EENT

WHITE PLAQUE ON MUCOSA

PREMALIGNANT

HPV

SMOKELESS TOBACCO

DIFF

ORAL HAIRY LEUKOPLAKIA ( EXCLUSIVE TO HIV)

MALIGNANT MELANOMA

SQUAMOUS CELL CARCINOMA

ACUTE PLUGGING OF MEIBOMIAN GLAND AND INFLAMMATION RESULTS IN TENDER RED BUMP

CAUSES

BACTERIA IN EYE MAKEUP

ROSACEA SUFFERERS

SEBORRHEIC DERMATOSES SUFFERERS

NODULAR LESION ON EYELID NOT INFLAMED

APPEARS IN A DAY

EXTERNAL ON EYELASH FOLLICLE

OR INTERNAL INFLAMMATION MEIBOMIAN GLAND -SWELLING UNDER CONJUNCTIVE

STAPH AUREUS MAIN CAUSE

RESOLVES SPONTANEOUSLY OVER 1—2 WEEKS

LITTLE DATA ON TREATMENT - EXPERT CONSENSUS

FACILITATE DRAINAGE -MOIST WARM COMPRESSES

4 X DAY FOR 5-10 MINUTES

MASSAGE AND GENTLE WIPING OF EYE AFTER MOIST CMPRESS( WITH CLEAN HANDS)

NO EYE MAKE UP

NO IMPROVEMENT TWO WEEKS -REFER OPTHALMOLOGIST

PT WITH FREQUENT HORDOLEUM MAY RESPOND TO TOPICAL ANTIBIOTIC /CORTICOSTEROID OINTMENT COMBO- BUT THESE PATIENT MUST BE MANAGED BY OPTHALM - * RISKS WITH TOPICAL GLUCOCORTISOID USE EYE

OUTPATIENT ADULT MILD PRESEPTAL CELLULITIS CAN USE ABX AND CLOSE FOLLOW UP

ABX AUGMENTIN ( FOR STAPH AUREUS) MRSA IS NOT COMMON IN THIS SETTING

(PCN ALLERGY USE SND OR THIRD GEN CEPHALOSPORIN EG CEFDINIR, CEFPOXIDINE, CEFUROXIME)

IF NOT IMPROVEMENT IN 24-48 HOURS COVER FOR MRSA-B

REMEMBER MRSA B- BACTRIM DS 160/800 Q 12 HOURLY

PLUS

ACTIVE AGAINST GASTREP AND H INFLUENZAE -

AUGMENTIN Q 12

OR CEPHALOSPORIN EG CEFDINIR, CEFPOXIDINE, CEFUROXIME)

SHOULD RESPOND RAPIDLY

FATIGUE

FEVER

LYMPHADENOPATHY( POSTERIOR CERVICAL NODES)

PHARYNGITIS ( 10% HAVE STREP)

ETIOLOGIC AGENT OF MONO IS THE EPSTEIN BARR VIRUS

AVOID AMOXICILLIN, CAN CAUSE RASH -NOT ALLERGY BUT EBV REACTING WITH PCN MOLECULE

CHALAZION

MOLLUSCUM CONTAGIOSUM ON EYELID

DIFF DX

PRE SEPTAL CELLULITIS-USU MILD

VS ORBITAL CELLULITIS -SERIOUS CAN CAUSE LOSS OF VISION

ORBITAL USU HAVE PAIN WIH EYE MOVENENTS, PROPTOSIS-PROTRUSION OF EYEBALL, OPTHALMOPLEGIA-PARALYSIS OR WEAKNESS OF EYE MUSCLES- CAN AFFECT III,IV OR VI,BLURRY VISION, DIPLOPIA, PTOSIS , DYSPHAGIA!

