Compiled File Notes PDF

Compiled le notes : ENT U world deviated nasal septum ⁃ If patient develops nasal whistling w respiration following rhinoplasty, suspect nasal septal perforation due to septal hematoma Nasal polyps ⁃ Aspirin exacerbated respiratory disease is a cli...

Compiled le notes : ENT U world deviated nasal septum ⁃ If patient develops nasal whistling w respiration following rhinoplasty, suspect nasal septal perforation due to septal hematoma Nasal polyps ⁃ Aspirin exacerbated respiratory disease is a clinical condition de ned by a triad of asthma, bronchospasm or nasal congestion following ingestion of aspirin or NSAIDs and chronic rhinosinitus w nasal polyposis Peritonsilar abscess ⁃ mu ed voice raises suspicion of disease other than uncomplicated pharyngitis and tonsillitis. A peritonsillar abscess is a potential complication of tonsillitis and requires both IV Abx therapy and urgent drainage of abscess. Deviation of uvula and unilateral lymphadenopathy can be helpful in distinguishing peritonsillar abscess for epiglottitis Salivary gland tumors ⁃ Sialadenosis is a benign, non in ammatory enlargement of the salivary glands, often caused by chronic alcohol use Acute otitis media ⁃ oral Abx for otitis media should be administered to children w high fever, severe pain or bilateral disease. Amoxicillin is the rst line therapy and amoxicillin clavulanate is indicated if persistent or recurrent Otitis media w e usion ⁃ Otitis media w e usion is middle ear e usion without tympanic membrane in ammation (bulging, erythema). Examination w show air uid level and immobility. Management is observation and follow up for resolution bc otitis media w e usion is associated w speech delay and long term hearing loss Otitis externa ⁃ otitis externa is caused by pseudomonas or staph aureus Necrotizing malignant otitis externa ⁃ malignant otitis externa is a severe infection of the external auditory canal that extends to the skull base and usually caused by pseudomonas. It’s seen more frequently in elderly patients w DM. IV cipro oxacin is the 1st line treatment Bone tumor ⁃ torus palatinus is a benign bony growth located on the midline suture of the hard palate. It can be congenital or develop later in life. It’s typically chronic and asymptomatic and diagnosis is usually clinical evident. Surgery is indicated of the mass becomes symptomatic, interferes with speech or eating or causes problems of tting of dentures fl ff ffl fi ff fl fl fi ff fl ff fi fi Vestibular neuritis/labeynthitis ⁃ vestibular neuritis is a self limited disorder of the vestibulocochlear nerve that sometimes follows a viral URTI. Vestibular neuritis w unilateral hearing loss is called labrynthitis Thyroid cancer ⁃ medullary thyroid cancer is followed up for reoccurrence using serum calcitonin levels Laryngeal papilloma ⁃ laryngeal papilloma can be due to recurrent respiratory papillomatosis caused by HPV 6 and 11, which also cause genital warts, so they’re most likely acquired through vertical transmission prior to delivery Ear trauma ⁃ barometric tymapnometric injuries resolve spontaneously in a few weeks so observe and follow up Osteonecrosis ⁃ biphosphonate related osteonecrosis of the jaw is characterized by chronic swelling, mild pain and exposed, necrotic bone. It’s often triggered by tooth extractions or other invasive dental procedures. The course can be intractable and treatment is largely supportive w careful oral hygiene and antibacterial rinses Perilymphatic stula ⁃ a perilymphatic stula can occur after head trauma and result in episodic vertigo triggered by sudden pressure changes (valsava) or loud noises Ent previous Nose anatomy and investigations ⁃ the cribiform plate of the ethmoid can’t be seen by anterior rhinoscopy ⁃ The tensor vali palentini muscle open the Eustachian tube during yawning and swallowing Ear anatomy and investigation ⁃ Galvanic stimulation is used to assess vestibular function ⁃ In case of recurrent meningitis, CT of temporal bone should be done to see if there’s any abnormalities or abnormal connections Hearing loss ⁃ ossicular discontinuity w an intact TM causes the maximum unilateral hearing loss w highly compliant TM on tympanometry (Ad) ⁃ The max decibel loss that OME can cause is 30-40 dB (actually 55 dB) ⁃ Hearing loss in presbycusis is often bilateral and symmetrical. Ototoxicity and noise induced hearing loss is also symmetrical fi fi  ⁃ Otoacpustic emission is an objective screening test of hearing loss used for neonates. It re ects the function of hair cells (hair cells in cochlea) ⁃ Auditory brainstem response is the most a ective objective test of congenital hearing loss ⁃ Wax impaction is the MCC of conductive hearing loss in adults and OM in children ⁃ Hearing loss contributes to the development of dementia ⁃ If a child underwent tympanoplasty and immediately developed hearing loss, start w tuning fork ⁃ The scale of pure tone audiobram is logarithmic not linear ⁃ CMV is the MCC of viral bilateral congenital SNHL ⁃ Varicella zoster/Ramsey hunt syndrome is the MCC of unilateral viral SNHR ⁃ Ramsay hunt syndrome causes facial nerve paralysis, sensinueral hearing loss and painful auricular rash vesicular lesions at external auditory meatus ⁃ About 90% of ppl older than 15 have been infected by VZV ⁃ If a normal patients wakes up in the morning w sudden hearing loss, it’s SNHR ⁃ Imaging is imp bc 10% of SNHR is cause by acoustic neuroma and hearing loss is the MC presentation ⁃ If patient has decreased speech recognition and no hearing loss w unilateral tinnitus, it’s imp to rule out acoustic neuroma ⁃ Acoustic neuroma is detected by internal ear MRI ⁃ MRI of internal acoustic meatus is the best for detecting shwannoma ⁃ The MC form of congenital hearing loss is SNHR ⁃ Congenital hearing loss should be treated at 1 month at least (has to be before 6 months) ⁃ Osteosclerosis a ects younger (30 yo) Caucasian women, is AD w incomplete penetrance. It’s due to imbalance of resorption and deposition causing sti ening of stapes. It causes progressive conductive hearing loss w paradoxical improvement in speech discrimination in noisy environment w/so reddish hue behind TM. Managed by hearing aids or surgery stapes reconstruction (stapedectomy/ stapedeostomy) ⁃ Osteoscelorosis causes hearing loss at 2000 Hz (cahart notch), which is associated with immobilization of stapes ⁃ Mild TM perforation is managed by observation at reassessing in 24 hrs ⁃ Poor speech discrimination indicates a retrocochlear lesion Ototoxicity ff fl ff ff  ⁃ CALM EAR: (C) Cisplatin and Carboplatin (A) Aminoglycoside (gentamicin and tobromycin) (L) loop diuretics (M) Malaria drug quinine (E) Erythromycin (A) Aspirin (R) Red man vancomycin Vertigo ⁃ BPPV is associated with canalolithiasis ⁃ Dix Hallpike is used to diagnose BPPV, while Eply maneuver is used to treat it ⁃ Endolympj hydrops is another name for Meniere disease, which is due to decreased reabsorption of endolymph ⁃ 40% of cases of Meniera come w hearing loss ⁃ Meniere disease causes uctuant SNHR low pitched roaring tinnitus (not pulsating tinnitus) and vertigo ⁃ Meniere disease can be given intratympain gentamicin ⁃ Vestibular neuritis presents w acute persistent vertigo which is a self limiting disorder of the vestibulocochlear nerve following an URTI. It’s associated w signi cant N/ V and unsteady gait where pt falls towards a ected side. The unilateral SNHR seen w vestibular neuritis is called labrynthitis. So vestibular neuritis is vertigo only, while acute labrynthitis is vertigo and hearing loss ⁃ Vertebrobasilar insu ciency is associated with vertigo ⁃ Dizziness and vertical nystagmus happens w central vertigo ⁃ If Pt has vertigo, vision loss and nausea that happens w neck extension, do carotid US to look for carotid body tumor ⁃ Carotid body tumor presents as lateral neck swelling w ipsilateral pulsatile tinnitus ⁃ Paragangliomas arising from the carotid body or vagus nerve may present as painless neck mass and some present w pulsatile tinnitus, hearing loss and otalgia ⁃ The MC site of vestibular shwannoma is vestibular nerve Otitis externa ⁃ take a biopsy of granulomatous mass in case of necrotizing otitis externa ⁃ Necrotizing otitis externa a ects the external auditory canal, base of the skull and temporal bone ⁃ 3 months of bilateral OME or 6 months of unilateral OME is an indication of myringotomy ⁃ Middle ear e usion is diagnose by pneumotoscopy ⁃ Otitis media w e usion causes a retracted TM ⁃ Down syndrome is a risk factor for OM ⁃ Tonsillectomy is avoided in craniofacial anomalies like cleft palate ⁃ Otorrhia is the MC complication of myringotomy tube the TM perforation ff ff ffi fl ff ff fi  ⁃ Gradenigo syndrome is classically described as a triad of otitis media, retro- orbital facial pain and abducens palsy that MC developed due to an infection of petrous temporal bone ⁃ Bezold abscess is a complication of OM or otomaatoiditis, an infection that erodes through the cortex medial to attachment of SCM ⁃ Sigmoid sinus thrombosis is a complication of AOM ⁃ Mastoiditis is a complication of OM that is treated with Abx, incision and drainage and myringotomy ⁃ Infection of middle ear can speed to brain through mastoid emissary veins Cholesteatoma ⁃ cholesteatoma causes TM perforation on atic (roof or top) in pars accida ⁃ Cholesteatoma presents w chronic supportive OM, attic TM perforation, granulation tissue, foul smelling ear discharge, and conductive hearing loss ⁃ Cholesteatoma can result in a perilymphatic atula Nasal wegener granuloma ⁃ wegeners granulomatosis MC a ects sinonasal tract ⁃ Wegeners granulomatosis presents w nasal obstruction (nasal polypoid mass) and epistaxis, hematuria proteinuria and RBC cases Adenotonsillar hypertrophy ⁃ the greatest complication of angioneuritic edema is upper airway obstruction ⁃ Sickle cell patients may have hypoxia due to adenotonsillar hypertrophy ⁃ Bleeding is the MC complication of tonsillectomy ⁃ IgG is the most abundant immunoglobulin made by tonsils Sinusitis ⁃ Toxic shock syndrome and septicemia are complications of sinusitis but glomeronephritis is not ⁃ Nasal carcinoma MC metastasize to sphenoid sinus ⁃ Nasal swab is used to screen for MRSA ⁃ Sinusitis is a clinical diagnosis, where patient has facial pain and mucopurelant discharge but CT can be done ⁃ Viral rhinitis is the MCC of nasal mucosal obstruction Allergic rhinitis ⁃ Nasal rinsing helps clear nose via mucociliary enhancement ⁃ Pregnancy is a contraindication for immunosuppression of allergic rhinitis Nasal septal disorders ff fi fl  ⁃ septal deviation is the MCC of unilateral atrophic rhinitis ⁃ Nasal cavity mucosa is paeudostrati ed columnar ciliated epithelium w goblet cells ⁃ Nasal septum deviation is MC caused by trauma and is a common physical disorder and treated surgically. Note that nasal hematoma and perforation are complications of surgery but not common ⁃ If someone has septal deviation, ask for history of nasal surgery ⁃ Swelling in nasal septum following nasal fracture is due to collection of blood bw the nasal mucosa and perichondrium ⁃ Anti-staphylococcus are used to manage pain and swelling post rhinoscopy ⁃ Septoplasty/septal operations are the MCC of septal perforation ⁃ The MCC of saddle nose deformity in adults is trauma and iatrogenic ⁃ The nasal septum consists of vomer, quadrangular cartilage, and maxillary crest. The perpendicular plate of palatine is not part of the nasal septum Epistaxis ⁃ hereditary hemorrhagic telengiectasis (osler weber rendu disease presents w triad of recurrent epistaxis, mucocutaneous telengiectaisis and one a ected 1st degree relative ⁃ Most of the blood supply to nose comes from internal maxillary artery which gives rise to sphenopalantine and greater palatine ⁃ The frequency of nasal