Mouth/Throat Disorders

Mouth/Throat Disorders-


-Acute Pharyngitis-

-Acute pharyngitis is one of the most common conditions encountered in the office practice

-Group A Streptococcus (GAS) makes up about 5-15 percent of the adults presenting with pharyngitis 

-Etiologies include GAS, mononucleosis, CMV, HSV, and many other viruses including influenza

-Non Group A Streptococcus a groups C and G cause pharyngitis but do not cause rheumatic fever

-Diphtheria, Neisseria Gonorrheae, Chlamydia, Mycoplasma,  and Tularemia can cause also

-Symptoms include sore throat, worse with swallowing, headache, malaise, and anterior neck pain form lymphadenopathy

-Exam may reveal pharyngeal erythema, tonsillar hypertrophy, and purulent exudates.  Palate petechiae may be present with lymphadenopathy

-may have hepatosplenomegaly with mono

-Centor Criteria-tonsilar exudate, tender anterior cervical lymphadenopathy, fever, and absence of cough

-The presence of 3 or more Centor Criteria a rapid antigen detection test should be performed (Rapid Strep)

-If there is two or less of the Centor Criteria neither throat culture or rapid strep is necessary

-Other dangerous infections causing sore throat include epiglottis, peri-tonsilar abscess, submandibular space infection, retropharyngeal space infections and primary HIV

-Best to use tylenol or NSAIDS for systemic pain control

-Can use topical lozenges or sprays

-Use of glucocorticoids is controversial 

-Penicillin VK, Amoxicillin or Bicllin CR times one dose treatment of choice

-Can use cephalosporins or macrolides for alternative therapy

-Augmentin for beta lactam resistance

-Aphthous Ulcers-

-aphthous ulcers are also known as canker sores

-they are painful lesions that appear as localized, shallow, round, ulcers with a grayish base

-local cell mediated immunity may be important in pathogenesis

-factors that predispose include trauma, hormonal factors, drug sensitivity, food sensitivity, immunodeficiency, and emotional stress

-also seen in patients with celiac disease or inflammatory bowel disease

-Vitamin and mineral deficiency have been implicated in the pathogenesis

-Treatment includes topical steroids and topical analgesics (magic mouth wash)

-Diseases of the Teeth and Gums-

-Periodontal disease is disease that effect the gingiva, cementum, periodontal ligament and the alveolar bone

-Periodontitis is inflammation of the gingiva and the alveolar bone

-Gingivitis dose not affect the alveolar bone.  It is characterized by inflammation land gingival redness and swelling.  Bleeds easy

-Gingivitis can be provoked by drug or pregnancy.   

-Scurvy is a gingival disease provoked by Vitamin C Deficiency

-Necrotizing ulcerative gingivitis is called trench mouth.  It can cause systemic symptoms, pain, ulcerative necrotic gingiva.  It is associated immune disorders and malnutrition

-Dental infections can cause hematogenous disseminations of the infection and cause to seed native or prosthetic heart valves, joints or other devices

-Dry socket is osteomyelitis of the alveolar bone that can happen after dental extractions

-Dental caries come as a complication of dental decay.  Treated with filling restoration and prevention

-Pulpitis is inflammation of dental pulp from dental decay presents with severe dental pain and temperature sensitivity

-Antibiotics help with local spread of infection and prevent hematogenous dissemination.  

-It is also recommended for patients with prosthetic heart valves and artificial devices that get antibiotic prophylaxis prior to any procedure 

-Usually penicillin VK is recommended or clindamycin

-Epiglottitis-

-Epiglottis is inflammation of the epiglottis and adjacent supraglottic structures

-Can lead to life threatening airway obstruction

-It results from direct spread of the epithelial layer of the bacteria

-Most common cause is Haemophilus Influenzae type B (HIB)

-Can be caused by many other bacteria or even viruses less likely

-The incidence of epiglottis has decreased with the HIB vaccine

-can come from noninfectious causes such as trauma, thermal injury or foreign body ingestion

-can come from fungal causes especially in immunocomprimised hosts

-presents with an abrupt onset of dysphagia, drooling, and respiratory distress.  Also see fever and sore throat

-direct visualization confirms the diagnosis

-on soft tissue neck should see "thumb sign"

-should try to minimize agitation for exam if high index of suspicion.   Have patient intubated in the OR with anesthesia

-Airway maintenance is the most important feature in the treatment of Epiglottis

-Intubation for 2-3 days is usually necessary before the patient can be safely extubated

-the role of glucocorticoids are controversial

-Empiric antibiotic therapy should include ceftriaxone and an anti-staph agent clindamycin or vancomycin

-racemic epinephrine may provide some temporary relief

-Laryngitis-

-Acute laryngitis is a self limited inflammatory condition lasting less than 3 weeks usually associated with a upper respiratory infection or voice strain

-The etiology is usually viral with acute laryngitis 

-Strep Pneumonia, H. Influenzae, and M. Catarrhalis have been isolated in patients with acute laryngitis 

-Acute laryngitis from a URI usually has sore throat, hoarse voice, and runny nose.

