Rosen's > HEENT > Flashcards

HEENT Flashcards

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1
Q

Monocular vs Binocular vs Cerebral/Polyopial diplopia?

A

Monocular - diplopia when good eye is covered

Binocular - no diplopia when either eye covered

Cerebral - diplopia no matter what eye is covered

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2
Q

Causes of monocular diplopia (6)

A
  1. Dry eyes
  2. Corneal irregularity
  3. Cataract
  4. Lens dislocation
  5. Retinal wrinkles
  6. Conversion disorder
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3
Q

Differential for Binocular Diplopia:

  1. Structural (3)
  2. Orbital myositis (8)
  3. Isolated cranial nerve palsy (6)
  4. Multiple nerve palsy (2)
  5. Neuroaxial involving the brainstem and cranial nerves (10)
  6. NMSK disorder (2)
A
  1. Trauma
    Infection
    Craniofacial mass
  2. Thyroid eye disease
    Wegener granulomatosis
    GCA
    SLE
    RA
    Dermatomyositis
    Sarcoidosis
    Idiopathic orbital infl syndrome
  3. Hypertensive vasculopathy
    Idiopathic intracranial HTN
    Diabetic vasculopathy
    MS
    Compression
    Trauma
  4. Cavernous sinus infection
    Orbital plex syndrome
  5. MS
    Tumor
    Stroke
    Hemorrhage
    Bilateral artery thrombosis
    Vertebral artery dissection
    Ophtalmoplegic migraine
    Infectious ie basilar meningioe
    Autoimmune ie Guillan Barre
    Metabolic ie Wernicke
  6. Myasthenia gravis
    Botulism
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4
Q

Cranial nerve 3 palsy:

  1. Corresponding muscle?
  2. Symptoms?
  3. Exam finding?
A
  1. Superior, Medial, Inferior rectii muscle + Levator Palpebrae + Inferior oblique + ciliary and constrictor muscle (pupil)
  2. Multidirectional, horizontal and vertical diplopia + eyelid droop (excluding lateral gaze)
  3. Ptosis + pupil dilation + eye down and out
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5
Q

Cranial nerve 4 palsy:

  1. Corresponding muscle?
  2. Symptoms?
  3. Exam finding?
A
  1. Superior oblique
  2. Diplopia that worsens on looking down and towards the nose
  3. Extorsion on downward gaze
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6
Q

Cranial nerve 6 palsy:

  1. Corresponding muscle?
  2. Symptoms?
  3. Exam finding?
A
  1. Lateral rectus muscle
  2. Horizontal diplopia that worsens on lateral gaze of effected eye
  3. Lateral gaze palsy
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7
Q

4 Critical causes of diplopia

A
  1. Aneurism
  2. Basilar artery thrombosis
  3. Basilar meningitis
  4. Botulism
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8
Q

4 Emergent causes of diplopia

A
  1. Vertebral artery dissection
  2. Cavernous sinus process
  3. Werneckie encephalopathy
  4. Myasthania Gravis
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9
Q

8 urgent causes of diplopia

A
  1. Brainstem tumor
  2. Orbital myositis, pseudotumor
  3. Orbital apex mass
  4. Ophthalmoplegic migraine
  5. Miller-Fisher syndrome
  6. MS
  7. Ischemic neuropathy
  8. Grave’s disease
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10
Q
  1. Vital sign of the eye?
  2. Who can skip it?
A
  1. Visual acuity exam
    • Those with acid, base or other toxins in eye
    • Significant trauma
    • Sudden complete vision loss
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11
Q

A test that can detect if there is decreased visual acuity due to abnormal refraction?

A

Pinhole testing

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12
Q

7 signs and symptoms associated with serious diagnosis in patients with red and painful eye? (Rosen’s Box)

A
  1. Severe ocular pain
  2. Proptosis
  3. Persistant blurred vision
  4. Corneal defect or opacity
  5. Pupil unreactive to light
  6. Reduced ocular light reflection
  7. Ciliary flush
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13
Q

What is a common, benign diagnosis of red eye without pain?

A

Subconjunctival hemorrhage

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14
Q

Who does not need antibiotics for bacterial conjunctivitis? (4)

A

Mild case, not wearing contact lens, no traumatic injury, not immunocompromised

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15
Q

Components of a complete eye exam? (VVEEPP + 2 more) (Rosen’s box)

A

Visual acuity
Visual field testing
External exam
Extraocular muscle movement
Pupillary eval
Pressure

+ Slit lamp
+ Fundoscopy for those w vision loss or vision change

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16
Q

corneal abrasion sign on fluorescene exam?

