NPLEX Combination ReviewEENT - 1

Paul S. Anderson, ND

Medical Board Review Services

Copyright MBRS

Otitis:

• Externa– Ear and Canal inflammation and infection

• Media– Tympanic Membrane and Middle Ear

• Interna– Inflammation and infection affecting the

internal structures (Cochlea and Vestibular apparatus)

• The normal TM should show the ‘cone of light’ from the otoscope, anatomy should be clear and there should be no bulging or retraction of the membrane

• Perforation can be partial (above) or complete• Tympanosclerosis can be secondary to repeat

infections, perforations and age.

• Serous effusion shows bubbles or a fluid line. It is often associates with poor drainage of the auditory tubes and middle ear and can set up an excellent media for bacteria to grow.

• Otitis Media with Effusion (OME) is an infectious process with bacterial overgrowth in the middle ear.

• Bullous Myringitis is a vesicular infection ON the TM. It is considered viral in most cases, although Mycoplasma infection can be associated with this finding.

• ** All these presentations can have sequele of TM rupture.

Conduction = Can’t transmit sound waves

Sensorineural = Can’t neurologically process the sound waves

Pharyngeal and Tonsil Abnormalities

• Tonsillitis– Tonsil inflammation (lymphatic tissue)– Recall the three tonsillar tissues

• Lingual• Palatine• Pharyngeal (‘Adenoid’)

• Pharyngitis– Inflammation of the pharynx and potentially tonsillar

tissues• Abscess

– Dangerous infections in deeper tissues

Tonsillar Swelling Grades

• Grade 0 = no swelling or flat, • Grades 1,2,3,4; Each is equal to 25% of the oropharyngeal opening• At Grade-4 the tonsils touch in the center

Midline (Grade-4) Grade-3 Grade-2 Grade-1

Centor Criteria for Group-A Beta Hemolytic Strep

• Presence of tonsillar exudates: 1 Point

• Tender anterior cervical LA: 1 Point

• Fever by history: 1 Point

• Absence of cough: 1 Point

• Age under 15 years, add: 1 Point

• Age over 45 years, deduct: 1 Point

Med Dec Making.,1981;1:239-246

CMAJ 1998;158(1):75-83

Thyroglossal Duct CystsPhotos courtesy of Bechara Y. Ghorayeb, MD – Houston, TX

Thyroglossal duct cysts are remnants of the embryonic thyroglossal duct that may occur anywhere from the base of the tongue to the thyroid gland.  The majority, however, are found at the level of the thyrohyoid membrane, under the deep cervical fascia.  They are midline or just off the midline, and move up and down upon swallowing

Branchial Cleft CystsThe most common congenital cyst formation in the neck.

UPPER RESPIRATORY DISEASE• Infectious Rhinitis: common cold viruses• Allergic Rhinitis: hay fever, IgE mediated• Chronic Rhinitis: superimposed bacterial infection on other two• Acute Sinusitis:

– usu preceded by rhinitis, usu mixed normal flora; – can spread into orbit or penetrate bone osteomyelitis

• Laryngitis: alone or as part of generalized resp. infection; mb associated with smoking > carcinoma

• Epiglottitis: potentially lethal – immediate ER referral.– H. influenza or beta hemolytic strep; – children, sudden swelling of epiglottis & vocal cords,, toxic, drooling child. – Don’t open their mouth; – “STEEPLE SIGN” on X-Ray

• Laryngeal cancer: tobacco smoke; 30-50% have metastasis at dx• Polyps: reactive nodes that rarely become cancerous; vocal cords of heavy

smokers or singers, men, • Leukoplakia of Larynx: any hyperkeratotic lesion,

– mb benign or malignant, depends on how much atypia present; – strongly correlated with tobacco & alcohol

Ear Complaints:• AOM / OME

– Infectious– Not always an indication for ABX– Drainage / mucolysis is indicated

• SOM– Provides basis for many OME cases– Drainage / mucolysis is indicated

• Bullous Myringitis– Viral (possibly Mycoplasma Bacteria)– Generally an indication Not to ABX Tx

• Retraction– Pressure in ext –vs- int ear is imbalanced.– Cause of dizziness, especially if retraction is uneven, R to L

Ear Complaints• Mucolytics

– NAC at HIGH doses may help (?) 2-3 grams tid– Guiafenasen at 600 mg bid works well– Steam with eucalyptus

• Decongestants– Sympathomimetics

• Pseudoephedrine• Ephedra

• Physical Medicine– Warming throat compresses– Nasosympatico– Pharyngeal massage with bitter orange (endonasal)– Upper cervical manipulation and massage– Hypertonic Saline ear lavage

• Herbs– Berberines– Mullen and Garlic topically

• Antibiotics– Generally Penicillins and Macrolides– Fluoroquinolones some times– Macrolides and Tetracycline's for Mycoplasma’s