-Chronic laryngitis it typically associated with one or more chronic irritants, that cause inflammation

-Oral Candidiasis-

-Also known as thrush

-It is a common infection in infants.  It occurs in adults who wear dentures, treated with antibiotics, radiation therapy, or chemotherapy

-Oral candidia also is seen in those in immunodeficient stats such as HIV

-Can occur with patients taking oral glucocorticoids

-Usual pathogen is candidia alblicans

-Pseudomembrane type or oral candidia is most common and is white plaques on buccal mucosa, palate, and tongue

-The other form is atrophic form also known as denture stomatitis.  Cotton mouth, loss of taste, and pain with eating

-Treatment involves nystatin swish and spit for uncomplicated oral thrush

-Oral Herpes Simplex-

-the herpes simplex virus is spread by direct contact with the epidermis and eventually the sensory and autonomic nerve endings

-the lesions are painful and can last for 10-14 days

-the lesions present as grouped vesicles on an erythematous base

-these are also known as cold sores

-treatment is Acyclovir 200 mg PO five times a day or 400 mg TID

-you can also use Famciclovir 500 mg TID or Valacyclovir 1000 mg BID

-Oral Leukoplakia-

-Oral leukoplakia is a precancerous lesion that is white patches or plaques of the oral mucosa

-It is hyperplasia of squamous epithelium

-It is associated with human papilloma virus (HPV)

-One to twenty percent of these lesions will progress to carcinoma within 10 years

-Smokeless tobacco is a major risk factor

-Oral hairy leukoplakia occurs in HIV patients is not premalignant.  It is caused by the Epstein Barr Virus

-These lesions need biopsied and monitored frequently

-Peritonsillar Abscess-

-Peritonsillar Abscess is a collection of pus between the capsule of the palatine tonsil and the pharyngeal muscles

-Peritonsillar infection is preceded by tonsillitis and progresses to cellulitis to phlegmon to abscess.  

-It can also occur without preceding infection

-Peritonsillar abscess can compromise the upper airway and surrounding structures

-Peritonsillar abscess usually present with sore throat, fever, and a hot potato voice.  Pooling of saliva or drooling may be present. 

-Trismus may be present 

-If there is these is a concern of possible epiglottis or the diagnosis of peritonsillar abscess is not definitive, imaging of the neck must be accomplished.  CT scan with IV contrast of soft tissue neck

-Empiric antibiotics for Group A Strep and Staph aureus and respiratory anaerobes should be accomplished

-Unasyn or Clindamycin is appropriate antibiotic coverage

-If there is no response to therapy or there is airway issues vancomycin should be used also in addition to above antibiotics

-Ultimate treatment for peritonsillar abscess is incision and drainage

-Parotitis-

-Parotitis can be caused by viruses or bacteria
-Bacterial Parotitis is usually caused by Staph Aureus and mixed oral aerobes and anaerobes
-Can occur in the presences of dehydration and poor oral hygiene
-May occur from salivary stasis and retrograde seeding of the Stensen's Duct of the parotid gland with oral flora
-Stensen's duct may also be obstructed with a salivary stone or tumor
-On physical exam it presents as a sudden onset of firm erythematous swelling of the pre and posterior auricular area that extends to the angle of the mandible
-Staphylococcus aureus is the most isolate bacteria
-Imaging studies such as CT scan of soft tissue neck with IV contrast or Ultrasound is helpful to determine if abscess or stone is present
-Treatment is with IV antibiotics.  Naficillin and Metronidazole recommended for immunocompetent patients.
-If patient is immunocompromised, vancomycin plus cefepime or imipenem is recommended






-Silaadenitis-

-typically presents with pain, swelling and erythema in the area of the gland
-there may be pus draining from the affected duct
-may be caused by salivary duct stone
-usually resolves within 7-10 days when treated with antibiotics
-if does not improve may develop an abscess and need to do a CT scan with IV contrast of the soft tissue neck
-dicloxacillin or cephalexin is ideal treatment for staph coverage






-Benign and Malignant Neoplasms of Oral Cavity-

-Squamous Cell Carcinoma of the mouth is associated with ulcers or masses that do not heal with dental changes or poorly fitted dentures

-Tongue and lip cancers present as ulcerative lesions usually painful

-Persistent plaques, ulcers, or erosions should be biopsied

-Melanoma-should be considered on oral pigmented lesions that have irregular borders and asymmetry or increasing diameter.  Surgery is treatment of choice

-Amalgam Tattoos-are blue black macules seen in the gingiva near dental fillings.  Benign lesions.

-Fordyce Spots-benign tumors of sebaceous gland etiology.  These are isolated white to yellow papules prominent on the vermillion and mucosal border

-Mucoceles-fluid filled cavities with mucous glands lining of the epithelium.  These are typically seen after mild oral trauma or disruption of the salivary duct.  Rupture can lead to complete resolution.

Nose/Sinus Disorders

Nose/Sinus Disorders-

-Acute/Chronic Sinusitis-

-Acute Sinusitis is symptomatic inflammation of the nasal cavity and nasal passages lasting less than 4 weeks
-Acute sinusitis is viral etiology and is only complicated by a bacterial etiology about 2 percent of the time
-Usually resolves itself within 7-10 days, even bacterial etiology may be self limiting
-Bacterial sinusitis should be suspected for symptoms lasting longer than 10 days, fever greater than 102 and purulent discharge or facial pain for at least 3 days, and the onset with worsening symptoms following viral URI that last 5-6 days and was improving
-major organisms are S. Pneumoniae, H. Influenza, and M. Cat.
-treatment includes analgesics, saline irrigation, and nasal steroids
-topical decongestants such as afrin should only be used for 72 hours
-antihistamines and mucolytics can provide some symptomatic relief
-Amoxicillin is considered first line in adults
-Augmentin is considered first line in children
-Doxcycline or Levaquin or Avelox are considered appropriate for penicillin allergic patients in adults
-Macrolides and cephalsporins are not acceptable for empiric therapy because of high rates of S. Pneumoniae and H. Influenzae resistance


-Chronic Sinusitis-
-defined as a inflammatory condition involving the paranasal sinuses  is persistent for more than 12 weeks
-4 signs of chronic sinusitis are: anterior or posterior purulent discharge, nasal obstruction, facial pain, and decreased sense of smell
-treatment is directed at controlling symptoms and drainage.  Nasal saline irrigation, topical nasal steroids, and decongestants
-the uses of antibiotics as monotherapy is limited.  The goal of therapy has shifted towards controlling the inflammation
-Leukotriene inhibitors have shown some benefit when used as adjuncts with nasal steroids
-Antihistamines can be helpful
-Surgery is sometimes needed to help clear passages as well as get cultures.  Antifungal treatment is reserved to after cultures obtained




