Most Commons in HEENT for Physician Assistants
HEENT (EENT) makes up 9% of the PANCE and is one of the most common “bread and butter” medicine topics you’ll come across. Below is a combination of “most commons”, “buzzwords”, and other clinical pearls I have come across since completing my didactic year. I compiled this in order to help myself prepare for the PANCE and for rotations. I hope it helps you in your studies as well.
- Head
- Onset within 72 hours
- Loss of taste sensation in anterior ⅔ tongue (chorda tympani)
- Ears
Acute Otitis Media | Otitis Externa - Bacterial | Otitis Externa - Fungal |
MC: viral (45-70%), S. pneumo (25-50%), H. Flu (15-30%), M. Cat (20%) MC (pediatric): S. pneumo | MC Path: Pseudomonas (50%), S. aureus/St. pneumo (40%), sterile (10%) | MC Path: Aspergillus-niger (black), -flavus (yellow), or -fumigatus (gray) Candida albicans (white) |
Pain when supine or leaning forward, pulling on ear Fever, hearing loss, aural fullness, pressure PE: red TM, purulence, pre- or post-auricular LAD with cervical LAD, loss of cone of light Associated rhinitis Ruptured TM = drainage Tuning fork: BC > AC | Pain with movement of pinna or eating Conductive hearing loss PE: swollen, red, yellow/green discharge, foul smelling, pre- or post-auricular LAD +/- cellulitis of face Tuning fork: BC > AC | ITCHY Weeping, pain, hearing loss, aural fullness PE: swollen, hyphae +/- spores, moist/wet-appearance |
TX: most resolve spontaneously Mild: no ABX, reevaluate 2-3 d Uncomplicated, previously untreated: HD (80-90 mg/kg/d) Amoxicillin or Augmentin x 10-14 d or IM ceftriaxone Switch ABX 48-72 h if no resp. PCN allergy: Sulfonamide + Erythromycin or Clindamycin, FQ Do not use: antihistamines, decongestants | TX: hygiene, clean, otowick, topical analgesics Otic drops: Ciprodex, Floxin Contraindicated: irrigation or Gentamicin/Tobramycin with perforated TM | TX: hygiene, clean Topical antifungal powder + Antifungal otic drops: acetic acid, Vosol Prophy: 1:1 ETOH/white vinegar in each ear after showering Contraindicated: Lotrimin with perforated TM |
Chronic Otitis Media (recurrent) | 3+ AOM in 6 months OR 4+ AOM in 1 year Autophony - can hear your echo | SX: continued pressure or fullness after resolution of infection, hearing loss, tinnitus, increased sensitivity to loud noises, not painful PE: dull TM with decreased movement, hearing loss, speech delay |
Serous Otitis Media HX: recent viral URTI, sinus infection, flare of allergies, flying while congested, recent AOM, adenoid hypertrophy, nasopharyngeal mass TX: resolves slowly (up to 12 weeks), follow up 4-6 W, nasal steroid sprays, short course of PO steroids Do not use: antihistamines, decongestants | Fullness, hearing loss, pressure, popping/gurgling after a yawn or blowing nose, dizziness or swimming sensation Unilateral or bilateral PE: retracted TM, amber or “coca cola” colored fluid, displacement of cone of light, air bubbles behind TM, pneumatic otoscopy reveals decreased movement of TM Tuning fork: BC > AC | |
Cholesteatoma Chronic negative pressure thins the TM and retracts, adhering to middle ear -> squamous epithelium forms inside and expands | Worsening hearing loss Chronic discharge, fullness Not painful History of AOM or previous surgery PE: pearly white mass, squamous debris, discharge Conductive hearing loss | |
Necrotizing (Malignant) Otitis Externa MC: diabetics, immunocompromised MC pathogen: pseudomonas | Deep severe pain Drainage, swollen red canal Granulation tissue, osteomyelitis at skull-base, pain with talking/chewing CN 7 and 12 involvement TX: control DM, oral FQ | |
Mastoiditis MC pathogen: S. pneumo, S. aureus | Fever, malaise, hearing loss, +/- headache History of ABX use without improvement PE: swollen over mastoid, redness, tenderness, LAD, outward protrusion of pinna TX: IM ceftriaxone or IV ABX CT Scan, refer to ENT |
