Eye Anatomy and Diagnosis Notes PDF

“The  Dusty  Guides”  Copyright  ©  2014  Dustin  J.  Sowards.                                                                                            General  Medical  Diagnosis  I...

“The  Dusty  Guides”  Copyright  ©  2014  Dustin  J.  Sowards.                                                                                            General  Medical  Diagnosis  I  |  Page  1   The  use  of  this  material  is  for  educational  purposes  and  is  not  for  commercial  use.   Anatomy  Review  of  the  Eye;  The  Acutely  Red  Eye   History  of  Ophthalmology     1. 1600  B.C.  in  Egypt  some  ocular  conditions  recognized   2. Middle  19th  century  ophthalmoscope  developed   3. Corneal  transplants  first  successful  transplant  (no  antigens  in  a  cornea;  cornea  transplants  have  high  success)   4. Development  of  micro  and  laser  surgery     Anatomy  of  the  Eye   1. Cornea:  anterior  1/6  the  of  eye’s  surface   a. Stratified  squamous  epithelium   b. Two  thirds  of  the  eye’s  refractive  power   c. No  blood  vessels  here,  but  more  nerves  here   2. Continuous  with  conjunctiva  (mucous  membrane)   a. Bulbar  portion  of  conjunctiva  covers  sclera   i. Does  have  blood  vessels   b. Palpebral  portion  lines  inner  eyelids   3. Sclera:  fibrous  connective  tissue  (white  of  eye)   4. Iris:  regulates  amount  of  light  entering  eye   a. Smooth  muscle   5. Pupil:  opening  in  center  of  iris   a. Controlled  by  the  iris  with  dilation  or  constriction   i. Dilation:  iris  becomes  closer  to  the  lens   6. Ciliary  body:  focuses  lens,  produces  aqueous  humor  (in  anterior  chamber  of  eye)   a. Contraction  relaxes  fibers  suspending  lens   b. Lens  thickens,  focus  up  close  (accommodation  for  near  vision)   7. Anterior  chamber:  between  cornea  and  iris,  filled  with  aqueous  humor   8. Posterior  chamber:  filled  with  vitreous  humor   a. Maintains  shape  of  eye   9. Angle  structures:  (drainage  system)   a. Iris:  front  of  ciliary  body,  trabecular  meshwork,  and  canal  of  Schlemm   b. Aqueous  humor  from  ciliary  body  flows  through  the  pupil  into  the  anterior  chamber   c. Through  trabecular  meshwork  and  into  canal  of  Schlemm   d. Balance  between  production  and  drainage  of  aqueous  humor  determines  IOP  (intraocular  pressure)   i. Normal  IOP  is  10-­‐20  mmHg.   ii. Puff  before  eye  drops  to  test  IOP  before  increasing  closure  of  angle  (R/O  risk  of  acute  glaucoma)           “The  Dusty  Guides”  Copyright  ©  2014  Dustin  J.  Sowards.                                                                                            General  Medical  Diagnosis  I  |  Page  2   The  use  of  this  material  is  for  educational  purposes  and  is  not  for  commercial  use.   Patient  History   1. Onset  and  duration  of  symptoms   a. “My  eye  is  red.”   2. Top  three  factors  to  assess:   a. Pain   b. Discharge   c. Visual  changes   3. Redness   4. Relieving  or  exacerbating  factors             Physical  Exam   1. Eyelids   2. Conjunctiva  (Bulbar  and  palpebral)   3. EOM  and  visual  acuity   4. Pupil  size,  reaction  to  light  and  accommodation   5. Fundoscopic  exam     Common  Signs  &  Symptoms   1. Pain   a. Knife-­‐like   b. Itching   c. Foreign  body   2. Erythema,  edema  (redness,  swelling)   3. Discharge   a. Yellow-­‐green  discharge  lasting  all  day   4. Blurred  vision   a. Clear  upon  blinking  or  constantly  disturbed   5. Eye  strain   6. Photophobia   a. Issues  with  