-Allergic Rhinitis-

-Allergic Rhinitis is characterized by paroxysmal sneezing, rhinorrhea, post nasal drip, and nasal obstruction
-there can be concomitant allergic rhinitis
-usually caused by tree pollen, grasses and weeds
-may also be caused by indoor allergens such as dust mites, mold, and animal dander
-on nasal exam may be visible pale bluish hue or pallor along with turbinate edema
-incidence of concomitant sinusitis and allergic conjunctivitis
-50% of children with asthma have allergic rhinitis
-Atopic Dermatitis is another associated condition
-the best treatment is avoidance of allergens
-intranasal steroids are the most effective single maintenance therapy
-For patients with symptoms refractory to intranasal steroids, singulair may be helpful
-antihistamines and combination decongestants can be used
-any underlying infection should be treated for sinusitis




-Epistaxis-

-most of the bleeds are anterior and resolve spontaneously
-90 percent of the nose bleeds occur in the watershed area of the septum called Kiesselbach's plexus
-posterior bleeds result in significant hemorrhage.  These usually require nasal packing, and ENT referral.  Some posterior nose bleeds may need admitted to hospital
-patients who are on warfarin in a therapeutic range, and hemostasis have been obtained are instructed to resume the warfarin
-recurrent posterior nose bleeds may be due to aneurysm of the carotid artery
-epistaxis may be a symptom of nasal neoplasm
-ASA has not been identified as a risk factor for epistaxis
-alcohol may increase the incidence of epistaxis
-airway intervention, fluid resuscitation, and emergent ENT consult may be necessary in a severe nose bleed
-to tamponade the epistaxis the patient blows nose to remove clots and then nares are sprayed with neosynephrine spray or afrin nasal spray.  Then pinch clamp across alae of nose
-the nose can be packed with merocel or rhino-rocket
-bilateral packing may be necessary if does not quit bleeding or bleeds on the other side
-Cautery is the first line for sources that are mild and can be visualized
-you administer prophylactic antibiotics usually keflex or amoxicillin for patients with nasal packing to prevent infection
-Follow up within 48-72 hours with ENT is necessary to remove packing



-Foreign Body (Nasal)-

-Two types of FB can cause damage to nasal structures:  button batteries and paired disc magnets
-Button batteries cause electrolysis at the negative battery pole and generates hydrogen ions that cause an alkaline environment and tissue necrosis
-Paired disc magnets in each nostril can cause prolonged attachment and perforation from chronic compression of the nasal septum
-Most nasal foreign bodies are most commonly located on the floor of the nasal passage just under the inferior turbinate
-Most present without symptoms.  Some will have foul odor, nasal drainage, epistaxis, or nasal obstruction
-Diagnosis is made by direct visualization, most of the time with an otoscope. Rarely need fiberoptic endoscopy
-ENT referral is necessary when there is posterior foreign body, chronic or impacted foreign bodies, penetrating or hooked FB, or any foreign body that cannot be removed during initial attempt
-most foreign bodies are removed with positive pressure techniques or direct instrumentation
-most common complication is bleeding but injury to nasal tissue or perforation possible




-Nasal Polyps-

-nasal polyps are growths inside of the nose and sinuses
-polyps usually occur on both sides of the nose
-nasal steroids are the mainstay of treatment
-patients that fail medical treatment should be considered for surgery if they are symptomatic

Ear Disorders

Ear Disorders-

-Acute Otitis Media-

-Acute Otitis Media-
-clinical diagnosis of acute otitis media requires a bulging tympanic membrane or other signs of acute inflammation and middle ear effusion
-comes usually from an antecedent event such as a viral URI with a colonized bacteria in middle ear, this results in inflammatory edema in the respiratory mucosa of nose, pharynx and eustachian tubes and this obstructs the drainage of the tubes.
-usual pathogens are Strep Pneumonia, Haemophilus influenza, and Moraxella Catarrhalis
-with antibiotic therapy typically symptoms and signs resolve themselves within 24-72 hours
-treated with analgesics ibuprofen or acetaminophen.  Topical benzocaine preparations are alternatives for ear drops except with perforation

-children less than 2 years  of age should be treated with antibiotics regardless
-children greater than 2 years who appear toxic, have an earache for over 2 days, have a temperature over 102.2 in the last 48 hours should be treated with antibiotics
-in addition children with bilateral otitis media or otorrhea should be given antibiotics
-first line therapy is amoxicillin
-augmentin first line if there children have increased risk of beta lactam resistance, antibiotic in the last 30 days or have an concomitant conjunctivitis
-macrolides or cefuroxime, or cefpodoxime, or rocephin are an alternative for those with allergy or hypersensitivity


-Indications for tympanostomy tubes-
-otitis media effusion who are at risk of speech, language or learning problems
-persistent otitis media with effusion with a hearing loss over 40 decibels
-bilateral otitis media for greater than 3 months or unilateral otitis media for greater than 6 months
-recurrent episodes of otitis media with a cumulative duration of greater than 6 months over a 24 month span.