Labyrinthitis (otitis interna), vestibular neuronitis, vestibular neuritis | ||
Etiology: viral, head injury, stress, allergy | Rapid onset severe vertigo (3-5 days), nausea, vomiting, imbalance Preceding URTI +/- nystagmus (severe) | Symptoms regress over 3-6 weeks |
Central Vertigo | Peripheral Vertigo |
Gradual and continuous symptoms, mild to moderate Focal signs, nausea, vomiting, hearing loss (rare) | Acute and intermittent symptoms, but severe hearing loss, tinnitus, fullness Hearing loss, severe nausea and vomiting, diaphoresis |
Etiology: MS, brain tumor, head injury, medications | TX: Valium, Meclizine |
- Acute otitis media - most common diagnosis for acute office visits in children
- Most common complication: tympanic membrane perforation
- Untreated complications - leads to facial nerve paralysis (Bell’s Palsy), cerebral venous sinus thrombosis, mastoiditis, short/long term hearing loss, speech delay, bacterial meningitis, intracranial abscess, TM perforation
- Bagel ear - bulging TM
- Most common cause of hearing loss: cerumen impaction
- Most common cause of unilateral sensory hearing loss: viral neuritis
- Presbycusis - Most common type of hearing loss in elderly
- Most common neuropathy associated with acoustic neuroma: loss of corneal reflex due to trigeminal involvement
- Bilateral nystagmus with cold caloric testing - signifies intact cortex, midbrain, and brainstem
- Recurrent unilateral serous otitis media - consider oropharyngeal cancer
- Drugs that cause nystagmus - MALES TIP
- Methanol
- Alcohol
- Lithium
- Ethylene glycol
- Sedative hypnotics, Solvents
- Thiamine depletion and Tegretol (carbamazepine)
- Isopropanol
- PCP, Phenytoin
- Medications that cause hearing loss: aminoglycosides, antineoplastic agents, loop diuretics, salicylates
- Meniere's Disease (endolymphatic hydrops) - excessive endolymph fluid in the cochlea overstimulates hairs causing vertigo and sudden hearing loss with aural fullness; most commonly unilateral and appears in adults
- SX: sudden vertigo, aural fullness or pressure, tinnitus, fluctuating hearing loss, nausea/vomiting, lasts hours
- TX: low salt, high water diet, diuretics, intratympanic steroids
- Avoid ETOH, caffeine, tobacco
- Dix-Hallpike Maneuver - diagnoses benign positional vertigo (eye twitching occurs), which is provoked by head movements or positioning
- Nystagmus - always positional, brief, and fatigable
- Rotatory nystagmus (posterior canal BPPV) - Epley maneuver
- Lateral nystagmus (lateral canal BPPV) - Lempert Maneuver
- Weber Test - sound is louder in ear with conductive loss
- Acoustic Neuroma (vestibular schwannoma) - tumor of 8th CN
- SX: unilateral hearing loss, vertigo (late), unsteadiness, tinnitus
- Bilateral acoustic neuroma - associated with Neurofibromatosis type II
- Decreased corneal sensitivity, diplopia, headache, facial weakness
- LP: elevated protein
- TX: MRI
- Eyes
- Myopia - “nearsighted”; vision rays come into focus in FRONT of retina
- Hyperopia - “Farsighted”; vision rays come into focus BEHIND retina
- Presbyopia - farsightedness caused by old age
- Strabismus (heterotropia) - eyes do not align (cross-eye)
- Hordeolum - occurs on upper or lower eyelid; red and painful; spontaneously resolves
- Abscess of Meibomian gland (internal) - points toward conjunctiva
- Glands of Zeis (external, stye) infection at eyelid margin, pointing outward
- Chalazion - obstruction of meibomian gland (granuloma) or internal posterior hordeolum; painless, non-tender, non inflamed swelling (nodule) developing over the course of weeks (chronic)
- TX: hot compress, oral doxycycline or tetracycline
- Pterygium (Surfer’s Eye) - commonly grows from the nasal side of the conjunctiva
- Eyelid Malposition
- Retinoblastoma - child with blurry vision and abnormal pupillary reflex with a white reflex upon fundoscopic exam
