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NP717 HEENT

Terms in this set (67)

A patient presents with severe eye pain, foreign body sensation, tearing, and photophobia. They are contact lense users and have a whitish lesion on the cornea found during PE. What is this and what is appropriate management?
Corneal ulcer - ophthalmologic emergency - refer to ED. Most commonly caused by pseudomonas, staph, or step - can permanently impair vision d/t scarring or perforation.
A patient presents with acute onset of sever unilateral eye pain, photophobia, tearing, and blurred vision. During the fluorescein dye process, fernlike lines in the corneal surface are seen. What is this and what is appropriate management?
Herpes keratits - either herpes simplex or herpes zoster. Refer to ED.
An elderly patient presents with acute onset of severe eye pain w/headache, N/V, halos around lights, lacrimation, and decreased vision. What is this and what is normally found on physical exam?
Acute angle-closure glaucoma
Mid-dilated pupil(s) that is oval shaped, cloudy cornea, cupping of optic nerve. Ophthalmologic emergency.

If chronic angle-closure glaucoma - possibly asymptomatic or dull ache/blurred vision.
A young caucasian woman in her 20s/30s reports loss of visual acuity over hours to days. Color vision is affected and a central scotoma (blind spot central vision) is common. May have other neurologic sx including aphasia, paresthesia, abnormal gait, or spasticity. May also have higher-than-normal temperature that worsens sx (Uhthoff phenomenon). Has recurrent episodes. What is this? Tx?
Multiple sclerosis (optic neuritis). - refer to neurology
A patient has an acute onset of erythematous swollen eyelid with proptosis (bulging of the eyeball) and pain in the affected eye. Unable to perform full ROM (abnormal extra-ocular movement) w/o pain. What do you expect? Management?
Orbital cellulitis - look for hx of recent rhino-sinusitis or URI - serious complications - refer to ED
Retinal detachment is an emergency requiring immediate refer to ED. S/sx?
sudden onset of floaters (or increase in floaters) associated w/"looking through the curtain" sensation w/sudden flashes of light.

Central vision may be intact or lost if macula is detached.
Patient presents with a severe sore throat, difficulty swallowing, odynophagia (pain on swallowing), trismus (jaw muscle spasm) and a "hot potato" voice. PE shows unilateral swelling of the peritonsillular area and soft palate. Accompanied by malaise, fever, and chills. Dx? Management?
peritonsillar abscess - refer to ED
Normal findings in the eyes include _____?
Fundi: veins are larger and darker in color than arteries
Cones: for color perception
Rods: for low-light (night) vision, peripheral vision
Macula (and fovea): responsible for central & color vision. Center of the macula is called the fovea and has large #s of cones.
Presbyopia: age-related visional changes as eye unable to accommodate and focus due to stiffening of the lens.
Patient presents with inflammation of the edges of the eyelids where eyelashes grow. Small scales like dandruff are present. Dx?
blepharitis - may be associated w/dandruff, seborrheic dermatitis, or rosacea
Nose norms:
Kiesselbach's plexus: located on the anterior inferior aspect of the nose (lower 1/3rd). An anterior nosebleed is the result if the area is traumatized.
Turbinates: only inferior turbinates usually visible. Bluish, pale, and/or boggy nasal turbinates seen in allergic rhinitis.
Cartilage: lower third of the nose; doesn't regenerate.
Septum: May perforate d/t cocaine use; refer to plastic surgeon.
Sinus norms:
4 types
ethmoid (upper nose), and maxillary (present at birth)
frontal (age 5 years)
and sphenoid (age 12 years)
What is leukoplakia?
leukoplakia are benign growths of thick, whitish patches on the surface of the tongue, floor of mouth, or inside cheek. Rule out oral cancer.
Risk factors for oral cancer?
- chewing/smoking tobacco
- alcohol abuse
- HPV
What are aphthous stomatitis? Cause? Tx?
Aphthous stomatitis (canker sores) - painful shallow ulcers that usually heal 7-10 days. Cause unknown. Tx w/"magic mouthwash" - liquid diphenhydramine, viscous lidocaine, and glucocorticoidsteroid. Swish, hold & spit q 4 hours prn.
What can you do for an avulsed tooth?
Store in cool milk (no ic), saline, or inside mouth by cheek (adults only). Dental emergency.
Salivary glands?
three salivary glands:
parotid, submandibular, and sublingual

