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Lecture 2: EENT (enochs) Flashcards

1
Q

What are the 3 CNs that control eye movement and their corresponding muscles?

A
  • CN3 (Oculomotor): Superior, Medial, Inferior, Inferior oblique
  • CN4 (Trochlear): Superior oblique
  • CN6: (Abducens): Lateral

Superior oblique: Down and out
Inferior oblique: Up and out

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2
Q

label this and tell me what each one does!

A
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3
Q

What can chronic use of ophthalmic drops do?

A
  • Chemical conjunctivitis
  • Inflammatory changes to cornea
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4
Q

What oral medications increase the risk for glaucoma?

A
  • Dilating eye drops
  • TCAs
  • MAOIs
  • Antihistamines
  • Antiparkinsonian drugs
  • Antipsychotics
  • Antispasmolytics
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5
Q

What kind of eye injury requires intervention prior to PE?

A

Chemical injury

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6
Q

What is the ideal way to assess VA?

A

With corrective lenses.

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7
Q

when is the finger counting or hand motion perception test used? if this fails, what other tests come next?

A
  • VA worse than 20/200 -> finger counting @ 3ft away or hand perception at 1-2ft.
  • if unable to detect hand motion -> determine if light perception is present
  • if unable to detect light perception -> check hx of nystagmus
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8
Q

What test assess for afferent pupillary defect?

A

Swinging light test

( switch light back and forth between eyes every 2 seconds. if normal, pupils will constrict each time the light hits them. if one side is affected, the pupils will both remain dilated while the light is on the affected pupil)

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9
Q

What is normal IOP? When should you NOT check IOP via tonopen?

A
  • 10-20 mmHg
  • CI if globe rupture from trauma
  • remember IOP is checked last in the exam due to discomfort. (only exception is fundoscopic exam IF you require dilation!)
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10
Q

How do you differentiate preseptal cellulitis from orbital cellulitis?

A

Presence of inflammatory proptosis of the eye = orbital.

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11
Q

what is periorbital cellulitis

A

infection anterior to the orbital septum

can arise from sinusitis, skin trauma, insect bite or hordeolum.

generally benign -> tx w outpatient therapy

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12
Q

What recent infections may suggest possible orbital cellulitis? How is this different from periorbital cellulitis

A
  • Ethmoid sinusitis
  • Maxillary sinusitis
  • infection extends behind the orbital septum
  • life and vision threatening. requires IV inpatient therapy.
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13
Q

what are s/s of periorbital and orbital cellulitis

A
  • fever (uncommon in periorbital)
  • excessive tearing
  • erythema
  • edema
  • warmth
  • tender to palpation of lids and periorbital soft tissue.
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14
Q

What are the red flags for orbital involvement of an infection?

A
  • Pain with EOM
  • Chemosis
  • Proptosis
  • Increased IOP
  • VA changes
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15
Q

If we suspect orbital cellulitis in a young child who is difficult to examine, what is the ideal imaging?

A

Orbital CT w/ con

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16
Q

Management for periorbital cellulitis OP for older child and up

A
  • Augmentin or keflex (clinda for PCN allergy)
  • Hot compresses
  • f/u in 24-48h with oph
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17
Q

Management of periorbital cellulitis for young children/severe presentation

A
  • Admit
  • (IV rocephin) OR (unasyn + vanco)
  • PCN allergy: FQ + metro/clinda
  • Oph consult
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18
Q

Management of orbital cellulitis

A
  • Immediate ophthalmology consult
  • IV abx: (Rocephin) or (unasyn + vanco) or (FQ + metro/clinda)
  • Topical nasal decongestant
  • Lateral canthotomy for increased IOP or optic neuropathy
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19
Q

Describe a hordeolum.

A
  • Stye
  • Acute infection of follicle or meibomian gland
  • Redness
  • Tender
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20
Q

Describe a chalazion.

A
  • Swelling d/t obstructed meibomian gland
  • Hard, non-tender
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21
Q

What are the S/S of both a hordeolum and chalazion?

A
  • Pain (more common in hordeolum)
  • Erythema
  • Swelling
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22
Q

How do you treat a hordeolum or chalazion?

