Ear, Nose, and Throat Exam PDF

Viral and Bacterial Sinusitis Acute Bacterial Rhinosinusitis Maxillary and frontal sinuses are most commonly affected after history of viral URI “common cold” or allergic rhinitis are. Fluid is trapped inside the sinuses, causing secondary bacterial infection (S. pneumoniae, H. influenzae). Symptom...

Viral and Bacterial Sinusitis Acute Bacterial Rhinosinusitis Maxillary and frontal sinuses are most commonly affected after history of viral URI “common cold” or allergic rhinitis are. Fluid is trapped inside the sinuses, causing secondary bacterial infection (S. pneumoniae, H. influenzae). Symptoms of unilateral facial pain or upper molar pain (maxillary sinus) or frontal sinus pain with nasal congestion for 10 days or longer with purulent (dark yellow-to-green) nasal and/or postnasal drip. Hyposmia (reduced ability to smell) Postnasal drip cough worsens when supine and may interfere with sleep Self-treatment with OTC cold and sinus remedies provides no relief of symptoms Examination Posterior pharynx purulent postnasal drip Sinuses tender to palpation on front cheek (maxillary) and/or frontal sinus area above the inner canthus of the eye Fever Transillumination of frontal and maxillary sinus ”positive” if glow of light on infected sinus is duller than on norm Treat with antibiotics if symptoms present for longer than 10 days or have worsened, severe symptoms (toxic, high fever, pain, purulent nasal discharge 2-3 days or longer), patient is immunocompromised. 1st line Adults: Amoxicillin-clavulanate (Augmentin) BID x 7 days (educate regarding GI side effects) Children: Amoxicillin 90mg/kg/day Penicillin allergy: Levooxacin (tendon rupture) or doxycycline (discolor tooth enamel, not pregnant), cefdinir (Omnicef), cefuroxime (Ceftin) Pain or fever Ibuprofen or acetaminophen Drainage Oral decongestants such as pseudoephedrine (Sudafed) or pseudoephedrine combined with guaifenesin (Mucinex D) Topical decongestant Afrin-limit use to 3 days maximum to avoid rebound congestion Saline nasal spray (Ocean Spray) Steroid nasal spray (Flonase ) Mucolytic (guaifenesin) and increased fluids to thin mucus Cough Dextromethorphan (Robitussin) Benzonatate (Tessalon Perles): do not crush or chew. Toxic for children < 10 years. Swallow pills with water. Acute Bacterial Rhinosinusitis Complications: Periorbital or orbital cellulitis (more common in children): Swelling and redness at periorbital area, double-vision  or impaired vision, and fever. May have abnormal EOM or altered LOC or mental status changes. Concern of abscess formation Refer to ED for hospitalization Meningitis: Acute onset of high fever, stiff neck, severe headache, photophobia, toxic. Positive Brudzinski’s (passively ex/bend the patient’s neck toward the chest, positive if patient reexively exes the hips and knee to relieve pressure and pain) or Kernig’s sign (ex hips one at a time, attempt to straighten leg while keeping hip flexed at 90 degrees, positive if resistance due to painful hamstring due to inflammation of lumbar nerve roots) and/or back pain. Refer to ED. Cavernous sinus thrombosis: Acute headache, abnormal neurologic exam, confusion, fever. Life-threatening emergency with high mortality. Refer to ED. Hearing Loss Hearing loss occurs when sound waves don't reach the brain. It can affect one or both ears and range from mild to severe. Causes Aging: Hearing loss can occur naturally as people age. Exposure to loud noises: Long-term exposure to loud noises can damage the hair cells in the inner ear. Earwax buildup: Earwax can block the ear canal and prevent sound waves from reaching the inner ear. Ear infections: Ear infections can cause fluid buildup in the ear, which can impact hearing. Ruptured eardrum: A ruptured eardrum can prevent sound waves from r eaching the inner ear. Medications: Some medications, like aminoglycoside antibiotics, loop diuretics, and certain chemotherapy drugs, can cause hearing loss. Diseases: Diseases like high blood pressure, diabetes, and strokes can contribute to hearing loss. Genetic conditions: Some genetic conditions can cause hearing loss. Symptoms: Difficulty hearing conversational speech or loud sounds, Higher pitched tones may sound muffled, Difficulty picking out words against background noise, Asking people to repeat themselves Treatment Treatments for hearing loss include hearing aids, cochlear implants, surgery, and special training Allergic Rhinitis Inflammatory changes of the nasal mucosa due to allergy Presentation: Chronic or seasonal nasal congestion with clear mucus rhinorrhea or postnasal drip Cough due to postnasal drip worse when supine Nasal, throat, eye itching, watery eyes, sneezing Nasal, throat, eye