A

Seidel’s sign

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17
Q

7 causes of not seeing a red light reflex? (Box)

A
  1. Opacification of corneas
  2. Hyphema
  3. Cataract
  4. Blood in the vitreous or posterior eye wall
  5. Retinal detachment
  6. Intraocular mass
  7. Extremely miotic pupil
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18
Q

Acid vs Base caustic injury:

  • What do they do to the eye?
  • How much irrigation for each until pH = 7?
  • Complications of liquefactive necrosis?
A

Acid: Coagulation necrosis, at least 2L and 20min

Base: Liquefactive necrosis; at least 4L and 40min ; Complications = cataract formation, damage to ciliary body, irreversible damage within 5-15 min of exposure

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19
Q

Orbital compartment syndrome:

  • Causes?
  • IOP > x?
  • Treatment?
A
  1. Retrobulbar hematoma/emphasyma/abscess
  2. > 20 abnormal; >30 may necessitate lateral canthotomy
  3. Lateral canthotamy
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20
Q

Penetrating globe injury:

  • S&S (4)
  • Tx (3)
A
  1. Localized redness
    Treatdrop pupil
    Blood in anterior chamber
    loss of red reflex
  2. Prevent from further injury (antiemetics, analgesics)
    Abx - systemic like Cefazolin or Vanco IV
    Tetanus
    Emergent ophthalmology consult
  • IN RSI, avoid succinylcholine bc might elevate IOP (weak evidence)
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21
Q

Hyphema

  1. S&S
  2. What is the general treatment?
  3. Longterm complications? (2)
  4. Who should get admitted for hyphema treatment? (5)
A
  1. Pain
    Decreased VA
    Blood in anterior chamber
    Dilated/fixed pupil if trauma
  2. First rule out open globe
    IOP if no globe rupture
    If > 30
    If > 20, may use cycloplegic to prevent iris motion
    Also: Bedrest/ head of the bed elevated (limited evidence)
    Gentle ambulation
    Eye patch
    Ophtho followup asap (next day recommended)

3.
Raised IOP
Permanent corneal damage

4.
1. Lost to follow up
2. Poor compliance
3. Hyphema > 50%
4. anticoagulants
5. Sickle cell traits

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22
Q

Subconjunctival hemorrhage

  1. What is it?
  2. What to rule out?
  3. Treatment?
A
  1. Blood beneath conjunctival membrane
  2. Rule out coagulopathy or thrombocytopenia
  3. None
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23
Q

Corneal abrasion

  1. Treatment
  2. Who gets abx? (4)
  3. Complications? (4)
A
  1. Antibiotic prophylaxis with polymyxin-B/trimethoprim solution 1 drop every 3 h while awake and erythromycin ointment while sleeping.
  2. Contact lens wearers
    Contaminated object
    Deep object
    IC patient
  3. Keratitis
    Corneal ulcer
    Traumatic iritis
    Recurrent erosion syndrome
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24
Q

