bleeds
-Anterior bleed (MC)- Silver nitrate cautery if able to see source of bleeding (never on septum)
-Anterior nasal packing: Surgicel/Surgiflo, Vaseline gauze, xeroform gauze, Merocel, Nasal tampon if still bleeding, place HORIZONTALLY
-Refractory tx, severe, anticoag
-Posterior bleed or persistent -> Foley or 7.0cm size rhinorocket -> need to be PACKED!!!
- if packed: give abx (augmentin) to prevent toxic shock syndrome
-ENT consult / transfer
labs: INR, pTT, coagulation -> consider reversal agents if on something
Acute otitis media and its complication
AOM:
-hearing loss
-impaired mobility of TM
-buldging/red
-if perf -> drainage / crust
-bullous myringitis = blisters on TM (mycoplasma)
-tx- analgesics, hydration, antibx, consider t-tube
-complication- mastoiditis, meningitis, facial nerve paralysis, intracranial abscess
MASTOIDITIS:
- MC complication of AOM
-abscess in mastoid bone
- clincial dx: postauricular edema, erythema, tenderness, proptosis of ear
-thin-cut CT temporal bone
-2wks antibx
-possible surgical drainage
-complications- meningitis, skill osteomyelitis, venous sinus thrombosis, brain abscess, facial nerve palsies
Acute otitis externa and its complication malignant otitis externa
AOE:
- pulling the pinna causes exquisite pain*
-RF: Swimming, excessive ear cleaning, hearing aids, headphones
-!Pseudomonas!, S. epidermis
-Significant drainage, debris, granulation tissue in EAC
-Must check TM, should be normal
-Tx:
-Debridement
-Topical antibiotics: neomycin/hydrocortisone suspension, ciprodex
-Consider ear wick (merocel) placement if very swollen
- fungal otitis externa: can be exarcerbated by topical abx; use topical acetic acid or antifungal and keep dry
OTITIS EXTERNA (necrotizing) (malignant)
-Osteomyelitis of temporal bone/skull, rapidly progressive
-Pseudomonas aeruginosa
-suspect in immunocompromised (DM)
-!!Exquisite pain and discharge, out of proportion
-radiate to jaw
-Granulation tissue and bony-cartilaginous junction is pathognomonic
-Possible CN7 palsy
-CT and admission most often
-4-6 wks of ORAL ciprofloxacin (topical not enough)
Ludwigs angina
-Emergency! -> sepsis, airway compromise
-Causes: dental infection/procedure , polymicrobial
-Rapid cellulitis of floor of mouth
-Pain, drooling, dysphonia, fever, trismus, hot potato voice, stridor (late sign)
-!Cellulitis of redness, brawny neck edema
-!Raised firm area under the tongue -> TONGUE ELEVATION OR PROTRUSION (no tongue swelling)
-!Neck/throat tenderness
-!Submandibular “WOODY” induration, crepitus, tenderness
-Often CT scan of neck, labs
-Intubate early
-broad spectrum IV antibiotics
-PROMPT ENT / oral surgery consult for possible surgical I&D, ICU admission
🧠 When to Suspect Ludwig’s Angina
🚨 Key Clinical Clues
Recent dental infection, extraction, or trauma
Submandibular swelling with brawny, indurated (woody) edema
No discrete abscess—this is cellulitis, not a drainable abscess early on
Tongue elevation or protrusion (not swelling!) due to floor-of-mouth induration
“Hot potato” voice, muffled speech, drooling
Trismus, dysphagia, or odynophagia
Stridor or respiratory distress = late & ominous sign
Fever and systemic toxicity = risk for sepsis
🧪 What to Do
Immediately secure the airway (early intubation if any signs of compromise)
Order:
CT neck with contrast to evaluate deep space involvement
Labs: CBC, lactate, blood cultures
Start broad-spectrum IV antibiotics (covering anaerobes, strep, gram-negatives)
STAT ENT or oral surgery consult—high risk of requiring surgical drainage
❗️Red Flags to Immediately Consider Ludwig’s:
Recent molar or dental procedure
Swelling under chin + difficulty speaking or swallowing
Firm floor of mouth on palpation