itching, watery eyes, sneezing Examination Pale, boggy turbinates Rhinorrhea clear, PND clear to yellow and thick (if green r/o sinusitis) Undereye dark circles “raccoon eyes” Children may have transverse nasal crease from frequent rubbing “allergic salute” Posterior pharynx may show cobblestoning Treatment: first line Nasal steroid sprays daily OTC Fluticasone (Flonase), triamcinolone (Nasacort) If only partial relief, topical antihistamine nasal spray azelastine (Astelin) If no relief, combination product azelastine and Fluticasone (Dymista) Decongestants PRN (pseudoephedrine, Sudafed) Epistaxis Oral antihistamine PRN. Second generation less sedating: cetirizine (Zyrtec), loratadine (Claritin) Eliminate environmental allergens Complications Acute sinusitis Acute otitis media Rhinitis medicamentosa: Prolonged use of nasal decongestants (>3days) causes rebound effects that result in severe and chronic nasal congestion (Afrin). Impacted Cerumen Impacted cerumen, also known as ear wax impaction, is a buildup of ear wax that can cause hearing loss, pain, itching, and other symptoms. Symptoms: Itching or odor in the ear, Ringing or other noises in the ear (tinnitus),Feeling of fullness in the ear Partial hearing loss,Earache,Discharge from the ear Causes: Earwax is normally expelled from the ear canal by jaw movement, but sometimes this process doesn't work.  Treatment: Softening the wax: Using drops with glycerin or carbamide peroxide to soften the wax Irrigation: Using a syringe to gently flush out the ear canal with warm water Manual removal: Using special tools to remove the earwax Prevention To prevent impacted earwax, you can: Avoid putting objects in your ear canal Clean your outer ear with a wet washcloth Use drops with glycerin or carbamide peroxide to soften earwax Epistaxis Anterior nasal bleeds are more common than posterior (more serious and can lead to severe hemorrhage). Risks: Aspirin use, NSAIDS, cocaine abuse, severe hypertension, and anticoagulant use. Most episodes are self-limiting. Presentation: acute onset of nasal bleeding, bright-red blood may drip externally through the nasal passages and/or the posterior pharynx. Profuse bleeding can lead to vomiting blood. Treatment: Apply direct pressure on the front of the nose for several minutes. Use of nasal decongestant to shrink tissue helps stop bleeding. Apply triple antibiotic ointment or petroleum jelly in front of nose using cotton swab for a few days (if trauma i.e.. Nose picking). Cauterization via chemical silver nitrate or electrical device applied to nasal mucosa. Can be done in office with local anesthetic. Foreign Body in the Ear A foreign object in the ear can be painful and cause itching or noise. The object may be visible or hidden, and it can be difficult to remove. Symptoms: Pain, Itching, Noise, Redness, Drainage, and Hearing difficulties. Treatment: Tweezers: If the object is visible and easy to grasp, you can try removing it with tweezers.  Water: If there's no hole in the eardrum, you can try flushing the ear with warm water using a rubber-bulb syringe. Oil or alcohol: If there's an insect, you can try tilting the head and pouring warm oil or alcohol into the ear. Magnets: If the object is metal, you can try using magnets. Suction: You can try using a suction catheter to pull the object out. Special instruments: A medical professional may use special instruments to grasp the object. What to avoid: Don't put a cotton swab or matchstick into the ear. Don't use water to remove batteries, food, or plant material. Don't use oil if you think there's a hole in the eardrum or if ear tubes are in place Periorbital Cellulitis Periorbital cellulitis is an infection and inflammation of the eyelid and skin around the eye. It's also known as preseptal cellulitis. Symptoms :Redness around the eye or in the white of the eye, Swelling of the eyelid, whites of the eyes, and surrounding area Causes :Bacterial infection, such as from Staphylococcus, streptococcus, or Haemophilus bacteriae, sinusitis, Minor injury to the eye, Spread of infection from another part of the body, such as a cough, cold, or impetigo, Insect bites Treatment :Oral antibiotics, which usually start working within 24 to 48 hours, Cool compresses to reduce swelling and discomfort Complications: If left untreated, periorbital cellulitis can lead to orbital cellulitis, which can cause loss of vision In rare cases, it can lead to meningitis, brain abscess, or cavernous sinus thrombosis When to seek medical care Seek immediate medical care for: Difficulty moving the eye Vision changes Symptoms worsen after treatment The eye looks bulging  Eustachian Tube Dysfunction Eustachian tube dysfunction (ETD) happens when the Eustachian