EENT

Physical trauma to the auricle which causes shearing of the tissues and a perichondral hematoma. The auricle will be very swollen.

Infection or Inflammation of the external auditory canal

Symptoms: Pain (esp. with manipulation of the auricle), Hearing Loss, Otorrhea, Fullness, Itching

conduction of environmental air into and out of the respiratory system.

mucus and cilia trap and remove airborne viral, bacterial, and particulate matter.

vascular mucosa overlaying the nasal cartilage and turbinates provides radiant heating of inspired air to 310 to 370 C

vascular mucosa increases the relative humidity of inspired air to 95% before reaching the nasopharynx.

olfactory sensation detects irritants, chemicals, and temperature abnormalities of inspired air.

nasal sensation may be linked to lower respiratory and vascular reflexes.

Airway; Filtration; Heating; Humidification; Chemosensation; Nasal reflex; Endocrine pheromone detection

Irritation and Infection of the nasal mucosa

Treat with topical antibiotic ointment and/or oral antibiotic; Bactroban, Polysporin Keflex, Clindamycin, Amox

Seen with allergic rhinitis

Treat allergies; Nasal steroids; Systemic steroids; Surgical if obstructive, freq. infections, bony destruction

Aspirin sensitivity; Nasal polyposis; Asthma; Often seen with allergic rhinitis

enlarged adenoids; the unusual growth ("hypertrophy") of the adenoid tonsil.

is due to an enlargement of the turbinates- the small structures within your nose that cleanse and humidify air as it passes through your nostrils into your lungs

Kiesselbach’s plexus

Woodruff’s plexus

Digital manipulation; Septal deviation; Inflammation (allergies, infection)Cold dry air, Foreign body

Clotting Disorder; Hypertension; Leukemia; Liver disease; Medication (aspirin, Plavix, Coumadin); Thrombocytopenia

IgE mediated reaction causing mast cells and basophils to release histamine, leukotriene, serotonin, and prostaglandins; This causes inflammation of the nasal mucosa

Nasal congestion; Rhinorrhea; Sneezing; Itching; Watery eyes; Allergic Shiner

Common allergens: Grass/Tree pollen, mold, dust, dander

swollen bluish turbinates; allergic shiner; allergic salute.

Similar to allergic rhinitis, but caused by non-allergy mediated inflammation due to irritation of nasal mucosa

Temperature; Exercise; Foreign body; Fumes; Food; Medication; smoking

Drug induced rhinitis caused by overuse of topical decongestants (phenylephrine, oxymetazoline)

Rebound congestion

Treatment: STOP using the spray; May substitute nasal steroids or antihistamine; Afrin taper

Upper respiratory tract infection caused by adenovirus, parainfluenza, corona virus, rhinovirus (and many more).

Symptoms usually last <7 days

Sore throat; Nasal congestion; Rhinorrhea (may be yellow/green); Fever; Cough (may be productive); Malaise; Fatigue

Treatment: Supportive and Time. OTC antihistamines, decongestants, mucolytics, fluids, ibuprofen/Tylenol, rest.

If viral URI does not clear in 7-10 days

Double Sickening

Localized Facial Pain; Upper Tooth Pain; Purulent nasal discharge; Fever, cough, fatigue may still be present; Facial Pain upon percussion

Strep. pneumo, H. flu, M. catarrhalis, Staph. aureus

Sinusitis for 4-12 weeks

Sinusitis for >12 weeks

Same as acute (S. pneumo, H. flu, M. cat., S. aureus); Klebsiella, Pseudomonas, Proteus, Enterobacter; Consider anaerobic and fungal etiologies. Consider antibiotic resistance as cause; Culture and sensitivity

is a bacterial skin infection that occurs on the face. The infection is characterized by swelling, redness, warmth, and pain.

a bacterial infection of the skin and soft tissue that surrounds the eye

redness, swelling, and tenderness of the skin around the eye.

A circumscribed collection of pus within the orbit; frequently an extension of purulent infection of the paranasal sinuses, usually the ethmoids.

Differential Diagnosis: Post-nasal drip; Viral pharyngitis; Group A strep; Tonsillitis; Mononucleosis; Peritonsillar abscess; Rare: gonorrhea, HSV, HIV

adenovirus, coronavirus, rhinovirus, influenza, parainfluenza, coxsackievirus

Erythema; Edema; Dysphagia; Pain; Fever; Lymphadenopathy; Upper respiratory illness symptoms; Resolves in 3-7 days

an inflammation of the pharynx caused by infection from Streptococcus. Spread by direct contact from person-to-person

indicated by the presence of a sore and/or red throat, an impaired ability to swallow, sudden onset of fever, and the swelling of the lymph nodes.

Can be viral or bacterial: Common bacteria Group A Strep pyogenes

Sore throat; Dysphagia and Odynophagia; Erythema (w/ or w/o exudate); Airway obstructive symptoms; Tender lymphadenopathy

Treat initially with GP (strep/staph) coverage; PenVK, Bicillin injection, Amox/clauv, EES, SMX/TMP

A collection of mucopurulent material in the peritonsillar space; Often follows tonsillitis

Severe throat pain and dysphagia; Inability to open jaw; Asymmetric swelling; Copious salivation; “Hot potato” voice

“Hot potato” voice

Incision and Drainage; Antibiotics with anaerobic cov.; Augmentin; Clindamycin

EBV- Epstein Barr Virus; CMV- Cytomegalovirus

Fatigue; Malaise; Sore throat with tonsillar; edema/erythema/exudate; Lymphadenopathy; Hepatosplenomegaly

Monospot (heterophile antibody test); CBC diff may show atypical lymphocytes

OTC, pain control, consider steroids, avoid contact sports, seatbelt counseling

fever, chills, facial pain, neck pain, and pain under the tongue pain and chin

Cellulitis of the submandibular spaces of the mouth, usually spreading to the sublingual and submental spaces.