CANNOT HEAR CONSONANTS

SYMMETRICAL

CANNOT HEAR SPEECH IN CROWDED ROOM

LOSS OF HIGH PITCHED SOUNDS

70% VIRAL

15% ALLERGIC

POOR HAND WASHING

HIGHLY CONTAGIOUS

SPREAD IN INSTITUTIONAL SETTINGS

ADENOVIRUS OR COMMON COLD COMMONEST CAUSE

EYEDROP MEDICATIONS CAN CAUSE-VASODILATORS

SWELLING OF OPTIC NERVE HEAD AND DISC 2/2 >ICP

CARDINAL SYMPTOM OF ICP IS HEADACHE, PAPILLEDEMA IS 2NDRY

HSV

RUBELLA

EPSTEIN BARR ( MAIN MONO)

MOLLUSCUM CONTAGIOSUM (POX) SUSPECT HIV IF IN ADULT

VZV

LASTS 5-10 DAYS

CONTAGIOUS IF TEARING 1 WEEK

COXSACKIE

RED EYE INJECTION

WATERY DISCHARGE

RECENT RESPIRATORY INFECTION IF ADENOVIRUS

BURNING

ITCHING

PHOTOPHOBIA

VISION NOT AFFECTED

FOREIGN BODY SENSATION

RESOLVES 1-2 WEEKS

ANTIHISTAMINE /DECONGESTANT EYE DROPS-

OLAPATADINE =PATADAY OR PATANOL

VISINE AC

ARTIFICIAL TEARS

COOL COMPRESS

REFER OPTHALMOLOGIST IF >10 DAYS OR CORNEAL INVOLVEMENT

FOLLICLE PAPILLAE

VIRAL CONJUNCTIVITIS

GONORHHEAL CONJUNCTIVITIS

HYPERACUTE

PURULENT COPIOUS DRAINAGE ,

EYES GLUED SHUT

REFER TO OPTHALMOLOGIST

CORNEAL INVOLVED < 2 DAYS

PERMANENT VISION LOSS

CHLAMYDIAL CONJUNCTIVITS PRESENTS WITH GENITAL LESIONS TOO

• Diminished visual acuity

• Photophobia

• Severe foreign body sensation preventing patient from keeping eye open

• Corneal opacity

• Fixed pupil

• Severe headache with nausea (angle-closure glaucoma)

• Proptosis

• LACK OF RESPONSE TO THERAPY

• CANNOT OPEN EYE

• Foreign body

• Uveitis, iritis, scleritis UVEA IS SCLERA, IRIS AND CHOROID( BLOOD VESSELS)

• Corneal abrasion

• Dacryocystitis INFLAMMATION OFLACRIMAL SAC

• Hyphema IS WHEN

  BLOOD COLLECTS IN FRONT OF EYE, BETWEEN CORNEA AND IRIS

• Angle-closure glaucoma

• Subconjunctival hemorrhage

• Periorbital cellulitis

ADULTS

STAPH AUREUS

CHILDREN, HEMOPHILUS INFLUENZAE

STREPTOCOCCUS PNEUMONIAE

• PCP NEVER PRESCRIBE TOPICAL GLUCOCORTISOIDS-MAY THREATEN VISION

• AZITHROMYCIN MACROLIDE 1DRP BID THEN DAILY

• AMINOGLYCOSIDES :