tubes are blocked or don't open properly. This prevents fluid and pressure from draining from the middle ear. Symptoms Ear pain, Feeling of fullness in the ear, Ringing in the ears (tinnitus) Popping or clicking sounds in the ears, Difficulty hearing, Dizziness or vertigo Pulling or tugging on the ear Causes: Common colds, Upper respiratory tract infections, Allergies, Chronic drainage of mucus, and Increased swelling at the opening of the Eustachian tube. Treatment: Yawning, Eating and drinking, Nasal decongestants, Steroid nasal sprays, Steam inhalations, Antihistamine Nasopharyngitis Contagious viral infection that causes inflammation of the nasal passages and throat. It's also known as the common cold. Symptoms: Runny or stuffy nose, Coughing, Sore throat, Sneezing Low-grade fever, Headache, Fatigue Causes Rhinovirus, the most common virus that causes the common cold, RSV, Parainfluenza virus, adenovirus, coronaviruses Transmission Spread through air or by touching contaminated objects. Highly contagious and can spread quickly in group settings Treatment: Over-the-counter medications like decongestants, antihistamines, and nonsteroidal anti-inflammatory drugs, Airway clearance treatments, Symptomatic treatment Prevention: Wash your hands, Avoid touching your eyes, nose, or mouth after touching contaminated objects Usually resolves within 8 to 10 days, but can last longer Pharyngitis/Tonsillitis Suspect viral etiology if cough and symptoms such as stuffy nose, rhinitis with clear mucous, and watery eyes (coryza). Streptococcal Pharyngitis Assessment Common in children and adults around children. Presents with abrupt onset of fever, sore throat, pain with swallowing, enlarged submandibular lymph nodes, anterior lymphadenopathy and tenderness, may be exudate (yellow, green) on tonsils. CENTOR Criteria – tonsillar exudate, tender anterior cervical adenopathy, hx of fever, absence of cough Examination: Pharynx dark pink to bright red Adults usually afebrile or with mild fever Tonsillar exudate Petechiae on the hard palate Anterior cervical lymph nodes mildly enlarged Rapid antigen testing (RADT) “rapid strep test” or throat culture Treatment: First line Oral Penicillin V 500 mg BID to TID x 10 days Alternative Amoxicillin 500 mg BID x 10 days Penicillin allergy Azithromycin (Zpak) x 5 days Throat pain and fever Ibuprofen or acetaminophen Throat pain Saltwater gargles, throat lozenges May return to work or school 24 hours after antibiotic initiated (considered not contagious) New toothbrush 24 hours after antibiotic initiated COMPLICATIONS OF STREP THROAT: Scarlet fever (Scarlatina): Sandpaper-textured pink rash with sore throat and strawberry tongue (red, sore tongue). Rash starts on the head and neck and spreads to the trunk, then to the extremities. Next, the skin desquamates (peels off). Increased risk of rheumatic fever - Inflammatory reaction to strep infection that may affect the heart and the valves, joints, and the brain. Fever Painful and tender joints — most often in the knees, ankles, elbows and wrists Pain in one joint that migrates to another joint Red, hot or swollen joints Small, painless bumps (nodules) beneath the skin Chest pain, fatigue Flat or slightly raised, painless rash with a ragged edge Jerky, uncontrollable body movements Peritonsillar abscess: Displaced uvula, red bulging mass on one side of anterior pharyngeal space, dysphagia, fever. Increased saliva, drooling, muted “hot potato” voice Refer to Emergency Department due to risk of airway closing Post streptococcal glomerulonephritis: Abrupt onset of proteinuria, hematuria, dark- colored urine, and RBC casts (urine) accompanied by hypertension and edema. Otitis Externa: Also known as Swimmer’s Ear Inflammation or infection of the external ear canal, the auricle, or both. Causes: Excessive moisture Bacterial: Pseudomonas (most common), Staphylococcus, Streptococcus Fungal: Aspergillus (most common), Candida albicans Risk factors: Prolonged exposure to water (swimming), hearing aid use, ear bud use, absence of cerumen, diabetes, trauma to external canal Assessment findings: Pain with movement (traction of the pinna elicits pain is hallmark sign of OE) Edema and redness in external ear canal Discharge and/or flaky debris in ear canal Itching in external ear canal Normal tympanic membrane Pharmacologic: Important to know which ear drops can and cannot be used when tympanic membrane is NOT intact Otic antibiotic with steroid combination selectively treats infection and decreases inflammation: Hydrocortisone/neomycin/polymycin B (Cortisporin) Ciprooxacin/dexamethasone (Ciprodex): product is sterile and may be used with ruptured TM Tobramycin/dexamethasone (TobraDex): may be used