A
  • Warm, moist compresses QID
  • Erythromycin ointment
  • Do not manipulate lesion
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23
Q

what is the presentation of bacterial conjunctivitis

A
  • painless mucopurulent discharge w matting of the eyelids
  • conjunctiva injected w occasional chemosis (swelling of eye membranes)
  • cornea is clear without fluorescent uptake
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24
Q

What diagnostics are indicated in bacterial conjunctivitis?

A
  • Fluorescein exam to r/o herpes, ulcers, abrasions
  • C&S if severe purulence
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25
Management for bacterial conjunctivitis
* Topical abx of TMP-polymyxin B * FQ or tobramycin for contact lens d/t pseudomonas * Admit for infants < 30d or hyperacute onsets.
26
What PE finding would suggest viral rather than bacterial conjunctivitis?
Watery discharge will also see: conjunctival injection chemosis preauricular lymphadenopathy
27
Management of viral conjunctivitis
* Cool compresses * Topical antihistamine/decongestant * Artificial tears | Much less dangerous
28
What PE findings suggest allergic conjunctivitis primarily over other etiologies?
* Intense itching * Papillae on inferior conjunctiva * Watery discharge * Cobblestoning
29
What diagnostic is appropriate for allergic conjunctivitis?
Fluorescein to r/o herpetic lesions
30
Management of allergic conjunctivitis
* Cool ompresses * Antihistamine/decongestants * Artificial tears * Refer if severe or resistant | Pretty much same as viral
31
How does anterior uveitis/iritis present?
* Unilateral/bilateral pain * **Photophobia with consensual photophobia** HALLMARK * Conjunctival injection/ciliary flush * Miosis with poor reactivity * Diminished VAs
32
What diagnostics are appropriate for anterior uveitis?
* Slit-lamp: keratic precipitates (Inflammatory cells), aqueous flares (protein) * Hypopyon check * Fluorescein stain * IOP measurement (usually normal)
33
Management of anterior uveitis
* Cycloplegics (dilate pupil to keep iris from lens) * Topical prednisolone * Refer to oph ## Footnote Cyclogyl or cyclopentolate or homatropine (DOC) for cycloplegic
34
When are topical steroids not indicated for anterior uveitis?
* Corneal abrasion * Infectious * Elevated IOP
35
What is a corneal ulcer and what causes it
* infection of the corneal stroma * bacterial/viral/fungal * can be associated w trauma (specifically contact lens wearers)
36
S/S of a corneal ulcer
* Pain * Redness * Tearing * **Photophobia** * **Blurry vision**
37
Diagnostics for corneal ulcer and expected findings
* Fluorescein: staining defect with **white hazy infiltrate**, iritis, and/or hypopyon * Culture ulcer
38
Management of corneal ulcer
* Ophthalmic FQ (ofloxacin or cipro or tobramycin) * Topical cycloplegic * **AVOID eye patching** * Consult oph for immunocompromised * **AVOID TOPICAL STEROIDS**
39
what is HSV keratoconjunctivitis?
an infection of the cornea and conjunctiva by HSV
40
S/S of HSV keratoconjunctivitis
* Unilateral photophobia * Pain, redness * VA loss * Preauricular LAN * Vesicular eruption arund eye
41
Diagnostics for HSV keratoconjunctivitis and expected finding
Fluorescein stain with dendritic lesion uptake or geographic ulcer
42
Management of HSV keratoconjunctivitis
* Eyelid involvement: oral antiviral * Conjunctival involvement: topical trifluridine (virpotic) with erythromycin ointment * Corneal involvement: urgent oph consult * **AVOID topical steroids** | If < 30d old, admit
43
What is HZV ophthalmicus?
HZV infection of V1 of trigeminal | Ramsay Hunt syndrome
44
S/S of HZV ophthalmicus
* Painful vesicular rash on erythematous vase involving upper eyelid and tip of nose **hutchinson sign** * Fever, malaise, HA * Red eye, blurred vision, eye pain/photophobia * Keratitis, uveitis * Elevated IOP ## Footnote Hunt at the zoo, so you know its zoster and not simplex