if infected: sialadenitis, sialadenosis, mumps, or can become blocked with calculi ("stone"; sialothiasis)
A 7 year female presents with acute onset of fever, headache, fatigue, myalgia, and anorexia. Within 48 hours, the salivary/parotid glands have become swollen and tender. (May be unilateral or bilateral). Checeks are puffy and angle of the jaw appears swollen. What is this?
Mumps (parotitis)
Complications: orchitis (of one testicle), meningitis, encephalitis, deafness, and others.

Nationally notifiable disease; report to local/state health department
If tonsillar exudate is ___________, what might this indicate:
1 - thick white exudate
2 - purulent yellow/green exudate
3 - peritonsillar abscess (quinsy)
1 - mononucleosis
2 - strep throat
3 - rare complication of tonsilitis - assess for airway obstruction - refer to ED/call 911
What is a geographic tongue? Concerns?
Geographic tongue - tongue surface has a map-like appearance; patches may move from day to day.

May complain of soreness with acidic/spicy foods.

Benign variant
What is a torus palatinus? Concerns?
Torus palatinus - painless bony protuberance midline on the hard palate (roof of the mouth); may be asymmetric; skin s/b normal.

Doesn't interfere with normal fx

Benign variant
What is a fishtail or split uvula?
Fishtail or split uvula:

- uvula is split into two sections and resembles a fishtail

- may be a sign of an occult cleft palate (rare)
What might cause papilledema?
Optic disc swollen with blurred edges d/t increased intracranial pressure (ICP) secondary to bleeding, brain tumor, abscess, pseudo-tumor cerebri
What might cause optic disc cupping?
Optic nerve cupping is associated with glaucoma. Caused by IOP (increased inter cranial pressure) and is measured by using the "cup-to-disc" ratio. The "cup" of the optic disk is the center; and the surrounding area the "disc". As glaucoma progresses; the cup-to-disc ratio becomes abnormal.
What might cause copper and silver arterioles, AV nicking and retinal hemorrhages?
Hypertensive retinopathy
What might cause microaneurysms, neovascularization, and cotton-wool spots in the eyes?
Diabetic retinopathy
Koplik's spots are associated with ________?
Koplik's spots - clusters of small red papules with white centers inside the cheeks by the lower molars - pathognomonic for measles (rubeola)
How are nasal polyps treated?
Intranasal glucocorticoids (fluticasone or budesonide BID) 1st line tx.

If poor response or recurrent sinus infection, refer to ENT for surgical tx.

Increased risk of ASA sensitivity or allergy
What is hairy leukoplakia associated with? Caused by?
Hairy leukoplakia - elongated papilla on the tongue that is pathognomonic for HIV infection.

Caused by Epstein-Barr virus (EBV)
What is cheilosis (angular cheilitis, perleche)? Causes? Tx?
Cheilosis (angular cheilitis, perleche) -
painful skin fissures/maceration at the corners of the mouth d/t excessive moisture. More common in the elderly w/dentures, pacifier use, lip licking, and thumb sucking

May have secondary infection with candida albicans (yeast) or bacteria (staph). May be from nutritional deficiences, poor fitting dentures, lupus, etc.

Tx:
- check vitamin B12 level
- remove underlying cause
- if yeast suspected: mmicroscope with KOH (potassium hydroxide) If positive (pseudohyphae and spores) tx w/ topical azole ointment (clotrimazole, miconazole) BID
- if suspect staph - order C & S. If positive, tx w/topical mupirocin ointment BID
- when infection has cleared, apply barrier cream w/zinc or petroleum jelly at night
What is the Ishihara chart used for?
color blindness
How is the Weber test administered? What is a normal finding?
Weber test - place the tuning fork midline on the forehead.

Normal: no laterization

Abnormal: Lateralization (hears the sound in only one ear or sound is louder in one ear)
How is the Rinne test administered? What is a normal finding?
Rinne test - place tuning fork first on mastoid process, then at front of the ear. Time each area.