with ruptured TM Ooxacin (Floxin): can be used in patients over 12 years with ruptured TM, over 6 months with intact TM Antifungals as needed Oral antibiotics reserved for severe cases May need to use ear wick if canal extremely edematous Pearls: Avoid prolonged exposure to warm, humid conditions (swimming, hot tubs, shower, bath) Dry ears after showering, profuse perspiration, and swimming Dry the ear with a hair dryer set on low heat. Position dryer 1 foot away and direct air for 1 minute Do not place objects in the ear that may cause trauma to the external auditory canal trauma (cotton swabs, paper clips, toothpicks, pen caps) OTC Swimmer’s Ear drops (isopropyl alcohol ear drying drops), home mixture of vinegar, rubbing alcohol, water) Treat eczema before it affects the external auditory canal turn into infection if fluid sits in middle ear Epiglottitis Epiglottitis is a life-threatening bacterial or viral infection that causes the epiglottis to swell and become inflamed. The epiglottis is a flap of cartilage at the base of the tongue that prevents food from entering the windpipe. Symptoms Difficulty swallowing, Drooling, Fever, Hoarseness or abnormal voice, Increased breathing rate, High-pitched sound when breathing in, Severe sore throat, Difficulty breathing Treatment Immediate emergency care, Oxygen mask or breathing tube, and Antibiotics administered intravenously. Antibiotics for epiglottitis include ceftriaxone, cefotaxime, ampicillin/sulbactam, and others. Causes bacterial infection and throat injury. Prevention The Hib vaccine can prevent epiglottitis. Complications: Epiglottitis can lead to airway obstruction and breathing problems that can worsen quickly Acute Otitis Media Acute Otitis Media (AOM) :Middle ear inflammation that causes bulging or full tympanic membrane (TM) associated with middle ear effusion. Ear infection. Causes: Etiology: viruses/bacteria, Strep pneumoniae most common, H. influenzae, rhinovirus, influenza Symptoms: Rapid onset of ear pain, fever, distorted TM landmarks, displaced light reflex, decreased TM mobility, cloudy/dull/opaque or erythematous TM, moderate to severe bulging TM Treatment: Amoxicillin is first line Second line – oral Augmentin, Cefdinir – both effective against beta lactamase producing strains of bacteria Treat pain with oral analgesic, treat Eustachian tube dysfunction (swelling due to inflammation, lack of drainage) with NSAID For patients with AOM and TUBES – antibiotic otic drops (Ciprodex, Floxin) Acute Otitis Media with Effusion: Fluid accumulation in the middle ear without evidence of infection, RSV Causes: After AOM infection resolves but fluid remains, Eustachian tube dysfunction, can turn into infection if fluid sits in middle ear Symptoms: Feeling of fullness in ear, diminished hearing, dull TM, decreased mobility of TM, retracted, visible air bubbles Treatment: Oral decongestants, steroid nasal spray, long acting oral antihistamine Infectious Mononucleosis Infection by the Epstein-Barr Virus (EBV) Presents similarly to viral and strep pharyngitis (acute symptoms, not prolonged) More common in 15 to 24 years. Mainly shed through saliva. “kissing disease” Classic triad of fever, pharyngitis, and lymphadenopathy (50%) prolonged fatigue (several weeks and may last months) enlarged cervical lymph nodes (may be tender) enlarged tonsils with white exudate After acute infection, EBV lies latent in the oropharyngeal tissue and can be reactivated and cause symptoms. Monospot (heterophile antibody) test Hepatomegaly (20%) and splenomegaly (50%) of patients. Avoid vigorous palpation of the abdomen. Ruptured spleen is a catastrophic event Acute stages: limit physical activity, no contact sports or weightlifting for 4 weeks due to risk of splenic rupture. Order abdominal ultrasound if splenomegaly/hepatomegaly is present. Repeat abdominal US in 4- 6 weeks if abnormal to document resolution. Treat symptoms (may use oral steroids for tonsillar edema, lidocaine gargle, analgesics). If concern of airway obstruction refer to emergency department for high-dose steroids. Up to 90% of people with mono who take amoxicillin will break out with a “nonallergic” generalized maculopapular rash. Avoid using amoxicillin for patients with mono and strep because it causes a generalized rash not related to allergy. (may use Penicillin VK (if not allergic) or macrolide antibiotic). Mastoiditis: Infection of the mastoid bone Usually caused by middle ear infection that results in damage to mastoid bone and pus- filled cysts. Symptoms: redness, swelling, and tenderness around the bone. Fever and ear pain. Lethargy, abnormal tympanic membrane, fever, otalgia, otorrhea, narrowing of auditory canal Refer for CT scan, possible