polyp increases in ages 40 and above ⁃ Bilateral polyps are treated by intraturbinate steroid injection. If it fails, then oral/systemic steroids w/wo Abx. If fails polypectomy or FESS ⁃ Bilateral nasal polyps are seen in CF or Kartgeners Facial nerve palsy ⁃ pregnant women are likely to develop facial nerve palay ⁃ Bell’s palsy has the best prognosis. It’s due to edema of facial nerve (idiopathic) and treated by steroids ⁃ Surgical treatment of facial nerve palsy is tarsorrhaphy ⁃ Lyme disease happens in patients w history of deer tick bite, cardiac arrhythmia and facial nerve palsy. Borriella Burgdorferi is the causative agent of Lyme disease Temporal nerve ⁃ muscles of mastication are medial and lateral pterygoid, masseter, temporalis. Buccinator is not a muscle of mastication and is innervated by facial nerve OSA ⁃ tracheostomy provides 100% cure rate in morbidly obese pt w OSA Pharyngitis fi ff  ⁃ the clinical pharyngitis score is used to check for strep pharyngitis/ pharyngitonsillitis ⁃ Center criteria: cervical lymphadenopathy (1) tonsillar exudate (1) absence of cough (1) high fever > 38 (1) age 3-14 (1). 2 or more give empirical antibiotics ⁃ Pharyngitis is treated with amoxicillin ⁃ Common cold most commonly caused by rhinovirus ⁃ Lemiere’s syndrome is thrombophlebitis of internal jugular vein Scarlet fever ⁃ Scarlet fever causes fever, sand paper rash, and strawberry tongue Oral lesions ⁃ tongue is MC site of oral cancer Tonsillar and peritonsillar abscess ⁃ throat swab and culture is the gold standard ⁃ Quinsy is peritonsillar abscess ⁃ Peritonsillar abscess is treated with IV uids, IV Abx and incision and drainage Salivary gland disorders ⁃ parotid gland has the greatest stimulation, sublingual sleeping, submandibular rest ⁃ Fever, leukocytosis and severe tenderness and swelling of left parotid gland following a recent surgical procedure is most likely acute supportive parotitis. Supportive parotitis often occurs in elderly post op patients, particularly those w dementia who are at risk of inadequate hydration and poor oral hygiene ⁃ Acute parotitis can happen in diabetic patient kept NPO for days ⁃ Lymphangioma is a parotid mass w bluish discoloration that expands w crying. Lymphangioma is not connected to orbital lymphatic system ⁃ Family history is an important risk factor of parotid pleomorphic adenoma ⁃ Pleomorphic adenoma is the MC benign salivary tumor, MC in parotid gland ⁃ Pleomorphic adenoma has a malignant potential, so it will grow rapidly if it becomes malignant ⁃ Ludwig angina is a mixed infection (strep viridans and anaerobes) usually arising from an infected mandibular molar, infection of upper airway or acute lingual tonsillitis. Predisposing factors include DM, alcoholism, or immunosuppression ⁃ Ludwig angina causes a submandibular space infection that presents w fever, mouth pain, sti neck, di culty swallowing and trismus. Airway obstruction may occur, thus rst step in management is to secure airway Brachial cleft cysts ⁃ 1st brachial cleft opens near the mandible at submandibular region fi ff ffi fl  ⁃ 2nd opens anterior to SCM at tonsillar fossa ⁃ 3 opens at piriform sinus Neck mass ⁃ brotic endoscopic evaluation of swallowing is used in patients w dysphagia ⁃ A mass near the piriform sinus can compress the vagus nerve, which provides sensory branches to the larynx pharynx and external auditory meatus ⁃ A brainstem lesion is the MCC of glossopharyngeal nerve disturbance ⁃ Left Supraclavicular lymphadenopathy is a marker of metastatic abdominal cancer ⁃ Facial nerve injury is a complication of removal of cystic hygroma ⁃ Following submandibular gland removal, there could be loss of somatostatin of anterior 2/3s of tongue bc of damage to lingual nerve, branch of mandibular branch of trigeminal nerve ⁃ In case of dermoid cyst, CT has to be done to check for intracranial extension ⁃ Odontogenic infections are the MCC of deep neck infections in adults. These infections are arising from dental abscess, periodontal infections, pericoronitus Nasopharyngeal carcinoma ⁃ lymphoepithelioma is a subtype of NPC characterized by presence of undi erentiated carcinoma w a prominent lymphoid in ltrate ⁃ Infectious mononucleosis causes 20% cellular Atypia (atypical lymphocytes) ⁃ There’s no vaccine for CMV, EBV RSV and HSV Epiglottis ⁃ in epiglottitis, examine patient in OR Croup ⁃ managed by nebulized epinephrine and dexamethasone, Oxygen, moist Air and IV hydration ⁃ The subglottis is the most narrow part of airway in children Stridor ⁃ laryngeal cancer is the MCC of stridor in elderly Diphtheria ⁃ Diphtheria leads to breathing di culty, heart failure and can cause vocal cord paralysis. Give anti-toxin and Abx ⁃ Encephalocele leads to mass that enlarges when crying Laryngeotracheal stenosis ⁃ endotracheal intubation is a common cause ff fi ffi fi  Laryngeal carcinoma ⁃ laryngeal carcinoma is MC in true vocal cords, causes by smoking and treated by radiation. ⁃ If glottis mass is seen, do biopsy ⁃ In cases of unilateral vocal cord paralysis, think of recurrent laryngeal nerve paralysis. ⁃ Posterior cricoarytenoid is the only abductor of the larynx ⁃ Plummer-Vinson syndrome presents as triad of dysphagia, glossitis, and iron de ciency anemia, gas been associated with postcricoid hypopharyngeal cancers, especially in women from Scandinavia ⁃ Functions of larynx include phonation, cough re ex, protection of lower respiratory tract, respiration ⁃ Stage 1-2 managed by radiation or transport laser resection or transport laser endoscopic resection ⁃ Stage 3 is managed by chemo and radiation ⁃ Stage 4 is managed but total laryngectomy then radiation Tracheostomy ⁃ mediastinal emphysema is a complication of tracheostomy ⁃ Don’t intubate post radiation patients ⁃ Complications of airway and airway management in children are: failure to secure the airway, esophageal intubation, hypoxic or