Airway Management; IV antibiotics; Surgical

Cervical Adenitis; Abscess; Sialodentitis; Cat Scratch

Thyroglossal Duct Cyst, Branchial Cleft Cyst

Lipoma, Neuroma, Fibroma

Lymphoma, Salivary, Thyroid, metastasis

Goiter Thyroid cyst

a fibrous cyst that forms from a persistent thyroglossal duct

this is a cavity that is a remnant from embryologic development present at birth in one side of the neck just in front of the large angulated muscle on either side (the sternocleidomastoid muscle).

A highly vascular ovoid body of chemoreceptive tissue lying adjacent to the TYMPANIC CAVITY; site of a rare neoplasm

a chemodectoma involving the tympanic body

Osteoma

Squamous papilloma

Inverted papilloma

Adolescent males with unilateral epistaxis, nasal tumor

Squamous Cell Carcinoma

Adenoid hypertrophy

Thornwald Cyst

Mucocele

Squamous Cell Carcinoma

Lymphoma

Torus

Leukoplakia

Erythroplakia

Lichen Planus

Oral Candida

Aphthous Ulcer

Squamous Cell Carcinoma

adherent white plaques or patches on the mucous membranes of the oral cavity, including the tongue

chronic red oral mucosal patch usually not attributed to traumatic, vascular or inflammatory causes but frequently caused by epithelial dysplasia, ca in situ, or squamous cell carcinoma

chronic mucocutaneous disease that affects the skin and the oral mucosa, and presents itself in the form of papules, lesions or rashes

canker sore, is a type of oral ulcer, which presents as a painful open sore inside the mouth or upper throat (including uvula) caused by a break in the mucous membrane

ear

Treat with I&D, then bolster both sides with dental rolls.

Failure to treat early can lead to permanent remodeling of the auricle in a Auricular Hematoma

Remove purulent debris; Suction, If the canal is too narrow, insert a wick; Topical Antibiotic Drops:

OE that causes temporal bone destruction; Usually caused by Pseudomonas aeruginosa

OE Seen in diabetics and immunocompromised patients; Diagnosed by Gallium uptake scan

usually very itchy; can look like bacterial infections

infections if antibiotic drops fail to resolve the problem

Remove Debris; Topical: Acetic acid/Hydrocortisone ear drops, Antifungal drops (Clotrimazole), Gentian Violet

Scarring of the tympanic membrane, Generally benign, but may cause a conductive hearing loss if severe.

Causes: Nasal Allergy, URI, Nasopharynx mass, Anatomic

Symptoms: Ear Pain, Hearing Loss, Ear Fullness

If acute ETD, counsel patience and time, Nasal steroid spray, If ETD is chronic and hearing loss is present, bilateral myringotomy with tube placement

Otitis Media with Effusion

Causes: Chronic ETD, Acute OM, Barotrauma

Symptoms: Hearing Loss, Ear Fullness, Tinnitus

Nasal steroids; Myringotomy with tube placement if not better in 3-4 months.

Symptoms: Ear Pain, Hearing Loss, Tinnitus, Ear Fullness

Treated with oral antibiotics

Symptoms: Hearing loss, Tinnitus, Otorrhea, Ear pain if acute

Treatment: Watchful waiting, Treat infections with topical drops (quinolones only), Tympanoplasty; Paper patch, Temporal muscle fascia graft

Occurs in the presence of a TM perforation or tympanostomy tube

Middle ear infection with otorrhea through the perforation

Treat with topical antibiotic drop (quinolone only), May need surgery

Non-cancerous skin cyst

Can arise from retraction pocket or after the middle ear is seeded with skin cells following perforation

Causes a conductive hearing loss, Destroys bone through enzymatic action, Requires surgical excision

Etiology: Thought to be viral vs. Mycoplasma, S. pneumo, H. flu

Symptoms: Severe ear pain, especially when sneezing, coughing, laughing, Yellow, clear otorrhea, Hearing loss

Treatment: Watchful waiting, Topical antibiotic drops, Oral antibiotics with atypical coverage (clarithromycin)

Ear Pain

Hypertension, Atherosclerosis, Diabetes Mellitus, Stroke, Sickle Cell

Lyme Disease, Syphilis, HIV, Labyrinthitis (Viral), Bacterial Toxins, HSV, Meningitis

Acoustic Neuroma, Cancer Metastasis to Temporal Bone

Ototoxicity, General Anesthesia

Sudden Sensorineural Hearing Loss

Absent 8th Cranial Nerve, Intrauterine Infection, Syndromes, Teratogens, Hypoxia, Prematurity, Low Birth Weight, Hyperbilirubinemia

Multiple Sclerosis, Autoimmune Hearing Loss, SLE, Giant Cell Arteritis

Noise Induced Hearing Loss, Temporal Bone Fracture, Radiation Therapy

Hypothyroidism, Ménière’s, Presbycusis, Cochlear Otosclerosis

Any abnormal sound in the ear

Only the patient can hear

Examiner may be able to hear

pharyngeal muscle spasm

patulous eustachian tube

referred vascular sounds vs. tumor

No impression of movement, Imbalance/Disequilibrium, Lightheadedness, Pre-syncope

False impression of movement; Rotational dizziness, Elevator sensation, Tilting room

Vertigo which lasts less than a minute, Intermittent

Provoked by supine head movements to the right or left

Caused by displaced otoliths in the semicircular canals, Positive Dix-Hallpike maneuver

A disorder of increased endolymphatic fluid pressure

Classic Triad- Episodic SNHL, Vertigo x hours, and Roaring Tinnitus

SNHL is low-frequency, usually unilateral.