Corneal ulcer

  1. S&S (4)
  2. Etiology (2)
  3. Treatment (5)
  4. Complications (2)
A
  1. Pain
    FB sensation
    White corneal defect
    Fluorescene uptake
  2. Contact lens
    Post infection
  3. No contact lens
    Cycloplegics
    Topical abx hourly
    PO analgesics
    Urgent ophthalmology FU
  4. Hypopion
    Perforation
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25
Traumatic mydriasis 1. What is it? 2. Tx?
1. Nonreactive dilated pupil NYD and no other eye abnormalities after trauma 2. None if all normal
26
Inflammatory pseudotumor 1. S&S (9) 3. Treatment? (3) 4. Ophtho follow up?
1. Nonspecific idiopathic Retrobulbar infl with: - eyelid swelling - palpebral injection of conjunctiva - chemosis - proptosis - blurred vision - painful ocular mobility - binocular diplopia - optic disk edema - venous engorgement of retina 2. Measure IOP Evaluate DM, infection, vasculitis CT orbit 3. IOP > 20 may be surgical emergency If IOP < 20 and all normal, may dc w steroid after discussing with ophthalmology
27
Orbital cellulitis 1. S&S 2. Tx (5) 3. Ophtho follow up? 4. Complications (5)
1. Eyelid swelling, redness, warm Tender skin overlying bone Palpebral injection Chemosis + systemic unwell blurred vision proptosis painful ocular movement binocular diplopia edema of optic disk venous engorgement of retina 2. - Measure IOP - Start ABX including Vanco + Cftx - Blood cultures, BW - Axial CT - Consider LP 3. All get admitted!!! 4. Vision loss CNS infection Abscess Osteomyelitis Cavernous sinus thrombosis
28
Periorbital cellulitis 1. S&S 2. Tx 3. Ophtho follow up?
1. Eyelid swelling, redness, warm Tender skin overlying bone Palpebral injection Chemosis 2. Rule out orbital cellulitis PO ABX 3. If concerns for orbital cellulitis
29
Dacrocystitis/Dacryoadenitis 1. S&S 2. Tx 3. Ophtho follow up?
1. Eye tearing and infl of lacrimal puncture 2. Abx (amox/clav) Warm compress Rule out orbital cellulitis, pus, 3. No if no concerns
30
Orbital tumor 1. S&S 2. Tx 3. Ophtho follow up?
1. Blurred vision Binocular diplopia Painful/limited mobility Proptosis 2. Measure IOP CT axial brain and orbital 3. As required
31
Hordeolum (Stye) 1. S&S 2. Tx 3. Ophtho follow up?
1. Abscess on lid margin, can be internal or external 2. External = warm compress x 4/d Internal = Abx (Amox/clav) + warm compress 3. If tx failure after 2 weeks
32
Blepharitis 1. S&S 2. Tx 3. Ophtho follow up?
1. Inflammation of eyelid margins Associated with crusts on awakening FB sensation Tearing 2. Warm compress Dry eye drops 3. If tx failure after 2 weeks
33
Chalazion 1. S&S 2. Tx 3. Ophtho follow up?
1. Infl of meibomian gland Subcutaneous nodule within the eyelid 2. Warm compress x 4/day 3. No unless tx failure for 2 weeks
34
Narrow angle (ie acute angle-closure) glaucoma 1. S&S 2. Tx (meds in another flash card) 3. Ophtho follow up? 4. Fundoscopy findings?
1. occurs when fluid cannot drain from the eye as it should, causing it to suddenly build up behind the iris Severe unilateral eye pain, blurred vision and "halos" around the eye Maybe: frontal headache, nausea, and vomiting; Puupil maybe fixed at midsize, Limbal injection of conjunctiva Symptoms may be precipitated in low light because pupils dilate causing pain 2. EMERGENT ophthalmology consult Elevate head of the bed Patient in well lit room Recheck IOP hourly Medications in ED if IOP >30 (another flashcard) 3. Any IOP > 20 yes 4. "Cupped" optic nerve Poor vascular supply
35
Glaucoma medications
Decrease production of aqueous humor: * Timolol 0.5% 1 drop (beta blocker) * Acetazolamide (carbonic anhydride inhibitor) * Apraclonidine 1% 1 drop * Dorzolamide 2% 1 drops or if sickle cell disease or trait, then methazolamide 50 mg PO Decrease inflammation: * Prednisolone 1% 1 drop every 15 min four times Constrict pupil/facilitate vitrous humour outflow: * Pilocarpine 1%–2% 1 drop Establish osmotic gradient/ absorb fluid: * Mannitol 2 g/kg IV
36
Keratitis (abrasion) ie corneal abrasion! 1. S&S 2. Tx 3. Ophtho follow up?