hypercapnic respiratory failure leading to arrest, injury to oropharynx or larynx, bleeding, soft tissue swelling, vocal cord injury ⁃ Fistula is a side e ect of tracheostomy where blood gushes from tracheostomy side and should be dealt with until proven otherwise Optha Eye anatomy ⁃ most of light refraction happens in the anterior surface of cornea ⁃ The aqueous humor ow rate is 2 microliters/minute ⁃ The vitreous body is behind the lens ⁃ Ciliary body extends from root of iris to ora serrata ⁃ Ora serrata is the weakest connection point bw sclera and uvea ⁃ Photoreceptors is the outer layer of the retina ⁃ The optic media of the eye are the structures through which light passes and is refracted before reaching retina fi ff fl fl  ⁃ The medial orbital wall contains optic foramen. The optic canal is in the sphenoid bone ⁃ The orbital oor is made from frontal bone and lesser ring of sphenoid ⁃ The orbital cavity is surrounded by paranasal sinuses except the lateral wall. It’s made of 7 bones (sphenoid, frontal, zygomatic, ethmoid, lacrimal, maxillary, palatine), and its volume is 30 cc ⁃ Superior rectus is the furthest from limbus ⁃ Medial rectus is the largest EOM ⁃ Blood supply to medial rectus is the ocular branches of ophthalmic artery ⁃ Superior rectus is responsible for elevation, intorsion and addiction ⁃ Extortion is the primary function of inferior oblique ⁃ Cyclotorsion is the function of oblique ⁃ The abducens enters the orbit through tendinous ring ⁃ Abducens nerve plasy causes uncrossed diplopia which is diplopia when looking at a ected side. Sjorgen ⁃ the type of dry eye in sjorgen is aqueous de cient ⁃ Schirmer’s test is a tear lm assessment to assess dry eye and tearing. It’s considered a quantitative test for sjorgen ⁃ Schirmir’s test is done via precorneal tear lm to check whether the eye produces enough tears ⁃ Choroidal neovascularization is often associated with conditions like age related macular degeneration but can occur in systemic diseases like sarcoidosis. ⁃ Sarcoidosis can present w lid nodules often referred to as sarcoid nodules, which can be mistaken for other lid nodules Trauma ⁃ trauma could cause primary optic atrophy ⁃ In orbital fracture, pt has diplopia on looking up and down ⁃ Commotio retina (aka Berlin’s edema) is a condition that occurs after blunt trauma or concussive injury to eye. It results in transient retinal whitening due to disruption of outer retinal layers (photoreceptors) without permanent structural damage in many cases ⁃ Hypopyon happens in endopthalamitis or anterior uvietis and doesn’t suggest globe rupture ⁃ The best initial management for hyphema is head elevation at 30-45 degrees to facilitate drainage of blood from anterior chamber and reduce intraocular pressure. Bed rest to minimize movement and decrease risk of rebleeding. Drainage is last resort ff fl fi fi fi  ⁃ The circulus iridis major is a circle of blood vessels that runs around the outer edge of iris. It’s the largest blood vessel in iris and is most likely to bleed after blunt trauma Cavernous sinus thrombosis ⁃ key features: high fever, decreased vision, opthalmoplegia, proptosis, chemosis Giant cell arteritis ⁃ If patient has jaw claudication and scalp tenderness, suspect permanent vision loss bc this is giant cell arteritis Glaucoma ⁃ acute glaucoma presents w a triad of high IOP, visual feild loss, and optic disk cupping and atrophy ⁃ Patient will have painful red eye and mid dilated pupil ⁃ In struge-Weber (port wine stain) patient will have episcleral hemangioma that increases IOP causing early onset glaucoma ⁃ Buphthalamous is associated with increased corneal diameter ⁃ Megalocornea is a corneal horizontal size of >13 mm after 2 years of age ⁃ Keratocornea presents with photophobia, tearing and large cornea. It’s characterized by thinning and conical shape of cornea, leading to visual disturbance. The cornea may appear large and irregular in shape ⁃ Large cornea predisposed patients to angle closure glaucoma. Small lens thick cornea makes glaucoma worse ⁃ Glaucoma a ects ganglion cells ⁃ Primary open angle glaucoma is hereditary. FHx increases risk of glaucoma 4-9 times ⁃ Asymptomatic optic nerve atrophy is seen in open angle glaucoma Lacrimal system disorders ⁃ in congenital duct stenosi, uorescent dye is applied and doesn’t drain properly, instead it remains in eye or ows out over the eyelid, suggesting a blockage is stenosis in nasolacrimal duct system ⁃ Nasolacrimal duct obstruction is the MCC of tearing in infants ⁃ The MC reason of failure of dacrocystorhinostomy is obstruction at level of common cuniculus or bony osteotomy site. DCR is used to eliminate uid and mucus retention within the lacrimal sac and to increase tear drainage in relief of epiphora. DCR involves removal of bone adjacent to nasolacrimal sac and incorporating the lacrimal sac w the lateral nasal mucosa in order to bypass the site of nasolacrimal tract obstruction. This allows tears to drain directly into nasal cavity from canaliculi via a new low resistance pathway In ammatory eyelid conditions fl ff fl fl fl  ⁃ meibomian gland dysfunction is a common eye condition in which the meibomian gland in eye doesn’t secrete enough oil (lipids) ⁃ The oil layer is made by meibomian gland, while the mucin layer of the precorneal tear lm is secreted by the goblet cells ⁃ Chalazion is the MC granulomatous in ammation of the eyelid ⁃ Sebaceous carcinoma mimics chalazion ⁃ Sebaceous gland carcinoma is more known the upper eyelid bc of the higher amount of meibomian glands there. It forms skip lesions, and is more in tarsal area Entropion, ectropion and trachitis ⁃ in involutional ectropion, the tarsoligamentous sling supporting the eyelid by attachment to the orbital rim via the medial and lateral canthal tendons becomes lax. This is the MC type of ectropion and is seen w advancing age Ptosis and myasthenia gravis ⁃ the degree of ptosis correction depends on how well the levator muscle can lift the eye ⁃ In congenital ptosis, myogenic is the MC while ptosis in late adulthood is most likely apneurotic ⁃ Lagopthalamus is a condition caused by levator muscle dysfunction ⁃ Myasthenia Gravis causes uctuating ptosis ⁃ Myasthenia gravis is diagnosed using single ber EMG Conjunctivitis ⁃ adenovirus is the MCC of viral conjunctivitis. In viral conjunctivitis, there are follicles in palpebral conjunctiva and tender lymphadenopathy. ⁃ Chronic conjunctivitis and blepharitis raises suspicion of sebaceous gland carcinoma ⁃ The diagnosis of sebaceous gland carcinoma is suspected in older patients w recurrent blepharoconjunctivitis that doesn’t respond to standard treatment ⁃ Ophthalmia neonateum is caused by gonorrhea and erythromycin is used as prophylaxis ⁃ Bacterial conjunctivitis is unilateral. Unilateral conjunctivitis rst think fungal, then bacterial ⁃ Giant papillary conjunctivitis is caused by repeated mechanical irritation (contact lenses) and aggravated by concomitant allergy ⁃ Conjunctival injection, tarsal in ammation and pale follicles are concerning for trachoma. Trachoma is due to chlamydia trachomatis and is leading cause of blindness worldwide. Trachomitis spreads in crowded unsanitary places. The active phase is the MC in children and in characterized by follicular conjunctivitis and pannus (neovascularization) formation in cornea. There is often a concomitant nasopharyngeal infection (rhinorrhea, pharyngitis). Repeated or chronic infection leads to scarring of fi fl fl fl fi fi eyelids and inversion of lashes (trichiasis). Over time lashes rub the eye causing ulceration and blindness ⁃ Topical and oral erythromycin is used in neonates w neonatal conjunctivitis caused by chlamydia trachomatis ⁃ Vernal conjunctivitis is seasonal allergic conjunctivitis ⁃ Don’t give steroids for allergic conjunctivitis ⁃ Congenital kaposi sarcoma is seen in HIV, which is an eye tumor Scleritis ⁃ presents w red eye, eye pain exacerbated by eye movement, photophobia, loss of vision, xed sclera nodules and sclera thinning Subconjunctival hemorrhage ⁃ chemosis is edema of conjunctiva due to oozing of exudates from abnormally permeable capillaries. Chemosis is a nonspeci c sign of irritation Cornea and anterior chamber ⁃ Descement membrane is made by endothelial cells ⁃ Patching of eye is contraindicated in child w mucopurulent bacterial conjunctivitis and bacterial corneal ulcer ⁃ The characteristic hypopyon corneal ulcer caused by pneumococci is called ulcus serpens, and the MC source of infection is chronic dacrocystitis ⁃ Thick globular discharge and the edematous hazy ulcerated cornea are indicative of bacterial keratitis, commonly associated with pseudomonas infection common in contact lens wearers ⁃ Ocular mycosis often involves trauma involving plant matter. So cornea is scratched by plant matter and days later becomes red and in amed and signs of corneal abrasion ⁃ Topical steroids are contraindicated in cases of viral corneal ulcers bc they can suppress the immune response, allowing the viral infection to worsen, which can lead to thinning of cornea and increased risk of corneal ulceration ⁃ Herpes simplex causes decreased corneal sensation ⁃ Bacterial keratitis usually occurs in contact lens wearers following corneal trauma or entry of a foreign body ⁃ The cardinal signs of bacterial keratitis are di use central in ltration of the corneal epithelial and stroma Uveitis and ciliary injection ⁃ uvietis has in ammatory cells and are in aqueous uid/anterior chamber ⁃ Anterior uvietis is usually unilateral ⁃ Anterior uvietis is treated with topic steroids and cycloplegic fi fl fl fi ff fl fl fi  ⁃ Granulomatous uvietis is associated with darkly pigmented keratin precipitates ⁃ Ciliary injection is seen in chronic iridocyclitis ⁃ Ciliary ush helps di erentiate between iritis and conjunctivitis Lens ⁃ anterior lens epithelium (germinative zone)is responsible for epithelial cell division and gives rise to new lens bers ⁃ Ectopia lentis is seen w homocysteinuria ⁃ Superior lens sublaxation can cause monocular diplopia ⁃ Correction of unilateral aphakia (no lens) w glasses will cause anisocoria (pupils di erent sizes) Cataract ⁃ after cataract surgery, the lens capsule can become opaci eddue to proliferation and migration of lens epithelial cells, particularly form the equatorial region of the lens. These cells migrate to the posterior capsule, leading to formation of brous membrane that can cause blurry vision ⁃ Positive iris shadow is a sign of immature benign cataract ⁃ Corticosteroids cause posterior subscapular cataracts ⁃ If someone is using steroids and notices gradual vision loss, think of cataracts, but if vision loss is sudden and had other complains like ashers and oaters, think retinal detachment ⁃ Nuclear cataract is the MC ⁃ Bilateral cataracts should be corrected before 3 months of age ⁃ In case of matter cataract, the fundus can’t be see so u can’t use a slit lamp and instead need a B scan ⁃ Vernal keeatoconjunctivitis (spring catarrh) is a chronic allergic conjunctivitis that is treated with topical steroids and long term use increases risk of cataracts, speci cally posterior subscapular cataracts which can cause vision loss in both eyes ⁃ Di culty driving at night and halos around light are characteristic symptoms of cataracts due to scattering of light by the cloudy lens Macular degeneration ⁃ drusen is the hallmark of macular degeneration and is bw the retinal pigmented epithelium and the bruch’s membrane ⁃ Choroidal neovascularization a ects the retinal pigmented epithelium. Drusen is deposition on choroidal vessels ⁃ Hydroxychloroquine (plaquenil) causes bulls eye macular degeneration ⁃ The macula is responsible for central vision, so is the degeneration leads to di culty in tasks requiring ne vision, such as