- Subconjunctival hemorrhage - bleeding of the conjunctival or episcleral blood vessels into the subconjunctival space; painless; self limiting - lasts 2 weeks
- Blepharitis - conjunctival and lid margin inflammation
- Slit lamp exam: greasy appearance of lid margin with scaling around the base of the lashes
- Hypopyon - accumulation of white inflammatory exudate in the anterior chamber
- SX: painful, red eye
- Slit lamp exam: localized, white, flocculent infiltrate in anterior chamber
- Hyphema - blood in anterior chamber resulting from tears in ciliary body or iris root vessels; most common in children (70%)
- RF for rebleeding: sickle cell disease or trait, black, ASA use, prior low visual acuity, hyphema > ⅓ anterior chamber, treated after 24 hours, elevated IOP
- 4 S’s of Hyphema (Complications)
- Staining of the cornea
- Synechiae - iris adheres to cornea or lens
- Secondary rebleeds on 2-5th day (20%)
- Significantly increased IOP
- TX: Rest, elevation of head, topical steroids, avoid ASA/NSAID
- Welder’s Flash - severe eye pain and multiple pinpoint areas of fluorescein uptake representing ruptured corneal epithelial cells
- Slit lamp exam: Diffuse Punctate Keratopathy
- Most common pathogens of
- Chronic Dacryocystitis: candida albicans, anaerobic streptococci, staphylococcus epidermidis
- SX: painful erythema over the tear duct at nasal side of eye with small amount of pus draining from tear duct
- Dacryoadenitis - acute inflammation of the lacrimal gland seen in sterile inflammatory disease
- SX: abrupt onset swelling of upper eyelids, laterally;
- Most due to gram positive bacteria, but EBV most common virus
- Normal range of intraocular pressure (IOP): 10-23 mmHg
Central Retinal Artery Occlusion (cherry red spot, ischemic retina): flow through CRA occluded Associated: atherosclerotic thrombosis, embolus, giant cell arteritis SX: sudden painless loss of vision in one eye (unilateral) PE: pale-gray retina, APD, cherry dot Irreversible damage to retina after 90 minutes - IMMEDIATE CONSULT (decrease IOP & arterial dilation) | |
Central Retinal Vein Occlusion (Blood & Thunder Fundus): sudden, painless unilateral vision loss, 50+ PE: macular edema, cotton wool spot, massive superficial/deep hemorrhage with vitreous involvement MC Associated: HTN, POAG | |
Age Related Macular Degeneration (ARMD): loss of central vision clarity, long smoking history, metabolic syndrome, FH, female, white, age 50+ PE: drusen formations, retinal atrophy TX: Anti-VEGF intravitreal injections | |
Dry AMD (Nonexudative) | Wet AMD (Exudative) |
Buildup of drusen Mild - asymptomatic Moderate - some vision loss Severe - central blind spots TX: vitamins to slow process | Choroidal neovascularization Early - mild distortion Late - central blind spot |
Differential of Red Eye with Decreased Visual Acuity | |
EMERGENT OPHTHALMOLOGY CONSULT “Halos around lights” (bilateral) Dull or severe pain, blurry vision, frontal headache, lacrimation, +/- nausea and vomiting Pain more severe in dark RF: asians, eskimos, hyperopes, elderly IOP: 40-80 mmHg (sudden increase) TX: IV mannitol, pilocarpine, IV acetazolamide, iridectomy | |
Visual changes begin peripherally Gradual, painless loss of vision More common than acute 4% of patients 40+ Most common cause: outflow obstruction through trabecular meshwork | |
SX: eye/periorbital pain, consensual photophobia, hypopyon, irregular pupil, Floaters, headaches, dilated ciliary vessels (ciliary injection or flush), “cells and flare” in anterior chamber, keratic precipitates (KP) on posterior surface of cornea TX: refer to ophthalmology +/- rheumatology, steroid and dilating drops | |
Corneal Abrasion Multiple vertical linear abrasions (ice rink sign) under upper eyelid suggests foreign body MC etiology: contact lenses TX: cycloplegic, topical NSAID, topical antibiotic, oral analgesics/sedatives Contraindicated: topical steroids, patching | |