exposure  to  bright  lights   7. Hyphema   a. Hemorrhage  in  anterior  chamber  caused  by  trauma   8. Scotomas  (negative  and  positive)   a. Negative:  dark  spot  in  field  of  vision   i. Sign  of  hemorrhage  of  retina  or  retinal  detachment   b. Positive:  moving  luminous  patches   i. Usually  in  one  eye  only   ii. Lasts  for  a  few  seconds  or  a  couple  of  minutes   iii. Abnormal  stimulation;  not  typically  dangerous,  usually  benign   9. Floaters   a. Usually  benign,  can  be  seen  with  retinal  detachment   “The  Dusty  Guides”  Copyright  ©  2014  Dustin  J.  Sowards.                                                                                            General  Medical  Diagnosis  I  |  Page  3   The  use  of  this  material  is  for  educational  purposes  and  is  not  for  commercial  use.         Scintillating  Scotoma                                                           Visual  Acuity  Abnormalities   1. Hyperopia  –  most  common  refractive  error,  farsightedness  (can’t  see  well  up  close)   a. Eyeball  is  too  short.     b. Image  focuses  behind  the  retina.   c. Not  age  related   2. Myopia  –  nearsightedness   a. Can’t  see  well  far  away.   b. Eyeball  is  too  long.   c. Image  focuses  before  it  reaches  the  retina.   3. Astigmatism   a. Warped  shape  of  eyeball   4. Presbyopia  –  loss  of  elasticity  with  age,  so  lens  can’t  accommodate  (thicken)  to  near  vision   a. Common  after  40  years  of  age             “The  Dusty  Guides”  Copyright  ©  2014  Dustin  J.  Sowards.                                                                                            General  Medical  Diagnosis  I  |  Page  4   The  use  of  this  material  is  for  educational  purposes  and  is  not  for  commercial  use.   External  Hordeolum  (External  Sty)   1. Inflammation  involving  hair  follicles   2. Zeiss  or  Moll  sebaceous  gland  blockage   3. Sebum  released  from  tarsal  plates  can  cause  a  foreign  body  reaction   4. Pain,  redness,  and  tenderness  at  lid  margin;  pain  is  not  severe.   5. Lacrimation,  photophobia,  and  foreign  body  sensation   External  Hordeolum   6. Does  not  usually  lead  to  anything  worse     Internal  Hordeolum  (Internal  Sty)   1. Inflammation  of  Meibomian  gland  on  eyelid   2. Suppuration  on  conjunctival  side  of  eyelid   3. Abscess  may  form  and  recurrence  is  common.   4. Refer  to  an  ophthalmologist  if  no  improvement  in  2-­‐3  days…   …  or  if  not  completely  resolved  in  1-­‐2  weeks.   Internal  Hordeolum     Other  Minor  Superficial  Diseases     1. Chalazion:  chronic  Meibomian  enlargement   Chalazion   a. Usually  takes  a  couple  of  months  to  go  away   b. Typically  painless   2. Entropion:  lid  inversion,  atrophy  or  scarring   Chalazion   a. Eyelashes  can  grow  into  cornea  and  cause  corneal  ulceration  or  scars     3. Ectropion:  lid  eversion,  tissue  relaxation   a. Consequence  of  aging   Entropion   b. Experience  excessive  tearing  or  redness  of  the  eye   4. Pinguecula:  conjunctival  thickening   a. Mild  scar  tissue  on  conjunctiva  due  to  wind,  sun  exposure     Ectropion   5. Pterygium:  conjunctival  thickening;  may  grow  onto  cornea   a. Conjunctival  thickening  expanding  to  cornea,  affecting  vision   b. Wind,  sun  exposure     Pinguecula   6. Keratoconjunctivitis  sicca:  lack  of  tears     a. Idiopathic  or  associated  with  RA,  Sjogren’s,  SLE   7. Corneal  arcus:  opaque  whitening  around  cornea     Pterygium   b. Elderly  (arcus  senilis)  or  hyperlipoproteinemia   8. Blepharitis     c. Inflammation  of  the  eyelids   Arcus  senilis   d. Bacterial  (usually  staph,  red,  scales  and  crusts)   e. Allergic  (no  inflammation,  greasy  scales)   f. Symptoms   Blepharitis   i. Itchy,  burning,  foreign  body  sensation;  may  cause  eye  lashes  to  fall  out   “The  Dusty  Guides”  Copyright  ©  2014  Dustin  J.  