• GENTAMYCIN 1-2 DROPS 0.3 %.OINTMENT FORM ALSO

• TOBRAMYCIN OINTMENT OR DROPS 0.3%

• FLUOROQUINOLONES: FIRST LINE FOR CONTACT USERS

• LEVOFLOXACIN 0.5% DROPS

• CIPROFLOXACIN 0.3% DROPS

• OFLOXACIN 0.3%

RHINITIS IN 50%

HEADACHE

PHOTOPHOBIA

POSITIVE FAMILY HISTORY ASTHMA HAYFEVER ATOPY

BOTH EYES

CLEAR WHITE STRINGY ROPY DISCHARGE

PAINLESS

ALLERGIC SHINERS

COBBLESTONE UPPER INNER EYELIDS

COBBLESTONE OF ALLERGIC

CONJUNCTIVITIS

IDENTIFY ALLERGEN AND REMOVE IT

CLARITIN-LORATIDINE 2ND GEN ANTIHISTAMINE

ALLEGRA- FEXOFENADINE-2ND GEN AH

BENADRYL

REMOVE CONTACTS

ANTIHISTAMINE VASOCONSTRICTOR( PATANOL0 DROPS CAN CAUSE REBOUND VASODILATION IF USED >2 WEEKS

HAND WASHING

THROW OUT OLD LENS SOLUTION , LENSES, HOLDERS

WASH BEDDING

NO POOLS

OPEN ANGLE

CHRONIC OPEN ANGLE

ANGLE CLOSURE

ALLT YPES TEH NERVE CONNECTING THE EYE TO THE BRAIN IS DAMAGED , USU 2/2 HIGH EYE PRESSUE

BLACK PEOPLE, LEADING CAUSE OF BLINDNESS

STEROID USE

ELDERLY

HTN

DM

FAMILY HISTORY

SLOW VISION LOSS, MOST COMMON

USU ASYMPTOMATIC SLOW VISION LOSS, MOST COMMON

>IOP INTRAOCULAR PRESSURE

>22MHG

HALOS

NOTCH IN CUP

CUPPING- REFER TO OPTHALMOLOGIST

DECREASED PERIPHERAL THEN CENTRAL VISION

SUDDEN INCREASE IN IOP

SUDDEN VISION LOSS

RAPID PERIPHERAL LOSS THEN CENTRAL

FIXED AND DILATED PUPIL THAT LOOKS OVAL

SUDDEN HEADACHE NAUSEA VOMIITING

ER REFER

ASIANS AND ESKIMOS

RARE

ACUTE CLOSED ANGLE GLAUCOMA

CONJUNCTIVITIS

UVEITIS

MACULAR DEGENERATION

FOREIGN BODY

SURGERY OR LASER TX TO REDUCE IOP

PHARM:

TOPICAL BETA ADRENERGIC BLOCKERS

LEVOBUNOLOL TIMOLOL

MIOTICS: DRUGS THAT CAUSE THE PUPIL TO CONSTRICT, ALLOWING BLOCKED DRAINAGE ANGLE TO OPEN

PILOCARPINE GLAUCOMA ONLY

SYSTEMIC AGENTS??

BRINZOLAMIDE ( AZOPT) I1 DROP

DO NOT PRESCRIBE BB EYE DROPS TO SOMEONE ON THEM ORALLY

MEDS THAT CAN CAUSE GLAUCOMA:

STEROIDS

DECONGESTANT

ANTHISTAMINES-DRAMAMINE-DIMENHYDRAMINE. 1ST GEN AH

PRESCR MEDS FOR BLADDER INCONTINENCE

DIET PILLS?? TOPIRAMATE- CONTAINS SULFA

SULFA

ALWAYS CHECK W YOUR OPTHALMOLOGIST BEFORE NEW MEDS IF YOU HAVE GLAUCOMA

MOST COMMON CAUSE OF VISION LOSS IN ELDERLY

SMOKERS

ATROPHIC OR DRY FORM -MORE COMMON LESS SEVERE

WET FORM - BLINDNESS 80% VISION LOSS IN PEOPLE

IST SIGN SCOTOMA-BLIND SPOT

PERIPHERAL AND COLOR VISION NORMAL

REFER

AREDS

DC SMOKING

 SWIMMERS EAR

INVOLVES EXTERNAL AUDITORY CANAL AURICLE OR BOTH

ASPIRIN

LOOP DIURETICS

ABX: AMINOGLYCOSIDES

VANCOMYCIN

ERYTHROMYCIN

SILDAFENIL

CISPLATIN

ANTIMALRIA DRUGS

• Tragal PALPATION and/or pinna pain

• Traction of the pinna elicits pain: hallmark sign of OE

• Otalgia/conductive hearing loss

• Edema and redness in the external auditory canal

• Itching in the external auditory canal

• Otorrhea(EAR DRAINAGE)/purulent discharge in external canal; usually foul smelling

• Discharge characteristics

  • Acute bacterial: scant white mucus; may be thick

  • Chronic bacterial: bloody if granulation tissue present

  • Fungal: fluffy and white to off-white; may be black, gray, bluish-green, or yellow

• Normal tympanic membrane (TM)

• Fever: occasional

• Tinnitus

• Bilateral involvement: rare

• EAC pain while chewing

• Regional lymphadenitis may be present

CIPROFLOXACIN AND HYDROCORTISON -CIPRO HC OTIC

3 DROPS BID X 7 DAYS

*DONT GIVE IF PERFORATED TYMPANIC MEMBRANE OR TYMPANOSTOMYTUBES

CIPROFLOXACIN /DEXAMETHASONE OTIC 4 DROPS BID 7 DAYS

OXOFLOXACIN

CAN BE USED WITH T TUBES

MIDDLE EAR EFFUSION

*BULGING TYMPANIC MEMBRANE,

*REDUCED MOBILITY OF TYMPANIC MEMBRANE-PNEUMATIC PRESSURE

*INTENSE ERRYTHEMA OF TM

DISTORTED LANDMARKS TM

OPAQUE TM ( FLUID-CAN BE CLOUDY OR YELLOW )