Normal finding: air conduction (AC) lasts longer than bone conduction
What is presbycusis?
presbycusis - normal age related loss of hearing
What are examples of sensorineural loss and conductive loss of hearing? How do the Weber and Rinne tests present in both types?
Sensorineural: presbycusis, Meniere's disease
(damage/aging of the cochlea/vestibule or nerve pathways, ototoxic drugs (oral aminoglycosides, erythromycin, tetracyclines, ASA, sildenafil) and stroke)
Weber: lateralization to "good" ear (sound heard louder in the ear that is normal)
Rinne AC>BC

Conductive: otitis media, serous otitis media, ceruminosis, perforation of tympanic membrane
Weber: Lateralization to "bad" ear (sound hear louder in the bad/affected ear
Rinne BC>AC
Treatment plan for eye complaint:
1 - always check visual acuity and check pupils w/penlight. R/o penetrating trauma, retained foreign body, and contact lens-associated eye infections. If suspected bacterial infection - C&S of eye discharge.

2 - Flush eye w/sterile normal saline to remove foreign body. Evert eyelid to look. If unable to remove, refer to ED

3 - Use topical ophthalmic abx w/pseudomonas coverage (especially if contact lens user), such as ciprofloxacin (Ciloxan), ofloxacin (Ocuflox), or trimethoprim-plymyxin B (Polytrim), applied to affected eye for 3-5 days

4 - Do not patch eye. F/U in 24 hours. If not improved, refer to ED or ophthalmologist STAT

5 - Avoid steroid ophthalmic drops for herpes keratitis

6 - Consider eye pain prescription (hydrocodone w/APAP for 48 hours)

7 - Topical pain med Acular 1 gtt 4x/day (contradicted if allergic to NSAIDs)
Patient presents with c/o an acute onset of a swollen, red, and warm abscess on the upper or lower eyelid involving one hair follicle that gradually enlarges. May spontaneously rupture and drain purulent exudate. Infection may spread to adjoining tissue (preseptal cellulitis). What is this? Treatment plan?
hordeolum (stye)

Treatment plan:
- hot compresses x5-10 minutes 2-3x/day until it drains
- if infection spreads (preseptal cellulitis), systemic abx like dicloxacillin or eryhtromycin PO 4x/day. Refer to ophthalmologist for I & D
Patient presents with a gradual onset of a small superficial nodule on the upper eyelid that feels like a bead and is discrete and moveable. No pain. May enlarge slowly over time. If large, may press on the cornea and cause blurred vision. What is this? Treatment plan?
Chalazion - chronic inflammation of the meibomian gland (specialized sweat gland) of the eyelid. May resolve spontaneously in 2-8 weeks.

Treatment is I & D, surgical removal, or intrachalazion corticosteroid injections by ophthalmologist.
What is the difference between a pinguecula and a pterygium? Treatment plan?
Pinguecula - raised, yellow-to-white, small round growth in the bulbar conjunctiva (skin covering eyeball) next to the cornea. Located on the nasal and temporal side of the eye. Caused by chronic sun exposure.

Pterygium - yellow triangular (wing shaped) thickening of the conjunctiva on the nasal side. Results from chronic sun exposure. "surfer's eye". Can be red or inflamed at times. May c/o foreign body sensation on the eye.

Treatment:
- if inflamed, refer to ophthalmologist for rx of weak steroid eye drops only during exacerbation. Use artificial tears as needed for irrigation.
- Use good-quality sunglasses
- remove surgically if growth encroaches on cornea and affects vision.
Patient presents with sudden onset of painless bright-red blood in one eye after an incident of severe coughing, sneezing, or straining. May also occur from a trauma like a fall. No visual loss. What is this? Treatment plan?
Subconjunctival hemorrhage

Watchful waiting and reassurance. F/u until resolution.

Resolves 1-3 weeks (blood reabsorbed) like a bruise with color changes from red, to green, to yellow. Increased risk if on ASA, anticoagulants, or has HTN.
Patient presents with some loss in peripheral vision and missing portions of words when reading. Funduscopic exam shows cupping. What is this? Plan? Risk factors?
Primary open-angle glaucoma (most common)

gradual onset of IOP>22 mmHg due to blockage of the drainage of aqueous humor inside the eye, undergoes ischemic changes and if untreated becomes permanently damaged.