Sowards.                                                                                            General  Medical  Diagnosis  I  |  Page  5   The  use  of  this  material  is  for  educational  purposes  and  is  not  for  commercial  use.   The  Acutely  Red  Eye   1. Danger  signs:  pain  and  vision  loss   2. Fluorescein  staining  (to  R/O  corneal  abrasion  or  ulceration)   a. Use  a  blue  light  to  observe  florescence  on  the  cornea.     Conjunctivitis   1. Causes:  infections,  allergies,  welding  arc  w/out  safety  goggles,  etc.   2. Symptoms:  itching,  D/C  (discharge,  slight  purulence),  conjunctival  injection   Conjunctivitis   3. PE  shows  normal  visual  acuity  and  pupillary  responses  with  a  negative  fluorescein  stain   a. No  ulcerations,  scarring,  abrasions   4. Usually  self-­‐limiting     Subconjunctival  Hemorrhage   Loa-­‐Loa  Worm   1. Bleeding  into  space  behind  conjunctiva   2. Many  causes   a. Idiopathic   3. No  associated  symptoms  (no  pain,  itching  or  D/C)   4. R/O  trauma  and  foreign  bodies   a. Ask  if  there  is  bleeding  elsewhere.   5. Severe  febrile  illness  may  result  in  this  condition.   Subconjunctival   6. Straining  after  childbirth  may  also  result  in  this.   Hemorrhage     Keratitis  (Corneal  Inflammation)   1. Infectious  causes   a. Bacterial,  viral  (Herpes  simplex  &  zoster),  fungal   2. Non-­‐infectious  causes   a. Contact  lens  wear,  trauma,  corneal  burn   3. Symptoms:  pain  (persistent  and  severe),  photophobia,  blurred  vision,  little  or  no  D/C   4. Fluorescein  stain  positive  for  damaged  epithelium,  hypopyon  (pus  in  anterior  chamber)  may  be  seen   5. Refer  to  ophthalmologist  immediately.                     Keratitis       “The  Dusty  Guides”  Copyright  ©  2014  Dustin  J.  Sowards.                                                                                            General  Medical  Diagnosis  I  |  Page  6   The  use  of  this  material  is  for  educational  purposes  and  is  not  for  commercial  use.   Herpetic  Eye  Diseases   1. HSV-­‐1   a. Begins  on  cornea  with  keratitis   b. Slit  lamp  exam  reveals  dendritic  ulcers  with  terminal  bulbs   c. 25%  chance  of  recurrence   d. Common  symptoms:   HSV-­‐1     Dendritic  Ulcer  w/   i. Pain  may  or  may  not  be  present.   Terminal  Bulbs   ii. Decreased  visual  acuity   2. Herpes  zoster  (10%  of  cases)   a. Reactivation  of  varicella  in  ophthalmic  division  of  CN  V   b. Dermatomal  rash  often  present   c. Loss  of  EOM  possible   d. Dendrites  have  tapered  ends  (instead  of  terminal  bulbs).   e. Starts  with  keratitis  may  progress  to  retinitis  with  necrosis   Herpes  Zoster   f. Severe  infection   Dendrites  w/  “tapered  ends”     Anterior  Uveitis  (Inflammation  of  the  Iris)   1. Iridocyclitis  (inflammation  of  ciliary  body  as  well)   2. Nongranulomatous  vs.  granulomatous  anterior  uveitis   3. Pathophysiology   a. Breakdown  of  blood/ocular  barrier  leads  to  extravasation  of  WBCs  and  protein  into  aqueous  humor       4. Symptoms   a. Pain,  worse  with  accommodation  to  close  vision   i. Danger  signs   b. Photophobia   c. Blurred  vision   d. Red  with  increased  tearing,  but  no  D/C   e. Most  cases  are  unilateral.   