Work up of dizziness / vertigo• Physical Examination

– BP / Vitals– Neuro Exam– HEENT– Chest and Abdomen Screening

• MRI– All recurrent cases– All acute cases with no peripheral explanation

• CT: Sinuses• Labs:

– Chemistry / CBC / RBC Element Profile

The “Red Eye”

• What findings should you key in on?– Pattern of injection

• Conjunctival, Ciliary or Hemorrhagic

– Level of (or presence of) PAIN• Is it constant, with blinking, on eye movement

– Visual Disturbance– Presence of or Level of Photophobia

• What are your common differential diagnoses?– Conjunctivitis

• Viral, Bacterial, Allergic, Toxic

– Conjunctival Hemorrhage– Keratitis (Corneal Irritation)– Corneal Injury

• Abrasion, Ulcer, Puncture

– Iritis / Uveitis– Scleritis– Acute Glaucoma Attack

Cornea and Conjunctiva

Cornea

Conjunctiva

sclera

Conjunctival art’s

Limbal Br. Of the Conjunctival art.

Anatomic basis of “ciliary flush” injectionThe ophthalmic artery also gives off the ciliary arteries, which divide into the anterior, short posterior, and long posterior ciliary arteries. The anterior supply the rectus muscles and form the posterior conjunctival arteries. The short posterior supply the bulk of the choroid. The long posterior pass forward to supply the ciliary body and the iris.

The long posterior also anastomoses with the limbal branches of the posterior conjunctival arteries, forming the vascular basis of ciliary injection (flush) in inflammatory conditions of the uveal tract and anterior chamber.

Non-ciliary flush (for comparison.)

Red Eye

Know the difference between Conjunctival and Ciliary Injection

Red EyeViral Conjunctivitis:

Red EyeAcute anterior uveitis with plasmoid aqueous and

hypopyon in a patient with ulcerative colitis.

                                    

Red EyeAcute angle-closure glaucoma with corneal clouding and diffuse conjunctival injection

Angle Closure GlaucomaAcute or chronic angle closure –

The fluid drain becomes blocked. The anterior chamber is shallow, the filtration angle is narrowed and the iris may obstruct the entrance of the canal of Schlemm or the pupil may become blocked. It is rare.

 

Symptoms:

Unilateral, severe pain and rapid loss of vision, possibly accompanied by nausea & vomiting.

Prodromal symptoms may present as transitory episodes of diminished visual acuity, colored halos around lights and pain in eye and head.

Signs:

Hazy cornea (Hypopion), fixed mid-dilated pupil, eye is usually firm to palpation

 

OTHER Types:

Secondary – from pre-existing ocular diseases such as uveitis, intraocular tumor or enlarged cataract. Prolonged corticosteroid use can produce an increased pressure.

 

Absolute – Last stage of any uncontrolled glaucoma.

Orbital Cellulitis

• Inflammation and potential infection around the eye, extending to the retrobulbar space. – Dangerous, as this space communicates with

the cranial cavity. Infection can spread quickly and easily to the brain.

– Hallmarks are systemic signs and symptoms of infection, and lid / EOM dysfunction.

• DDX is Preseptal Cellulitis (Inflammation anterior to the orbital septum).– This condition will not typically have fever / systemic

toxicity or lid / EOM dysfunction.

A male with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited pain on eye movement, fever, headache, and malaise.

The same patient exhibited chemosis and resistance to retropulsion of the globe.

Other Pathology noted in painful EOM function

• Retrobulbar (Optic) Neuritis– Pain on eye rotation– Inflammatory disorder– Typically self limiting

• MD Tx often is NSAIDS

– May indicate systemic disease• Orbital Cellulitis (includes swelling)• Other Neuritides

• Ocular or Atypical Migraine Headache– May exhibit pain with eye movement– May include photophobia

• DDX by doing EOM in darkened room

UVEITIS / IRITIS • Uveitis is inflammation of the uveal tract, most

commonly in the iris and ciliary body portions. – The uveal tract is the functional lymphatic channel of

the eye, and thus is prone to inflammation. Uveitis can be either acute or chronic.

• Acute uveitis is due to either trauma, inflammation in an adjacent tissue (secondary uveitis), or an acute episode of a chronic condition (ie Crohns Disease).

• Chronic uveitis is most often associated with systemic diseases such as Bechet’s, IBD, Juvenile RA, Reiters, Sarcoidosis, Syphilis, Tuberculosis, and Lyme’s disease.

• The chronic nature of the disease is probably due to deposition of antigen / antibody complexes in the uveal tract (Type III Hypersensitivity) as well as stimulation of immunologically sensitive eye cells which can become reactive during systemic inflammatory disease.