45
Diagnostics for HZV ophthalmicus and expected findings
Fluorescein stain showing pseudodendrites. | Small, no central ulceration, no terminal bulbs, lack of central stain.
46
Management of HZV ophthalmicus
* Consult * If severe: admit for IV acyclovir * Skin involvement: Cool compresses, oral antivirals for short-term rash, topical abx (bacitracin/erythromycin) * Ocular involvement: erythromycin ointment, cycloplegics, opioids, cool compresses * If anterior uveitis present: topical steroids via oph * **If occurring in patient < 40y, work up for immunocompromised state**
47
S/S of subconjunctival hemorrhage
* Bright red blood under bulbar conjunctiva * Hx of trauma by sneeze, cough, valsalva, HTN
48
Management of subconjunctival hemorrhage
Reassurance | 2-3 weeks to self-resolve
49
S/S of UV keratitis
* Slow onset of FB sensation and mild photophobia * Blepharospasm, tearing, conjunctival injection ## Footnote Foreign body
50
Risk factors for UV keratitis
* Welding * Tanning * Prolonged sun exposure
51
Dx of UV keratitis
* Slit lamp showing diffuse, punctate corneal edema * Fluorescein showing punctate corneal abrasions
52
Management of UV keratitis
* +/- eye patching * Cycloplegic, oral analgesics, topical abx
53
S/S of corneal abrasion
* Tearing, photophobia, pain * Blepharospasm * Often need topical anesthetic
54
Dx of corneal abrasion
* Look for any ocular FBs * Fluorescein
55
Management of corneal abrasion
* Ketorolac drops * Erythromycin ointment * **FQ/tobramycin for contact lens** * **DO NOT RX topical anesthetics**
56
What may occur if a FB persists in an eye > 24 hrs?
WBC ring forms in anterior corneal chamber
57
Presence of what suggest globe perforation due to corneal FB?
Hyphema or microhyphema | Do seidel test if suspected. (cobalt blue light) ## Footnote Hyphemas present with pain, subconjunctival is often painless
58
When would a CT orbit be added for suspected corneal FB?
If we think its intraocular or globe rupture
59
Management of corneal FB
* Consult if hyphema present * Remove FB (unless pt uncooperative or drunk) * F/u with oph in 24h if rust ring, central FB, or deep * f/u with oph in 48h if symptoms persist * Update tetanus
60
When would a consult for lid laceration be warranted?
* Lid margin involvement * Within 6-8mm of medial canthus * Lacrimal duct or sac involvement * Inner surface of lid * Ptosis * Tarsal plate invovement * Levator palpebrae muscle involvement (horizontal lac with ptosis)
61
Management of lid lac
* No sutures of lid margin < 1mm * Soft, absorbale/nonabsorbale 6/7-0 sutures (SMALL) * Oral kelfex and erythromycin ointment * Cold compresses * Discharge with oph f/u in 24h
62
What usually precipitates a globe rupture?
History of high spd FB or penetrating injury
63
PE findings associated with globe rupture
* Severe subconjunctival hemorrhage * **TEAR DROP pupil** * Limited EOM * Extrusion of globe content * Seidel test (if wound is unsealed)
64
Dx of globe rupture
CT scan of orbit
65
Management of globe rupture
* Eye shield, NPO, upright * Vanco + ceftazidime + zofran (avoid IOP increases) * Emergent oph consult
66
Why should you not use fingers to examine blunt eye trauma?
It will worsen IOP
67
Complications associated with blunt eye trauma
* Ruptured globe * Postseptal hemorrage * Hyphema * Orbital blowout fx
68
Features of orbital blowout fx
* Fx of inferior/medial orbital wall * Entrapment of **inferior rectus muscle** * Restricted upward/lateral gaze * Bruising around the eye
69
Dx of blunt eye trauma
CT facial bones without contrast
70
Management of blunt eye trauma