Herpes Simplex (HSV) Keratitis EMERGENT OPHTHALMOLOGY CONSULT Etiology: HSV-1 SX: painful eye, blurred vision, conjunctivitis, photophobia, tearing Slit lamp exam: dendritic ulcer (branch-like) lesion Hutchinson’s sign: herpetic lesion on tip of nose (nose and cornea supplied by nasociliary nerve) TX: most spont. resolve in 3 weeks Contraindicated: topical steroids or patching | |
Bacterial (Microbial) Keratitis SX: rapid onset red, painful eye with discrete corneal infiltrate, photophobia, and decreased vision +/- hypopyon (+) Seidel sign/test Most common: pseudomonas (contact lens wearers), Enterobacter VISION THREATENING PROCESS - rapid progression (24-48 h), REFER If small, peripheral - FQ every 1-2 h | |
Conjunctival Injection Anterior vessels - produce more redness, move with conjunctiva and constrict with vasoconstrictors Posterior - stationary and less red | |
Viral Conjunctivitis (pink eye) Most common: adenovirus Associated symptoms: recent URTI, no resolution with eye drops SX: unilateral or bilateral, benign, self-limiting (2-4 weeks), preauricular adenopathy, epiphora, hyperemia, chemosis, follicular conjunctival injection, subconjunctival hemorrhage TX: supportive (cold compress, lubricants - artificial tears), hand hygiene | |
Bacterial Conjunctivitis Associated: steroid or OTC eye drops, contact lens wearers, age, sexual activity, immunodeficiency Segmental or diffuse injection, purulent discharge, “mattering” or lid margin, difficulty prying open lids after awakening Topical FQ and erythromycin | |
SX: Itching, history of rhinitis, clear discharge, conjunctival injection +/- chemosis, +/- eyelid edema Summer, Spring, Fall Usually symptom free in winter | |
Vernal Keratoconjunctivitis (VKC) Bilateral, chronic inflammation or “Spring catarrh” summer conjunctivitis Shield ulcer (pathognomonic) caused by inflammatory mediator release Onset in puberty Most common in males | |
Giant Papillary Conjunctivitis (GPC) RF: contact lens overuse, plastic prosthetic eye First: itching with mucoid discharge Large cobblestone papillae >0.3 mm TX: stop wearing contact lenses | |
Atopic Keratoconjunctivitis (AKC) Bilateral, inflammation of conjunctiva AND eyelids, eczematoid dermatitis of eyelid with dry, scaly, inflamed skin Associated with atopic dermatitis (eczema) TX: topical antihistamines, mast cell stabilizers, olopatadine, topical NSAID (ketorolac), topical steroid (prednisolone) | |
Gonococcal Conjunctivitis (neonatal = ophthalmia neonatorum) N. gonorrhoeae or C. trachomatis Pain, tenderness, hyperemia, chemosis Purulent, mucoid or mucopurulent May ulcerate, resulting in vision loss | |
Episcleritis: inflammation between conjunctiva and sclera (episcleral tissue) Mild, self-limiting, recurrent Vessels blanch with topical vasoconstrictors 2 Types Simple: intermittent (1-3 months), lasts 7-10 days, mod-severe inflammation, spontaneously resolves after 2-3 weeks Nodular (shown): prolonged, acute onset, mild-mod + systemic disease TX: none required +/- oral NSAID | |
Scleritis: inflammation of the sclera Diffuse or Nodular VISION THREATENING - REFER IMMEDIATELY SX: awakened from sleep due to deep boring pain, vessels will not blanch or move with topical vasoconstrictors |
Hard Exudate: deep yellow with sharp margins; circinate | Leakage from pre-capillary arterioles Ex. von Hippel Lindau disease, radiation, HTN Most common cause: DM | |
Due to ischemia of superficial retina (microvasculature) | Neural micro infarctions Ex. HIV, connective tissue disease, DM Most common cause: HTN Most common funduscopic exam finding in AIDS patients (CMV retinitis) | |
Retinal Drusen: clusters of yellow-orange spots, centered around fovea | Metabolic debris from retinal pigment epithelium Most common cause: ARMD | |
Diabetic Proliferative Retinopathy Prolonged hyperglycemia causes: 1. Basement membrane thickening 2. Decreased pericytes (hyperproliferation) 3. Microaneurysms 4. Neovascularization | Neovascularization breaks through ILM (inner limiting membrane) leading to tractional retinal detachment | |