reading or recognizing faces, but peripheral veins on is preserved ffi fi ff ffi fl fi ff fi ff fl fi fi fl  ⁃ Age related macular degeneration is a common cause of central vision loss in elderly Diabetic retinopathy ⁃ proliferation diabetic retinopathy is treated by laser photo coagulation ⁃ Pan retinal photo coagulation is performed to kill areas of peripheral ischemic retina. Thus, less ischemia, less VEGF, leading to cessation and regression of neovascularization. Although some of the retina is sacri ced in PRP, it’s worth saving the central vision ⁃ Focal laser therapy is used to peg down retinal tears and help with leaking vessels ⁃ Metamorphosis is seen in macular edema, a feature of non proliferative macular edema ⁃ First line is Anti VEGF in diabetic retinopathy ⁃ Microaneurysms is the earliest sign of non proliferative diabetic retinopathy ⁃ Hard exudate is accumulation of lipid in the outer plexiform layer ⁃ Diabetic retinopathy is the MCC of blindness in KSA ⁃ Age related macular edema is the MCC of blindness in western world ⁃ Diabetes is the MCC of vitreous hemorrhagic ⁃ Check for diabetic retinopathy immediate at diagnosis of type 2 and 5vyears after diagnosis of type 1 Retinal detachment ⁃ high myopia is a risk factor for retinal detachment. Hyperopia doesn’t contribute ⁃ Cataract surgery is a risk factor for rhegmatogenous retinal detachment ⁃ Scleral buckling surgery is best for rhegmatogenous RD ⁃ Rhegmatogenous RD is managed by closing the retinal defect (scleral buckling, pneumatic retinopexy) ⁃ Retinal detachment is often associated with low IOP as a result of increased out ow by active pumping of uid through the exposed retinal pigment epithelium ⁃ RD presents w oaters, curtains, shadows ⁃ The MCC of oaters and ashes is posterior vitreous detachment ⁃ Virtuous hemorrhage has a sudden onset of symptoms usually unilateral and painless w oaters and visual loss typically worse after sleep ⁃ Vitreous hemorrhage happens w proliferative diabetic retinopathy, proliferative retinopathy following vascular occlusion and vasculitis, trauma, retinal breaks and posterior vitreous detachment wo retinal breaks ⁃ Simple retinal detachment has no posterior virtuous detachment. Posterior vitrious detachment happens when vitreous pulls away from retina. When PVD occurs, fl fl fl fl fl fl fi  bleeding can occurs as the vitreous gel pulls away, it may cause holes or tears in retina. RD happens when retina is separated from the back of eye wall. Unlike RD, vitreous detachment is typically a benign condition that doesn’t cause permanent vision loss ⁃ Tractional RD presents w visual eld defects ⁃ Uncontrolled diabetic was sudden vision loss is most likely written on detachment as a concept consequence for the hemorrhage traction RD ⁃ Vitreous hemorrhage is a common complication of PDR where the fragile neovascularization bleed causing vitreous hemorrhage that presents w sudden painless vision loss and can lead to hazy obscured view on retinal exam. The dim red re ex indicates blood in vitreous, which blocks light from re ecting if retina ⁃ Trauma can cause rupture of the blood vessels in the eye causing vitreous hemorrhage. Only seeing hand movement indicates signi cant vision impairment which can happen w vitreous hemorrhage described as oaters or shadows ⁃ In anemia and leukemia, there is decreased oxygen supply to retinal tissues, causing neovascularization which can lead to retinol hemorrhage Central retinal artery occlusion ⁃ cherry red spot as a result of contrast bw the pale retina and reddish choriod ⁃ central retinal artery supplies the inner layers of the retina , thus its occlusion leads to loss of blood supply to the retina, pale retina, however chorionic behind the retina remains perfused causing red appearance and cherry spot ⁃ Central retinal artery occlusion is caused by atherosclerosis ⁃ On fundal exam, CRAO will show retinal edema and attenuation ⁃ CRAO is the MCC of sudden painless vision loss ⁃ Presence of carotid bruit means there’s risk of embolic events which can cause transient episodes of vision loss due to CRAO ⁃ Hollenhorst plaques are cholesterol crystals that are found in the retinal artery. They’re often observed during fundoycopic exam and indicative of embolic disease, often atherosclerosis ⁃ Swollen optic disk is bc of ischemic optic neuropathy Central retinal vein occlusion ⁃ central retinal vein occlusion presents w thunderstorm appearance, so ares, ame hemorrhages and turturous veins ⁃ It causes gradual vision loos, while CRAO causes sudden ⁃ In CRVO, fundoscopy reveals focal retinal hemorrhages instead of a pale white retina seen in CRAO Retinopathy of prematurity ⁃ abnormal neovascularization of retina in preterm Hypertensive retinopathy fl fl fi fl fl fi fl  ⁃ hypertensive retinopathy results in AV nicking, ame shaped hemorrhages and exudates. Cotton wool spots are the earliest nding ⁃ Hypertension can cause sudden painless vision by occlusion of central retinal artery or vein ⁃ The presence of several yellow white exudates adj to fovea and retinal vessels is characteristic for CMV retinitis. AIDs patients, especially w CD4 count < 50 cells, are at high risk of CMV retinitis Optic disk swelling ⁃ optic disk swelling can happen w papilledema, CRVO and hypertensive retinopathy Retinitis pegmintosa ⁃ retinitis pegmintosa may be caused by a null mutation in AD cases ⁃ Rod-cone dystrophy is more severe than cone-rod dystrophy Visual eld ⁃ the nasal retina perceives light from the temporal visual eld. The temporal retina perceives light from the nasal visual eld ⁃ The lower retina perceives light from the upper visual eld. The upper retina perceives light from the lower visual eld ⁃ Optic chaism sits on cavernous sinus ⁃ The dilator pupillary muscle is innervated by adrenergic bers which are part of sympathetic ⁃ Goldmann visual testing eld is a type of vision test in