TRANSIENT HEARING LOSS

HANDHELD OTOSCOPE

*STANDARD FOR DX AOM PNEUMATIC OTOSCOPE FOR TM MOBILITY

TYMPANOMETRY

OTITIS MEDIA WITH EFFUSION (OME):

NO PAIN/MILD PAIN

FULL FEELING

DIMINISHED HEARING

• NO BULGING TM

OTITIS EXTERNA

CHOLESTEATOMA

TMD

DENTAL CAUSES

NON

LOCAL HEAT

MYRINGOTOMY ( TUBES)

NO DIAGNOSTICS INDICATED EXCEPT CULTURE IF REPEATS

PHARM

IBUPROFEN TYLENOL

*NO DECONGESTANTS /ANTIHISTAMINES-PROLONG MEE

ABX AUGMENTIN 500 TID

PCN ALLERGY

CEFURIXIME OR CEFUROXIME( 2ND GEN CEPH)

AZITHROMYCIN MACROLIDE.500 MG X 5 DAYS

*CIPRO/DEXAMETH OTIC -FOR PT WITH TUBES ONLY

FLAGS

IF NO IMPROVEMENT 48-72 HOURS CONSIDER SWITCHING TO 2ND LINE

• ENT referral for recurrent OM (three presentations in 6 months or four in 1 year)

• Emergency treatment needed for signs of mastoiditis and/or meningitis

• F/U CALL IN 72 HOURS

DEFINITIVE DX REQUIRES SPECIFIC IGE REACTIVITY ( ALLERGIST REF)

20-30% ADOLESCENTS

SEASONAL

PERENNIAL

LESSENS WITH AGE

ALLERGIC SHINERS

ALLERGIC SALUTE

DRY MOUTH/MOUTH BREATHING

COBBLESTONE PHARYNX AND TONSILS

LYMPH NODES

CONJUNCTIVAL INJECTION

PALE BOGGY TURBINATES

CLEAR NASAL SECRETIONS

rupture of mast cells and release of histamines, leukotrienes, prostaglandins,

INTRANASAL STEROIDS (INS)

FLONASE 1 SPRAY EACH NOSTRIL DAILY

TRIAMCINOLONE NASACORT 2 DAILY

BECLOMETHASONE 1 SPRAY DAILY

ST GEN ANTIHISTAMINE:

BENADRYL/ HYDROXYZINE-ATARAX

2ND GEN A/H LESS DROWSY

CETIRIZINE( ZYRTEC

LEVOCETRIZINE XYZAL

LORATADINE CLARITIN

FEXOFENADINE, ALLEGRA

ASTELAZINE 2 SPRAYS DAILY

PATANASE

(2ND TREATMENT INS- AHS

AHS-INS

ORAL AHS-ORAL DECONG)

CAN ADD SINGULAIR MMONOLEUKOTRIENE RECEPTOR ANTAGONIST

DECONGESTANTS CAUSE REBOUND DECONGESTION DUE TO WEAKENED AFFINITY FOR ALPHA ADRENERGIC RECEPTOR

NO IMAGING,

REFER TO ALLERGIST

SURGICAL REDUCTION OF TURBINATES

IGE ALLERGY TESTING SKIN OR BLOOD FOR PT WHO DOES NOT RESPOND TO EMPIRIC TREATMENT

OR REFER TO SOMEONE WHO TESTS

VIRAL

ADENOVIRUS

RHINOVIRUS

MONO

RSV

HIV

HSV

BACTERIAL :