Non-proliferative Retinopathy | Aneurysms Hard exudates Hemorrhage | |
Papilledema: optic disc swelling caused by increased intracranial pressure (ICP) | Bilateral, develops over hours to weeks Transient obscurations of vision (lasts seconds) ICP: most commonly occurs bilaterally | |
Optic Neuritis: optic nerve swelling causes destruction of myelin sheath Papillitis - head of optic nerve Retrobulbar neuritis - posterior nerve PAIN PRECEDES VISUAL LOSS | Most common cause: Multiple sclerosis Normal ICP Sudden unilateral loss of central vision MC symptom: blurry or “foggy” vision Pain with movement of affected eye (NOT RED) PE: swollen disk, APD TX: IV/oral steroids | |
Cataracts Any opacity of the lens, whether visually significant or not Most common cause: age related nuclear sclerosis | SX: glare, myopic shift, multiple images due to refraction, blurry vision | |
Retinal Hemorrhage | Causes: HTN, retinal vein occlusion, DM, shaken baby syndrome or severe head trauma | |
Vitreous Hemorrhage: extravasation (leakage) of blood into areas in and around vitreous humor Age 50+ 50-70% of acutely symptomatic patients have retinal detachment | Most common cause: proliferative diabetic retinopathy Others: trauma, retinal detachment “Flashing lights”, floaters Blurry vision, reddish tint, photopsia (brief flashes of light in periphery) Most asymptomatic | |
Retinal Detachment EMERGENT OPHTHALMOLOGY CONSULT Peripheral -> central vision loss TX: inferior - patient sits up superior - patient lies down | Preceded by posterior vitreous detachment: photopsia, floaters, feeling of heaviness in eye Painless vision loss “Curtain of darkness” with peripheral flashes or spider webs and floaters Gray detached retina | |
Amaurosis Fugax Etiology: atherosclerosis (retinal artery emboli), carotid stenosis | “Fleeting blindness” or “curtain coming down vertically into field of vision” Painless, transient (quickly returns), unilateral visual loss Lasts 2-20 minutes | |
Non-arteritic Anterior Ischemic Optic Neuropathy (NAION): damage to optic nerve head from microvascular occlusion RF: HTN, DM, hypercholesterolemia, smoking | Sudden upon awakening, non-painful, unilateral optic disc swelling Afferent pupillary defect (APD), most upper or lower half of visual field Age: 50-70 Visual loss does not progress or recover Resolves 4-8 weeks | |
Arteritic Anterior Ischemic Optic Neuropathy (AION): damage to optic nerve head from microvascular occlusion | Age: 70-90 (older) Severe visual loss, jaw claudication, temporal artery tenderness, temporal headache, unintentional weight loss, fatigue, myalgias, loss of appetite Significant APD DX: STAT ESR, temporal artery biopsy TX: high dose steroids to prevent blindness in contralateral eye | |
Hypertensive Retinopathy | Hallmark: Diffuse arteriolar narrowing (AV nicking) | |
Osteogenesis Imperfecta (brittle bone disease, Lobstein syndrome) | Blue-gray sclerae due to underlying choroidal veins showing through a thin sclera (defective Type 1 collagen) Most common type of OI: Type 1 |
- Cellulitis
- Most common cause of orbital cellulitis: Staphylococcus aureus
- LIFE THREATENING - EMERGENT OPHTHALMOLOGY CONSULT
- Most common cause of periorbital (preseptal) and orbital infections: Staph aureus, Strep pneumo, and H. flu
Periorbital (preseptal) Cellulitis | |
Gross lid edema, chemosis Toxic, febrile Proptosis, limitation of ocular mobility +/- decreased vision | Lid edema, chemosis ONLY NO proptosis, limitation of motility, or decreased vision |
- SX: decreased visual acuity, IOP (“Squishy eye”), bloody chemosis, visible wound of cornea/sclera, change in anterior chamber depth, displacement of pupil or shape, prolapse of ocular tissue (brown)
- Lateral canthotomy contraindicated if suspected ruptured globe!