Anterior  Uveitis   Resembles  “pink  eye”   5.      Physical  exam  findings   Notice  irregular  pupil.   a. Ciliary  flush  (circumcorneal  redness)   b. Small  pupil  initially,  irregular  later  (via  scarring  or  adhesions  between  iris  and  lens)   c. Fluorescein  stain  positive:  pus,  flares,  cells,  and  hypopyon   d. May  have  decreased  IOP  (due  to  decreased  production  of  aqueous  humor  by  ciliary  body)   e. Complications:  cataract  and  glaucoma  (chronic)             “The  Dusty  Guides”  Copyright  ©  2014  Dustin  J.  Sowards.                                                                                            General  Medical  Diagnosis  I  |  Page  7   The  use  of  this  material  is  for  educational  purposes  and  is  not  for  commercial  use.   Acute  (Closed  Angle)  Glaucoma   1. Middle  aged  and  older  patients     a. Usually  due  to  a  shallow  anterior  chamber  and  narrow  angles   2. Impaired  drainage  of  aqueous  humor  increases  IOP.   3. Dilation  of  pupil  exacerbates  this  condition.   4. Chronically  increased  IOP  can  cause  optic  nerve  damage.   5. Common  causes  of  acute  glaucoma   a. Pupillary  block  is  the  most  common  cause.   b. The  anterior  iris  becomes  stuck  to  the  trabecular  meshwork  and  the  angle  closes;  drainage  is  interrupted.   c. This  can  happen  after  cataract  surgery  as  well  as  spontaneously.   6. Other  causes  of  acute  glaucoma   a. Plateau  iris  (a  genetically  narrow  angle  that  becomes  occluded  with  pupil  dilation)   b. Medications:  sulfa  derivatives,  bronchodilators  (may  dilate  eyes  as  well)   c. Space-­‐occupying  lesions  of  the  brain   7. Symptoms   a. Severe  pain  with  nausea  and  vomiting   b. Unilateral  vision  loss  or  halo  vision  (due  to  edematous  cornea)   c. Diffuse  redness  with  a  hazy  cornea   d. Large  and  fixed  pupil  (not  reactive  to  light  and  accommodation)   e. Eye  feels  hard.   f. IOP  40-­‐80  mmHg   Acute  Glaucoma   8. This  is  an  emergency;  give  referral  to  an  ophthalmologist.   Notice  diffuse  redness  &  hazy  cornea.              General Medical Diagnosis I Sudden & Gradual Vision Loss Sudden Vision Loss 1. Painless sudden vision loss has many causes 2. Four main causes a. Arterial occlusion b. Venous occlusion c. Vitreous hemorrhage d. Retinal detachment Arterial Occlusion** 1. Atherosclerosis, emboli, inflammation a. Temporal arteritis Arterial Occlusion 2. Amaurosis fugax (Artistic Interpretation) a. Arterial spasm (lasts seconds to minutes) b. As if a “dark shade” is being lowered in field of vision 3. If occlusion is lasts greater than 1 hour, then optic nerve may atrophy. 4. Other causes a. Migraine headaches b. Hysterical blindness i. Factious (patient makes up the condition) c. Psychological blindness d. How to distinguish between Hysterical & Psychological blindness: i. Bring mirror up to patient’s face. 1. If vision is intact the eye reflex will occur automatically. ii. A drum can be used that spins and has vertical stripes. 1. If vision is intact, then the eyes will move back and forth automatically. 5. Decreased visual acuity 6. Retina pale and edematous 7. Cherry red spot at macula 8. Auscultate head and carotids to R/O temporal arteritis Normal Retina 1 Arterial Occlusion  General Medical Diagnosis I Venous Occlusion** 1. More common than arterial a. Note: Veins and arteries share a common sheath. 