Refer to ophthalmology.

Mostly seen in elderly patients, especially AA or Caucasians or diabetics.

Check IOP (use tonometer) normal range 8 to 21 mm HG
What medications are associated with glaucoma? (Although ophthalmology should manage).
Betimol 0.5% (timolol): beta blocker eye drops (decreases aqueous production)

Latanoprost (Xalatan): topical prostaglandin eye drops (increase aqueous outflow)

Side effects: same as oral form; includes bronchospasm, fatigue, depression, HF, bradycardia

Contraindications: asthma, COPD, 2nd or 3rd degree heart block, HF
An older patient complains of acute onset of decreased/blurred vision with severe eye pain and frontal headache that is accompanied by nausea and vomiting. PE shows fixed and mid-dilated cloudy pupils. What is this?
Primary angle-closure glaucoma - sudden blockage of aqueous humor causes marked increase of the IOP, resulting in ischemia and permanent damage to optic nerve.

Refer to ED.
An elderly smoker complains of gradual (or sudden), painless loss of central vision in one or both eyes. Straight lines (doors/windows) appear distorted or curved. What is this?
Age related macular degeneration (damage to the pigment of the macula). Leading cause of blindness.

Refer to ophthalmologist.
What is Sjogren's syndrome?
chronic autoimmune inflammatory disorder w/daily sx of dry eyes and dry mouth (xerostomia) for >3 months

Use OTC artificial tears tid
refer to ophthalmologist and dentist (more dental caries)
refer to rheumatologist for management
What is blepharitis? Tx plan?
Chronic inflammatory condition of the eyelids (hair follicles, meibomian glands). Associated with seborrheic dermatitis and rosacea. Or infectious process w/staff. C/o itching in the eyelids, gritty sensation, eye redness, and crusting.

Tx:
-Johnson's baby shampoo w/warm water. Scrub eyelid margins until resolves.

- erythromycin topical abx drops if infectious

- warm compresses
Patient presents with c/o chronic nasal congestion with clear mucus rhinorrhea or postnasal drip. Coughing due to PND worsens when supine. Possible dx? Tx plan?
Allergic rhinitis

PE: nose has blue-tinged or pale and boggy nasal turbinates. Mucus clear. Posterior pharynx thick mucus - clear, white, yellow, or green (r/o sinusitis).
Possible undereye circles, transverse nasal crease, or cobblestoning.

Tx:
1st line: topical nasal sprays
- OTC Fluticasone bid, triamcinolone (nasacort allergy 24hr) 1-2 sprays q day
- if only partial relief, another option is topical antihistamine nasal spray with azelastine (Astelin) daily or bid
- if no relief, consider combo (azelastine and fluticasone spray)

- use decongestants (pseudoephedrine or sudafed prn) not for infants/young children
- consider oral antihistamines 2nd generation antihistamines like cetirizine (zyrtec), loratadine (claritin) daily or prn. diphenhydramine (benadryl) may cause sedation.
- eliminate environmental allergens

Complications:
-acute sinusitis
-AOM
Patient complains of acute onset of nasal bleeding secondary to trauma. From what area in the nose does this usually occur? Treatment plan?
Epistaxis:
anterior nasal bleeds from Kiesselbach's plexus
worse w/ ASA, NSAIDs, cocaine abuse, HTN, anticoagulants

Tx:
- apply direct pressure on the front of the nose for several minutes. Use of nasal decongestants (Afrin) to shrink tissue helps to stop bleeding.

- Apply triple abx ointment or petroleum jelly in the front of the nose for a few days

- if recurrent, refer to an ENT specialist for cauterization

Complications -
posterior nasal bleeds may hemorrhage - refer to ED
If Afrin or another topical nasal decongestant is used longer than 3 days, what might occur?
Rhinitis medicamentosa -
rebound effects that result in several and chronic nasal congestion

Tx:
- stop nasal decongestants
- use nasal saline spray to control sx
8 year old child presents with abrupt onset of fever, sore throat, pain on swallowing, and mildly enlarged submandibular nodes. On exam, purulent exudate is seen on the tonsils along with mildly enlarged and tender anterior cervical nodes. Tx plan?
Streptococcal pharyngitis/tonsillopharyngitis

May also have petechiae on the hard palate

Centor score: tonsilar exudate, tender anterior cervical adenopathy, hx of fever, and absence of cough.