IV antibiotics, hospitalization Complications: Meningitis, Epidural or subdural abscess, facial nerve palsy, hearing loss, labrinithitis, osteomyelitis, venous sinus thrombosis  Peritonsillar Abscess Displaced uvula, red bulging mass on one side of anterior pharyngeal space, dysphagia, fever. Increased saliva, drooling, muted “hot potato” voice Refer to Emergency Department due to risk of airway closing Dental Abscess A dental abscess is a pus-filled pocket in the gums, teeth, or jawbone that's caused by a bacterial infection. It's a serious condition that requires urgent treatment from a dentist. Symptoms :Throbbing pain in the tooth or gums that may spread to the jaw, ear, or neck, Pain that worsens when lying down, Swelling in the face, gums, or jaw, Redness and inflammation of the skin, Tenderness, discoloration, or looseness of the affected tooth, Fever, Bad breath or unpleasant taste in the mouth, Sensitivity to hot or cold Causes: A dental abscess can be caused by tooth decay, a broken or chipped tooth, or an injury to the tooth. Bacteria can enter the tooth through a cavity, crack, or chip, infecting the pulp and causing a buildup of pus Treatment: Over-the-counter pain relievers like ibuprofen, naproxen, or aspirin can help with pain and swelling. Prescription NSAIDs can treat more severe pain. Common antibiotics include penicillin, amoxicillin, cephalexin, metronidazole, a zithromycin, and erythromycin. Procedures Incision and drainage: A minor surgical procedure that involves making a small cut in the gum to drain the pus. Root canal: A procedure that involves drilling into the tooth to remove the infected pulp, draining the abscess, and filling and sealing the tooth. Extraction: If the tooth can't be saved, the dentist may remove it Conjunctivitis: Conjunctivitis (Pink Eye) Description An inflammation of the conjunctiva Common Causes: Viral Conjunctivitis, Bacterial Conjunctivitis, Allergic Conjunctivitis Viral Conjunctivitis: Highly contagious, 2nd eye usually becomes infected within 24-48 hours. Injected conjunctiva- initially unilateral, then bilateral Profuse tearing Watery mucus discharge Burning/sandy/gritty Viral prodrome with concurrent URI Preauricluar lymphadenopathy Causes: Adenovirus most common Coxsackie virus Herpes simplex Varicella zoster Molluscum Treatment POCT Adenovirus testing: utilizes tears to determine if bacterial or viral Treat symptoms with Vasoconstrictor/antihistamine for severe itching Artificial tears for symptomatic relief Herpetic Conjunctivitis: Herpes simplex or zoster require urgent referral Herpes simplex and varicella zoster. Burning sensation, rarely itching Unilateral, herpetic skin vesicles in herpes zoster Palpable Preauricluar lymph nodes Neonates appears 6-14 days after birth Treatment: Refer urgently to ophthalmologist for treatment Wood’s Lam/Slit Lamp will show dendritic lesions Treatment by ophthalmologist Oral acyclovir Topical ophthalmic antiviral Bacterial Conjunctivitis: Purulent exudates Eyes “stuck” shut in morning, matting Conjunctival erythema Sensation of foreign body/gritty/burning/itching Causes: Multiple organisms Staph aureus more common in adults Pseudomonas common in contact lens wearers Strep pneumoniae H. influenzae M. catarrhalis STI N gonorrhea Chlamydia trachomatis. Treatment Fluoroquinolones eye drops are 1st line for contact lens wearers Children: parents may prefer ointment over drops Many choices for eye drops, preference based on cost and likelihood of adherence STI Conjunctivitis Chlamydia & Gonorrhea Common cause of neonatal conjunctivitis Chlamydial 5-14 days after birth. Unilateral or bilateral Watery discharge progresses to mucopurulent Conjunctival and eyelid erythema and edema Lack of follicular response Gonorrhea rapidly 24-48 hours after birth Bilateral Copious purulent discharge Diffuse eyelid and conjunctival edema Occurs in adults due to exposure to genital secretions Treatment: IV or IM ceftriaxone and oral azithromycin or erythromycin Allergic Conjunctivitis: IgE or mast cell hypersensitivity reaction Environmental allergen- often coexists with allergic rhinitis Contact (makeup) Diffuse redness severe itching Tearing Conjunctival edema  Treatment Topical antihistamine eye drops Oral antihistamine Topical vasoconstrictor EDUCATION FOR VIRAL OR BACTERIAL CONJUNCTIVITUS: Both types highly contagious Good hand washing Use clean washcloth each time face is washed Wash pillowcase or any linens that may have had contact with drainage & change daily TAKEAWAYS for Conjunctivitis: Always chart testing of visual acuity Refer to ophthalmologist if herpes, hemorrhagic conjunctivitis, ulcerations present, lack of response to treatment NEVER prescribe steroid eye