UVEITIS IRITIS : Diagnostic informationA. Sn / Sx: Photophobia, pain, excessive tearing, boring eye pain, foreign

body sensation, and periorbital radiating pains. Visual acuity may be unaffected, but accommodation is typically painful. Ciliary injection is present, as well as protein and inflammatory cell matter in the aqueous.

B. DDX: Conjunctivitis, Glaucoma, Acute toxic exposure (ie. Chemical).

C. Lab Dx: For systemic disease processes.  

Referral information: These patients will be in an acutely painful state which needs to be addressed, along with the inflammatory response. If you do not have the pharmacological means to do this, refer them out and treat their systemic complaints when the acute situation is resolved.

Standard treatment: #1 Immobilize the iris and ciliary body with Homatropine, Scopolamine, or Atropine cycloplegics. #2 Stop the inflammatory cycle with a topical steroid @ q2h. A loading dose of oral Prednisone 60 to 80 mg (with subsequent tapering) may be necessary.

Uveitis / Iritis clinical thinking:• Eye exam

– VA, External & Media, Flourescein, EOM, Adnexa

• Patient History– PMH (Other inflammatory Dz’s?)– Meds (any inflammatory Dz’s being “masked”?)– HPI (Remember, someone with systemic

inflammatory disease CAN “Just” have conjunctivitis)

• Level and nature of pain?• Any exposure to conjunctivitis?• Allergies acting up?

• Always keep these patients on short follow-up if you are the primary treating doctor!

HERPES ZOSTER OPHTHALMICUS Pathogenesis: Etiology is latent Varicella Zoster virus in those who have had Chicken pox.

A. Sn / Sx:1). Herpes Zoster (Shingles) is an intraepidermal vesicular eruption occurring in a dermatomal

distribution. 2). Primary lesions are the vesicular dermatomal eruptions.3). Secondary lesions are rare, except in imminocompomised patients. In these patients the

eruption may spread viscerally to the Liver, Lungs, CNS4). Eye involvement may include follicular keratitis, epithelial / interstitial / dendritic

(INFILTRATIVE) keratitis, Uveitis, Optic Neuropathy, CN 3, or 4, or 6 palsy.5). Distribution Is dermatomal, commonly about the trunk. Also common in the nasociliary branch

of the V-I nerve (ophthalmic portion of trigeminal) involving the tip of the nose (Hutchinsons Sn.- a harbinger of eye involvement 75 % of the time), and the cornea.

6). Course is typically macular to vesicular lesions progressing to pustules which commonly crust over and heal in 2-3 weeks. They may progress to hemorrhagic bullae which become gangrenous and scar.

7). Prodrome of itch / burn / painful sensation typically precedes eruption. May simulate migraine.8). Configuration is dermatomal. Respects the midline.9). Contagion depends largely upon the immune status of the person coming into contact with the

virus. Contact with a person with zoster infection may also transmit Chicken pox to a susceptible person, and the reverse may also happen.

10).Incidence is highest in immunocompromised people. The next highest group is age 80-89. 2/3 of those who contract zoster are over 50 years old.

HERPES ZOSTER OPHTHALMICUS

B. DDX: Dermatomal distribution is considered diagnostic, although Herpes simplex may also form in dermatomes. DDX HSV from HZO in the cornea by Biomicroscopy: HSV dendrites are ulcerative, HZO dendrites are infiltrative

C: Complications: Anterior uveitis/keratitis. Corneal ulcer – May scar.

D: Referral information: Second opinion is advisable in all dendritic corneal lesions.

 

E: Standard treatment:

1. Domeboro (astringent) local compresses

2. Acyclovir (Zovirax) in immunocompromised, 800mg 5x / day for 7-10 days

3. Famcyclovir (Famvir) 100 mg BID – or- QD X 14 days

4. Viroptic (Off label use) ointment, apply QHS

5. Capsaicin creme (Zostrix) topically for pain 3-4 x / day. NOT near the eye.

6. Amitriptyline (Elavil) 50-100mg QD for post herpetic neuralgia

HERPES ZOSTER OPHTHALMICUS

DIET AND NUTRITION:-- Stop Refined SUGARS -- Avoid FOOD ALLERGENS -- Avoid l-Arginine foods

VITAMINS AND MINERALS:-- C : 10g. po QD in divided doses WITH Bioflavinoids of equal dose.-- B-5 : daily po or IM/IV (po=2000mg tid.) (IM/IV=1000-2000 mg)-- B-12 : 1000mcg IM Qdx7 then once weekly x 5-7-- Selenium : 400mcg daily from onset through acute outbreak.-- Zinc picolinate : 30 – 60 mg bid -- Lithium carbonate : 300 mg po QD x 2-6 weeks With Flax oil supplement.-- l-Lysine 500 to 2000 mg tid x 2-7 weeks I.V. -- : B-100 (2ml), B5(2000 mg), B12 (1000mcg), MgSO4 (50%, 3ml), C-500 (20-25 G.), Glycyrrhizin