GABHS

HEMOPHILUS INFLUENZAE

MYCOPLASMA PNEUMONIAE ATYPICAL

CHLAMYDIA/ GONORRHEA

SORE THROAT

PHARYNGEAL EDEMA

TONSILLAR EXUDATE +/OR ENLARGED TONSILS

MALAISE

ACCURATE FINDINGS NEEDED FOR STREP - PREVENT GABHS GLOMERULONEPHRITIS

PERITONSILLAR ABSCESS

MASTOIDITIS

3-4 POINTS TREAT EMPIRICALLY FOR STREP

2 POINTS : RADT + TX IF POS+

1 POINT : STREP UNLIKELY

0-1 POINT: NO STREP NEEDED

RADT IS RAPID ANTIGEN DETECTION TEST-STREP TEST

URI

TONSILITIS

MONO

PERITONSILLAR ABSCESS

EPIGLOTTITIS

RABT 95-99% SPECIFIC

SWAB FROM TONSILS + PHARYNGEAL WALL

NO STREP TEST IF VIRAL SYMPTOMS

(RHINORRHEA ORAL ULCERS COUGH)

CBC FOR POLYPS

10% OF PTS WITH MONO HAVE STREP ALSO

ASO DETECTS PAST INFECTION -NOT PRESENT

• Gargling with warm salt water

• Increased fluid intake

• Patient education about disease, course and treatment

• Change toothbrush after treatment

TYLENOL /NSAID

PCN G X 1 DOSE IM

PEN VK X 10 DAYS

AMOXICILLIN X 10 DAYS

AZITHROMYCIN( NOT FIRST LINE, GOOD CHOICE FOR ALLERGIES)

CEPHALEXIN BID X 1O DAYS 1ST GEN CEPH

CLINDAMYCIN MACROLIDE

CLARITHROM( BIAXIN) MACROLIDE

INFLAMMATION NASAL CAVITY PARANASAL SINUSES

<4 WEEKS ACUE

4-12 WEEKS SUBACUTE

>12 WEEKS CHRONIC CRS

4OR > EPISODES A YEAR RECURRENT ARS (RARS)

SMOKERS SWIMMING BAD H2O

COMMON COLD '

ALLERGIC RHINITIS

SEPTUM DEVIATION

NASAL POLYPS

VIRAL

RHINOVIRUS

, CORONAVIRUS

FLU A B , PARA

RSV

BACTERIAL

STREP PNEUM -MOST

HEMOPHILUS INFLU -SMOKERS

MORAXELLA CATARHALIS

BACTERIAL CRS

STAPH +

PSEUDOMONAS -

PREGNANCY -PHYSIOLOGIC NASAL CONGESTION

3 MAIN

PURULENT NASAL DISCHARGE

NASAL OBSTRUCTION

FACE PAIN PRESSURE FULLNESS

(FRONTAL FOREHEAD

MAXILLARY CHEEK TEETH

ETHMOID EYES)

VIRAL

MILD SYMPTOMS 1ST 3 DAYS

DONT WORSEN ,<10 DAYS

BACTERIAL

> 10 DAYS

SYMPTOMS WORSEN

HIGH FEVER >102

SEVERE SYMPTOMS 1ST 3 DAYS

DOUBLE SICKENING

NASAL TURBINATE EDEMA ERYTHEMA AND DISCHARGE

HYPONASAL SPEECH

REDUCED OR ABSENT SMELL

CHECK FOR NOSE SYMMETRY PATENCY OF NARES

RED THROAT ( PND)

EXAM EYES

PALPATE SINUSES

EXAM EARS (R/O OTITIS MEDIA)

TAP EXAMINE TEETH

TRANSILLUMINATION -NOT ALWAYS ACCURATE

• Viral URI

• Allergic rhinitis

• Nonallergic rhinitis (triggered by strong odors or change in temperatures)

• Dental abscess

• Headaches

• Nasal foreign body

• Wegener’s granulomatosis

EMPIRIC PRESUMPTIVE DIAGNOSIS

CT IMAGING NOT APPROPRIATE FOR UNCOMPLICATED ARS. FOR SEVERE HEADACHE, FACILAL SWELLING, CRANIAL NERVE PALSIES

CT AFTER MEDICAL MGT,NEURO DEFICITS OR IMMUNOCOMPROMIISE

• Avoid environmental irritants (e.g., cigarette smoke)

• Manage allergic rhinitis appropriately

• Humidified air can improve mucus clearance

• Look for otitis media when evaluating patient with rhinosinusitis (and vice versa)