1. Pain FB sensation Fluorescene pooling If neglected may ulcer 2. Fluorescene exam Rule out corneal penetration/siedel sign Anesthesize eye Inspect eye for FB 3. Rule out globe rupture Topical Abx/Anesthetics NSAIDs
37
Keratitis (herpetic) 1. S&S 2. Tx 3. Ophtho follow up?
1. Same signs as other keratitis + dendritic pattern 2. Topical anesthetic Acyclovir 5% ointment (5drops x day for 1 week + taper for 2 weeks) Trifluridine 1% solution (1 drop q2h x 7 days + taper for 2 weeks) Varicella-zoster and CMV no antivirals if immunocompetent. 3. Yes esp if needing debridement or culture before abx
38
Scleritis 1. S&S 2. Tx 3. Etiology? (7)
1. Severe inc eye pain, usually unilateral Decreasing vision Phototopia Tearing Pain w eye motion 2. PO NSAIDs Discuss with ophthalmology about PO/Topical steroids 3. RA Vasculitis Gout HSV/EBV Malignancy HIV/TB Surgery
39
Anterior Uveitis & Hypopyon 1. S&S 2. Tx 3. Ophtho follow up?
Uveitis = inflammation of uvea of eye, which includes iris, ciliary body, choroid. 1. Pain Photophobia Tearing Limbal injection of conjunctiva Hypopyon is layering of white cells (pus) in anterior chamber 2. IOP measurement. Otherwise okay to dilate pupil with 2 drops of cyclopentolate 1% 3. prednisolone acetate 1% discuss with ophthalmology prob admit if hypopyon
40
Endophthalmitis 1. S&S 2. Tx 3. Ophtho follow up? 4. Causes?
Progressively increasing eye pain & decreasing vision Diminished red reflex Cells/ flare (possibly hypopyon) in anterior chamber Chemosis Eyelid swelling 2. Empirical parenteral antibiotic (vancomycin and ceftazidime) to cover Bacillus, enterococcus, and Staphylococcus Ciprofloxacin or levofloxacin if above contraindictated 3. Always admit Intravitreal abx 4. Penetrating trauma FB Surgery
41
Keratoconjunctivitis 1. S&S 2. Tx 3. Ophtho follow up?
1. Conjunctivitis with subepithelial infiltrates in cornea Pain Decreased vision Possibly halos 2. Treat conjunctivitis 3. Ask about prednisone FU in 2-3 days
42
Episcleritis 1. S&S 2. Tx 3. Ophtho follow up?
1. Focal redness Pain (but less severe than scleritis) Pain with eye movement 2. Artificial tears PO NSAIDs 3. If no improvement in 2 weeks
43
Inflamed pingueceula 1. S&S 2. Tx 3. Ophtho follow up?
1. Infl of soft yellow patches in temporal and nasal edges of limbal margin 2. Decrease inflammation w naphazoline or ketorolac drops 3. Only if no improvement in 2 weeks
44
Inflamed pterygium 1. S&S 2. Tx 3. Ophtho follow up?
Inflammation of firmer white nodules extending from limbal conjunctiva onto cornea ^ all rosens had
45
Bacterial conjunctivitis 1. S&S 2. Tx 3. Ophtho follow up?
1. Purulent discharge usually unilateral Eyelid infl Chemosis Maybe subconjunctival hemorrhage 2. Polymyxin-B/trimethoprim in infants and children, bc more Staphylococcus Topical sulfacetamide or gentamicin in most adult Use topical fluoroquinolone if Pseudomonas 3, All infants All with sepsis
46
Chlamydia conjunctivitis 1. S&S 2. Tx 3. Ophtho follow up?
1. Bilateral palpebral injection of conjunctiva 2. Empirical PO azithromycin for Chlamydia Consider ceftriaxone for gonorrhoea 3. Not if uncomplicated - 3 days of azithro is fine If infant or complicated yes
47
Contact Dermatoconjunctivitis 1. S&S 2. Tx 3. Ophtho follow up?
1. Redness Swelling 2. Irrigate with tapa water/ normal saline naphazoline drops to dec inf 3. Only in 2 weeks if not better
48
Toxic Conjunctivitis 1. S&S 2. Tx 3. Ophtho follow up?
1. Diffuse conjunctivitis Chemisis Lip edema 2. Irrigate with tapa water/ normal saline naphazoline drops to dec inf 3. Only in 2 weeks if not better
49
Allergic conjunctivitis 1. S&S 2. Tx 3. Ophtho follow up?
1. .. 2. Antihistamines consider topical naphazoline drops 3. Only in 2 weeks if not better
50
Viral conjunctivitis 1. S&S 2. Tx 3. Ophtho follow up?
1. .. 2. Decrease irritation with artificial tears, naphazoline, or ketorolac drops. 3. Yes for neonates Ask about pregnant mothers, infants, and IC pts Education
51
Signs of open globe injury (6)