Tx:
- Rapid antigen detection testing or throat C & S
- 1st line oral PCN V 500 mg bid or tid x 10 days
- alternative amoxicillin 500 mg bid x 10 days
- PCN or beta-lactam allergy - azithromycin (z-pak) x5 days
- sx tx saltwater gargle, throat lozenge, increase fluids
-repeat c & s after abx tx if hx of mitral valve prolapse or heart valve surgery

Complications:
Scarlet fever - sandpaper-textured pink rash w/sore throat and strawberry tongue. Rash starts on the head and neck and spreads to the trunk and then extremities. Next the skin desquamates (peels off). Increased risk of acute rheumatic fever.

Acute rheumatic fever: inflammatory reaction to strep infection that may affect the heart, valves, joints, or brain.

Peritonsillar abscess: displaced uvula, red bulging mass, dysphagia, fever. ED stat.

Poststreptococcal glomerulonephritis: abrupt onset of proteinuria, hematuria, dark-colored urine, and RBC casts w/HTN and edema.
What are some of the complications to "strep" throat?
Complications:
Scarlet fever - sandpaper-textured pink rash w/sore throat and strawberry tongue. Rash starts on the head and neck and spreads to the trunk and then extremities. Next the skin desquamates (peels off). Increased risk of acute rheumatic fever.

Acute rheumatic fever: inflammatory reaction to strep infection that may affect the heart, valves, joints, or brain.

Peritonsillar abscess: displaced uvula, red bulging mass, dysphagia, fever. ED stat.

Poststreptococcal glomerulonephritis: abrupt onset of proteinuria, hematuria, dark-colored urine, and RBC casts w/HTN and edema.
What organisms cause acute otitis media?
Adult infections: streptococcus pneumoniae (high rates of beta-lactamase resistance)

- S. pneumoniae (Gram+, up to 40% of cases)
- Haemophilus influenzae (Gram -; up to 50% of cases)
- Moraxella catarrhalis (Gram -; up to 20% of cases)
What is bullous myringitis?
Bullous myringitis - type of AOM infection that is more painful d/t blisters (bullae) on a reddened and bulging TM. Conductive hearing loss. Caused by different types of pathogens (mycoplasma, virus, bacteria). Tx the same as bacterial AOM.
Tx plan for AOM (purulent or suppurative otitis media)?
1st line: Amoxicillin 500 mg PO TID 5-7 days (any age group if no abx in the past month) - 10 days for severe disease

Most will respond in 48-72 hours. If no response to tx, switch to second-line such as Augmentin TID, cefdinir, or cefprozil, levofloxacin or moxifloxacin

MEEs (middle ear effusion) may last for 8 weeks or longer after tx of AOM.
Patient presents with c/o unilateral facial pain or upper molar pain with nasal congestion for 10 days or longer w/ purulent nasal and postnasal drip. Has hyposmia (reduced ability to smell). Self-tx with OTC cold/sinus remedies provide no relief. What is suspected? Treatment?
Acute bacterial rhino sinusitis

2 options:
- SX tx w/o abx (oral fluids and saline nasal irrigation). F/u in 10 days. If no better or sx have worsened, then abx tx.

- Tx w/abx if severe sx (high fever, pain, purulent nasal drip for >2-3 days, maxillary toothache, unilateral facial pain, sense of bad odor in nose (cacosmia), initial sx improved, then worsened), patient is immunocompromised, sx present for >10 days (or have worsened).

- Most cases of adult acute rhino sinusitis d/t viral infection. Bacterial accounts for only 0.5% to 2% of cases.

1st line: Amoxicillin-clavulanate (Augmentin) 1,000/62.5 mg or 2,000mg/125 mg one tablet bid 5-7 days.