Drooling, voice change, trismus
Febrile with neck cellulitis
🔑 Clinical Tip:
Tongue pushed up = floor swelling → think Ludwig’s
Tongue swollen = angioedema/anaphylaxis
causes of submandibular facial swelling
Sialolithiasis - stones; sialadenitis (inflammation
- unilateral and episodic for weaks
- hx of dehydration, anticholinergic use, sjogrens
- dry mouth for long time -> swelling
- 90% = wharton’s duct
- tx: heat, massage, suck on lemons to increase salivation
parotitis
- firm and erythematous swelling in pre and post auricular areas at the angle of the jaw
- Low grade fever, unvaccinated, general malaise, concomitant orchitis
- hx of MUMPs
- tx: suppurative subtype needs IV abx; push inside the cheek and see if pus comes out
dental infection/abscess
- bad oral hygiene , cavity
- can be sudden or gradual
- radiation to ear, jaw, temple, neck,
- tx: abx, analgesics with prompt dental f/u
- abscess: fetid breath, warmth -> needs abx and large fluctuant must be drained; maxilary > mandibular more concern for sinus and CN involvement
retropharyngeal abscess vs peritonsillar abscess
PERITONSILLAR ABSCESS:
-20-40yo
-Recent or current strep, acute tonsillitis
-!Muffled “hot potato” voice
-!Uvula deviation
-!TRISMUS = cannot open jaw d/t pterygoid muscle irritation
-!fluctuant, swollen, red, loss of landmarks
-May be drooling, halitosis
-Dx: Clinical! -> can get CT or U/S
-Def tx = drainage!: Needle aspiration vs. I&D
-Obtain wound culture
-Complication: hitting the carotid
-Send home with antibiotics !(clindamycin or ampicillin/sulbactam 10-14 days)
- drainage be careful internal carotid is close to tonsils
RETROPHARYNGEAL ABSCESS:
- “sounds like PTA with normal throat”
-young <6yo -recent strep, OM, tonsillitis, Post op (dental, endoscopy), trauma (fish bone)
-Sore throat, fever, neck pain, dysphagia, odynophagia, neck stiffness (meningitis mimic)
-!Pain / limitation of neck extension/flexion *
-Unilateral posterior pharyngeal edema & erythema
-Stridor, pooling secretions, sniffing position, voice change -> bad
-Dx: Lateral neck XR or CT scan w/ contrast*
-Tx:
-Antibiotics (IV clindamycin)
-ENT consult (surgical incision & drainage)
-Intubate if signs of impaired airway
-Complication: Mediastinitis, Lemierre’s syndrome, Obstruction
🎭 PTA = “The Drama Queen Tonsil”
Age: 20–40 y/o
Screams with a “hot potato voice”
So dramatic it pushes the uvula away
Can’t open mouth to talk (trismus from pterygoid irritation)
Smells bad (halitosis)
Needs a needle (aspiration or I&D) — but don’t hit the carotid!
🔑 Memory hook: The “Queen Tonsil” swells up, pushes others out of the way (uvula), won’t open her mouth, demands drainage.
🦖 RPA = “The Dinosaur Baby”
Age: <6 years
Appears with fever, neck stiffness, and a “meningitis-like” look
But: normal throat (don’t be fooled!)
Can’t look up! → Pain with neck extension
Sounds bad: sniffing position, muffled voice, stridor = danger
Needs CT or X-ray lateral neck, maybe ICU
🔑 Memory hook: Imagine a little dinosaur baby with stiff neck, can’t look up, grunting and drooling — airway emergency
what is this
PERITONISLAR ABSCESS
* * Abscess of the tonsil and soft tissue surrounding it
* Recent or current strep pharyngitis untreated, acute tonsillitis
* Muffled “hot potato” voice
* UVULA DEVIATION**
* TRISMUS = cannot open jaw d/t pterygoid muscle irritation **
* Inflamed unilateral tonsil: fluctuant, swollen, red, loss of landmarks
* May be drooling, halitosis
* Diagnosis: Clinical good ENT exam, can get CT or U/S
* Definitive treatment is drainage: Needle aspiration vs. I&D
* Obtain a wound culture
* Complication: hitting the carotid
* Send home with antibiotics (clindamycin or ampicillin/sulbactam 10-14 days)
RETROPHARYNGEAL ABSCESS!