Treatment: Diuretics, Low sodium diet, Anti-vertigo medication, Surgery (to prevent vertigo)

Infection or inflammation of the inner ear.

affects semicircular canals only

vertigo and hearing loss

Vertigo is severe, lasts 24-48 hours, is disabling. Vertigo subsides and the patient will have several weeks of imbalance

Treat with steroids and physical therapy

Slow growing non-cancerous tumors arising from Schwann cells on 7th/8th Nerve

Causes Asymmetric SNHL (any slope possible)

Early Symptoms: asymmetric hearing loss, tinnitus, imbalance (not vertigo)

Late Symptoms: Due to brainstem compression

Diagnosed with MRI of Internal Auditory Canals with contrast

Treatment includes: observation, stereotactic radiation, and/or surgery.

lasts seconds, head movements, no hearing loss

lasts several hours, associated hearing loss, tinnitus, ear fullness

lasts 1-2 days, gradual recovery

Years, Imbalance, with unilateral hearing loss

flashes of light

loss of night vision

double vision

Light focuses on the retina

Focal point falls outside of retinal plane

Nearsighted

Light focuses in front of the retina

Farsighted

Light focuses beyond the retina

Light does not focus to a point

Decrease in the ability to focus near

Over 40 syndrome

Corrected with concave lens (diverges light)

Written as a minus prescription: -3.00

Corrected by a convex lens (converges light)

Written as a plus prescription: +3.00

May “worsen” with age as accommodation lost

Treatments: Glasses, Contact lenses, Lens implant, Surgical correction (laser)

Comparison between normal and patient

Trial frames, phoropters and pinholes

Normal range 10-21mmHg

Visual Fields: superior

Visual Fields: nasal

Visual Fields: inferiorly

Visual Fields: temporally

Hirschberg light reflex

Cover-Uncover Test

Alternating cover test

used to measure deviation

Horizontal misalignment; Visual axes form a divergent angle; eyes diverge- as one eye fixates, the other eye is turned outward

Refractive error, Cataracts, Diabetic retinopathy, Macular Degeneration, Glaucoma, CVA

Migraine, Transient ischemic attack, Dry eyes

TIA, CVA, Tumor, Glaucoma, Retinitis Pigmentosa, Optic Neuritis, Optic Neuropathy

Physiological, Hemorrhage, Retinal detachment, Vitreous detachment, Uveitis

Vitreous traction, Migraine, Occipital Ischemia, Detached retina

Refractive error, Aging, Cataracts, Retinitis Pigmentosa, Vitamin A deficiency

Strabismus, Cranial nerve palsies, Restrictive/ Mechanical

Conjunctivitis, Iritis, Foreign body, Corneal abrasion, Corneal ulcer, Dry eyes, Herpetic keratitis

Horizontal misalignment; Visual axes form a convergent angle; The eyes are crossed- as one eye fixates, the other eye is turned inward

Decreased vision in one or both eyes

Also called “lazy eye”

decrease in vision for which no explanation can be found on physical examination; Can be binocular but usually is monocular

Etiology: the result of disuse from reduced or inadequate foveal or peripheral retinal stimulation.

Main Causes: Anisometropia, strabismus, media opacities

Innervates levator palpebral muscle

Pupillary constrictor muscle

passes under tentorial ridge in brain and susceptible to uncal herniation (look for elevated ICP)

Ptosis; Eye down and out; Unable to elevate, depress, adduct (turn inward); Look for pupil involvement (dilated)

Innervates levator palpebral muscle (ptosis)Inferior oblique: medial, inferior, and superior recti (eye turns down and out; Pupillary constrictor muscle (mydriasis)

Superior oblique palsy; Cannot look down and in; Will cause torsional diplopia; Hypertropia; Compensatory head tilt(contralateral to site of palsy); May be bilateral or congenital

Vertical deviation; Patient with oblique diplopia; Hypertropia (elevated) eye worse in ipsilateral head tilt and opposite gaze (adduction); Usually from ischemia; also minor head trauma, tumor

Lateral rectus muscle palsy; Cannot adduct eyes; May be congenital; May mimic strabismus

Unable to abduct (turn out) eye; Usually ischemic; Can also be from moderate head trauma, elevated ICP, tumor, aneurysm, MS

Thyroid Eye Disease; Retraction of eyelids; Prominent globes; Diplopia; Corneal exposure; Possible optic neuropathy

Superior oblique palsy

Hypertropia (elevated) eye worse in ipsilateral head tilt and opposite gaze (adduction)

Lateral rectus muscle palsy

Cannot adduct eyes

Cannot look down and in

Unable to abduct (turn out) eye

Drooping of one or both eyelids; Usually age-related, involutional

If sudden ptosis, consider 3rd nerve palsy

If new and variable ptosis

sebaceous glands located in the tarsal plates along the eyelid margins

sebaceous glands located on the margin of the eyelid.

Chronic inflammation of the eyelid

Burning, watering, foreign body sensation, crusting & matting of the lashes and medial canthus, red lids, red eyes, photophobia, pain, decreased vision

Posterior Blepharitis: Involves the meibomian gland orifices

Involves the eyelashes & follicles; can be Staphylococcal or Seborrheic

Pathophysiology: Direct microbial invasion of the lid tissue; Damage caused by bacterial toxins; waist products & enzymes, Immune system-mediated damage

Three steps: Warm soaks, Lid scrubs, Baby shampoo and/or warm water, Antibiotic ointment (anti-staphylococcal)

Refractory cases: Low dose oral antibiotics (long term)Topical antibiotics (short term)Topical corticosteroids (short term)

Focal, chronic, lipogranulomatous inflammation of the Zeis or meibomian glands

Underlying meibomitis

Stasis of the secretions leads to the contents of the glands (sebum) being released into the tarsus/ adjacent tissues to incite a noninfectious inflammatory reaction

often evolve from internal hordeola

Usually self limited; May impress on cornea; Incision and curettage

glands of Zeis

stye

meibomian glands

Usually there is an underlying meibomitis; Stasis of the secretions leads to secondary infection