Loss of anterior chamber depth Blood in anterior chamber Prolapsed iris Irregular/teardrop iris 360 degree subconjunctival hemorrhage Positive Seidel's test on fluorescein *IF any of the above, stop the investigations immediately and ophtho consult STAT
52
Who gets anti-pseudomonas abx for eyes? What are the abx?
1. Contact wearers 2. Deep or contaminated objects 3. IC patients Examples of abx: 1. Tobramyecin 2. Ciprofloxacin 3. Moxifloxacin 4. Gentamycin
53
Causes of RAPD (7)
1. Optic neuritis 2. Optic tumors 3. CRAO 4. CRVO 5. Retinal detachment 6. Retinal infections 7. Severe glaucoma
54
IOP lowering agents? Procedure in ED to lower IOP?
1. Carbonic anhydrase inhibitor 2. Topical beta blocker 3. Alpha agonist 4. IV Mannitol Procedure = Lateral canthotamy
55
Hyphema vs Hypopyon
Hyphema = blood in anterior chamber Hypopion = pus in anterior chamber, associated with keratitis or endophthalmitis
56
Clinical exam to differentiate "anterior uveitis" to "scleritis"
Anterior uveitis will lead to consensual phototopia!
57
Normal Angle VS Close angle glaucoma differences: 1. Lens? 2. Anterior chamber? 2. Eye pain? 3. IOP?
Normal Angle: 1. Lens normal 2. Anterior chamber normal 3. Minimal eye pain 4. IOP mildly elevated Close angle: 1. Lens bulging 2. AC tense 3. Eye painful (esp in low light setting) 4. IOP elevated > 30 usually
58
Glaucoma risk factors IMPORTANT!! (6)
1. Age 40-50 2. F > M 3. Positive fmhx 4. Hyperopia (far sighted) 5. Thin cornea 6. Medication use: - Anticholingergics - Antihistamines - Salbutamol - Septra - Stimulants - SSRIs - TCA
59
Signs of glaucoma?
At least 3 of: IOP > 21 Decreased VA Ciliary flush Dilated non reactive pupil Shallow anterior chamber Corneal edema/cloudiness
60
Symptoms of glaucoma?
At least 2 of: Occular pain Blurred vision Halos N/V
61
DDX elevated IOP (7)
Open angle glaucoma Acute close angle glaucoma Retrobulbular hematoma Chemical burns Ketamine TCAs Atropine
62
DDX Painless vision loss? (5)
CRAO CRVO Retinal detachment Vitrous detachment Vitrous hemorrhage
63
DDX Painful vision loss? (4)
Optic neuritis Glaucoma Traumatic Inflammatory/Infectious
64
Ocular trauma delayed complications? (4)
Glaucoma Retinal detachment Corneal Ulcer Endophthalmitis
65
Retinal detachment 1. S&S 2. Risk factors 3. Treatment
1. Flashes and floaters Curtain like loss of vision Decreased VA Painless 2. Trauma Surgery PVD Diabetic retinopathy CRVO Vasculitis Eclampsia Neoplasm 3. Urgent referral to ophthalmology ; no ED tx
66
Retrobulbar hemorrhage triad?
1. Proptosis 2. Ophthalmoplegia 3. Altered vision
67
Difference between treatment of HSV vs Herpes Zorster Keratits?
HSV: TOPICAL antivirals AVOID steroids bc worsens infection Topical abx and cycoplegic only if iritis HZV: SYSTEMIC antivirals STEROIDS and topical abx can be used *Look for Hutchinson's sign
68
What is Amaurosis Fugax?
TIA of the eye! Transient loss of vision of the eye
69
Central Retinal Artery Occlusion (CRAO) 1. Causes? 2. Who is at risk? 3. Fundoscopy findings? 4. Treatment?
1. TIA of retinal artery Occlusion of retinal artery Inflammatory cause ie temporal arteritis 2. Ages 50-70 Vascular RFs Increased IOP RFs (glaucoma, retrobulbar hemorrhage etc) 3. Cherry red spot Whitening of the retina 4. Occular emergency!!! No good evidence but some include: - Occular massage - Carbon - Hyperbaric O2 - tPA? * Can just observe
70
Central Retinal Vein Occlusion (CRVO) 1. Causes? 2. Risk factors? 3. Fundoscopy findings 4. Treatment
1. Pooling of fluid and blood causing ischemia 2. HTN, Hyperlipid, DM, Smoking, Obesity, Glaucoma 3. Disk edema, dilated veins, "Blood and Thunder" 4. Ophtho consult, very little ED treatment
71
Optic Neuritis 1. S&S 2. Risk factors? 3. Tx
Inflammatory, demyelination of optic nerve, associated with MS 1. Eye pain, vision loss unilateral Colour loss > VA Retroorbital headache painful EOM + RAPD 2. MS ages 20-50 Caucasian and female dominant 3. IV STEROIDS!
72
1. Name of teeth 2. Numerical?