• Increase fluid intake

• Sleep with head of bed elevated to aid with drainage

• EDUCATE ON NO ABX RIGHT AWAY

TYLENOL

NSAID

INS FLONASE 1 SPRAY BID

NEIL MED SALINE NASAL IRRIGATION

DECONGESTANTS/ANTIHISTAMINES NOT SHOWN TO BE EFFECTIVE FOR BACTERIAL SINUSITIS

ASPIRIN

LOOP DIURETICS

ABX:

AMINOGLYCOSIDES( EG GENT)

VANCOMYCIN

ERYTHROMYCIN

SILDENAFIL

CISPLATIN

ANTIMALARIA MEDS

ABX

AMOXIL 500 MG Q8 X5-10 DAYS OR

875 MG Q 12 X 5—10 DAYS

AUGMENTIN 500/125 Q 8 X 5-10 DAYS

875/125 Q 12 X 5-10 DAYS ,IF TRIED AMOXIL IN LAST MONTH

AUGMENTINXR 2000 /125 BID X 10 DAYS, RECENT ABX USE RECENT HOSPTALIZATION(5 DAYS) HIGH RESISTANCE, RX FAILURE, COMORB

PCN ALLERGY

LEVAQUIN 500 MG OD X 10-14 DAYS OR 750 OD X 5 DAYS

DOXY-TETRACYCLINE 100 BID X 10 DAYS

MOXIFLOXACIN (AVELOX) 400 MG OD X 10 DAYS

2ND LINE

CLINDAMYCIN

3RD GEN

CEFIXIME

CEFPODIXIME

HIGH PERSISTENT FEVER F>102

PERIORBITAL EDEMA, ERYTHEMA

CRANIAL NERVE PALSIES

DIPLOPIA, PROPTOSIS ( EYE PROTRUSION), AOMS ABNORMAL

SEVERE HEADACHE

AMS

MENINGITIS SIGNS

often missed by clinicians

nasal obstruction

nasal polyps

facial congestion/pressure

discolored nasal discharge

hyposmia

halitosis

2 or more symptoms >12 weeks is crs

periorbital edema

1in 5 have asthma ,

allergies , smoke exposure, cystic fibrosis , ciliary dyskinesia

immunodeficiency

SINUS ENDOSCOPY FIRST LINE

GOLD STANDARD TESTING IS CT SCAN-DONE FOR COMPLICATED OR SURGERY TO BE DONE

ALLERGY TESTING IGE if suspected cause

SALINE IRRIGATION

INS STEROIDS FOR 8 -12 WEEKS

F/U 3-5 DAYS AFTER INITIATION OF ABX THERAPY TO SEE IF IMPROVED

REFER TO ENT - RECURRENT INFECTIONS AFTER MAXIMAL MEDICAL THERAPY

ALLERGIST

ER IF MENINGITIS SUSPECTED

LIPOGRNAULOMATOUS INFLAMMATION OF EYELID FROM INFLAMED AND OBSTRUCTED SEBACEOUS GLANDS OF EYELID

MOST COMMON EYELID LESION

RISK FACTORS:

STYE ( HORDEOLUM) CAN DEVELOP INTO ONE

EYELASH MITES

ROSACEA

TRAVEL TO TB COUNTRIES

NON TENDER PALPABLE NODULE FOR MONTHS, CAN BE INNER MARGIN

CORNEAL ASTYGMATISM can develop FROM PRESSURE ON CORNEA

CHALAZION

STYE

HSV

MOLLUSCUM

LEISHMANIASIS

CELLULITIS

FOREIGN BODY

XANTHELASMA

PAPILLOMA

NONE, IF PAIN DO FLUORESCIN STAIN TO ASSESS CORNEAL DAMAGE

Chalazia are inflammatory, not infectious. Antibiotics only appropriate for associated infection. Majority of chalazia respond well to conservative management. Refer patients with recurrent or refractory chalazia-OPTHALMOLOGIST

WHO MAY DO BOTOX, EXCISION, STEROIDS

2-4 WEEK F/U IF SMALL AND SIMPLE

NON PHARM

• Warm, moist compresses on affected lid for 15 minutes 2-4 times per day

• Baby shampoo application and eyelid massage

PHARM

DOXYCYCLINE 100 BID X 10 DAYS OR MINOCYCLINE 50 X 10/7

METRONIDAZOLE IF TETRA CONTRA

REFER TO OPTHAL FOR INTRALESIONAL STEROIDS