BOTANICALS:--TOPICAL FORMULA: Echinacea Tinc. (2dr), and Hamamelis (1oz), QSAD 8 oz/H2OSig. Apply topically frequently, allow to dry, then cover with bentonite clay.--NEURALGIA TINCTURE

Aconite (10gtts), NuxVomica (10gtts), Valerian (3.5 dr.) Sig. 20 gtts PO tid 

HOMEOPATHY:-- Consider : Staphylococcinum, Apis, Aconite, Arsenicum, Graph., Med.,Thuja, Hypericum

HERPES ZOSTER OPHTHALMICUS

Herpes dendritic keratitis (fluoroscein stain) with hypopyon - HSV may also produce a necrotizing stromal inflammation (with no overlying ulcer) or endothellitis (keratic precipitates on the corneal endothelial surface)

Opacities

Pupillary Abnormalities - 2

(UP TO 20% DIFFERENCE IN PUPILS)

Lateral Recti (via CN-6) is pulling, unopposed by the Oculomotor (CN-3) nerve

Pupillary Abnormalities - 3

Normal Fundus

Internal Pathology – 1Normal Variation

Internal Pathology – 2Common disorders in the Optic Nerve Head

Internal Pathology – 3

The Cup and Disc:

The Cup/Disc Ratio: The fraction of the total optic disc space taken up by the optic cup. Expressed in decimal form 0.0, 0.1…to 0.9.

The example on the left is a 0.1 and that on the right is a 0.9. The greater the ratio the deeper the cup is – and the more likely the patient has glaucoma and resultant optic nerve damage.

*As you focus on the outer margin you can estimate depth of cup by focusing with the ophthalmoscope into the cup. 1Diopter of focus is 0.3mm depth*

Internal Pathology

Glaucomatous Cupping:Progression

Chronic open angle glaucoma:1.       Most common and is more than 70% of all cases. Drainage of the aqueous humor

is impeded, with a rise in intraocular pressure.. The patient is often over 65. High risk; Vascular abnormalities, especially carotid region, HTN, heart disease, smoking excessive alcohol consumption, diabetic, myopic, pigment dispersion syndrome, family history, and African American.

 Symptoms: 1. Most patients are asymptomatic in early stages. 2. Slow progressive loss of peripheral vision and when uncontrolled, late loss of

central vision and ultimate blindness. 3. Possible early indications, frequent glass changes, mild headaches, vague visual

disturbances, halo’s around lights, impaired dark adaptation. 4. Scotomas (areas of absent or reduced vision) present. Signs: 1. 1.       Intraocular pressure rises gradually (elevated slightly 22-30 mm HG or

markedly 30-45 mm Hg) or a difference of 5 mmHg between eyes. A single normal reading does not rule out glaucoma.

2. 2.       The fundus shows nasal displacement of the vessels 3. 3.       Enlargement of the cup:disc ratio (0.5 or greater) or a difference of between

eyes4. 4.       Temporal pallor of the optic nerve

Chronic open angle glaucoma:

Allopathic treatments: 1.  Prostaglandin Analog: Topical Latanoprost, synthetic analog of PGF2a. Increase aqueous outflow via

uvescleral pathway. Newer drug, less side effects.

Side effects: darkening of iris, increased eyelash fullness, swelling of macula with post cataract surgery patients

2.       Beta adrenergic blockers: Topical Timolol, Levobunolol, Metapranolol and Carteolol,

Topical Betaxolol (less pulmonary complications, but may still occur)

Decreases aqueous humor formation by the ciliary body

Side effects: bronchospasm, cardiac failure, bradycardia, and systemic hypotension. Deaths have occurred, even with topical meds especially Timolol

3.       Cholinergic Stimulating drugs

a. Topical Pilocarpine drops and ointment) – increases aqueous outflow via trabecular

network.

b. Topical Echothiphate – long acting anticholinesterase mimics parasympathetic activity. Contraindicated with some anesthesia

Side effects: local such as headaches from ciliary spasm, pupillary constriction, diminished vision

4.       Adrenergic Stimulating: Topical epinephrine and Dipivefrin occasionally used

Side effects: hypertension and cardiac arrythmia

5.       Carbonic Anhydrase Inhibitors: Oral Acetazolamide, Methazolamide and

Dichlorphenamide.

The only oral glaucoma meds. They are aqueous suppressants:

Side effects: GI, electrolyte imbalance, renal calcui, paresthesia, anorexia, headaches

and rarely bone marrow suppression

6. Surgical Trabeculotomy / Iridotomy