HEENT Review: Glaucoma, Otitis, Conjunctivitis

HEENT Review:

• The content covers Glaucoma, Otitis (Externa and media), Conjunctivitis, Blepharitis, Meniere's/BPPV, and Bell's Palsy vs. Ramsay Hunt.

Glaucoma:

• Glaucoma can occur even with normal IOP (Intraocular Pressure).
• Elevated IOP is a risk factor, not necessarily the direct cause of glaucoma.
• The pain may or may not be present in glaucoma patients.
• Glaucoma is not reversible and tends to progress over time.
• Loss of peripheral vision, central vision impairment, and blindness are associated with glaucoma.
• Pathophysiology involves the slow death of the optic nerve.
• Elevated IOP deforms the lamina cribrosa and blocks anterograde and retrograde axonal transport.
• Excitotoxic amino acids like glutamate have been found to be increased in glaucomatous eyes.
• A persistent increase in glutamate levels may cause retinal ganglion cell death.
• Anterior compartment contains aqueous humor which is less viscous.
• The vitreous humor in the posterior compartment is gel-like and formed by the ciliary body.
• Elevated IOP needs controlled by managing aqueous humor production.
• Open-angle glaucoma has an angle between the trabecular meshwork and the iris to promote flow.
• Closed-angle glaucoma causes peripheral vision loss, becomes acute and is often painful.
• Increase drainage and decrease production to control pressure.
• Latanoprost is a prostaglandin agonist used to treat glaucoma.
• Opening to the canal of Schlemm increases patency to improve outflow.
• Improve outflow with Alpha-2 agonists
• Timolol (beta blocker) alters the production of aqueous humor.
• Beta-adrenergic blockers decrease aqueous fluid production; major side effects: heart block, cardiac failure, bronchospasm.
• Cholinergic agonists improve trabecular outflow; side effects: miosis, brow ache, decreased vision.

Conjunctivitis:

• Bacterial conjunctivitis presents with pus and generally starts in one eye.
• Viral conjunctivitis may not have the same purulent exudate and can start in one or both eyes.
• Allergic conjunctivitis generally affects both eyes.
• Diluted shampoo is recommended to treat blepharitis.
• Topical steroids should be avoided due to glaucoma or cataracts as a side effect.

Otitis:

• Mild to moderate otitis externa is typically treated with a topical antibiotic.
• S. pneumoniae is the most likely bacterial etiology of otitis media
• First-line empiric treatment of uncomplicated otitis media includes Amoxicillin or Amoxicillin-Clavulanate.
• Bacterial or viral load and eustachian-tube dysfunction are causes of otitis media

Meniere's Disease and Tinnitus:

• Meniere's disease is likely etiology for increased pressure in the endolymphatic system.
• BPPV (Benign Paroxysmal Positional Vertigo) involves calcium carbonate crystals that displaced in the semicircular apparatus.
• Meniere's often has some hearing loss; BPPV tends not to have hearing loss.
• Epley maneuvers are for BPPV.
• Tinnitus has a cognitive behavioural element involved.

Bell's Palsy and Ramsay Hunt Syndrome:

• Bell's Palsy involves Cranial Nerve VII, the facial nerve.
• Risk factors for Meniere's Disease include allergies, autoimmune disorders, and genetics, but not diabetes.
• Moderate to severe Bell's Palsy treated with steroids and antiviral medications.
• For Herpes ophthalmicus, the facial nerve is not involved; this is an incorrect statement
• Ramsey Hunt has vesicular presentation with ear pain

Women's Health:

• During menstrual cycle hypothalamus produces releasing hormones,
• Anterior pituitary produces FSH and LH with the influence of GnRH.
• Follicular growth is triggered by the production of FSH and LH
• Ovaries contain follicles in different stages with flat layer of epithelial cells that grown into cuboidal which grows under the infuence of FSH
• When LH kicks accelerates grown and releases oocyte
• Theca and granulosa cells produce estrogen
• Prostaglandins are a luteal outflow
• surge of hormones during ovulation, fertilization occurs
• Corpus luteum produces progesterone and estrogen
• The surge decreases as the corpus luteum forms
• The surge decrease are the corpus luteum hormones
• In response to decreased estrogen and progesterone HCG) is produced by the conceptus (trophoblast cells keeps uterine lining a receptive place for embryo
• Increased risk of 1st degree relatives with endometriosis.
• Oral contraceptives is one of the treatments for endometriosis
• Polycystic ovary syndrome (PCOS) is associated with increased aromatase and testosterone.
• Aromatase is a conversion enzyme that makes estrogen from testosterone.
• Plan-B (morning after pill) contains progestin which inhibits LH surge to inhibit ovulation and thickens cervical mucus secretions.
• Increased estrogen and increased inhibin are not effects from Oral Contraceptives
• Most oral contraceptives will decrease LH and FSH.
• At ovulation a surge of LH (luteinizing hormone) causes ovulation.
• Medications may cause amenorrhea (Non-menstruating) such as: Hormonal contraceptives, Anticoagulants, atypical antipsychotics, SSRIS, or chemotherapy

Male Reproductive Treatment & Diagnoses

• Elevated LH & FSH with low free testosterone indicates primary testosterone deficiency, also known as primary hypogonadism
• Opoid Use includes a secondary cause of TDS
• First-line treatment of bacterial prostatitis is Fluroquinolone
• Testosterone deficiency needs to be tested in the AM
• Alpha Antagonist is a treatment for HPH
• Gonorrhea and chlamydia are sexually transmitted infections can be treated with Doxycycline and Ceftriaxone
• It is best to avoid nitrates w/ Cialis due to risk factors with HTN

Self Assesment Q&A:

• A history of pulmonary embolism is a contraindication for HRT.
• Elevated free testosterone levels hallmark of PCOS.
• Chlamydia trachomatis is causative agents for pelvic inflammatory disease. ceftriaxone + doxycycline are standard outpatient regimen.
• Menopause involves loss of ovarian sensitivity to gonadotropins.
• Aromatase inhibitors increase testosterone production
• Test levels are highest in the morning, peaking within the first three hours of waking.
• Cialis exhibits its effect over longer duration.
• Treat bacterial prostatitis with bactrim
• At ovulation, a surge of LH (luteinizing hormone) causes ovulation.
• Elevated free testosterone levels hallmark of PCOS.
• Danozol reduce endometriosis.
• With PID or tenderness or fever, ceftriaxone and doxycycline should be treated.
• increased FSH is present during menopause
• Thrombosis are common side effects
• The combination of estrogen and progesterone could indicate MRT or HRT
• Prostatitis is a condition for fluoroquinones to be made
• Menieres' disease will have increased pressure in the endolymphatic system and cause hearing loss

Quick Guide to Bacteria Based Infection

• PSA: Pseudomonas, S.aureus with swimmers ear.
• SHM: S.pneumoniae, Haemophilus influenzar, Moraxella catarrhalis. for otitis or ear media.
• CGMP for caused by chalmydia.
• Non Infections will be caused by Gardener's, SE asks PP.
• STIS w/ chlmyida or gonorrhea are treated w/ Cef + Doxy
• For youg boys with epipdimytiis think more gonorrhea or chalmydia while older folks are commonly cased by E. Coli