2. Causes: HTN, increased blood viscosity a. Diabetes, COPD 3. Flame hemorrhages 4. Swollen optic disc 5. Engorged retinal vessels Venous Occlusion (Artistic Interpretation) Vitreous Hemorrhage** 1. More common in diabetics 2. History of floaters (usually benign) a. Increased with retinal detachment (which follows hemorrhage) 3. Unable to see retina (due to blood in vitreous humor) 4. Vitrectomy needed if blood does not reabsorb within a few months Vitreous Hemorrhage (Artistic Interpretation) Retinal Detachment** 1. Associated with: a. Diabetes mellitus b. ROP (Retinopathy of prematurity) i. In premature infants, oxygen is toxic to retina. c. Trauma 2. Floaters, flashing lights, descending curtain 3. Retinal folds & retina becomes pearly grey 4. Emergency referral Retinal Detachment 2  General Medical Diagnosis I Gradual Vision Loss 1. More common than acute (sudden) vision loss 2. Six main causes a. Cataracts b. Chronic (open angle) glaucoma c. Diabetic retinopathy d. Proliferative diabetic retinopathy e. Hypertensive retinopathy f. Senile macular degeneration Cataracts Cataracts 1. Opacity of the lens 2. Blurred vision, 3. Children present with squinting and amblyopia (crossing of the eyes). 4. Decreased red reflex Chronic (Open Angle) Glaucoma** 1. Can occur without sudden increase in IOP 2. Atrophic changes to optic nerve a. Due to increase in aqueous humor in anterior chamber 3. Risk factors a. Diabetes, family history, hypothyroidism, age 4. Patient complains of blind spots in vision (negative scotomas) 5. Pale optic disc with cupping Chronic (Open Angle) Glaucoma (Artistic Interpretation) 3  General Medical Diagnosis I Background Retinopathy** 1. Decreased circulation with endothelial damage 2. Retinal ischemia occurs 3. Microaneurysms develop and rupture as capillaries weaken. a. These rupture and you get flame hemorrhages. b. Bleeding goes deeper into retina to develop blot hemorrhages. 4. Soft and hard exudates a. Soft exudates due to increased permeability of blood vessels b. Hard exudates are fatty deposits on the retina. 5. Cotton wool spots Background Retinopathy a. Areas of nerve fiber ischemia 6. Macular edema leads to decreased visual acuity a. Diabetics should have an ophthalmologic exam each year. b. #1 cause of preventable blindness is diabetes. Proliferative Diabetic Retinopathy** 1. Same findings as background retinopathy 2. Neovascularization near optic disc 3. New vessels bleed easily. 4. Retinal detachment possible due to bleeding 5. Blindness may also develop. Diabetic Retinopathy (Artistic Interpretation) Retinopathy w/ Macular Edema Retinopathy w/ Ischemia of Retina (Notice the indistinct optic disk margins.) 4  General Medical Diagnosis I Hypertensive Retinopathy** 1. Copper-silver wiring a. Blood vessels appears this way instead of normal red hue. b. Engorged blood vessels increase light reflex, causing the copper-silver wiring appearance. c. Opaque wall (appears silver over red column of blood) 2. A/V nicking a. Due to thickened arterial walls 3. Flame hemorrhages and soft exudates 4. Papilledema (indistinct disc margins) a. This is not just seen in hypertensive retinopathy. b. May also be a sign of a brain tumor c. You observe a retina with papilledema and this is a red flag; could be mass inside of brain. d. Optic disc may be several times larger than normal (maybe half of the retina) Senile Macular Degeneration 1. Affects central field of vision 2. Usually bilateral 3. Pigmented macula, exudates 4. Drusen: pale fatty deposits around macula Hypertensive Retinopathy (Artistic Interpretation) Normal Vision Senile Macular Degeneration Macular Degeneration 5  General Medical Diagnosis I Ear Disorders Overview 1. The ear has 2 functions: balance (vestibular) and hearing (cochlear) 2. Innervated by cranial nerve VIII, which carries both afferent components in 2 different divisions. 