-Chronic Otitis Media-
-it is a recurrent infection of the middle ear and/or mastoids in the presence of tympanic membrane perforation
-usually have decreased acoustic acuity, otorrhea, otalgia, and may have vertigo
-Cholesteatoma, keratinized tissue in the middle ear or mastoid, can occur as a primary lesion or secondary to tympanic membrane perforation
-chronic serous otitis media is characterized by continuous serous drainage that is straw colored
-duration is controversial ranging from 2 weeks to 3 months
-usually comes from eustachian tube dysfunction (URI or allergic rhinitis)
-pseudomonas and staphylococcus aureus are the most common isolated organisms.  Fungi can cause
-treatment is focused at stopping otorrhea, healing tympanic membrane and eradicating infection
-topical antibiotic are first line treatment with uncomplicated otorrhea, topical floxacin or vigamox
-systemic antibiotics should be considered for patients at risk for invasive ear infections or failed therapy with topical antibiotics.   Imipenem is the most effective
-may require surgery if above fails




-Acoustic Neuroma-

-also known as vestibular schwannoma
-these are tumors that arise from the vestibular portion of CN VIII
-symptoms associated can be due to cranial nerve involvement, cerebellar compression or tumor progression
-major symptoms include hearing loss, tinnitus, unsteady gait, true vertigo is uncommon
-trigeminal nerve impingement can cause paresthesia, pain, and hyperesthesia
-facial nerve impingement can cause facial paresis, and taste disturbances
-large tumors can but pressure on the posterior fossa and adjacent structures causing ataxia
-bilateral acoustic neuromas should lead clinician to suspect neurofibromatosis
-MRI is the imaging study of choice
-treatment options are surgery, radiation, and observation


-Barotrauma-

-barotrauma to the middle ear can happen when there is pressure difference between the outside world an inside of the middle ear.
-pressure can be increased with eustachian tube dysfunction or something obstructing the eustachian tube
-the pressure differences distort the tympanic membrane and can cause discomfort, hearing loss or perforation
-eustachian tube dysfunction etiologies include URI, otitis media, or allergic rhinitis
-barotrauma can happen from flying, diving, or blast injuries
-presenting symptoms and signs are pressure in the ear, hearing loss may occur
-may cause vertigo or tinnitus
-best treatment is prevention.  Analgesic can help.  Antihistamines, nasal sprays decongestant may help decrease obstruction from the eustachian tube
-antibiotics orally should only be used with the middle ear is contaminated with perforation



-Cholesteatoma-

-Cholesteatoma is a keratinized tissue in the middle ear that occurs as a primary lesion or can be from TM perforation
-patients may be asymptomatic or have combinations of hearing loss, dizziness, or otorrhea
-diagnosis is made by visualization
-gram stains and cultures should be obtained if they fail standard topical therapy
-if there is no response to medical therapy biopsy should be obtained


-Eustachian Tube Dysfunction-

-eustachian tube dysfunction is a failure of the functional valve of the eustachian tube to open and or close properly
-eustachian tube dysfunction can come from pressure dysregulation, impaired protective function, and diminished clearance
-functional obstruction is most commonly from mucosal inflammation with edema and secretions inhibiting valves ability to open and close
-there can be negative pressure within the eustachian tube from usual circumstances of diving or air travel
-a dull bluish gray or yellowish discoloration can denote an effusion
-can tray decongestants and nasal spray but no study has demonstrated consistent efficacy
-surgery is only indicated when medical management fails




-Ear Foreign Body-

-successful removal of foreign bodies requires appropriate local anesthesia or may even require procedural sedation for more difficult foreign bodies
-local anesthesia mainly necessary for removing foreign bodies from the pinna
-proper restraint, good lighting, and appropriate instruments are needed for removal
-infection of the cartilage should be treated with antibiotics.  Pseudomonas is the main pathogen.  MRSA should also be considered.  Cipro in adults.  Parenteral antibiotics with vancomycin or clindamycin and cefiazidime)
-insects in the EAC should be killed with mineral oil, ethanol, or lidocaine prior to removal
-can irrigate ear for smaller objects unless tympanostomy tubes or perforated tympanic membrane or removal of vegetable matter or button batteries
-can try to remove with mosquito forceps under direct visualization
-have low threshold for referral to ENT especially for high risk for TM perforation or EAC laceration



-Hearing Impairment-

-Hearing loss is classified into 3 types:  sensorineural, conductive, or mixed
-Sensory:  involves the inner ear, cochlea, or the auditory nerve
-Conductive:  involves limiting the amount of external sound gaining access to the inner ear (cerumen impaction, middle ear effusion, or lack of movement of the small bones of the inner ear
-Mixed:  a combination of sensory and conductive hearing loss
-Weber Test-pressing the handle on the tuning fork to the bridge of the nose, forehead, or teeth and asking the patient if the sound is louder in one ear than the other
-Weber test is normal if heard in both ears equally
-Rhinne test- tunning fork is placed on mastoid bone versus when it is held near the ear.  Its abnormal when the sound is at least equally loud or louder when the fork is placed on the bone as compared when it is by the ear (bone>air conduction)
-Rhinne test normal when the air conduction > bone conduction

-Weber and Rhinne help decide if sensory or conductive hearing loss
-Weber test the sound is louder on the good side and less on the bad side (conductive hearing loss)
-If the Weber test goes to an ear and the Rhinne is normal, and if there is a normal Rhinne test in the other ear, sensory hearing loss is implied.  Audiogram should be preformed.