hx:
* < 6 years old
* Preceding strep throat, OM, tonsillitis
* Post op complication (dental, endoscopy)
* S&S: Sore throat, fever, neck pain, dysphagia, odynophagia, neck stiffness (meningitis mimic)
* Physical exam:
* Pain / limitation of NECK EXTENSION/FLEXION *****
* Unilateral posterior pharyngeal edema & erythema
* Stridor, pooling secretions, sniffing position, voice change bad; DROOLING
* Diagnosis: Lateral neck XR or CT scan w/ contrast
* Management:
* Antibiotics (clindamycin)
* ENT consult (surgical incision & drainage)
* Intubate if signs of impaired airway
* Complication: Mediastinitis, Lemierre’s syndrome, Obstruction
pharyngitis, mono, exudative tonsillitis
-sore throat- Usually viral URI!
-dysphagia, referred pain to ears, neck, jaw, fevers, chills, myalgias
-tonsil enlargement, posterior pharynx injected/red, cervical lymphadenopathy
-Intervention: +/- throat cx, cbc, bmp, monospot, flu
-Meds: OTC NSAIDs, salt-water gargles, lozenges, consider decadron 10mg IM for severe pain
Exudative tonsillitis:
-Strep throat
-Centor criteria (fever, exudates, no cough, anterior cervical LAD)
-tx- Amoxicillin
-Mono:
-EBV; less common CMV, HIV, HBV, toxo
-Fever, fatigue, tonsillar exudate, anterior or posterior! cervical LAD
-Monospot (heterophile antibody test) -> low sensitivity and high specificity
-Doesnt work in <5yo -> bc no antibodies
-Refrain from sports 21 days
stridor: epiglottitis (supraglottiis) and croup
EPIGLOTTITIS:
-Etiologies:
-HiB (Haemophilus influenzae B) * before vaccines
-Strep or staph aureus
-RAPID onset 12-24 hrs of:
-Fever
-Sore throat
-Muffled voice
-stridor
-Anxious and ill-appearing
-Dx:
-before even examine -> CALL
-Lateral neck XR: Thumbprint sign (“swollen epiglottis”)
-Tx:
-Early airway management
-Emergent ENT consult
-O2, nebulized meds
-IV Ceftriaxone (3rd gen cephalosporin)
-Admit if airway compromise
CROUP (laryngotracheitis):
- MC = parainfluenza VIRUS
-barking
-NO DROOL
-low fever
-worse at night
-Dx- XR- steeple sign (narrowing of the subglottic trachea)
-Tx- humidified O2, nebulized racemic epi and albuterol!!!, observe 2 hrs
-low O2 sat, young (<3mo)- nebs, steroids, admit
-Other stridor in kids:
-Anaphylaxis
-Foreign body
-Neck abscess
-Congenital abnormalities compressing the airway
-angioedema -> steroids, diphendydramine, famotidine, epinephrine IM if airway compromise
CRAO: painless vs painful vision loss and overview, fundoscopy and tx
PAINLESS monocular visual loss
- “stroke of the eye”
-central retinal artery occlusion:
-usual stroke RF
-preceded by amaurosis fugax
-afferent pupillary defect (swinging light test)
-fundoscopy- pale retina, cherry red spot, fixed, dilated
-tx- ASAP optho consult (anterior chamber paracentesis), admit with stroke work up
-gentle massage globe- dislodge emboli
-dec IOP- acetazolamine, mannitol, timolol
-inc CO2- hyperventilation
-inc O2- 100% nonrebreather
->2hr -> vision loss
- ADMIT PT WITH A STROKE WORKUP
CRVO: painless vs painful vision loss and overview, fundoscopy and tx
-central retinal vein occlusion:
-DVT of eye
- RF: anything causing hypercoagulability - smoker, over 50, vein compression from thyroid or orbital tumors
-fundoscopy(pic)- blood and thunder hemorrhage, cotton wool spots, macular/optic disc edema
-check b/l dont miss papilledema
-tx- urgent consult - consider ASA, lower IOP
CRVO = older, vascular risk factors, painless vision loss, “blood & thunder” fundus → urgent referral
retinal detachment: painless vs painful vision loss and overview, fundoscopy and tx
PAINLESS vision loss
-flashers & floaters and webs
-“lowering of curtain”
-ocular US
-check visual fields