3. Vestibular division receives messages from the hair cells in semicircular canals. a. Their central processes enter the brainstem at the pons-medulla junction. b. They then proceed to the cerebellum, thalamus and ultimately to the parietal lobe and superior gyrus of temporal lobe near the auditory cortex. 4. Cochlear division of VIII nerve a. Receives input from cochlea cells b. Enter brainstem at pons and proceed centrally on both sides of the brainstem via the lateral lemniscus to the thalamus and then to the auditory cortex a portion of the superior temporal gyrus buried in the lateral sulcus Common Presenting Symptoms 1. Hearing loss 2. Tinnitus 3. Vertigo 4. Earache Hearing Loss** 1. Two types: a. Conductive** b. Sensorineural** i. Differentiate between the two by comparing air conduction with bone conduction. 2. **Conductive—lesion in the external canal or middle ear. a. If someone has an ear infection, we call this otitis media (middle ear infection). b. This is a conductive type of hearing loss. 3. **Sensorineural—lesion in the inner ear or cranial nerve VIII. 1  General Medical Diagnosis I Weber – Rinne Tests** 1. Weber – Bone conduction through bones of skull; lateralization to affected ear a. Sound conducts through the bones of the skull; sound should be equal volume in both ears. b. If the sound is not conducted equally, then we have lateralization. c. Decreased ability to hear in one ear leads to lateralization. d. Lateralization to the affected ear means sound is heard well in that ear, indicating conductive hearing loss. e. Note: Lateralization to the normal (good) ear would then indicate sensorineural hearing loss. 2. Rinne test – Air conduction to bone conduction a. Normal: air conduction is greater than bone conduction. b. Placement of tuning fork: i. Placed next to ear is air conduction. ii. Placed on mastoid is bone conduction. c. Conducted hearing loss i. Bone conduction will be greater than air conduction in the affected ear. d. Sensorineural hearing loss: i. Air conduction will be greater than bone conduction (normal Rinne test). 3. Hearing Loss a. Conductive hearing loss – lateralization to the affected ear b. Sensorineural hearing loss – lateralization to the normal ear Etiology of Hearing Loss** 1. Presbycusis: most common cause of sensorineural hearing loss (nerve deafness) a. Starts in 40s; decreases gradually b. More common in men c. Loss of higher frequency sounds first 2. Infections a. Otitis media: most common cause of temporary hearing loss (conductive) b. Bacterial meningitis: permanent healing loss c. Cytomegalovirus: transmitted to infants intrauterine; causes deafness as well 3. Otosclerosis a. Most common inherited cause of conductive hearing loss 4. Meniere’s disease a. Triad: Hearing loss, tinnitus, vertigo 5. Noise a. Destroys cochlear cells; paralyzes cochlear cells b. Over a long period of time with high noise, permanent destruction occurs. 6. Medications and others a. Aspirin toxicity presents with tinnitus and may lead to deafness. b. Chemotherapy drugs c. IV antibiotics, tumors, cerebral palsy, trauma, etc. 2  General Medical Diagnosis I Tinnitus** 1. Perception of sound in absence of stimulus a. Ringing, tinkling sound b. Continuous or episodic? c. Hearing loss or vertigo present? 