Central incisor Lateral incisor Canine 1st Premolar 2nd Premolar 1st - 3rd Molar Start at UR (#1) --> UL (#16) --> LL (#17) --> LR (#32) * Essentially starts at Upper right and goes counterclockwise
73
Block for single tooth? Block for multiple teeth?
Supraperiosteal nerve block Alveolar nerve block
74
Gingivitis vs Periodontitis vs Pericoronitis Treatment?
Gingivitis = infl of gum Periodontitis = infl of gum and surrounding structure of tooth - can see recession of gum, inc tooth mobility, bone loss, tooth loss Pericoronitis = infl of gingiva and surrounding soft tissue Treatment - Proper oral hygiene - NSAIDS - Topical infiltrate - Smoking cessation - Dental FU - Abx if really bad (amox clav, Pen V, clinda, flagyl, Nystatin - ROSENS BOX)
75
Acute Necrotizing Ulcerative Gingivitis 1. What is it? 2. Risk factors? 3. Name for infection that involves gingiva but also tonsils and pharynx? 4. Most severe end of dz name? 5. Treatment?
1. Polymicrobial bacteria invading tissue and causing pain, bleeding, destruction 2. Poor oral hygiene, smoking, DM, IC 3. Vincent Angina 4. Noma 5. Oral ABX , Mouthwash, OMFS for debridement
76
1. 3 causes of gingival hyperplasia? 2. Medication classes and risk of gingival hyperplasia (3 classes) ; most common?
1. Medications Poor oral hygiene Leukemia 2. Anticonvulsants: - Phenytoin MOST COMMON - Valproic acid - Carbemazapine Immunosuprassants - Cyclosporine (2nd most common, common in kids) Calcium channel blockers: - Nifedipine - Amlodapine - Verapamil - Diltiazam - Felodipine
77
Alveolar Osteitis 1. Lay name? 2. Cause? 3. Treatment?
1. Dry socket 2. Dislodgement of clot in fossa where root was, exposing bone. Usually after wisdom tooth extraction 3. R/o infection Analgesics (NSAIDs, topical, nerve block) **Iodoform gauze with eugenol** Dentist appointment next day
78
Infection of maxillary canine root: 1. What space will get infected? 2. Sign? 3. Complication?
1. Maxillary canine space 2. Flattening of the nasolabial fold 3. Cavernous sinus thrombosis
79
3 spaces in the mandible that can get infected? When all 3 are infected, what is it called? Feared complication?
Submandibular, sublingual, submental = Ludwig's angina ; airway compromise
80
6 RFs for deep space neck infections?
1. Poor oral hygiene/dental infections 2. Recurrent pharyngitis 3. Sinusitis 4. AOM 5. IC patient 6. IVDU
81
Teeth injuries: 1. Subluxed vs Luxed vs Avulsed? 2. Avulsion: Medium to leave tooth in to save periodontal ligaments from dying? 3. ED management of Avulsion? abx? 4. Tooth #, what solution used to tape back together?
1. Subluxed = mobile but in anatomical position Luxed = out of anatomical position but not fully out .. can be Extrinsic, Intrinsic, Lateral Avulsed = fully out 2. Milk is good, can last 3-8 hours Hank's balanced salt solution can last 24h If nothing else, saliva! Avoid water bc hypotonic and cells die 3. Ensure no aspiration --> Dental block --> Hold teeth at crown --> irrigate w NS --> irrigate socket w saline --> re-implement! --> if no immediate dentist FU, use Resin to make splint --> FU within 24/48h + soft diet + abx Abx adults = doxy x 7d Abx kids = penicillin x 7 days 4. Calcium hydroxide
82
The Ellis Classification of tooth #: Class 1 vs II vs III What solution is used to adhere teeth back together in ED?
Class I - Enamel only Class II - Enamel + Dentin Class III - Enamel + Dentin + Pulp Calcium Hydroxide *Tooth must be bone dry!
83
TMJ dislocation: 1. What bones in TMJ? 2. How does it happen? 3. Causes? 4. Treatment?
1. Temporal bone and mandible bone condyle 2. When mandible condyle moves anteriorly (instead of inferiorly) 3. Teeth grinding, jaw clenching and open wide mouth , muscle spasms (ie due to seizure or dystonia) and trauma 4. Reduce with procedural analgesia
84
Acute otitis media (AOM) vs Otitis Media with effusion (OME)
AOM - Middle ear effusion with infection OME - Middle ear effusion w/o infection
85
2 Criteria to diagnose AOM
1. Middle ear effusion 2. Infection
86
2 Criteria to dx chronic AOM?
- >3 or more in 6 months - 4 in 1 year
87
Common AOM pathogens (4)