- if macula intact with central vision preserved -> reversible and time sensitive for ophtho consult
- with macula involvement and central vision loss -> irreversible
-fundoscopy: grey retina with folds, vitreous hemorrahge (cant r/o w/ fundoscopy)
-tx- emergent ophtho consult
vitreous hemorrhage: painless vs painful vision loss and overview, fundoscopy and tx
PAINLESS -> sudden red haze or hue vision of floaters, cobwebs and shadows
- bleeding within the vitreous humor of the eye
-etiology: abn neovascularization -> bleed; think proliferative DM ; or trauma/concominent retinal detachment
-red haze, cobwebs, shadows
-worse in morning
-check IOP, pupillary reflex
-ocular US
-tx- underlying cause
Painless + floaters or red haze → think vitreous hemorrhage
Absent red reflex on exam is a huge clue
Always rule out retinal detachment on ultrasound
optic neuritis: painless vs painful vision loss and overview, fundoscopy and tx
PAINLESS monocular vision loss with PAINFUL EOM
- def: inflammation of the optic nerve -> color loss, vision loss, pain, afferent pupil defect
-MS until proven otherwise!!!
-afferent pupillary defect
-painful EOM
-optic disc swelling
-MRI or CT head
-loss of color (RED) vision or contrastic**
- fundoscopy: unilateral papilledema (papilitis)**
-tx- IV steroids, neuro or ophtho consult
👁️🗨️ Optic Neuritis Overview
🧠 Definition
Inflammation of the optic nerve
Two types:
Retrobulbar neuritis (nerve behind the eye; fundus may appear normal)
Papillitis (inflammation visible at the optic disc)
🔍 Classic Presentation
Feature Finding
Vision loss Subacute, monocular, painless at rest
Pain With eye movement (orbital pain)
Color loss ↓ Red saturation, contrast sensitivity
Field defect Central scotoma (blurry or missing central vision)
Pupils Relative afferent pupillary defect (RAPD on swinging light)
Fundoscopy - Normal if retrobulbar
- Swollen, hyperemic disc if papillitis
🧪 Diagnosis
Clinical + confirm with:
MRI of orbits and brain with contrast
Look for optic nerve enhancement
Helps identify multiple sclerosis
Red desaturation test, visual acuity, swinging flashlight test
Consider CSF analysis (oligoclonal bands) if suspect MS
Serology: rule out infections (Lyme, syphilis) or autoimmune disease
💉 Treatment
IV methylprednisolone x 3–7 days
Then oral prednisone for 11–14 days
Neuro consult (often first MS sign!)
May need:
Plasmapheresis or IVIG if severe or not responding
Long-term MS therapy if diagnosed
📈 Prognosis
Most recover vision within weeks
Some have persistent visual deficits
~50% develop MS within 15 years
🧠 What is MS (Multiple Sclerosis)?
Autoimmune CNS demyelination disorder
Affects optic nerves, brain, and spinal cord
Often presents first as optic neuritis
Diagnosed via MRI and CSF oligoclonal bands
🧠 Memory Hook:
“Young woman with sudden one-eye vision loss and painful EOM = MS until proven otherwise.”
🔁 Pain with eye movement? Think optic neuritis
🎯 Monocular vision loss + RAPD? Think MS-related optic neuritis
stroke: painless vs painful vision loss and overview, fundoscopy and tx
PCA: occipital lobe involvement
- Contralateral homonymous hemianopia -> ex: loss of the left half of the visual field in both eyes
- b/l
- will have other neuro sx
- normal ocular exam and positive neuroimaging
wet age-related macular degeneration: painless vs painful vision loss and overview
painless
Rapid central vision loss, typically in older adults
Subretinal fluid or hemorrhage; drusen in macula
Rapid central vision loss, typically in older adults
Distorted lines
Subretinal fluid or hemorrhage; drusen in macula
Elderly smoker
Intravitreal anti-VEGF