- SX: Pain, eccyhmosis, bloody chemosis, resistance to retropulsion
- Afferent pupillary defect (APD)
- Increased IOP
- Most common pathogens causing bacterial conjunctivitis: Staph aureus, Strep pneumo, H. flu
- Most common cause of vision loss in patients 24-70 - Diabetic retinopathy
- Most common cause of vision loss in patients 65+ - Age related macular degeneration (ARMD)
- Most common cause of drusen - ARMD
- Most common cause of exudates: Diabetes
- Viral conjunctivitis - most commonly caused by Adenovirus
- Red-green color blindness - one of the most common genetic disorders, affecting 7% of all males
- Most common findings associated with orbital floor fractures: diplopia, globe lowering, numbness over the cheek (V2)
- Marcus Gunn Pupil (Afferent Pupillary Defect) - due to optic nerve damage or retinal detachment
- DX: Swinging Flashlight Test - decreased bilateral pupillary constriction when light shown in affected eye
- Most common conditions: ischemic optic neuropathy (ION), glaucoma, optic neuritis
- Seidel Test - assesses the presence of anterior chamber leakage in cornea, including post-trauma, corneal perforation or degeneration
- Tangential Light Test - determines the presence of narrow angle glaucoma or perforating corneal injury; if part of the iris is in the shadow, the angle is narrow
- Cycloplegics vs. Sympathomimetics
- Cycloplegics - inhibits parasympathetic stimulation which constricts the iris and inhibits the ciliary muscle, paralyzing the ciliary muscle and causing loss of accommodation (ex. atropine and cyclopentolate, scopolamine, tropicamide)
- Sympathomimetics - stimulates iris’ dilator muscle
Bilateral optic disk swelling | Unilateral optic disk swelling |
Raised intracranial pressure, malignant hypertension | Optic neuritis, ION, central retinal vein occlusion, intracranial optic nerve compression, posterior scleritis |
- Nose
Acute Viral Rhinosinusitis (common cold, URI) | Influenza | Sinusitis |
Etiology: adenovirus Incubation: 2-4 d (3 day shed) Direct contact, droplets | Influenza virus Incubation: 1-4 d (infectious day before to 5 days after onset) | MC Etiology: antecedent viral URI, allergies, tumors, FB, deviated septum or polyps MC sinus: maxillary (cheek pain), ethmoid (retro orbital pain), frontal (lower forehead) MC pathogens: S. pneumo, H. flu, M. Cat |
Const SX: Fever, chills, malaise Rhinorrhea - clear, watery Nasal congestion, sneezing Sore throat, non-prod cough Myalgia, headache PE: low fever, nasal/throat erythema, congested turbinates/discharge, sinus tenderness, cervical LAD | Abrupt onset fever Sore throat, retro-orbital headache, myalgias, malaise, nonproductive cough PE: fever, clear nasal discharge, pharyngeal erythema, cervical LAD | Major Symptoms Facial pressure or pain worse with bending forward Nasal obstruction, discharge (purulent), hyposmia Minor Symptoms Fever, fatigue Headache, halitosis, dental pain, cough, ear pressure 2 Major OR 2 Minor + 1 Major PE: purulent discharge, PND, halitosis, sinus tenderness, transillumination of sinuses |
Resolves 5-8 days Analgesics: ASA, Tylenol, NSAIDs Topical analgesics - Chloraseptic Nasal saline washes, humidifier Decongestants - Sudafed, Afrin Mucolytic - Mucinex Antihistamines - Benadryl, Claritin, Zyrtec, Allegra | Symptoms last 3 days to 2 weeks Antipyretics, bedrest Oseltamivir (Tamiflu) within 40 hours of symptom onset IM/ID Vaccine for anyone >6 months up to 5 years and >50 years old Nasal spray: non-preg 2-49 | Acute: lasts <30 d with complete resolution Subacute: 30-90 d with complete resolution Chronic: >90 d with persistent symptoms Non-contrast CT Scan - first line (chronic, unresponsive) Sinus aspirate culture - gold standard First line: Amoxicillin, Cefdinir (Omnicef) 10-14 d Beyond 2 W: Augmentin, Cefuroxime Chronic: add inhaled steroids Severe: Levaquin, Bactrim PCN Allergy: Azithro, Clarithro |
Hydration, humidifiers, saline sprays Decongestants: topical or PO Analgesics: NSAID, Tylenol If allergic: nasal steroids, antihistamines Refer to ENT immediately: changes in vision, mentation, or periorbital edema |
- Sinusitis - Maxillary most commonly affected, followed by ethmoid
- Most common etiology for acute sinusitis: antecedent viral URI
- Most common bacterial pathogens: strep. pneumo, H. flu, M. cat.
