Wk 2 EENT

Eyes, Ears, Nose, Throat, Sinuses

This set of notes provides a comprehensive overview of ocular, otolaryngological, and sinus conditions relevant in clinical practice. It includes evaluation techniques, differential diagnoses, and treatment approaches.

Red Eye

Evaluation of Red Eye

The evaluation of red eye involves measuring visual acuity and conducting a penlight exam. This helps in identifying potential causes of redness and discomfort.

Key History Questions

  • Vision affected? Establishes if there is a change in visual acuity.

  • Foreign body sensation? Determines if there is a perceived obstruction or irritation.

  • Photophobia? Assesses sensitivity to light, indicative of several conditions.

  • Trauma? Relevant for recent injuries that may exacerbate symptoms.

  • Wear contact lens? Identifies risk factors for infections or irritation.

  • Discharge? Differentiates between types of conjunctivitis based on discharge characteristics.

Physical Exam Findings

  • Pupil response to light: Check for abnormalities.

  • Pupil size: A very small pupil can indicate conditions like corneal abrasion, infectious keratitis, and iritis.

  • Discharge characteristics: Purulent discharge signals a bacterial cause; patterns of redness also differentiate types of conjunctivitis.

  • White spots or opacities may indicate serious underlying conditions.

Types of Conjunctivitis

  1. Bacterial Conjunctivitis

    • Often caused by organisms such as Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

    • Characteristic discharge: purulent, often unilateral, with redness and crusting.

  2. Viral Conjunctivitis

    • Typically presents with bilateral redness and watery discharge. May follow a prodromal phase with systemic symptoms like fever and malaise.

    • Highly contagious; mucoid discharge is common.

  3. Allergic Conjunctivitis

    • Bilateral redness with watery discharge and itching, often associated with seasonal allergies.

    • History often includes exposure to allergens like pets or pollen.

  4. Non-specific (toxic, dry eye): Symptoms vary and often require symptomatic management.

Red Flags for Serious Eye Conditions

Understanding the critical signs that may indicate serious underlying issues:

  • Reduction of visual acuity: This may signal infectious keratitis, iritis, or angle-closure glaucoma.

  • Ciliary flush: A significant redness around the cornea can indicate severe conditions such as infectious keratitis or iritis.

  • Photophobia: Suggests underlying inflammation or irritation, cautioning against infectious processes.

  • Severe foreign body sensation: Can be indicative of keratitis, preventing the patient from keeping the eye open.

  • Corneal opacity or fixed pupil: May indicate serious conditions requiring immediate attention.

  • Severe headache with nausea: Possible signs of angle-closure glaucoma need immediate assessment.

Treatment of Conjunctivitis

Bacterial Conjunctivitis:

  • Erythromycin 5 mg/gram ophthalmic ointment

  • Trimethoprim-polymyxin B 0.1% - 10,000 units/mL ophthalmic drops

  • Bacitracin-polymyxin B 500 units - 10,000 units/gram

  • Ofloxacin 0.3% (preferred for contact lens wearers)

  • Azithromycin 1% ophthalmic drops

Viral Conjunctivitis:

  • Antihistamine/decongestant drops (available over-the-counter)

Allergic Conjunctivitis:

  • Antihistamines/decongestant drops

  • Mast cell stabilizers/antihistamine drops

Non-specific Conjunctivitis:

  • Eye lubricant drops or ointment (available over-the-counter).

Bacterial and Viral Keratitis

Bacterial Keratitis

  • Exam findings include corneal opacity, photophobia, and foreign body sensation. Corneal infiltrate >0.5 mm identified with penlight exam; stained with fluorescein. Treatment and urgency necessitate consultation.

Viral Keratitis

  • Commonly caused by herpes simplex; characterized by symptoms similar to red eye with the addition of faint branching grey opacity visible via fluorescein staining. Treatment should include topical or oral antivirals.

Iritis

  • This condition involves inflammation of the anterior uveal tract. The classic symptom includes photophobia, but the absence of foreign body sensation distinguishes it from conjunctivitis. The cardinal sign is ciliary flush, which presents as a red ring around the iris. Management usually requires urgent referral for topical steroids.

Subconjunctival Hemorrhage

  • Typically asymptomatic, may occur spontaneously or due to valsalva maneuver (coughing, sneezing, etc.). Blood typically reabsorbs within 1-2 weeks. Following a blunt trauma, evaluate for possible ruptured globe or retrobulbar hemorrhage.

Blepharitis

  • A chronic condition of eyelid inflammation presenting with symptoms like gritty sensation, burning, and red, swollen eyelids. Crusting may occur upon waking. The examination should look for signs of seborrheic dermatitis or acne rosacea.