drop Primary care providers should never prescribe topical glucocorticoids or anesthetics due to risk of sight- threatening complications (delayed wound healing, ulceration, scarring, perforation, blindness) Tetracyclines should not be used in pregnant or lactating patients or children < 8 years Discard eye makeup Discard or disinfect contact lenses Do not wear contact lenses until symptoms resolve 7-10 days TMJ Temporomandibular joint (TMJ) disorders are a group of conditions that cause pain and dysfunction in the jaw joint and muscles. TMJ disorders can include pain, clicking, jaw locking, and headaches. Symptoms: Pain when chewing, talking, or yawning, Clicking, popping, or crackling in the jaw, Swelling in the face, Earaches, congestion, or ringing in the ears, Headaches, including migraines, Jaw locking, Jaw doesn't open and close symmetrically Causes: Injury to the temporomandibular joint, Clenching or grinding your teeth at night, Tension, fatigue, or spasms in the muscles around the joint, Disruption or displacement of the disc within the joint Treatment: Resting the jaw, Eating soft foods, Avoiding clenching your jaw, Wearing a mouth guard while sleeping, and Mouth splints to treat teeth grinding. Diagnosis: Examination of jaw for swelling or tenderness, Imaging tests like X-rays, CT scans, or MRIs may be used Blepharitis: Inflammation of the eyelids that presents with burning, itching, tearing lid crusting in the morning, flaking or scaling of eyelid skin, red eyes If anterior – staphylococcal, seborrheic dermatitis, rosacea If posterior – Meibomian gland dysfunction When assessing test visual acuity and also examine the skin and eyelids Risk factors – frequent hordeola or chalzia, facial or scalp seborrhea, immunocompromised state, rosacea, acne, dry eye First-Line treatment: Topical antibiotics and lid hygiene Pharmacologic Management Topicals: erythromycin ointment, azithromycin otic drops Orals for severe cases, resistant to topicals consider oral tetracycline or doxycycline for several weeks, azithromycin as alternative Nonpharmacologic Management Treat with eyelid margin scrubs (diluted baby Johnson’s shampoo) BID and warm compresses. Discourage eye rubbing Lid massage to empty Meibomian glands Discontinue contacts during acute phase Consultation/Referral Refer to ophthalmologist for severe infections or for conditions which do not improve with treatment Hand-Foot-Mouth Disease KEY POINTS Hand, foot, and mouth disease (HFMD) is common in children under 5 years old, but anyone can get it. The illness is usually not serious, but it is very contagious. To prevent spreading HFMD, wash your hands often, clean and disinfect surfaces, and avoid close contact with others. HFMD is a common illness that usually causes fever, mouth sores, and skin rash. It can spread quickly at schools and day care centers. Most people get better on their own in 7 to 10 days. Signs and symptoms Most children have mild symptoms for 7 to 10 days. Symptoms may include: Fever Sore throat Painful mouth sores that blister Rash commonly found on the hands and feet Complications from HFMD are rare Hordeolum (Stye) : Description: Acute inflammation or infection of the eyelid margin involving the sebaceous gland of an eyelash (external hordeolum) or a Meibomian gland (internal hordeolum) Etiology: Commonly caused by staphylococcus aureus Clinical Presentation Sudden onset of localized tenderness, redness, swelling of the eyelid Usually spontaneously drains aided by warm compresses Pharmacologic Management: Erythromycin ophthalmic ointment to eyelid margin Non-pharmacologic Management: Apply warm, moist compresses for 15 minutes throughout the day Cleanse eyelids daily with Johnson’s No Tears Baby Shampoo Hordeolum should NOT be expressed Thrush Chalazion: Description: Acute, benign granulomatous inflammation of the Meibomian gland, typically following an occurrence of internal hordeolum Etiology: Obstruction of Meibomian gland Clinical Presentation May appear the same as a stye but painless lesion that does not involve the lashes Lid edema or palpable mass Pharmacologic Management: Usually NOT necessary Topical ophthalmic antibiotic for secondarily infected chalazion Nonpharmacologic Management: Warm, moist compresses Consultation/Referral Incision and curettage may be needed if no resolution w/ conservative treatment If chalazion persists steroid injection may need to be performed **Chronic recurrent chalazion in same place may be an eyelid tumor (sebaceous gland carcinoma) Refer to ophthalmologist if no improvement after 6 weeks Stomatitis Stomatitis is inflammation of the mouth and lips that can cause swelling, redness, and painful sores. It can be caused by a number