- Orbital Cellulitis - associated with ethmoid sinus
- SX: fever, eyelid edema, ptosis, proptosis, chemosis
- Osteomyelitis - Frontal sinus most commonly affected
- SX: fever, headache, doughy edema over bone, large forehead abscess
- Initially IgE mediated, then recruits neutrophils, eosinophils, lymphocytes
- SX:
- Irritative: sneezing, itching, rhinorrhea
- TX: antihistamines
- Congestive: congestion, stuffiness
- TX: decongestant (Sudafed, Afrin), anti-leukotriene
- First line: antihistamines, topical nasal steroids
- Adjunctive: mast cell stabilizer
- Vasomotor rhinitis - most common in anxious patients (non-allergic, unknown etiology), causes congestion & profuse rhinorrhea
- TX: topical anticholinergics (ipratropium bromide)
- Aspirin induced asthma (Samter's triad) - aspirin precipitates acute bronchospasm in patients with nasal polyps and asthma
- Triad: nasal polyps, asthma, Aspirin-sensitivity
- Nasal polyposis - usually bilateral; if unilateral, consider tumor; congestion & fullness
- Rhinitis medicamentosa - rebound rhinitis following sudden cessation of topical decongestants (3-5 d)
- SX: extreme nasal obstruction, pressure
- “3 sprays, 3 times daily, for 3 days”
- Squamous cell carcinoma - most common form of nasopharyngeal cancer
- Most common cause of Septal Hematoma: nasal trauma
- Saddle nose deformity - complication if untreated
- Toxic Shock Syndrome (TSS) - previous nasal packing for anterior nosebleed
- Etiology: toxin releasing S. aureus
- SX: fever, nausea, vomiting, and hypotension
- Most common cause of Epistaxis: digital trauma
- “Colder, older, males” - most commonly occurs in colder months, older population, and males
- Most common type of epistaxis: anterior epistaxis
Anterior epistaxis | Posterior epistaxis |
Origin: Kiesselbach plexus Visualized easily TX: anterior nasal pressure | Origin: sphenopalatine artery’s lateral nasal branch Unable to visualize bleeding site, blood trickles down oropharynx and both sides of nose, unable to control with pressure TX: posterior-anterior packing or balloon tamponade device |
- Mouth/Throat
- Centor Criteria for diagnosis of Strep Throat - Fever > 38 C, lack of cough, tonsillar exudate, tender anterior cervical LAD (3 out of 4 present, sensitive)
Etiology: Strep (GAS), Staph Incubation: 12 h - 4 d | Etiology: Coxsackie A&B, adenovirus, rhinovirus, echovirus, HSV | EBV or CMV Prodromal: 2-5 d (infectious) |
SX > 1 week Odynophagia, dysphagia, cough, hoarseness Rhinorrhea Fever, anterior cervical LAD (60%) +/- Purulence PE: tonsillar exudates | SX < 1 week Odynophagia, dysphagia, cough, hoarseness Rhinorrhea LAD, myalgia, malaise, fever | Exudate - think EBV Posterior cervical LAD Splenomegaly, hepatomegaly Sore throat Fever, malaise “hairy leukoplakia” - lateral tongue; will not scrape off |
Rapid strep test (specific, less sensitive) - not required | CBC - lymphocytosis Mono-spot test (specific, not sensitive), reveals previous infection IgM & IgG titer to VCA, EA, EBNA (2-3 d for results) | |
Hydration 1: Benzathine PCN, Pen-V K 2: Clinda, Amox, Cefuroxime 3: Levaquin, Cipro Do not treat with Ampicillin: causes measles-like rash & type 3 immune-complex GN | Supportive: hydration, Tylenol HSV: acyclovir | Supportive Ampicillin Avoid contact sports & being hit in abdomen |
Adolescents or adults Incubation: 2-3 d Drooling, sore throat, low fever, trismus (lock jaw), odynophagia Ipsilateral otalgia Unilateral swelling of soft palate, uvula deviation Tonsillitis | IV hydration IV Clindamycin or PCN Intraoral drainage Elective tonsillectomy | ||