Usually Staphylococcus aureus

Usually self limited; Treatment: 4 levels[Eyelid hygiene- warm soaks & lid massages; Topical antibiotic ointment; Systemic antibiotics- If complicated by preseptal cellulitis; Incision & drainage if refractory to medical therapy]

Infection limited to the eyelid

Infection involving the structures posterior to the orbital septum

Signs include: proptosis, pain with eye movement, restricted motility, deceased vision, fever, decreased sensation along V1

An abnormal outward turning of the lid margin

Seen in elderly; Look for corneal drying; Can cause tearing, cosmetic problem; May require surgery

Seen in older people; Look for corneal abrasion from lashes; May need surgical correction

Misdirection of the eyelashes toward the globe

Epiphora (watering eyes); Usually in infants, but can occur in adults

Infection of the Lacrimal sac

Painful swelling in the lower nasal canthal area

Infection of the Lacrimal gland

Painful swelling in the temporal upper lid

Usually staphylococcus

May be acute or chronic; usually unilateral, Systemic antibiotics; May need surgery to relieve obstruction

A red eye indicates

The redness is caused by

Involves branches of the anterior ciliary arteries

Indicates inflammation of the cornea, iris or ciliary body

Mainly affects the posterior conjunctival blood vessels

More superficial than ciliary vessels; Produce more redness; Move with the conjunctiva; Constrict with topical vasoconstrictors

Inflammation of the eyelids; Often associated with conjunctivitis

Mildly red eye (usually unilateral); Chronic, usually over age 50; “Pouting punctum”; Slight discharge- Discharge can be expressed from the punctum

Characterized by vascular, cellular infiltration, and exudation

More purulent discharge

Follicles on palpebral conjunctiva; Preauricular node- large and tender

Papillary reaction on palpebral conjunctiva; Pruritus; Hx of allergic disease

Localized pain, edema, and erythema (redness) over lacrimal sac at the medial canthus; Usually unilateral; Often purulent discharge from the puncta

Decreased vision and photophobia; Severe eye pain; Epithelial defect may be evident - may require fluorescein; May be accompanied by anterior chamber reaction; Any opacification of the cornea in a red eye

Must be differentiated from injection of the more superficial conjunctival vessels and from deeper scleral vessels; Inflammation tends to be limited to an isolated patch; Hx of recurrent episodes is common; Mild to moderate tenderness

Mild to moderate to severe pain; Eye should be stained with fluorescein to detect corneal abrasion; Lid should always be everted; Penetration of the globe must be excluded by slit lamp examination and dilation

On slit lamp examination: Cells and Flare in the anterior chamber

“Perilimbal flush” (cornea/scleral junction); DDX: conjunctivitis -where intensity of the vascular engorgement decreases toward the limbus; Usually unilateral; Direct and consensual photophobia

Slit lamp examination: Corneal edema, anterior chamber/corneal thickness ratio, mild cell and flare

Severe pain; Colored haloes around lights- common; Age- usually older than 50; Pupil may be: Mid-dilated, Vertically oval & Non-reactive to light; Nausea & vomiting common; IOP is elevated ( normal range- 21 and under)

Eyelids sticking together on waking; Itching and burning; Gritty foreign body sensation; Mucus /pus effects vision but visual acuity is normal; Photophobia is minimal

Most commonly: staphylococcal & streptococcal

Preauricular adenopathy -sometimes occurs Chemosis( thickened, boggy conj.)- common Discharge- copious, thick and purulent Injection-moderate to marked

Microbial infection of the mucous membrane of the surface of the eye; Usually self limited and benign

STI: N. gonorrhea and Chlamydia -Sexual transmission; Newborns exposed during birth(Elderly pt: Increased susceptibility to infections)

Minimal pain; Pruritus is common; Exposure HX: Clear watery discharge; epiphora or mucous; Occasionally severe photophobia and F/B sensation

also cause follicular conjunctivitis and preauricular adenopathy

Associated viral illness; Preauricular adenopathy; Chemosis - variable; Discharge – copious, watery, scant exudate, Injection

Viral infection of the mucous membrane of the surface of the eye

Adenovirus- the most common; Herpes simplex (HSV)- the most problematic

Varicella-zoster (VZV); Poxvirus( molluscum contagiosum, vaccinia-rare now); Human immunodeficiency virus (HIV)

Usually acute, benign and self limited; Longer course than bacterial conjunctivitis(2-4 weeks)

Characterized by: Acute follicular reaction, Preauricular adenopathy

Acute or subacute onset; No pain; No exposure history; Pruritus- extremely common; Discharge- clear, watery, w/or w/out moderate mucus

Pruritus; Preauricular adenopathy- absent; Discharge – moderate, stringy or sparse, clear; Injection-moderate

Chronic wing shaped growth; Can become inflamed or grow into the visual axis

Treatment: topical; Topical antihistamines; Mast Cell Stabilizers; Corticosteroids; NSAIDS

Yellowish conjunctival nodule; Usually on nasal side and bilateral; Commonly due to exposure to elements; Does not interfere with sight

History of trauma; Recurrent erosions

History of trauma

Pain, tenderness, photophobia, tearing; Purulent or watery discharge; Infection; Trauma; Contact lens use; Exposure

Dendritic ulcerations; Lid lesions; Reoccurrences; Corneal scarring; (Do not use corticosteroids: refer for treatment)

Frequently involves ophthalmic branch of trigeminal nerve; Neurotrophic keratitis; Chronic uveitis

Inflammation of the uvea (iris, ciliary body, choroid)

iris, ciliary body, choroid

Symptoms: redness, pain, photophobia, decreased vision

The most treatable cause of blindness worldwide

A clouding (opacity) of the lens of the eye that typically occurs with age

Can also be found after trauma, congenitally, in association with other systemic (diabetes) or ocular disease, from medications (steroids) or radiation, UV light, cigarette smoking

