HEENT

What is Ménière’s disease? What is common patient presentation of Ménière’s disease?

disorder caused by fluid build up in the inner ear; sensorineural hearing loss

Vertigo, tinnitus, ear pressure, nystagmus and nausea

What is our biggest concern when providing care for a patient with Mèniere‘s disease? what does treatment look like?

Permanent hearing loss

no cure, but medications, diet changes and therapy can diminish symptoms

A new graduate nurse practitioner has a patient present with a hearing complaint. The patient states that they have had decreased hearing on the right side for the last month that is continuing to worsen. The nurse practitioner completes both the Rinne and the Weber test. If the patient has Ménière’s disease, what would be the expected finding on the Weber test?

The sound will lateralize to the left ear

What is a primary concern when dealing with a patient who has bells palsy?

Maintaining eye lubrication to prevent corneal abrasions

Conductive hearing loss vs sensorineural hearing loss

With conductive hearing loss, you can visualize the issue ( cerumen impaction). Will cause lateralization of sound to BAD ear during Weber test

With sensorineural hearing loss, you cannot physically visualize the issue, example such as meningitis or mumps.

Will cause lateralization of sound to the GOOD ear

Rinne Test

Place tuning fork on the mastoid bone.

A normal finding yields that air conduction is two times longer than bone conduction; an abnormal finding yields that bone conduction is two times longer than air conduction

Webber Test

Place tuning fork on midline of skull.

A normal finding yields that the sound will be heard equally by both ears, meaning NO lateralization to either ear

What is the number 1 priority when a patient presents with an eye complaint?

Assessment of visual acuity

What is amblyopia?

Lazy eye

At what vision level is a patient considered legally blind?

20/100

What is the test for color blindness

Ishihara

What does a normal fundoscopic exam yield?

• retinal arteries are thinner and lighter in color than veins

• No hemorrhages or bulges

• No cotton wool spots

• No swelling of the optic disc (papilledema; needs referral)

• Optic disc should have sharp margins

• Positive red reflex

How can hypertension affect the appearance of the eye seen on fundoscopic exam?

• copper wire arteries

• arteriovenous nicking

• flame hemorrhages

What is arteriovenous nicking?

Artery crosses a nerve causing a bulge

How can diabetes affect the appearance of the eye seen on fundoscopic exam!

• cotton wool spots

• neovascularization

• microaneurysms

A patient presents to the office with an ocular presentation as seen below. They endorse sudden severe eye pain, blurred vision, and states that their eye feels firm to the touch. What diagnostics are we using? What is likely the diagnosis and how is it treated?

1. Tenometry

2. Acute angle closure glaucoma; increased intraoccular pressure

3. Refer to ED immediately

A patient states they they feel like “a curtain is being pulled over their eye”, are experiencing floaters, blurred vision, and flashes of lights. What is this patient experiencing? What do we do?

Retinal detachment; refer to the ED immediately

Central vision loss may suggest…

Macular Degeneration

What is the only curative treatment for cataracts?

removal and replacement of the occluded crystalline lens

What is this and what causes it? How are we treating this?

Arcus senilis is a common, harmless white, gray, or bluish ring or arc that forms around the edge of the cornea.

It is caused by fatty deposits (lipids and cholesterol) building up in the outer part of the cornea

We want to possibly increase statin doses and encourage lifestyle modifications

What is this and what causes it? How are we treating it?

xanthelasma

elevated cholesterol; want to possibly increase statin dose and encourage lifestyle modifications

What is this? What will we advise the patient?

Pterygium; which is a benign, noncancerous overgrowth of the conjunctiva that crosses over the cornea

Related to chronic sun exposure

vision may be impacted

Patient should wear UV sunglasses and discuss possibility of surgery

What are the 3 types of conjunctivitis? How do we differentiate them?

1. Bacterial; presents unilaterally and can spread to become bilateral; purulent drainage

2. Viral; presents unilaterally and can spread to become bilateral; serous drainage

3. Allergic; presents bilaterally; serous drainage that is often stringy/ropey

What is adenoviral conjunctivitis?

Pink eye

A patient presents with complaints of bilateral vision changes, difficulty driving at night, difficulty seeing things from a distance, and foggy/cloudy vision. A fundoscopic exam reveals an absent red reflex. What is likely the diagnosis?

Cataracts

What is presbyopia?

a normal, age-related eye condition where the lens inside the eye becomes less flexible, making it hard to focus on close-up objects like books or phones

How do corneal abrasions present? How do we diagnose a corneal abrasion

patient may state they feel as if something is stuck in their eye/sand sensation on the surface of their eye

fluorescein stain

What does tenometry measure?

Intraoccular fluid pressure

What is iritis? What might a patient complain of with this condition?

Inflammation of the iris

Patients will complain of eye pain, light sensitivity, decreased visual acuity, and a reddened scelera with visible swelling iris

Patient will need referral to opthlamology due to concern for blindness

treatment = steroid eyedrops

What can occur if a patient with Bell’s palsy does not properly lubricate their eyes.

Corneal abrasion

What is presbycusis? How is it diagnosed and what is the first line treatment?

Gradual, progressive, symmetrical hearing loss in older adults (60+)

Patients may also experience tinnitus and mild dizzinesss

Diagnosed using audiogram testing

First line treatment is hearing aids

What is otomycosis?

Fungal infection of the external ear

What is presbyopia?

Progressive visual impairment that causes farsightedness

Describe oral candidiasis. What are common risk factors? What is the treatment?

Oral thrush; will present as white plaques that appear in a patients mouth, commonly the tongue. Will often be able to scrape off the plaque using a tongue depressor

Patients may also report changes to taste, mouth pain and some difficulty swallowing

Risk factors include immunosuppression, use of inhaled steroids, and diabetes

Treatment can be use of topical antifungals

What is the first line pharmacological treatment for allergic rhinitis? How does it normally present?

Fluticasone (Flonase)

Presents as pale, boggy mucosa and patient will report rhinorrhea, sneezing, obstruction, mucosal swelling and pharyngeal itching

What is this? What will we advise the patient?

a harmless, non-cancerous yellowish bump or patch that forms on the conjunctiva but does NOT cross into the cornea

results from chronic sun exposure

vision is typically not affected

advise patient to wear UV sunglasses

hordeolum vs chalazion

hordeolum = style; typically caused by an infection; presents with pain, tearing, sensitivity to light and purulent drainage; patient may need abx

chalazion = blockage of duct/oil gland that results in painless swelling; presents as a small, red, beadlike nodule on the eyelid; treatment is a warm compress

what is herpes keratitis? how i it diagnosed and treated?

HSV infection of the cornea

Patients report “fern-like” lines on the cornea

diagnosed using a black lamp exam to visualize the cornea

treatment is antivirals

what is otosclerosis? how is it treated and how does it present?

is bone growth inside the middle ear that causes remolding

presents with hearing loss, vertigo and dizziness

treatment = hearing aid for mild cases; surgery in severe cases

what is cholesteatoma? how does it present and how is it treated?

abnormal, white, cauliflower looking skin growth in the middle ear (behind ear drum)

presents as recurrent ear infections with a foul smell

treatment = surgery; as it can damage CN7 if not removed

what is leukocoria? what do we need to advise the patient

white reflect seen during eye examination

patients should be referred to opthamology for evaluation of potential lens surgery; could indicate cataracts if seen bilaterally

Inhaled corticosteroids carry a risk of oral thrush when patients do not rinse their mouths properly after use. What do we do in this case?

Prescribe oral nystatin mouthwash and educate patients to rinse their mouths thoroughly after use of inhaled corticosteroids