-If had conductive hearing loss, should have otoscopy to determine if cerumen impaction or reason for conductive hearing loss

-Etiologies of hearing loss:  congenital, trauma, infection, tumor, exostosis, polyps, osteoma, cerumen, systemic disease, and dermatologic (psoriasis can cause scaling and edema of the EAC and meatus), ototoxic ingestion of substances

-Presbycusis- age related hearing loss

-Hearing aids helpful for bilateral sensory hearing loss or long term conductive hearing loss
-Cochlear implants are good for children with profound bilateral hearing loss who do not benefit from traditional amplification

-Surgery is indicated for surgically correctable causes



-Hematoma of the External Ear-

-ear hematomas typically comes from blunt trauma during sports
-this injury requires prompt drainage to his ear and measures to prevent reaccumulation of blood
-cauliflower ear is the permanent deformity caused by fibrocartilage overgrowth that occurs when an auricular hematoma is not fully drained or reoccurs
-all auricular hematomas should be drained as soon as possible after the injury



-Labyrinthitis-

-labyrinthitis is characterized by a sudden onset of severe, persistent vertigo, nausea, vomiting and gait problems.
-on physical exam there is vestibular imbalance, nystagmus, and a positive head thrust
-there is unilateral hearing loss with this.  If there is no hearing loss it is vestibular neuritis
-it is a post viral inflammatory disorder of the eighth cranial nerve
-clinical features of cerebellar infarction or bleeding are similar so brain MRI or CT is required to rule out
-can treated vertigo with antivert, Ativan or valium
-condition will be self limiting
-physical therapy can help preserve vestibular function



-Mastoiditis-

-acute mastoiditis is the most common suppurative complication of otitis media
-it is defined as a suppurative infection of the mastoid air cells
-defines as acute if it is less than one month in duration
-most common pathogen is Streptococcus pneumoniae
-pseudomonas should be considered for recurrent with recurrent otitis media and ruptured tympanic membrane
-antibiotic therapy and drainage of the middle ear and mastoids are cornerstones of therapy
-vancomycin and cefazidime are recommended for empiric therapy for mastoiditis
-diagnosis can be confirmed with CT scan or MRI



-Meniere's Disease-

-Meniere's disease arises from abnormal fluid an ion homeostasis in the inner ear
-syndrome causing episodic vertigo, tinnitus, and hearing loss
-usually presents between the ages of 20-40
-it is associated with endolymphatic hydrous and distention of the labyrinthine system
-clinical diagnosis.  Definitive diagnosis is only made postmortem
-MRI indicated to rule out CNS etiology that may mimic Meniere's disease
-management is geared at improving quality of life and management of symptoms
-anti-emetics and antivert helps with symptoms.  Valium or ativan can help with vertigo also



-Otitis Externa-

-otitis externa refers to inflammation of the external auditory canal
-can be infectious, allergic, or dermatologic related
-also called swimmers ear
-risk factors include swimming or other water exposure, trauma from aggressive cleaning, wearing ear devices
-allergic contact dermatitis can lead to otitis externa
-dermatologic conditions such as psoriasis or atopic dermatitis can can cause otitis externa
-Staphylococci are the most common organisms
-Clinical features of otitis externa are ear pain, purulent drainage, discharge and hearing loss
-there is pain with movement of the tragus and or pinna
-rarely can be fungal in etiology
-cultures are reserved for patients with severe otitis externa
-the removal of cerumen, desquamated skin and purulent material aids in the penetration of the drops
-Cipro and Oflaxacin ear drops are excellent and provide coverage of the main pathogens staph aureus and psuedomonas
-Cortisporin provides great coverage also
-wick placement is for when canal is swollen shut to allow for better penetration of drops



-Tinnitis-

-Tinnitus is the perception of sound in proximity to the head in the absence of an external source
-Can be in one or both ears
-Tinnitus can be described as a ringing, hissing or buzzing
-Can be continuous or intermittent
-Can be triggered anywhere along the auditory pathway
-Most patients have sensorineural tinnitis due to hearing loss at the cochlear nerve level
-Pulsatile tinnitus is most commonly due to a vascular etiology
-arterial bruits near the temporal bone may transmit sounds and cause tinnitus
-congenital AV malformations can be associated with hearing loss or tinnitus
-paragangliomas are benign tumors that can cause tinnitus
-Venous hums from systemic hypertension and increased ICP (sometimes due to pseudotumor cerebri) can cause conductive hearing loss and cause tinnitus
-eustachian tube dysfunction can cause tinnitus and also somatic disorders
-also ototoxic medications and vestibular schwannoma (tumor compressing on cochlear nerve)
-treatment of tinnitus involves treating or correcting the etiology



-Tympanic Membrane Perforation-

-perforated tympanic membranes are caused by middle ear infections, barotrauma, or the patient is poked with a sharp object
-patients can range from no symptoms to, ear pain, ear pain that quickly resolves, otorrhea, tinnitus, or hearing loss
-treatment involves oral and topic ear antibiotic drops if caused by an infection
-usual treat involves amoxicillin and floxin ear drops and analgesics
-should be referred to ENT to make sure TM heals properly
-need to wear ear plugs to ensure no water makes it into the middle ear when showering or bathing





-Vertigo-

-Vertigo is a symptom that the patient is moving.  It is a sense of swaying, tilting, or spinning
-Vertigo happens because of asymmetry of the vestibular system due to damage of the labyrinth, vestibular nerve, or central vestibular structures of the brainstem
-Benign Paroxysmal Positional Vertigo -tends to have recurrent brief episodes of vertigo, predictable with head movements or positions, will have no auditory symptoms and have a positive Hallpike maneuver
-Vestibular Neuritis- usually has a single episode that last for days, viral syndrome may accompany or precede symptoms, nystagmus fall toward the side of lesion.  Head thrust is abnormal
-Meniere's Disease-has recurrent episodes that last several minutes to hours.  This has episodes of ear fullness or pain with unilateral hearing loss or tinnitis.
-Migranous Vertigo-will have recurrent episodes last several minutes to hours, history of migraine, may have a nystagmus with central or peripheral characteristics.  Tests are usually normal
-Vestibular TIA-single episode lasting minutes to hours, central nystagmus, usually older patient, MRI may show lesion
-Cerebellar Infarction or Hemorrhage-sudden onset of symptoms over days to weeks, older patient, central nystagmus, trouble walking, CT/MRI will show lesion
-history and physical is the best tool for determine the etiology, but imaging is required to exclude life threatening or more severe causes.
-Treatment is directed at determining the etiology.  If correctable cause, it needs to be corrected.
-Antivert, valium or ativan good for managing vertigo on as needed basis.
-May need physical therapy if debilitating symptoms

Eye Disorders

Eye Disorders-

-Blepharitis-

-Blepharitis is characterized by inflammation of the eyelids

-There is anterior and posterior blepharitis

-Anterior is characterized by inflammation of the base of the eyelashes.  Less common than posterior

-Posterior is characterized by inflammation of the inner portion of the eyelid, at the level of the meibomian glands.  