1. S. Pneumoniae 2. H. Influenzae 3. Catarrhalis 4. Group A strep Also could be viral!
88
Risk factors for AOM (8)
1. Non hispanic white race 2. Male 3. Daycare 4. Parents smoking 5. Bottle fed 6. Pacifiers 7. Family hx of AOMs 8. Anatomical variety ie cleft plate
89
3-intertemportal and 2-intracranial complications of AOM?
Intertemporal ○ Mastoiditis ○ Hearing loss ○ Facial nerve paralysis Intracranial ○ Meningitis Abscess
90
DDX AOM (6)
- FB - Otitis externa - Otitis media with effusion - Trauma - Mastoiditis - Referred pain
91
AOM abx: who gets them? (3)
< 2 years Bilateral AOM Otorrhea
92
Who to consider "watch and wait" for 48-72h for AOM? (7)
1. > 6 months 2. Healthy 3. Unilateral 4. Temp < 39 5. < 48h of symptoms 6. Mild otalgia 7. Responsive
93
AOM Abx: 1. First choice + Dose/course? 2. If allergic? (1) 3. If failure to treatment? (2) 4. Who gets 10-day course? (3)
1. Amoxicillin 80-90mg/kg/day 2. 2nd/3rd gen cephalosporin 3. Amox-clav or Cftx 4. < 2 years Chronic infection TM perf *Always abx if perf * Adults ALWAYS abx cz almost always bacterial
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RetroPharyngeal Abscess 1. Causes (10) 2. Dx: Gold standard + alternatives 3. Tx
1 . Pharyngitis Tonsillitis PTA AOM Dental infections FB Trauma Ludwig Angina Oral procedures Endoscopy 2. CT gold standard XR and US also able 3. Tazo + Vanco (polymicrobial) Airway management! ICU/ENT dispo
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Otitis externa: 1. Common pathogens (3) 2. RFs (4) 3. S&S (6)
1. Staph aureus Pseudomonas Aspergillus 2. Hot temp Humidity Repeated exposure to moisture Trauma 3. Ear pain Ear discharge Hearing loss Jaw pain Tragus/auricle reproduces pain Lymphadenitis
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EOM DDX (6 - 3 inner ear, 3 outer ear)
1. AOM 2. Otomycosis 3. Perichondritis 4. Auricular cellulitis 5. Skin condition (eczema etc) 6. Herpes zoster optics
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EOM management 1. Mainstay 2. Who gets systemic ABX (2)? Which one? how long?
1. Ciprodex 4 drops BID x 7days 2. If extending beyond middle ear, IC patient Cipro 500mg PO BID x 7 days
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Otomycosis 1. Pathogens 2. S&S 3. RFs 4. Tx
1. Candida, Aspergillus 2. Itching but NO PAIN 3. Topical climate, DM, IC 4. Locacorten Vioform
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Perichondritis 1. What is it? 2. Pathogens? 3. Treatment? (3)
1. Infection of connective tissue covering cartilage - happens with rubbing hearing aid, piercing, trauma 2. Pseudomonas (almost always) 3. I&D if collection, Cipro, ENT if severe
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Necrotizing (Malignant) External Otitis 1. What is it? 2. RFs (3) 3. S&S (5) 4. Dx (1) 5. Treatment (3) 6. Complications (5)
1. OE spread through temporal bone --> osteomyelitis of bones, tissue, face 2. DM, IC, Elderly 3. Otorrhea, otalgia, headache, Periauricular pain, CN7 probs 4. CT head 5. Cipro 400mg IV q12h (for 6-8 weeks!) + Tazo if pseudomonas + ENT 6. 5-10% mortality Skull base osteomyelitis Sigmoid sinus thrombosis Meningitis Brain abscess
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Mastoiditis 1. S&S (6) 2. DDX (7) 3. Dx 4. Tx (3)
1. Otalgia Erythema Postauricular pain Protrusion of auricle Fever Headache 2. AOM OE Skull # Malignant OE Lymphadenopathy Lymphadenitis Deep space neck infection 3. Clinical but also can do CT 4. IV Vanco + Ceftriaxone (pseudomonas) ENT consult
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Sudden hearing loss 1. DDX (3 outer ear, 2 ME, 5 inner ear) 2. Dx 3. Tx (3)
1. Outer ear: - Cerumen impaction - OE - FB Middle ear - AOM -TM perf Inner ear - Meds (amino glycoside, loop diuretics, ASA) - Barotrauma - Autoimune - infection - Neoplasm 2. Clinical MRI if vertigo 3. Prednisone with taper (within 2 weeks onset of sx if able) Steroid drop ENT EMERGENCY!
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Tinnitus 1. Red flags (4) 2. Primary vs Secondary - 1 vs 8 categories