* Discharge home if normal VA and normal anatomy * Traumatic iritis tx with prednisolone acetate and cycloplegic * Emergent Oph consult if rupture, postseptal hemorrhage, hyphema, orbital blowout, or intraocular FB
71
Approach to chemical ocular injury
1. Eye irrigation 2. Physical
72
Management of chemical ocular injury
* Cycloplegic * Opioids * Emergent oph consult: increased IOP, chemosis, conjunctival blanching, epithelial defect, corneal edema, opacification, exposure to HCl, lye or concrete
73
Which glaucoma type is acute?
Narrow angle/closed angle/acute angle closure
74
What part of the eye does glaucoma involve?
Trabecular meshwork: draining aqueous humor via anterior chamber
75
What makes aqueous humor?
Ciliary body
76
What is the characteristic finding of glaucoma on fundoscopic exam?
Cupping of the optic disk
77
Define glaucoma
Eye diseases characterized by **neuropathy to optic nerve, with or without IOP elevation**
78
What is the primary and secondary leading causes of blindness?
1. Cataracts 2. Glaucoma
79
What are the usual predisposing events to acute angle closure glaucoma?
* Exposure to dark room * Reading * Dilating agents (anticholinergics) * Cocaine
80
How does acute angle closure glaucoma present?
* **Sudden onset** eye pain * Blurred vision **colored halos around lights**, **N/V** * HA * Fixed midposition pupil * **Hazy cornea** * Increased IOP (firm eye)
81
Gold standard test for acute angle closure glaucoma
Gonioscopy showing iridocorneal angle
82
Management of acute angle closure glaucoma
1. Oph consult 2. Supine position 3. Pharmacologic therapy 4. **Definitive**: Laser peripheral iridotomy
83
Pharmacologic tx of acute angle closure glaucoma
1. Topical BB (timolol) and a2-agonist (apraclonidine) (block production) 2. Acetazolamide (block production) 3. Mannitol (decrease IOP by reducing volume) 4. Pilocarpine once IOP < 50 to increase outflow
84
When should acetazolamide be given IV for acute angle closure glaucoma?
* IOP > 50 * Severe vision loss * Unable to tolerate PO
85
How does optic neuritis present (ON)?
* Painless vision loss * **Color vision usually more commonly affected** * VA should be altered via red desaturation test * Positive afferent pupillary defect * Edematous/swollen optic desk in anterior ON * Normal optic desk in retrobulbar ON
86
How does Central Retinal Artery Occlusion present?
1. Sudden, monocular painless vision loss (Amaurosis fugax) 2. Positive RAPD 3. Infarcted retina, pale, less transparents, and edematous 4. **Cherry red spot** 5. **Boxcarring**, segmented arterioles
87
Management for CRAO
Emergent oph and neuro consult
88
How does Central retinal vein occlusion present?
* RAPD * Optic disc edema * Diffuse retinal hemorrhages (Blood and thunder fundus)
89
Management of CRVO
Oph consult
90
How does retinal detachment present?
* Sudden onset of painless, monocular vision changes * Floaters, flashes of light, **dark veil/curtain** * Only PE changes are VA and visual field by confrontation | Bedside US can be helpful
91
Management of retinal detachment
Urgent consult within 24h ophthalmology for dilated eye exam
92
Presentation of AOE
* Pruritis, otalgia, and tenderness of external ear * Otorrhea and decreased hearing in severe * Erythema and edema of external auditory canal * Clear/purulent discharge * Severe cases: complete occlusion of auditory canal
93
Management of AOE
* Analgesics: tylenol/motrin * Cleansing of external canal * Otic drops: acetic acid/hydrocortisone * Ofloxacin or ciprofloxacin drops * Ear wick for swelling
94
When is acetic acid/hydrocortisone contraindicated in AOE? Ciprofloxacin?
* CI in perforated TM * CI if TM can't be seen * Cipro cannot be used in perforated TM either.
95
What red flags suggest malignant otitis externa?
* Elderly * Diabetic immunocompromised * Persistent symptoms despite standard therapy * Severe otalgia/edema * Granulation tissue on floor of canal