-can cause colonization of staphylococcal organisms

-can be associated with Rosacea and Seborrheic Dermatitis

-typically patients will have red eyes, a gritty sensation, excessive tearing, eyes may burn, swollen erythematous eyelids, crusting, and photophobia.

-lid hygiene is important for treatment

-warm compresses can be helpful

-topical antibiotics such azithromycin, erythromycin, or bacitracin may be helpful in reducing bacterial load of the lashes

-oral antibiotics such as tetracycline for severe cases of blepharitis

-Blowout Fracture-

-blowout fractures of the eye are fracture of the floor of the orbit

-typical mechanism is getting hit with a round object

-may causes entrapment of the inferior rectus muscle

-ischemia may cause loss of the muscle function and result in edema or hemorrhage of the muscle

-enophthalmos (the eyeball receded into the orbit) may develop when the globe is displaced posteriorly

-injury to the inferior orbital nerve may result from this causing sensory loss in that distribution

-Cataract-

-leading cause of blindness in the world

-it is an opacity in the lens of the eye that can cause total or partial blindness

-embryonic development and lifelong growth of the lens produce a complex layering of cells

-the lens does not shed its nonviable cells and this causes degenerative effects on its own cell structure leading some opacity problems

-risk factors for acquired cataracts are:  age, smoking, alcohol, sunlight, metabolic syndrome, diabetes, statins, and long term use of high dose steroids

-no convincing evidence that vitamin supplementation decreases incidence

-only treatment is surgical correction

-Chalazion-

-Chalazion is an inflammatory lesion that develops when the meibomian tear gland becomes obstructed

-may first present as eyelid swelling and erythema, then evolve to a nodular rubbery lesion

-commonly seen in patients with blepharitis and rosacea

-antibiotics are not indicated

-frequent hot compresses are effective
-most of the time not painful or tender

-symptomatic patient can be referred to ophthalmology for incision and curettage or steroid injection

-Conjunctivitis-

-conjunctivitis is inflammation of the conjunctiva.  Can be infectious or non infectious

-conjunctiva is usually transparent and gets red when inflamed

-infectious can be viral or bacterial

-non infectious can be allergic or non allergic

-bacterial typically caused by strep pneumonia, staphylococcus aureus, haemophilius influenzae, and moraxella catarrhalis 

-can be caused by neisseria gonorrheae and chlamydia

-viral is usually adenovirus

-allergic conjunctivitis is caused by airborne allergens contacting the eye that cause mast cell degranulation

-itching is the cardinal symptom for allergic conjunctivitis

-can be non allergic from chronic dry eye

-contact lens wearer need to throw away contacts and irrigation solution and case

-bacterial conjunctivitis include erythromycin ointment or polytrim drops.  

-Can also use sulfacetamide, azithromycin drops or bacitracin ointment

-Ciloxin needed for contact lens wears in bacterial conjunctivitis because of pseudomonas prominence

-for allergic conjunctivitis can use OTC decongestants, antihistamines, and patanol.

-students must receive topical therapy 24 hours before returning to school

-Corneal Abrasion-

-usually result from trauma to the eye or from improper contact lens use
-diagnosis is made with slit lamp exam and fluoroscein dye exam
-treatment consists of topical antibiotics (drops or ointment) and oral pain medication
-most corneal abrasions heal within twenty-four hours after the accident
-patients present with photophobia, pain and foreign body sensation
-if a foreign body is detected can be removed with irrigation or swab after instillation of topical anesthetic
-superficial foreign bodies can be removed with a twenty five gauge needle or foreign body spud
-no patching of the eye




-Corneal Ulcer-



-corneal ulcers tend to be round on fluoroscein staining but are typically evident as a white spot on penlight or direct inspection
-diagnosis is made similar to a corneal abrasion with slit lamp and staining
-treatment is similar
-cover for herpes if there is any suspicion or if dendrites evident
-refer to ophthamology



-Dacrocystitis-

-dacrocystitis is caused by nasolacriminal duct being blocked
-can occur anywhere in the nasolacriminal duct system but mostly occurs at the distal end of the duct
-first line of treatment is massaging the tear duct
-probing may need to be done by an ophthalmologist
-acute dacrocystitis should be treated with antibiotics
-common organisms include alpha hemolytic strep, staph epidermis, and staph aureus
-coverage with clindamycin, doxycycline, or bactrim is helpful
-vancomycin is needed for more severe infection
-can lead to peri-orbital cellulitis



-Ectropion-

-Defined as an eversion of the eyelid away from the globe
-Frequency increases with age
-left untreated can cause dry eye and inflammation and damage the eye
-artificial tears should be used to treat dryness
-surgical treatment is directed at the etiology



-Entropion-

-Entropion is the turning in of an edge of an eyelid
-It usually is seen on the lower eyelid.
-trachoma an infection seen in the lower eyelid can cause
-trachoma can cause blindness but rarely seen in the US
-artificial tears should be used to help with dryness
-surgery is usually needed to correct condition

-Foreign Body-

-Diagnosis is by gross examination, slit lamp exam and fluoroscein stain
-Slit lamp exam necessary to help determine the depth and position
-eyelids should be everted to look for residual foreign body
-attempt at foreign body removal can be made after topical anesthesia eye drops applied
-can be made with swab, 25 gauge needle, or eye-burr
-referral should be made to eye doctor if cannot be removed the same day or to ensure proper follow up
-no contact lenses until further instruction
-sit in a dark room, sunglasses to help with photophobia
-rust ring will need to be removed also with metal
-treated otherwise the same as corneal abrasions with eye drops or ointment