1. Pulsatile Unilateral Hearing loss Focal neuro deficits 2. Primary - Idiopathic, associated w SNHL (Webbers test), multifactorial Secondary - Infectious (Lyme, fungal, viral) - Metabolic (DM, HDL) - Neurological - Otolgic (Manners, AOM) - Somatic (injury) - Tox (meds/substance) - Trauma - Vascular (bruits, AV malformation, dissection)
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Epistaxis anterior, what vessel?
Kiesselbach's plexus
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15 causes of Epistaxis
Anatomical - Polyps - FB Environmental - Low humidity - Nasal trauma - Nose picking - Irritants - Cocaine Diseases - URTI - Allergies - Neoplasm - Surgery Bleeding disorder - Hepatic disease - Alcoholism - Vitamin K deficiency - Folic acid deficiency
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6 steps to managing epistaxis
1. Blow your nose/clip 2. Apply 2% lidocaine with gauze 3. Cauterize with silver nitrate UNILATERAL ONLY 4. Anterior packing with rhino rocket 5. Topical TXA *If all above fail, prob posterior bleed * ENT consult can be done to also embolism
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Who gets prophylaxis ABX for nose packing? (2)
> 48hours IC patient
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Sialolithiasis 1. What is it? 2. RFs (6) 3. S&S (3) 4. DDX (5) 5. Dx 6. Tx (3)
1. Tonsilar stones 2. - Dehydration - Diuretic use - Anticholinergic meds - Smoking - Trauma - Gout 3. - Pain esp during eating or salivating - Swelling - Infection 4. - Salivary gland pathology - LN dz - Granulomatous process - Soft tissue mass - Neoplasm 5. CT 6. Massage, sialogouges, analgesics
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Neck masses rule of 80?
in children, 80% benign in adults, 80% malignant
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Neck masses DDX ROSENS BOX (5 categories)
- Inflammatory ○ Adenitis ○ Bacterial ○ Viral ○ Fungal ○ Parasitic ○ Cat scratch dz ○ Tularemia ○ Sialodenitis ○ Thyroditis - Congenital ○ Brachial cleft cyst ○ Dermoid cyst ○ Torticollis ○ Ranula - Masses benign ○ Lipoma, fibroma ○ Salivary gland masses ○ Hemangioma, aneurism - Masses malignant ○ Sarcoma ○ Salivary gland tumor ○ Thyroid tumor ○ Lymphoma -Mets
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GAS pharyngitis complications (12)
Rheumatic fever Scarlet fever Abscess Ludwig's Angina AOM Mastoiditis Osteomyelitis Sinusitis Post strep GN TSS Meningitis Bacteremia
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Jones criteria for diagnosing acute rheumatic fever - Major criteria (5) - Minor criteria (4) *JONES FACE
Major (JONES) - Joints poly arthritis - Carditis - Nodules SubQ - Erythema marginatum - Sydenham Chorea Minor (FACE) - Fever > 38.5 - (Poly)Arthralgia - CRP > 30 / ESR > 60 - ECG prolonged PR *2 major OR 1 major + 2 minor
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GAS treatment: 1. Mainstay dose? 2. If allergic abx dose? 3. If anaphylactic? (3)
Amoxicillin 50mg/kg/d x 10d Cephalexin 20mg/kg PO x 10d If anaphylactic: Clinda Azithro Clarithromycin
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Dysphagia: Oropharyngeal vs Esophageal
Oropharyngeal - difficulty INITIATING swallow - occurs RIGHT AWAY - multiple swallowing attempts - C pain - coughing - choking - drooling Esophageal - difficulty transporting material down - occurs 2-4s after swallowing
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Oropharyngeal dysphagia DDX (10)
NMSK - Stroke (most common) - Myopathy - Myasthania Gravis - MS - DM neuropathy - Botulism - Tetanus - Diphtheria Obstructive - Tumor Other - Dry mouth
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Esophageal dysphagia DDX (15)
Dysmotility - Achalasia - LES HTN - Esophageal spasm - Connective tissue disorder Mechanical - Stricture - Rings - Webs - Post-op - Tumor - Esophagitis - GERD - FB Extrinsic mechanical - Goitre - Aneurism compression - Zenker's diverticulum
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