No pain or redness; Gradual loss of vision

Gradual progressive thickening of the lens; Gradual progressive loss of transparency of the lens

Treatment depends on severity of visual loss: Do nothing; Change glasses; Surgical removal

is responsible for the most acute vision, color perception

Early stages may produce reduction of vision or distortion rather than scotoma

Leading cause of blindness in the USA over age 65; More common in Caucasians

Complaints of: Blurred vision; Metamorphopsia (distorted visual loss); Central scotoma; Difficulty reading and recognizing faces

When choroidal vessels penetrate damaged Bruch’s membrane, subretinal neovascularization occurs

When leakage occurs, subretinal hemorrhage results

Soft drusen; Chorioretinal atrophy, RPE hyperpigmentation

Subretinal fluid/ hemorrhage; Choroidal neovascular membranes; Disciform scars; Primary cause of blindness in Acute Macular Degeneration

Amsler grid; Diet; fruits and vegetables; High in lutein and zeaxanthin (xanthophylls in macula); High LDL and low HDL cholesterol increase risk; Long chain omega 3 fatty acids; Supplements (Vit C, Vit E, Beta carotene, Zinc Oxide, Copper)

Laser; Photodynamic therapy; Intraocular injectables; Surgery (sub macular surgery, macular translocation)

Retinitis pigmentosa; Diabetic retinopathy (post PRP); Retinal detachment; Choroideremia

Complaints of new flashes, floaters, veil obscuring part or all of the vision

“Curtain” spreading over vision

Usually due to retinal tear(s); Spontaneous, seen more likely over 50; “Curtain” spreading over vision; May have sudden loss of vision; No pain or redness; Surgical treatment(s); Refer emergently/urgently

African-Americans affected 4-5 times more frequently than Caucasians

An optic neuropathy usually caused by elevated intraocular pressures

Damage to retinal ganglion cells; Elevated IOP; Impeding axoplasmic flow within nerve or reduction of blood flow to the nerve

vertical and horizontal dimensions (nl <0.4)

Progressive Visual Field loss

Most common, chronic; Gradual loss of peripheral vision; Target IOP 30% reduction; Glaucoma suspect-Ocular hypertension & Abnormal nerve appearance; Vision loss is permanent; Normal tension glaucoma; Screening for this is crucial!

Acute, chronic, or intermittent; May be precipitated by medications; Anticholinergics and sympathomimetics; Pupillary dilation may precipitate

Painful, red, congested eye; Nausea, vomiting; Blurred vision; Halos; Chronic may be asymptomatic; Occurs in small, hyperopic, older eyes, often female, Asian, Eskimo, Caucasian

High IOP (>30); Mid dilated sluggish pupil, Red eye; Corneal edema; Chronic/ intermittent may have peripheral anterior synechiae

decrease aqueous production

Cholinergics

increase uveoscleral outflow

Leading cause of blindness in ages 20-64

Symptoms: NONE; Blurring; Distortion of vision; Decreased night vision; Decreased color vision; Floaters

Microaneurysms; Dot and blot hemorrhages; Hard exudates; Venous beading; Intraretinal microvascular abnormalities; Cotton wool spots

Neovascularization; Vitreous hemorrhage; Fibrous tissue along posterior vitreous adherent to the retina causing traction retinal detachment

Most common cause of loss of vision in diabetics

Retinal edema within 500 microns of fovea center

Hard exudates within 500 microns if associated with thickening

Treat with focal laser

Severe form of glaucoma; Difficult to treat. Requires extensive laser surgery; Often requires glaucoma surgery; Often results in blindness and pain

Prevention: Diabetic Control and Treatment Trial (DCCT); Glucose control; Blood pressure control; Lipid control

Cotton wool spots

Narrowing of the arterioles

Intraretinal hemorrhages

Retinal vein occlusion

Retinal artery occlusion

Retinal hemorrhages, retinal edema, cotton wool spots

Dilated veins, swollen optic nerve, intraretinal hemorrhages, retinal edema; May lead to neovascularization

Sudden unilateral vision loss; No pain or redness

Workup for hypertension, diabetes, hypercholesterolemia, blood dyscrasias, vasculitis

Treat underlying disorder; Laser for macular edema; Laser for neovascularization

Sudden unilateral vision loss; No pain or redness

May see intraluminal plaque; Whitening of retina

Sudden, severe, painless loss of vision; Must consider Giant Cell Arteritis

Pseudoephedrine

Oxymetazoline

Phenylephrine

Diphenhydramine

Chlorpheniramine

Loratadine

Desloratadine

Fexofenadine

Cetirizine

Levocetirizine

Azelastine (also an antihistamine)

Epinastine

Olopatadine

Budesonide

Ciclesonide

Fluticasone

Mometasone

Azithromycin

Ciprofloxacin

Moxifloxacin

Tobramycin/dexamethasone

Brimonidine

Dorzolamide/timolol

Bimatoprost

Latanoprost

Polymyxin B/Neomycin/Hydrocortisone(hydrochloric acid)

Ciprofloxacin/dexamethasone

Class: Pseudoephedrine/ Sudafed

Class: Oxymetazoline/ Afrin

Class: Phenylephrine/ Neo-Synephrine

Class: Diphenhydramine/ Benadryl

Class: Chlorpheniramine/ Chlor-Trimeton

Class: Loratadine/ Claritin

Class: Desloratadine/ Clarinex

Class: Fexofenadine/ Allegra

Class: Cetirizine/ Zyrtec

Class: Levocetirizine/ Xyzal

Class: Azelastine (also an antihistamine)/ Astelin (nasal spray) Optivar (ophthalmic solution)

Class: Epinastine/ Elestat (ophthalmic solution)

Class: Olopatadine/ Patanase (nasal spray)Patanol, Pataday (ophthalmic solution)