of things, including infections, injuries, allergic reactions, and certain medications. Symptoms: Painful sores in the mouth or lips, Swelling and redness of the mouth lining, Difficulty eating, drinking, or swallowing, Burning sensation, Sensitivity to temperature changes, Irritation from certain foods Causes: Viral or bacterial infections such as cold sores, Canker sores, which can be caused by poor oral hygiene or a weakened immune system, Allergic reactions to food, flavorings, or certain bacteria in the mouth, Burns from hot food or drinks, Side effects of cancer treatments, Certain medications, such as mouth rinses with ethanol, Vitamin or mineral deficiencies, Inflammatory bowel diseases or autoimmune diseases Treatment: Treating the underlying condition, Taking pain medication or using special mouth rinses, Avoiding products that may be causing the sores, Practicing good oral hygiene, such as using a soft toothbrush and salt-water rinses, Eating a soft diet that avoids acidic or salty foods Stomatitis can be mild and localized or severe and widespread. It usually lasts for a short time, but it can take up to two weeks for the sores to heal Ocular Foreign Body Presence of substance, material, objects adhering to the eye or imbedded in the eye in the cul-de-sacs, under the upper lid, or on the cornea. Risk factors: Improper use of protective eyewear Lack of protective eyewear Clinical Presentation: Red eye with foreign body sensation Blurry vision; photophobia; pain; tearing Appearance of dark speck against the iris Feeling of “something is in my eye” Red eye Tearing Pain Photophobia Frequent eye rubbing Differential Diagnosis: Corneal abrasion; intraocular penetration of foreign body Consultation/Referral: A penetrating injury is a medical emergency and must be referred immediately Refer to ophthalmologist for all but simple non-penetrating injuries Refer to ophthalmologist if changes in visual acuity occur with any eye injury Herpangina Herpangina is a viral infection that causes painful sores in the mouth, throat, and sometimes on the hands, feet, and buttocks. It's also known as mouth blisters. Symptoms: Small, blister-like bumps or ulcers in the mouth, throat, or roof of the mouth, Fever.Sore throat, Difficulty swallowing, Headache Causes: Coxsackie viruses A, B, or echoviruses Treatment: Rest, Drink fluids, especially cold milk products, Take acetaminophen (Tylenol) or ibuprofen (Motrin) for fever and discomfort, Gargle with cool water, Eat a non- irritating diet, Use topical anesthetics for the mouth Prevention: Wash hands frequently and Isolate patients in well-aerated rooms. Complications: Dehydration and More serious problems for people who are immunocompromised or pregnant. Herpangina is usually mild and goes away on its own within a week  Iritis/Uveitis/Keratitis Iritis, uveitis, and keratitis are all eye conditions that involve inflammation. Iritis is a type of uveitis that affects the iris, the colored part of the eye. Keratitis is an inflammation of the cornea. Iritis: Also known as anterior uveitis, iritis is inflammation of the iris Symptoms: include eye pain, redness, and sensitivity to light can be caused by infection, injury, or autoimmune disease Treatment includes prescription eye drops and anti-inflammatory drugs If left untreated, iritis can lead to vision loss or blindness Uveitis: Inflammation of the uvea, the middle layer of the eye Symptoms include eye pain, redness, and sensitivity to light Uveitis can affect one or both eyes caused by infection, injury, or autoimmune disease Treatment includes prescription eye drops and anti-inflammatory drugs Keratitis: Inflammation of the cornea Symptoms can include eye pain, redness, and sensitivity to light Keratitis can be confused with other eye conditions that cause similar symptoms Aphthous Ulcer also known as canker sores, are painful sores that appear in the mouth. They are non-contagious and usually heal within 10–14 days. Symptoms: Small, shallow, white or yellow sores with a red border ,Can appear on the gums, tongue, cheeks, lips, or throat, Can occur alone or in groups , Can make it difficult to eat or talk Causes: In most cases, the cause is unknown, May be caused by a deficiency in iron, folate, or vitamin B, May be caused by certain drugs, such as nonsteroidal anti- inflammatory drugs (NSAIDs) , May be caused by sodium lauryl sulfate (SLS), a detergent found in some oral care products Treatment: Over-the-counter or prescription products can help relieve symptoms Treatments include topical anesthetics, mouth rinses, and corticosteroid ointments Aphthous ulcers can recur at any time Minor aphthous ulcers often recur intermittently Major aphthous ulcers heal with