If PCN allergy: if type 1 (anaphylaxis) levofloxacin 750 mg daily or doxycycline bid x 5-7 days
if type 2 (rash) cefdinir, cefpodoxime, cefuroxime PO bid 5-7 days

If sx persist despite tx, then switch abx. If on amoxicillin, change to augmentin or levofloxacin. If recurrent sinusitis, refer to otolaryngologist.
Patient c/o ear pressure, popping noises, and muffled hearing in affected ear following AOM. What is suspected? Tx plan?
Otitis media with effusion (serous otitis media)
- TM may bulge or retract
- TM s/not be red
- a fluid level and/or bubbles may be visible

Tx:
- oral decongestants
- steroid nasal spray bid/tid for a few weeks
Allergic rhinitis: steroid nasal spray w/long-acting oral antihistamine
Patient c/o external ear pain, swelling, discharge, pruritus, and hearing loss. What is suspected? Tx plan?
Otitis externa (Swimmer's ear)

- Polymyxin B-neomycin-hydrocortisone (Cortisporin otic) suspension 4 gtt QID x7 days or ciprofloxacin (cipro) otic ear drops bid x7 days

- if immunocompromised give topical abx plus systemic/oral abx such as cipro bid for 7-10 days

- stay out of water during tx. If recurrent episodes, us alcohol and vinegar (to dry ears)
What 2 organisms often cause Swimmer's Ear?
Pseudomonas aeruginosa (gram - )
S. aureus (gram +)
What is the triad for infectious mononucleosis?
- fever
- pharyngitis
- lymphadenopathy
Teenage patient presents w/hx of sore throat, enlarge posterior cervical nodes, symmetric lymphadenopathy, and fatigue (for several weeks). What is suspected? What labs might help w/dx?
infectious mononucleosis

CBC - atypical lymphocytes and lymphoctosis (repeat CBC until resolves)

LFTS - abnormal for 80% for several weeks

Heterophile antibody test (Monospot) - positive for 80-90% of adults

occasionally may have a generalized red maculopapular rash
Tx plan for infectious mononucleosis?
Tx:
Acute stages: limit physical activity (exercise, contact sports, weightlifting) for 4 weeks to reduce risk of splenic rupture. Order abdominal US if spenomegaly/hepatomegly is present. Repeat abd US in 4-6 weeks if abnormal to document resolution.

Tx sx.

Avoid using amoxicillin if patient has "strep" throat (drug rash from 70-90%)
What are some possible complications for infectious mononucleosis?
- splenomegaly/splenic rupture is rare but serious
- airway obstruction - hospitalize and give high-dose steroids to reduce swelling
- neurologic complications - Guillain-Barre syndrome, aseptic meningitis, optic neuritis, others
- blood dycrasias (atypical lymphocytes) - repeat CBC until normal
Name 4 of the 5 differential dx of vertigo.
Differential dx of vertigo:

- Meniere's disease

- BPPV (benign paroxysmal positional vertigo)

- acoustic neuroma (vestibular schwannoma)

- labyrinthitis

- cerebella infarction or hemorrhage (cerebellar stroke)
Patient presents with recurrent vertigo, tinnitus, and unilateral hearing loss that is chronic w/some n/v with episodes. No associated neurologic sx. What do you suspect? Assessment and tx?
Meniere's disease:
Initial tx - lifestyle changes including salt restriciton (2-3 g/day), avoid MSG and nicotine, minimize intake of caffeine and alcohol.

Vestibular suppressant PRN; N/V med PRN.

Persistent attacks, refer to ENT
Patient presents with abrupt onset with brief episodes of vertigo that last <1 minute induced by sudden head movements and positions. What is the gold-standard test? Tx plan?
Dix-Hallpike maneuver is gold-standard test.

Epley maneuvers in the clinic/at home

Meclizine PO q4-8 hs,

Avoid sleeping on the side of the affected ear for several days
Patient presents with chronic hearing loss and chronic tinnitus. May also have facial numbness and pain. How can you assess this? What might you suspect?
Weber and Rinne tests, hearing testing, cranial nerve testing

Refer to ENT
Patient presents with sudden onset of severe vertigo accompanied by hearing loss and tinnitus. Episodes can last from hours to days. What do you suspect?
Labyrinthitis - vestibular suppressants PRN.

If bacterial, tx with abx and refer to ENT.
Patient presents with sudden onset of severe headache, vertigo, N/V, motor deficits, impaired gait. Tx plan?
Call 911. MRI is gold standard for dx infarction on the brain.
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