-Glaucoma-

-Glaucoma is a group of eye disorders that has elevated intra-ocular pressure (IOP)
-open angle glaucoma is an optic neuropathy that has a progressive peripheral visual loss followed by a central field loss, not always having increased IOP.  Has cupping of the optic nerve
-acute closure glaucoma is characterized by closure of the anterior chamber angle and the aqueous humor cannot drain.  This leads to increased IOP and damage to the optic nerve.  It presents as a painful red eye that has to be treated within 24 hours to prevent blindness
-glaucoma can be secondary to uveitis, trauma, steroid therapy, vasoproliferative retinopathy, or ocular syndromes.
-glaucoma can be mixed
-the current evidence shows that lowering elevated IOP in glaucoma betters clinical outcomes
-screening only by IOP is inappropriate because pole with open angle glaucoma can have normal IOP
-IOP greater than 40 should dictate an emergency referral especially if symptomatic
-treatment with Xaltan drops



-Hordeolum-

-a hordeolum (stye) is a painful red lump on the eyelid
-it happens when a gland on the edge of the eyelid gets inflamed
-most styes get better on their own after a few days
-a stye caused by an infection and is painful
-warm compresses are the mainstay of treatment
-also treatment with antibiotic eye ointment or drops



-Hyphema-

-a hyphema is blood in the anterior chamber of the eye.  Usually caused by trauma
-can result in permanent vision loss
-early intervention by an ophthalmologist can decrease the likelihood of recurrent bleeding and avoid intraocular hypertension
-slit lamp exam necessary to look for micro hyphema
-emergent imaging is necessary if an open globe is suspected
-patients on anticoagulants or blood dyscrasias need labs including CBC and coagulation studies
-emergently limit bathroom privileges, keep head elevated to 30 degrees
-cycloplegia may help with pain control.  Or oral analgesics
-patient likely will need surgical intervention to correct it





-Macular Degeneration-

-Macular degeneration is a degenerative disease of the central portion of the retina (macula) that results in central vision loss
-it is the leading cause of adult blindness and severe visual impairment
-there is wet (neuromuscular or exudative) and dry (atrophic) macular degeneration
-you can see sub retinal drusen deposits with dry macular degeneration
-large soft drusen spots or RPE pigmentary clumping increases with wet macular degeneration
-risk factors include age, smoking, family history, diet, and cardiovascular disease
-central vision loss is affected
-treatment of macular degeneration is targeted at type but can involve risk factor modification, antioxidant vitamins and zinc, and laser surgery



-Nystagmus-

-Nystagmus is a twitching of the eye
-the two major types of nystagmus are jerk and pendular nystagmus
-types of jerk nystagmus are downbeat, upbeat, horizontal, torsional, and mixed
-the direction named is the direction of the fast phase
-other nystagmus come out during certain conditions peripheral gaze and positional
-jerk nystagmus are the result of asymmetry in vestibular input in the central or peripheral nervous system
-pendular nystagmus has sinusoidal oscillation without fast phases
-pendular nystagmus may occur in any direction and can sometimes only be on one eye
-Differential diagnosis included structural lesion, metabolic derangement, infections, and intoxications
-four types of therapy include: medications, botulinum injections, prism lenses, and surgery
-therapy is targeted at specific type
-baclofen and neurontin good for specific forms of nystagmus
-surgery is reserved for certain types mainly congenital nystagmus




-Optic Neuritis-

-optic neuritis is an inflammatory, demyelinating condition that causes acute, usually monocular vision loss.
-optic neuritis is highly associated with multiple sclerosis
-it is the presenting symptom in 15-20 percent of MS cases
-usually monocular when presents, but can occur in both eyes 10 percent of the time
-vision loss develops over hours to days.   Eye pain is usually present
-an afferent pupillary defect is present if the other eye is otherwise healthy
-the visual field defect is typically characterized with a central scotoma
-loss of color vision sometimes happens
-Papillitis with hyperemia and swelling of the optic disc and blurring of the disc margins is seen in optic neuritis
-optic neuritis can have infectious and non infectious etiologies also
-diagnosis is made by fundoscopic exam
-MRI can be helpful in the diagnosis and LP can by used for atypical cases
-treated with high dose steroids



-Orbital Cellulitis-

-orbital cellulitis is an infection that involves the fat and muscles around the orbit
-preseptal or periorbital cellulitis is an infection of the anterior portion of the eyelid
-infections do not effect the globe
-preseptal cellulitis is usually mild and almost never causes any serious complications
-orbital cellulitis can cause loss of vision or loss of life
-orbital cellulitis can cause ophthalmoplegia, pain with eye movements, and proptosis
-Imaging studies can be helpful to establish the diagnosis, CT or MRI
-orbital cellulitis is an uncommon complication of bacterial sinusitis
-other causes of orbital cellulitis are eye surgery, peri-bulbar anesthesia, orbital trauma with fracture or foreign body, dacrocystitis, dental infections, otitis media, or infected mucocele that erodes into the orbit
-fungal etiologies and TB are rare causes
-most common bacteria are streptococcus aureus and streptococci
-the infection can be complicated with an abscess, vision loss, cavernous sinus thrombosis, and brain abscess
-empiric treatment with vancomycin and rocephin or unasyn or zosyn