Class: Budesonide/Rhinocort Aqua

Class: Ciclesonide/Omnaris

Class: Fluticasone/ Veramyst

Class: Mometasone/ Nasonex

Class: Azithromycin/ AzaSite

Class: Ciprofloxacin/ Ciloxan

Class: Moxifloxacin/ Vigamox

Class: Tobramycin-dexamethasone/ TobraDex

Class: Brimonidine/ Alphagan P

Class: Dorzolamide-timolol/ Cosopt

Class: Bimatoprost/ Lumigan

Class: Latanoprost/ Xalatan

Class: Polymyxin B/Neomycin/Hydrocortisone(hydrochloric acid)--Cortisporin Otic Solution

Class: Ciprofloxacin-dexamethasone/ Ciprodex Otic

vocal cords are _____ to breath

vocal cords are ____ to speak

Visualization of the larynx either indirectly or directly

The use of an instrument (mirror, angulated scope, or flexible scope) to visualize an image or reflection of the larynx

Straight visualization of the larynx (no reflections)

Examiner has laryngeal mirror, head mirror, light source, mirror warmer

Patient is seated in the “sniffing” position.

Grasp the tongue with gauze, elevate the upper lip with finger

Warm mirror is placed on the soft palate and uvula without pressing against the back of the throat or tonsils.

ADVANTAGES: Can be done in exam room; No anesthesia required; Quick

DISADVANTAGES: Can cause gag reflex; Image is not high quality; Cannot see entire larynx

Nasal passages are topically decongested and anesthetized

The scope is passed through the most patent nasal passage.

The scope is passed through the most patent nasal passage.

ADVANTAGES: more comfortable than mirror exam and avoids the gag reflex. Better visualization of the entire upper airway; Better image quality than mirror exam. Can be done quickly in the clinic or on the floor.

DISADVANTAGES: Medicine tastes bad; Anesthesia can give sensation of choking; Visualization only, biopsy not available. Exam does not give mid-line view of larynx; Quality not as good as direct laryngoscopy

The need for better visualization of the larynx

To palpate the vocal cords(to distinguish between paralysis and fixation)

Treatment of the larynx (injection, etc)

Biopsy of the larynx

Prior to laryngeal intubation

A curved laryngoscope can be used to aid in laryngeal intubation; Under anesthesia, Avoid the teeth (which can break) and the lips (which can be pinched); Usually only performed by skilled clinicians.

is an inflammation of the larynx. It causes hoarse voice or the complete loss of the voice because of irritation to the vocal folds ...

also known as polypoid degeneration, is the swelling of the vocal folds due to fluid collection (edema). often seen in smokers

Good for showing air fluid levels in the maxillary and frontal sinuses.

Not good for showing mucosal thickening and soft tissue abnormalities.

2 standard views: Waters (Maxillary) & Caldwell (Frontal)

Not a preferred modality for sinus imaging. Does not image detailed bone structures well

Mucosa can also be improperly represented giving the impression of inflammation in a normal patient.

is good for evaluating soft tissue abnormalities such as neoplasms, mucoceles, and encephaloceles.

The study of choice to evaluate nose/sinus structures

Best done when patient is maximally treated to reduce inflammation and evaluate underlying structures.

shows the Osteomeatal Complex (OMC) best; in the plane of surgical approach.

Fine cuts (0.5mm) recommended to avoid missing abnormalities.

sinuses: Frontal, Maxillary, Ethmoid, Sphenoid

All newborns have screening

Retest all newborns who fail screening

Eight Cranial Nerve

Cochlear Nucleus

Olivary Nucleus

Lateral Lemniscus

Inferior Colliculus

Waves VI and VI

To determine Conductive versus Sensorineural loss in unilateral loss

To compare patient’s air and bone Conduction hearing

Fork Placement: midline

Fork Placement: Alternately between patient’s mastoid and entrance to ear canal

Normal Hearing: Midline sensation; tone heard equally in both ears

Normal Hearing: Tone louder at Ear.(Air Conduct > Bone Conduct)

Tone louder in poorer ear

Tone louder on Mastoid. (Bone Conduct > Air Conduct)

Tone louder in better ear

Tone louder at Ear.(Air Conduction > Bone Conduct)

0-25 dB

25-45 dB

45-65 dB

65-85 dB

85+ dB

Normal Tympanogram.

Flat Tympanogram indicates perforation or fluid (due to ETD)

Negative pressure indicates Eustachian Tube Dysfunction (ETD).

Normal pressure equalization with a rigid TM

Normal pressure equalization with flaccid TM/ ossicle disarticulation

How quiet a patient recognize speech

How well a patient understands speech

Normal Speech Discrimination is considered

Hypertension, Atherosclerosis, Diabetes Mellitus, Stroke, Sickle Cell

Lyme Disease, Syphilis, HIV, Labyrinthitis (Viral), Bacterial Toxins, HSV, Meningitis

Acoustic Neuroma, Cancer Metastasis to Temporal Bone

Ototoxicity, General Anesthesia

Sudden Sensorineural Hearing Loss

Absent 8th Cranial Nerve, Intrauterine Infection, Syndromes, Teratogens, Hypoxia, Prematurity, Low Birth Weight, Hyperbilirubinemia

Multiple Sclerosis, Autoimmune Hearing Loss, SLE, Giant Cell Arteritis

Noise Induced Hearing Loss, Temporal Bone Fracture, Radiation Therapy

Hypothyroidism, Ménière’s, Presbycusis, Cochlear Otosclerosis

Sudden SNHL

Acute Labyrinthitis

Acoustic Neuroma

Ménière's Disease

Intracranial (Trauma, CVA)

Noise Induced Trauma

HTN, DM, Atherosclerosis

Ototoxic Medications

Hypothyroidism

Presbycusis

Lyme, HIV, Syphilis

Autoimmune

Cerumen impaction, Foreign Body, Neoplasm/mass, Exostosis, Edema from Otitis Externa, Otorrhea, Congenital Atresia/Stenosis