scarring Acute Angle Closure Glaucoma : Treatment: Refer to emergency department! Sudden increase in intraocular pressure Assessment: Sudden vision loss Pain (Usually unilateral), severe, throbbing Headache, nausea, acute vomiting blurry of hazy vision, halos around lights photophobia rapid loss of peripheral vision, then central vision Poorly reacting pupils Corneal Abrasion Complete or partial tear of the epithelium of the cornea Caused by: Disruption of the outermost layer of the cornea, the epithelium, by either chemical of mechanical means (trauma, foreign body, contact lens) Clinical Presentation: C/O “gritty” feeling or “something” in eye, Eye pain when opening/closing the eye Photophobia, Red eye, Tearing, Haziness of cornea eye pain with inability or unwillingness to open eye, light sensitivity, tearing Assess visual acuity (should be normal) Ocular exam: Fluorescein staining (Wood’s Lamp/Slit Lamp) after ocular exam to confirm Fluorescein is instilled in the eye, areas of epithelial disruption to fluoresce green with exposer to Wood’s lamp May need to use numbing eye drops first to get eye open Invert eyelid to rule out foreign body under the lid Wood’s Lamp Indications Used to assess for corneal abrasion (scratch) on the surface of the eye. Uses transillumination (light) to detect bacterial or fungal skin infections. It also can detect skin pigment disorders such as vitiligo and other skin irregularities. Abrasions or scratches will glow when the light is on it. There are no risks associated with the procedure. Management Use NS to irrigate eye after topical anesthesia Evaluate for foreign body Topical antibiotics: Same rules apply here. Remember 1st line for contact lens wearers are topical fluoroquinolones, do not wear contacts until healed Pressure patching no longer recommended (risk of ulcerative keratitis, infection) Consultation/Referral Refer to ophthalmologist if injury involved thermal or chemical materials; blunt or sharp objects; or penetration into eye Distorted vision No improvement within 24 hours If ophthalmic steroid or anesthetic needed Subconjunctival Hemorrhage: Note differences in appearance of sub conjunctival hemorrhage (benign) versus hyphemia (blood in anterior chamber is an emergency) Sub conjunctival hemorrhage is a broken blood vessel in the eye, conjunctiva can’t absorb blood quickly so blood gets trapped. Causes: Sudden or severe sneeze or cough Heavy lifting Straining Vomiting Vigorous eye rubbing Self-limiting Usually disappears within 2 weeks No change in vision Not painful Asymptomatic Nasolacrimal Duct Obstruction Nasolacrimal duct obstruction, also known as blocked tear duct, occurs when the tear drainage system is blocked. This can be caused by a number of factors, including infections, aging, or injuries. Symptoms: Tearing, Mucus or pus discharge from the eye, Blurred vision, Watery eyes, and Irritation. Causes: Congenital issues, Infections, Inflammation, Medications, Surgery, Tumors, Facial injuries, Age-related changes, and Cancer treatments. Treatment: Infections: Treat with antibiotics like ciprofloxacin or Bactrim Surgery: Dacryocystorhinostomy (DCR) is a surgical procedure that bypasses the blocked duct  Stenting: A thin plastic tube is placed in the tear duct to keep it open Prognosis In infants, about 90% of cases resolve on their own by 12 months In adults, treatment depends on the cause of the obstruction Hyphema: Occurs when blood enters the anterior chamber of the eye between the iris and cornea. Bleeding underneath the conjunctiva appearing as a bright red patch in the white of the eye. EMERGENCY Dacryostenosis/Dacrocystitis Dacryostenosis: Blocked lacrimal sac (tear duct), most common cause of ocular discharge in newborns, inferior turbinate fails to complete canalization Persistent overflow of tears (epiphora) Acute distention and inflammation of lacrimal sac, mucus with pressure Common; resolves in 6-9 months, refer if lasting longer than 9-12 months Treatment: massage duct 2-3 times per day Dacrocystitis: Infection of the lacrimal sac due to obstruction Pain, redness, and swelling over the inner aspect of the lower eyelid and watery eyes (epiphora) commonly caused by Staph aureus or Strep pneumoniae Treatment: warm compresses, oral antibiotics Retinal Detachment At risk: myopia, trauma, glaucoma, PVD, hx of cataract surgery Sudden flashes of light Shower of floaters Visual field loss “curtain coming across vision” Poor visual acuity Emergent referral Periorbital Edema Emergent referral for urgent CT and ophthalmology consultation Concerning symptoms: diplopia, vision changes, preseptal cellulitis (acute eyelid erythema and edema) Concern is that abscess has formed and proximity to brain