2. Etiology a. ASA (aspirin) toxicity b. Noise, trauma c. Infection i. Otitis media; conductive, temporary d. Other conditions i. Otosclerosis ii. Hypothyroidism iii. Cholesteatoma iv. Eustachian tube blockage Vertigo 1. Definition: Sensation of moving around in space (subjective) or having objects moving around the patient 2. Both ears (peripheral) and CNS disease (central) may be the cause. a. Central vertigo: no hearing loss; mild vertigo b. Peripheral vertigo: severe; nausea, vomiting 3. Etiologies a. Viral upper respiratory infection b. Otitis media c. Meniere's disease d. Tumors e. Acoustic neuroma Earache 1. Etiology: a. Infection b. Middle /external ear canal—inf, neoplasms c. Referred from TMJ, wisdom teeth, grinding of teeth d. Tonsillitis e. Atlas /axis subluxation f. Cold wind does NOT give you an earache (otitis media). i. However, if your ear drum is already infected or inflamed, then it will hurt with contact of cold wind g. Other: Tumor in nasopharynx; Eustachian tube dysfunction; thyroiditis; trigeminal neuralgia; allergies 3  General Medical Diagnosis I Inner Ear Diseases 1. Meniere’s disease 2. Vestibular neuronitis 3. Benign positional vertigo 4. Acoustic neuroma Meniere’s Disease** 1. Disease: idiopathic; familial predisposition 2. Syndrome: Usually secondary to other conditions a. Thyroid problems b. Autoimmune disease c. Syphilis d. Trauma 3. Onset usually found in 50’s 4. Vertigo (sudden; severe isolated attacks) a. Lead to nausea and vomiting b. Usually, the attacks last several hours at a time. 5. Progressive hearing loss a. 10-15% of cases have bilateral hearing loss. 6. Tinnitus a. Constant or intermittent 7. Endolymphatic hypertension a. Underlying pathophysiology 8. Pathophysiology a. Endolymph and perilymph i. Endolymph; membranous region; potassium rich ii. Perilymph: boney region; sodium rich b. Break in membrane separating fluids c. Blockage of depolarization in vestibular nerve receptors i. Causes sensation of vertigo d. Mechanical distortion of organ of Corti i. Due to increase in pressure ii. Affects apex greatly, which alters the low frequency sounds heard 9. Diagnosis of Meniere’s a. Do a complete neuro exam. b. Weber and Rinne tests i. Inner ear = sensorineural hearing loss c. Thyroid studies, electrolytes, and glucose d. CBC, ESR, ANA, fluorescent treponemal antibodies (syphilis) e. MRI of the brain i. Acoustic neuroma (benign tumor of eighth cranial nerve) f. Dietary changes: Decrease salt intake; avoid caffeine. Decrease tobacco use. 4  General Medical Diagnosis I Vestibular Neuronitis** 1. Inflammation of vestibular division CNVIII a. Peak incidence in 30s and 40s b. May be due to viral infection 2. Abrupt onset of debilitating vertigo 3. First attack is usually the most severe! a. May last a 7 to10 days b. Nausea and vomiting c. Nystagmus 4. Several more attacks may occur over 12-18 months. 5. No hearing loss or tinnitus, only vertigo 6. Unidirectional horizontal nystagmus a. Cause of peripheral vertigo b. Nystagmus in general: i. Involuntary movements of the eye ii. Vertical or horizontal or rotational iii. Named for direction eyes move in the fast phase c. Peripheral features of vertigo: i. Nystagmus has latency (takes a while to start) or may fatigue (wear offs). ii. Ameliorated by gaze fixation iii. Unidirectional 7. Romberg test (+) a. Patient falls toward affected side. 8. Labs / Imaging a. CBC, glucose levels i. Imbalance may reveal faintness or lightheadedness. b. MRI if suspicious of CNS cause of vertigo i. Nystagmus does not fatigue. Dix-Hallpike Maneuver ii. Multidirectional iii. Not ameliorated by gaze fixation 5  General Medical Diagnosis I Benign Positional Vertigo (BPV)** 1. Short duration, intermittent (~30 seconds) 2. Elicited by certain head positions 3. Occasional episodes