Retropharyngeal Abscess | Etiology: B-hemolytic Strep Common 6 M to 3 y/o Prefer supine position Dysphagia, muffled voice, stridor, drooling Fever, dyspnea, stiff neck Cervical LAD | Lateral XR: wide retropharyngeal space at C4, air/fluid level PE: Uvula/tonsil displaced away from abscess | ABCs IV antibiotics ICU admission |
Corynebacterium diphtheriae (gram + rod) - exotoxins MC: first decade of life Sore throat, dysphagia, fever, tachycardia Gray-black membrane - do NOT try to remove | Antitoxin (CDC) | ||
N. gonorrhoeae Asymptomatic or presents like bacterial/viral pharyngitis Tonsillar hypertrophy LAD | IM Ceftriaxone Treat for Chlamydia - Azithromycin | ||
MCC: Candida albicans Cheesy, creamy mucosal plaques | Gram stain Budding yeast with pseudohyphae Can be scraped off | Oral Nystatin (swish & swallow) PO Fluconazole | |
Oral Cancer | Age: 50-60 with PMH of ETOH or smoking SX: weight loss, localized pain Odynophagia, dysphagia, oral mass, LAD, CN involvement | Refer | |
Parotitis | Non-suppurative: paramyxovirus (mumps), influenza A, Coxsackie A, CMV, echovirus, Sjogren’s Suppurative: Staph, strep SX: Pain, swelling, pus from Stensen's duct (parotid) | CT | 1. Clindamycin 2. Cefuroxime, Amox Hydration, warm compress, lemon drops |
- Infectious Mononucleosis (EBV, CMV) - infects B-lymphocytes
- First line treatment for Group A beta-hemolytic strep: PCN
- PCN Allergy: Clindamycin or Erythromycin
- Most common sequelae: post-strep GN, rheumatic heart disease
- Dental abscess treatment - Clindamycin or Augmentin
- Dental caries - most common chronic disease in children
- Most common cause of xerostomia: medications (antihistamines and antidepressants)
- Most common form of glossitis: vitamin B12 deficiency
- Nutritional deficiencies leading to aphthous ulcers: B12, Folate, Iron
- Sialadenitis - most commonly affects the submandibular gland due to stasis of flow of saliva
- Infectious (children, post-op) - most commonly S. aureus, Strep pneumo, E. coli, H. flu
- Obstructive (more common form) - most common in middle-aged men
- Sialolithiasis (mealtime syndrome) - pain and swelling of submandibular gland worse with thought, smell, sight or taste of food
- Ludwig’s Angina - abscess of the submandibular, submental, or sublingual space
- Most common origin: lower second and third molar
- Most common agents: hemolytic strep, staph, mixed anaerobic/aerobic bacteria
- Alveolar osteitis (dry socket) - severe pain, foul mouth odor, and taste several days after tooth extraction
- Most common site affected in oral cancer: lateral ventral tongue
- Oropharyngeal thrush - most common oral manifestation of AIDS
- Epiglottitis - most common in 2-4 year old boys
- Viral pharyngitis - most common cause of pharyngitis
- Most commonly caused by Coxsackie A & B
- Most common viral agents of laryngotracheitis - parainfluenza virus I, II, III
- Most common bacterial agents: S. aureus, Strep. pneumo
- Herpangina - caused by Coxsackievirus group A
- Sjogren syndrome - most common in women 50+
- SX: diminished lacrimal and salivary gland secretion (dry mouth and eyes), salivary gland enlargement, arthritis
- Etiology: lymphatic infiltration of lacrimal/salivary glands
MC: 2-4 y/o boys Etiology: HIB (children) Child: fever, irritable, dysphonia, dysphagia Drooling, inspiratory stridor Adults: recent viral URI, severe pain, dysphagia, drooling, muffled voice | Clinical DX High WBC, neutrophils Lateral view: “Thumb print sign” | ABCs ABX: 3rd Gen Cephalosporin, Unasyn | |
Etiology: M. Cat, H. flu, N. gonorrhoeae Non-infectious: reflux Sudden onset hoarseness, rhinorrhea, cough, sore throat | Self-limiting: 2 weeks Voice rest, hydration Cough suppression - no antihistamines | ||
Chronic Laryngitis | > 2 weeks | Refer |
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