which progressively dimmer lights and moved from the peripheral vision into central vision and used to detect neurological abnormalities ⁃ Retrobulbar neuritis is a form of optical neurotis characterized by in ammation of optic nerve behind the eyeball. Patients present with impaired vision, mild pain that is worse w eye movement, and mostly normal ndings on opthalmoscopy. MC associated w MS ⁃ Occulomotor nerve palsy presents w ptosis, eye down and out, and dilation of aneurysm. CN 3 palsy is common in DM ⁃ In neuro bromatosis, patient may have optic glioma and Lisch nodules ⁃ In tuberous sclerosis, examine retina for astrocytoma. Retinal astrocytic hemartomas are benign retinal tumors composed of glial cells. It’s typically encountered as an asymptomatic lesion in tuberous sclerosis patients Ophthalmology diagnostic tools ⁃ retinoscopy is for refractive error. During retinoscopy, the examiner notices the movement and characteristics of light re ex (red re ex) re ected o the patients retina. The examiner observes the direction and the speed of movement of light re ex as the refractive power of di erent lenses is changed in front of the patients eye. By assessing how the light re ex moves (against or w the direction of movement) the examiner can determine if patient is hyperopic or myopic or emmotropic fl fi fi ff fl fi fi fi fl fi fl fi fl fl fi fi fi ff fl  ⁃ In direct opthalmoscope, the optic disc is upright ⁃ The direct opthalamoscope has a magni cation of 15x ⁃ Optic nerve function is best assessed by perimetry (visual eld assessment) ⁃ Genioscope is used to visualize the anterior chamber angle and to check for glaucoma (open or closed angle) ⁃ The MC method of applanation tonometry is performed using a goldmann tonometer or tonomoter tip attached to slit lamp. The amount of force required to atten the cornea is directly related to the IOP. A thick cornea can lead to a falsely elevated IOP bc increased corneal thickness results in more pressure needed to atten it ⁃ If visual activity is recorded 20/200, to pinhole bc it decreases the refractive error allowing only focused light to enter the eye. This helps determine if reduced visual acuity is due to refractive error or other ocular abnormalities. If patient vision improves when looking through pinhole, the issue is likely a correctable refractive error. If there’s not improvement, it’s likely a more serious underlying issue ⁃ If patient is unable to read 20/400, decrease distance till they can Refraction ⁃ the refractive power of the lens is 16-20 ⁃ Astigmatism is irregular corneal curve Strabismus ⁃ weakening if an extraocular muscle is recession. A recession weakens function by changing the attachment site of muscle on eyeball and is used to treat strabismus. Resection refers to strengthening of muscles ⁃ Cover uncover test is used to di erentiate bw phoria and tropia in ortho position ⁃ The cover test detects tropia and its amount ⁃ Accommodative esotropia is seen in hypetropia. Accommodative esotropia is a condition where an excessive e ort of accommodation results in inward deviation of both eyes ⁃ Coordinated movement of both eyes in the same direction is version ⁃ Sherrington law is regarding monocular movement. Sherrington law is about reciprocal innervation and states that increased innervation and contraction of a muscle is automatically associated with reciprocal disease in innervation and contraction of its antagonists ⁃ Herrings law of equal innovation suggests the eye movement are symmetrical due to equal innervation of yoke muscles ⁃ At birth, the eye is hypertropic cuz its small and it becomes normal w dveelopment Relative a erent pupillary defect ⁃ Marcus Gunn is examined by swinging ashlight. Marcus Gunn is a pupillary defect that a ects the a erent arm of pupillary response ff ff ff ff ff fl fi fl fi fl  ⁃ In relative a erent pupillary defect, both pupils dilate when light is shone on a ected eye ⁃ Amylopia is one of the causes of relative a erent pupillary defect ⁃ Polycoria is multiple pupils ⁃ O centered pupils is corectopia Tumors of eye and skin ⁃ papilloma is the MC tumor of eyelid ⁃ Retina is the least commonly involved in metastases bc of the blood retinal barrier ⁃ Rhabdomyosarcoma is the MC orbital (not ocular) malignancy in children ⁃ Retinoblastoma is the MC intraocular tumor in children. Biopsy of retinoblastoma shows exner-wintersteiner bodies ⁃ If a child has asymmetrical red re ex, do dilated fundoscopic exam ⁃ Choroidal melanoma is the MC intraocular tumor in adults ⁃ Lentigo malignant management is surgery w safe margins ⁃ Malignant melanoma of eyelid skin can be treated w cyrotherapy but rst line is excision w wide margin ⁃ The lower eyelid is the MC location of BCC ⁃ Surgery is the primary means of SCC of skin ⁃ Eye surgery is associated with bullous keratopathy complications Ortho Shoulder exam ⁃ anterior instability of shoulder can be diagnosed by anterior apprehension test. Anterior apprehension test is for shoulder dislocation ⁃ Speed test is to diagnose long head of the biceps tendinitis. In speed test, patients is asked to rst extend their elbow and fully supinate the forearm. Then patient is asked to ex the shoulder forward against resistance. At the same time examiner should palpate the anterior joint line for tenderness Rotator cu ⁃ rotator cu syndrome: (1) pain felt during activities involving overhead movements or lifting (2) weakness often noticed during abduction or external rotation (3) decreased ROM (4) di culty lifting or rotating arm Acromioclavicular joint sprain ⁃ AC joint sprain MC occurs when there’s signi cant force applied to the lateral or superior shoulder, causing a sprain of the ligament that connects the acromion and the clavicle. The resultant injury can range from mild stretching to complete tear of the ligament. This type of injury is common in contact sports (rugby, football) where