96
If malignant otitis externa is suspected, what diagnostic imaging should be ordered?
CT head w/ con showing **bone erosion**
97
Management of otitis externa
* ENT consult * IV tobramycin + piperacillin or rocephin or cipro * IV opiate
98
How does AOM present?
* Otalgia * Otorrhea, possible fever, hearing loss * TM erythema * Retracted/bulging TM
99
Top 3 causative organisms for AOM?
* Strep pneumo * H flu * M. cat
100
Management for AOM
* Amoxicillin (Cefdinir if allergy) * If recent abx use or recurrent OM, augmentin/cefdinir * Analgesics
101
Presentation of acute mastoiditis
* Otalgia * Fever * **Postauricular pain** * Postauricular swelling, erythema, and tenderness
102
Dx of acute mastoiditis
* CT head with contrast * Mastoid clouding * Loss of bony septae * Destruction/irregularity of mastoid cortex * Perisoteal thickening
103
Management of acute mastoiditis
IV vanco + rocephin
104
Presentation of bullous myringitis
* Severe otalgia * Intermittent otalgia * Intact bullae along the TM and EAC (external auditory canal) * Middle ear infusion
105
Management of bullous myringitis
Same as OM
106
Presentation of auricular hematoma
* Accumulation of blood between skin and cartilage of auricle d/t blunt trauma * Swelling, pain, and ecchymosis of auricle
107
Management of auricular hematoma
* Consult ENT: immediate I&D * Compressive dressing after * If left untreated, scarring and cauliflower ear
108
Management of ear FB
* Immobilize live insects with 2% lido * Use forceps or hooked probe or suction * Irrigation with warm water or saline for **non-organic objects**
109
Presentation of TM perforation
* Hx of barotrauma * Sudden onset of pain and hearing loss * +/- bloody otorrhea, vertigo, tinnitus * Rupture of TM
110
Management of TM perforation
* Most heal spontaneous * Uncomplicated = discharge home * Complicated = penetrating TM rupture = 24h f/u with ENT
111
Presentation of anterior epistaxis
* Visualized on external exam * MC at **kiesselbach plexus**
112
Presentation of posterior epistaxis
* Unable to directly visualize bleed * Failure to control bleeding * MC at sphenopalatine artery * Use nasal speculum
113
114
Management of epistaxis
* Type and crossmatch blood if hemodynamic unstable **MC in posterior bleed and pts taking AC** * Place in sniffing position * Direct pressure application w/ intranasal vasoconstrictor ## Footnote Oxymetazoline or phenylephrine
115
Chemical management of anterior epistaxis
* Utilize after 2 failed attempts of direct pressure with **visualized vessel** * Anesthetize with 3 swabs soaked in 1:1 of oxymetazoline and lidocaine * Apply silver nitrate stick ## Footnote CI in active hemorrhage, bilateral bleeding, recent cauterization
116
If chemical cautery fails for epistaxis tx, what else can we do?
* Thrombogenic foam * Oxidized cellulose * Floseal gelatin matrix * Nasal packing via balloon, tampon, or ribbon packing.
117
Among the 3 nasal packing options, which is the absolute last resort and why?
Ribbon gauze, due to its difficulty in usage and comfort.
118
In posterior epistaxis, chemical cautery cannot be used. What is the alternative to posterior nasal packing?
Catheter with balloon.
119
When are prophylactic abx indicated for nasal packing? What is the abx?
1. Indicated for packing > 48h 2. Augmentin (cephalosporin or bactrim) | Ideally, ENT removes it in 2 days. ## Footnote Advise pt to not take any **NSAIDs** for 3-4d
120
Centor criteria symptoms and purpose
1. Tonsillar exudate 2. Tender Anterior cervical LAN 3. Absence of cough 4. Fever 5. **Purpose: Whether pharyngitis is due to strep and how to manage.** | Young age is +1, middle is 0, old is -1
121
What specific symptoms suggest **Viral pharyngitis**?
* Cough * Rhinorrhea * Nasal congestion * Vesicular lesions
122