Tympanosclerosis, Perforation, Retraction (atelectasis)

Otitis Media with effusion, Hemotympanum, Acute OM, Cholesteatoma

Ossicular discontinuity, Otosclerosis, Ossicular Fixation/Malformation

Bilateral, high frequency SNHL

Onset is subtle, gradual, stable; Difficulty with social situations; Better in quiet environments; Treat with hearing aids

Sudden or prolonged Noise exposure

Notched Audiogram 3000-6000Hz

Recovery high frequency; Unilateral or Bilateral; Loss is permanent; Advise Hearing protection

Acute onset of SNHL (<72 hours), 30db loss in at least 3 frequencies

Small Ear Canal Volumes Bilaterally

Normal Ear Canal Volumes Bilaterally; The Patient has history of allergic rhinitis and recent viral URI

Eustachian Tube Dysfunction with Tympanic Membrane Retraction Pockets

Tympanic Membrane Perforation

Slow growing non-cancerous tumors arising from Schwann cells on 7th/8th Nerve

Causes Asymmetric SNHL (any slope possible)

Early Symptoms: hearing loss, tinnitus, imbalance, poor speech discrimination

Late Symptoms: Due to brainstem compression

Diagnosed with MRI of Internal Auditory Canals with contrast

Treatment includes: observation, stereotactic radiation, and/or surgery.

A disorder of increased endolymphatic fluid pressure

Classic Triad- Episodic SNHL, Vertigo, and Tinnitus

SNHL is low-frequency, unilateral.

Diuretics, Low sodium diet, Anti-vertigo medication, Surgery (to prevent vertigo)

Patient history of: TM perforation; Ear Surgery; Pressure Equalization Tubes; Retraction Pockets

Progressive Hearing Loss on the right with a positive Family History; Moderate CHL with “Carhart” notch

Schwartze Sign

Most common cause is Group A Streptococcus

Amoxicillin may be used in place of penicillin V

IgE mediated reaction to allergens Usually immediate and late-phase reactions

Symptoms include clear rhinorrhea, sneezing, nasal congestion, postnasal drip, pruritic eyes/ears/nose/palate

Complications include AOM, chronic middle ear effusions, asthma, dental/orthodontic problems, asthma, sinusitis, nasal polyps

Symptoms Controlled: Sneezing, rhinorrhea, itching, conjunctivitis

Symptoms Controlled: Conjunctivitis

Symptoms Controlled: Sneezing, rhinorrhea, nasal pruritus

Symptoms Controlled: Nasal congestion

Symptoms Controlled: Nasal congestion, Don’t use more than 3 days

Symptoms Controlled: Sneezing, rhinorrhea, itching, nasal congestion, Can use for seasonal & perennial rhinitis

Symptoms Controlled: Sneezing, rhinorrhea, nasal congestion, Use prior to exposure; blocks both early and late phase reactions

Symptoms Controlled: rhinorrhea; Used only when other therapies fail

inflammation of the conjunctiva

Redness and yellow, white, or green discharge unilaterally or bilaterally

Purulent discharge at the lid margins and in the corners of the eye

Erythromycin ophthalmic ointment

Sulfacetamide ophthalmic drops

adenovirus most commonly

Clear watery, scant and stringy discharge; burning, sandy, or gritty feeling in one eye; second eye usually affected within 24-48 hours

Pus does not appear continuously at the lid margin and in the corners of the eye

No specific agents available; Symptomatic relief with OTC antihistamine/decongestant drops

local mast cell degranulation and release of chemical mediators including histamine, eosinophil chemotactic factors, and platelet-activating factor

Contact of airborne allergens with the eye

bilateral redness, watery discharge, and itching

diffuse injection with a follicular appearance to the tarsal conjunctiva and profuse watery or mucoserous discharge

may have morning crusting, clinical findings similar to viral conjunctivitis except for ITCHING

Antihistamine/decongestant drops OTC

Mast cell destabilizer/antihistamine

cromolyn sodium (Crolom, Opticrom) 1-2 drops 4-6 times daily, NSAID ophthalmic drop

Group of eye diseases characterized by elevated Intraocular Pressure

Optic neuropathy results in progressive loss of retinal ganglion cell axons to visual field loss to blindness

obstruction of the outflow of aqueous humor through the trabecular meshwork

Acute presentation with redness of the eye and eye pain

most common glaucoma

Optic nerve takes a hollowed-out appearance on ophthalmoscopic exam (“cupping”)- associated with loss of ganglion cell axons

Occurs gradually, with blockage of aqueous outflow despite a seemingly open space (chamber angle) in the front of the eye

At least 2 of the following symptoms: Ocular pain; Nausea/vomiting; History of intermittent blurring of vision with halos

At least 3 of the following signs: IOP > 21 mm HG; Conjunctival injection; Corneal epithelium edema; Mid-dilated non-reactive pupil

Acetazolamide; Topical beta-blocker

To relieve pupillary block

Caution: could increase axial thickness of lens and induce anterior lens movement, worsening situation

Reduces rate of aqueous humor formation by direct inhibition of carbonic anhydrase on secretory ciliary epithelium, causing a reduction in IOP

Oral forms can cause transient myopia, nausea, diarrhea, loss of appetite and taste, paresthesias, lassitude, renal stones, and hematological problems.

lower IOP by suppressing aqueous humor production

Side effects include ocular irritation and dry eyes

lower IOP by suppressing aqueous humor production

do not use if pt has received MAO inhibitors, precipitate optic nerve ischemia in those with advanced glaucomatous optic neuropathy; Caution in patients with cerebral or coronary insufficiency, Raynaud’s, postural hypotension, hepatic or renal impairment

reduce ocular inflammation

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis

pull the peripheral iris tissue away from the trabecular meshwork helping to eliminate obstructed aqueous humor flow