direct shoulder trauma is common ff fl ff ff fi ffi fl ff ff fl ff fi fi Fractures ⁃ ORIF for displaced fractures ⁃ Manual and cast is the method of managing a wrist fracture. It involves manually realigning the fractured bones and then immobilizing the wrist w a cast ⁃ Extreme out of proportion pain after casting raises suspicion of compartment syndrome ⁃ Compartment syndrome has 5 Ps: pain, pallor, pulseless, paresthesia and paralysis Nerve ⁃ In pregnant woman w carpal tunnel, do wrist splint Spine ⁃ conventional full spine radiography is the gold standard for scoliosis diagnosis. MRI is added if there’s pain, rapidly progressive course, or inconclusive diagnosis ⁃ Cobb angle 50 or rapidly progressive surgery ⁃ 25 is the cutto of monitoring or investigation ⁃ Idiopathic scoliosis is usually curved to right and painless ⁃ Spinal TB, aka potts disease, typically starts at the vertebral bodies. Spinal Tb can present as a groin swelling due to psoas abscess, which can track down to groin spaces ⁃ A cold abscess can form due to psoas muscle involvement or lymphatic spread, characterized by a painless swelling that can present in areas like groin or hip ⁃ Spinal TB primarily infects the vertebral body leading to kyphotic deformity due to collapse of vertebral bodies. Skip lesions are seen in spinal TB ⁃ Thoracolumbar region is the MC a ected in spinal TB ⁃ Anti TB meds should be started immediately in spinal TB Charcot arthropathy ⁃ diabetes is the MCC of arthropathy in upper limb, syringomyelia is the MCC of arthropathy in lower limb ⁃ Chronic pain insensitivity is also a cause Hip examination ⁃ ober test is used for iliotibial band tenderness/contracture. Over test is for abductor contracture ⁃ Gluteus medius is an abductor of hip joint ⁃ Irritation of anterior branch of femoral nerve causes hip pain that radiates to knee ff ff  Lower limb fractures ⁃ femur neck fracture is managed by ORIF or arthroplasty. Femur neck fracture results in severe hip pain and inability to bear weight. Leg will be shortened and externally rotated ⁃ Non displaced closed fracture of femur is treated by closed intramedullary nailing. Midshaft femur fractures are treated by plate and screw xation ⁃ Hemiarthroplasty replaces the fractured femoral head w a prosthetic implant, commonly performed in elderly women displaced or unstable femur neck fractures, while preserving native acetebelum ⁃ If there is subluxation, do total hip replacement bc acetebelur component degenerated too ⁃ If patient has an open displaced fracture: disinfect, debride and external xation ⁃ If patient has a closed displaced fracture, ORIF DDH ⁃ apparent leg length discrepancy occurs due to issues above the hip joint, such as pelvic obliquity, scoliosis, or muscle contractures, which makes one leg appear shorter than the other Knee injury and special tests ⁃ Quadriceps tendon tear causes inability to extend knee w a low lying patella ⁃ A popliteal cyst is due to extrusion of synovial uid from the knee joint into the gastrocnemius or semimembraneous bursa through the communication bw the joint and the bursa. Excessive synovial uid production (due to osteoarthritis or rheumatoid arthritis) and positive pressure in the knee during extension can cause passage of the uid into the bursa and gradual enlargement of the cyst. Popliteal cysts are often asymptomatic and present as a chronic painless bulge behind the knee. The diagnosis is usually apparent on examination w soft tissue mass in medial popliteal space that is most noticeable w knee extension and less prominent w exion. Rupture of popliteal cyst can cause posterior knee and calf pain w tenderness and swelling if calf resembling DVT. An arc of ecchymosis is often visible distal to medial malleolus (crescent sign) US can rule out DVT and con rm popliteal fossa Foot and ankle injury ⁃ injury to the anterior talo bular ligament causes inability to planter ex ⁃ Thompson test is for injury to Achilles tendon. Inability to planete ex is a classic sign of Achilles tendon injury Osteomyelitis ⁃ in tibial osteomyelitis, involucrum is new bone formation ⁃ Dead necrotic bone is sequestrum ⁃ Osteomyelitis most likely spread’s to metaphysis ⁃ The growth plate is a barrier to infection spread to the joint fi fl fi fl fi fl fl fi fl fl  ⁃ Pediatric osteomyelitis is treated with cefrraxione, nafcillin and clindamycin Hemiarthosis ⁃ in vWF disease, administer factor 8 and platelets ⁃ Warfarin inhibits vitamin K dependent factors ⁃ In hemophilia patient that suddenly can’t extend knee, with no history of injury , fever or swelling, it’s most likely femoral nerve palsy secondary to hematoma Bowed legs ⁃ Tibia Vara (Blount disease) pathogenesis is growth arrests at medial proximal tibia ⁃ Blount disease is MC in proximal tibia Osteogenesis imperfecta ⁃ ochronosis is least likely to present w chondrocalcinosis. Ochronosis is a syndrome caused by accumulation of homogenistic acid in CT ⁃ Chondrocalcinosis can be caused by gout, pseudo gout, hyperparathyroidism, hemochromatosis. Sickle cell and ochronosis don’t cause it Arthritis ⁃ enteropathic arthritis is associated with IBD, celiac, whipple and presents w diarrhea ⁃ Ankylosing spondylitis presents w sacroiliac sti ness Rieter disease (reactive arthritis) ⁃ can’t see, can’t pee and can’t bend a knee. Presents w triad of conjunctivitis urethritis and arthritis Bone tumors ⁃ prostate causes osteoblasts metastasis ⁃ Osteosarcoma causes knee swelling after minimal trauma and aging will show bone sclerosis ⁃ Ewing sarcoma is an eating bone tumor. It has a lytic appearance on imaging ⁃ Osteoid osteoma classically presents w night pain that is relieved w NSAIDs ⁃ The pelvis is the MC site of costochondroma Amputation and prosthesis ⁃ reason for amputation below knee is peripheral claudication ⁃ Peripheral vascular disease is the MC diagnosis precipitating below knee amputation ff