What specific symptoms suggest **bacterial pharyngitis**?
* Tonsillar exudate * **lack of cough** * Cervical LAN * Sore throat | MCC: Strep pyogenes (GAS)
123
What centor score is recommended to perform rapid strep?
At least 2 or more
124
Tx for viral pharyngitis and bacterial pharyngitis
* Viral: Supportive * Bacterial: Single dose of PCN G or amoxicillin 500mg 10d BID (keflex/cefdinir)
125
Patient education for pharyngitis
* Change toothbrush * Not contagious after 24h of tx * Self-resolving in 2-3 weeks but will remain contagious without tx.
126
What S/S suggest peritonsillar abscess?
* **Hot potato voice** * Odynophagia/dysphagia * **Contralateral deflection of uvula** * Drooling * Unilateral tonsillar enlargement * Fever
127
Dx of peritonsillar abscess
* Clinical, but if needed: * Intraoral US to differentiate cellulitis from abscess * CT con of the neck (Not C-spine)
128
Management of peritonsillar abscess
* Needle aspiration or I&D * Non-toxic: PCN VK + metro for 10d if PO tolerable. (clinda/metro) * **Toxic: sepsis w/u with Zosyn**
129
S/S of a retropharyngeal abscess
* **Muffled voice** * **Cervical adenopathy** * **Respiratory distress** key differentiating factor from peritonsillar abscess? * Stridor * Neck pain/torticollis
130
Dx of retropharyngeal abscess
* Neck XR: Thickening and protrusion of retropharyngeal wall * **GOLD STANDARD TEST: CT NECK w/ con**
131
Findings seen for retropharyngeal abscess via CT Neck w/ con
* Early: nonsuppurative edema, mild fat stranding, linear fluid, minimal mass effect. * Later: **Necrotic nodes**, **low attenuation, ring enhancement**
132
Management for retropharyngeal abscess
* Prep for airway placement * IVF + NPO * IV clinda/cefoxitin (zosyn or unasyn)
133
S/S of epiglottitis
* Progressive dysphagia, odynophagia, dyspnea * **tripoding** * Anterior neck tenderness (larynx/upper trachea) * Tachycardic
134
Dx of epiglottitis
* Neck XR: **thumbprint sign** * **transnasal fiberoptic laryngoscopy is gold standard**
135
Management of epiglottitis
* Prep for airway * Humdified O2, IVF * IV cefotaxime + vanco (respiratory FQ) * IV methylprednisolone 125mg
136
Etiology of odontogenic abscess
Extension of dental abscess into retro or parapharyngeal spaces or floor of mouth.
137
S/S of odontogenic abscess
* **Hx of dental pain/abscess** * Erythema/edema of labia/buccal gingiva or intraoral (tooth abscess) * Ludwig's angina (trismus, fever, edema of floor, displacement of tongue) * Retro-parapharyngeal abscess: sore throat, dysphagia, dyspnea
138
Dx of odontogenic abscess
* Beside US if superficial * CT Neck w/ con if deep
139
Two main complications of odontogenic abscess
* Ludwig's angina: cellulitis of sublingual/mandibular space = verify airway * Necrotizing infection: **toxic appearance w/ hemodynamic instability** = surgical fasciotomy ASAP.
140
Management of odontogenic abscess
* Non-toxic & superficial: Oral PCN VK or amoxicillin 500mg TID x10d (clinda) * Toxic, deep or complication: IVF, NPO, **unasyn + clinda + cipro**
141
MC food lodged in esophagus
Meat
142
Dx of swallowed FB
* "foreign body film" for radiopaque * CT w/o con for non-radiopaque
143
What object features make obstruction risky if it gets past the pylorus?
* Irregular/sharp * Wider than 2.5cm * Longer than 6cm
144
Management of swallowed FB in distal esophagus
IV glucagon to relax LES and hopefully allow it to pass | Provided no red flags for obstruction
145
Management of food impaction, coins, or sharp objects swallowed
* Emergent endoscopy * Consult sx
146
Management of swallowed battery
1. If in esophagus, REMOVE ASAP 2. If in stomach, f/u in 24h 3. Takes 48-72 hrs to pass
147
Management of swallowed narcotics
1. **NO endoscopy** 2. Admit for obs until it reaches rectum

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