-Papilledema-

-papilledema is a swollen optic nerve secondary to an increased intracranial pressure
-cause of papilledema include:  intracranial mass lesions, cerebral edema, increased CSF production (pseudotumor cerebri), decreased CSF reabsorption, obstructive hydrocephalus, obstruction of venous outflow (venous sinus thrombosis, and jugular vein compression)
-Papilledema is usually bilateral
-may have headache, nausea, vomiting, and blurry vision out of affected eye
-MRI of brain and Lumbar Puncture with opening pressure helpful for determining etiology
-Treatment is directed at the etiology.  If pseudotumor cerebri is the cause diamox is helpful


-Pterygium-

-pterygium is a triangular wedge of conjunctival tissue that usually starts medially on the nasal conjunctiva and extends laterally onto the cornea
-classified a a corneal degenerative disorder
-may be a more proliferative condition with possible exacerbating factors of UV light, abnormal conjunctival tumor suppressor gene, presence of angiogenesis related factors, HPV infection, or abnormal HLA expression
-gets its name because looks like an insect wing
-usually occurs over months to years
-usually just observe unless causes visual impairment
-may induce an astigmatism (defect in the cornea)
-dryness can be treated with artificial tears
-surgery should be avoided for cosmetic reasons alone
-surgery should be done to correct a visual impairment or astigmatism that is induced



-Retinal Detachment-

-Retinal detachment happens when the multilayer retina separates from the underlying retinal pigment epithelium from the choroid
-this may occur passively due to accumulation of fluid between these two layers
-may also be due to vitreous traction of the retina, with diabetic traction retinal detachment
-separation of the retina results in ischemia and rapid progressive photoreceptor degeneration
-without treatment, most symptomatic retinal detachments involve the entire retina and will lead to loss of vision
-can be traumatic in etiology also
-risk factors include myopia, cataract surgery, PVD, ocular trauma, diabetes, and family history of retinal detachment
-patients typically complain of increasing number of floaters in one eye
-floaters may resemble a cobweb
-patients may notice a flash of light
-patients who present with a sudden onset of floaters, flashes of light, and monocular decreased visual acuity of field loss should be seen urgently by an ophthalmologist.
-diagnosis is made by fundoscopic exam
-treatment is dependent on type but is often corrective surgery



-Retinal Vascular Occlusion-

there are 3 main groups of retinal occlusion branch retinal vein occlusion, central retinal vein occlusion, and hemiretinal vein occlusion
-it is the second most common cause of vision loss from retinal vascular disease behind diabetic retinopathy
-risk factors include age, hypertension, diabetes, smoking, hypercoagulable states, glaucoma and retinal arteriolar abnormalities
-some patients are asymptomatic diagnosed on routine fundoscopic exam
-symptomatic patients may have scotoma or visual field defect with blurred or gray vision.  If the macula is involved, they complain of blurred central vision
-patients who undergo neovasuclarization of the anterior chamber may acquire glaucoma
-eye exam should entail extra ocular movements, intraocular pressure, pupillary function, confrontation visual fields, slit lamp exams, visual acuity and dilated fundoscopic exam
-patients with branch and central retinal vascular occlusion should have retinal hemorrhage and edema, in addition to dilated retinal veins
-cotton wool spots are observed in approximately half of patients with central retinal vascular occlusion
-Fluorescein angiogram aids in the diagnosis
-Optical coherence tomography allows for high resolution cross sectioning of the retina
-in the absence of macular edema or neovascularization, there is no evidence that treatment improves outcomes and can be associated with sequela
-treatment when there is neovascularization and macular edema can involve laser photocoagulation, and medical therapy with vascular endothelial growth factor inhibitors or intravitreal glucocorticoids




-Retinopathy-

-diabetic retinopathy may cause vision loss by macular edema, hemorrhage from new vessels, retinal detachment, or neovascular glaucoma
-diabetic retinopathy has two types non proliferative (no new blood vessels) and proliferative (has new blood vessels)
-non proliferative retinopathy has nerve fiber layer infarcts (cotton wool spots), intra-retinal hemorrhages, hard exudates, and microvascular abnormalities
-proliferative retinopathy has neovascularization arising from the disc or retinal vessels, vitreous hemorrhages, fibrosis, and traction retinal detachment
-macular edema can occur at any stage of diabetic retinopathy
-the majority of patients who develop diabetic retinopathy have no symptoms until very late stages and can be too late for effective treatment
-the best treatment is prevention and control of diabetes and risk factor modification
-more rigorous control of blood pressure slows the rate of progression of diabetic retinopathy
-surgical intervention is helpful for certain stages and types of diabetic retinopathy



-another type of retinopathy, Retinopathy of Prematurity occurs in the retina of preterm infants with incomplete retinal vascularization.
-It is the most common cause of childhood blindness in the US
-the rate of retinopathy of prematurity increases with decreased gestational age
-risk factors include low birth weight, low gestational age, ventilation for greater than 7 days, surfactant therapy, high blood transfusion volume, hyperglycemia, fluctuations of blood gas measurements, and insulin therapy
-treatment consists of ablation of the peripheral avascular retina with laser therapy


-other forms of retinopathy include hypertensive retinopathy and atherosclerotic retinopathy caused by hypertension and atherosclerosis
-treatment is directed risk factor modification



-Strabismus-

-strabismus is used to describe an anomaly of ocular alignment
-can occur in one or both eyes in any directs
-a latent strabismus is only present when the fixation is interrupted
-cranial nerve IV (trochlear nerve) innervates the superior oblique muscle, the lateral rectus muscle is innervated by the abducens nerve (cranial nerve VI) and the others by cranial nerve III (oculomotor)
-causes of strabismus include idiopathic, infantile esotropia, intermittent exotropia, and other congenital syndromes
-other secondary causes include retinoblastoma, optic nerve hypoplasia, macular scars, head trauma, cranial nerve palsies, orbital fracture, myasthenia gravis, and Graves Disease
-a trial of medical and physical therapy may precede surgical intervention in some cases of strabismus