Contraindicated in acute inflammatory disease of anterior chamber

Used primarily to break an attack of acute angle-closure glaucoma and facilitate laser iridotomy

increase serum osmolarity, causing a fluid shift from the eye into the vascular space; subsequent osmotic diuresis reduces IOP

Topical agents; Systemic medications; Argon laser trabeculoplasty; Trabeculectomy

Principles: Increasing aqueous outflow; Decreasing aqueous production

Beta-adrenergic blockers; Alpha-adrenergic agonists; Carbonic anhydrase inhibitors

Prostaglandin analogs; Alpha-adrenergic agonists; Cholinergic agents

Initial therapy: Topical beta-blocker (Unless cardiac or pulmonary contraindications) and/or Topical prostaglandins

lower IOP by suppressing aqueous humor production

most potent of IOP-lowering drugs available; reduce IOP by increasing uveoscleral outflow

lower IOP by suppressing aqueous humor production

Reduces rate of aqueous humor formation by direct inhibition of carbonic anhydrase on secretory ciliary epithelium, causing a reduction in IOP

Side effects include fatigue, dizziness, and headache

increase cholinergic action by inhibiting cholinesterase; similar adverse effects as direct-acting miotics

Alpha/beta agonist, vasoconstrictor; stimulate alpha and beta receptors, resulting in an acute reduction in aqueous humor production (alpha-adrenergic stimulation of the ciliary body), followed later by an increase in outflow (alpha- and beta-adrenergic)

dorzolamide/timolol

brimonidine/timolol

Minor discomfort, pruritus

Partially occluded canal, moderate pain/pruritus

Canal completely occluded, intense pain, possible auricular erythema

Canal completely occluded, severe pain, auricular erythema, periauricular erythema, possibly adenopathy, and fever

Clean the ear canal thoroughly; Can irrigate with a 1:1 dilution of 3 percent hydrogen peroxide at body temperature if the tympanic membrane is visible and intact; Treat inflammation and infection, Control pain

MZ is a 34 yo Caucasian male, computer technician job site and experienced sudden onset of fever, chills, and headache 2 days ago. He went home from work early, and has remained at home since with continued fevers (102.5°F), severe fatigue, and headache.

TS is a 67 yo AA female, with a history of sickle cell anemia. She presents to the clinic today (January 4) with runny nose, sneezing, muscle aches and cough for the past 3-4 days.

Rhinovirus, coronavirus, parainfluenzae and respiratory syncytial virus (RSV) indistinguishable

Useful for nonproductive cough

Narcotic antitussive, More potent than codeine

Expectorant; May increase secretions, may have a role for productive cough

May block prostaglandins

Non-opiate antitussive

can also be administered to help decrease cough

Less rhinorrhea and sneezing; no change nasal congestion

Onset of symptoms: Over a few days

Onset of symptoms: Sudden, worsening over 3-6 hours

Fever: Uncommon in adults, Children, as high as 102°F

Fever: Usually present ≥ 100 °F for 3-4 days

Headache: Uncommon

Headache: Common, sudden onset

Chills: Uncommon

Chills: Common

Sore throat: Common

Sore throat: Uncommon

Muscle aches

fatigue, weakness

Stuffy nose & Sneezing

Inflammation of the middle ear

Fluid in middle ear plus signs or symptoms

Anatomic or physiologic dysfunction of the eustachian tube; Secretions accumulate in the middle ear

If a pathogen is present, suppuration occurs

Streptococcus pneumoniae: Haemophilus influenzae: Moraxella catarrhalis: Streptococcus, Group A:

Ear pain, ear drainage, hearing loss, Fever, lethargy, irritability, Bulging, cloudy tympanic membrane, Fluid in middle ear

Amoxicillin remains drug of choice

Azithromycin, clarithromycin; Clindamycin Less optimal: sulfamethoxazole/trimethoprim, erythromycin/sulfasoxazole

Cephalosporin: cefdinir, cefpodoxime, cefuroxime, ceftriaxone

Acetaminophen; Antipyrine/benzocaine (Auralgan); Ibuprofen (Motrin)

Ciprofloxacin/hydrocortisone (Cipro HC Otic), Hydrocortisone/neomycin/ polymyxin B (Cortisporin Otic) Ofloxacin (Floxin Otic)

Pneumococcal vaccines & Influenza vaccine

Inflammation of the lining of the paranasal sinuses

symptoms lasting for 10 to 30 days, primarily infectious

symptoms lasting from 4 to 12 weeks

symptoms lasting >3 months; infectious or noninfectious

S. pneumoniae: H. influenzae: M. catarrhalis:

Mucosal inflammation leads to obstruction of

most commonly involved when osteomeatal complex is obstructed

Fluid trapped in the sinuses serves as a good medium for bacterial growth and proliferation

Purulent nasal secretions more that 10 days, Worsening of symptoms after initial improvement; Also: Maxillary tooth or facial pain (especially when unilateral); Unilateral maxillary sinus tenderness

b-lactamase–producing H. influenzae and

Reduce mucosal inflammation

Can clear inspissated secretions blocking sinus ostia

reduce inflammation

for pain and fever

Pseudoephedrine

Oxymetazoline

Phenylephrine

Diphenhydramine

Chlorpheniramine

Loratadine

Desloratadine

Fexofenadine

Cetirizine

Levocetirizine

Azelastine

Epinastine

Olopatadine

Budesonide

Ciclesonide

Fluticasone

Mometasone

Azithromycin

Ciprofloxacin

Moxifloxacin

Tobramycin/dexamethasone

Brimonidine

Dorzolamide/timolol

Bimatoprost

Latanoprost

Polymyxin B/Neomycin/Hydrocortisone (HCl)

Ciprofloxacin/dexamethasone

Decongestants

Antihistamines

Mast cell stabilizers

Intranasal Corticosteroids

Ophthalmic Abx drops

Glaucoma

Otic Drops