for days to weeks 4. Patient usually well between attacks 5. No hearing loss or tinnitus 6. Type of nystagmus depends on semi-circular canals (SCC) 7. Pathophysiology a. Inner ear has 3 SCC. b. Crista amupllaris in SCC detects flow of fluid to determine head rotation c. Particles (otoliths) interfere with sensory input and cause vertigo 2. In benign paroxysmal positional nystagmus (BPPN), the nystagmus fast phase is horizontal-rotary directed Figure 4 In benign paroxysmal positional nystagmus (BPPN), the nys toward the undermost ear when gaze is directed toward the undermost ear (upper panel). directed toward the undermost ear when gaz phase is horizontal-rotary toward the undermost ear (upper panel). The nystagmus fast phase is u a. Gaze directed to uppermost ear (middle panel): the forehead when gaze is directed to the uppermost ear (middle panel in the central orbital position, the nystagmus fast phase is vertical upw i. Nystagmus fast phase is upward toward the forehead toward the down ear (bottom panel). b. With the eyes in the central orbital position: i. Nystagmus fast phase is vertical upward and rotary toward the down ear (bottom panel) Acoustic Neuroma** 1. Benign tumor CN VIII 2. Unilateral tinnitus usually first symptom 3. Hearing loss occurs years later 4. Central vertigo a. Vertical nystagmus worsened by gaze fixation and is non-fatiguing) 5. MRI and audiogram to diagnose a. Audiologist; otolaryngologist Acoustic Neuroma (indicative by the left arrow) Middle Ear Diseases 1. Acute otitis media 2. Chronic otitis media 3. Otitis media with effusion 4. Infectious or Bullous myringitis 5. Cholesteatoma 6. Acute mastoiditis 7. Otosclerosis 6  General Medical Diagnosis I Ear Exam of the Middle Ear 1. Pinna up and back (to straighten out ear canal) 2. Good ear first a. If right ear hurts, then look in left ear first. 3. Pinna and external canal 4. Light reflex 5. Long process and umbo of malleus 6. Pars tensa and flaccida (checking for debris) 7. Structures around the tympanic membrane Normal Tympanic Membrane a. This is the left tympanic membrane. b. The malleus is most medial (left). c. Superior to the malleus is the pars flaccida (where debris collect). d. The pars tensa is lateral to the pars flaccida. e. The umbo is the most concave part, located more centrally. Acute Otitis Media (AOM)** 1. Incidence: 70%, peak ages 3 months to 3 years a. Increased risk in families with smokers, attending daycare Acute Otitis Media 2. Pathogenesis: ET (Eustachian tube) dysfunction, usually follows a viral URI (a “cold”) a. Peak age is young due to anatomy of ET in small children b. The ET is more horizontal than vertical and is more compliant so it can collapse easily. c. The ET is also shorter, so less distance to middle ear; ET in young children is a good place for infection. d. Lack of breast-feeding increases risk of infection. 3. Symptoms: a. Otalgia (ear pain) b. Irritability, fever i. Children run higher fevers; 103-104 with otitis media. c. Vomiting and diarrhea (V/D) d. Decreased oral (p.o.) intake i. Leads to dehydration, hypoglycemia, respiratory distress in infants 4. AOM findings a. TM (tympanic membrane) with erythema, decreased light reflex and decreased mobility i. Note: otitis media is typically unilateral. ii. Crying/screaming can lead to appearance of erythema (and appear like OM) b. Bulging of TM with effusion (difficult to see the malleus) c. Drainage with TM rupture i. Pain subsides for a while as drainage occurs. ii. When this happens, nothing should be put into the ear. iii. The rupture will heal on its own, but there will be a scar, which may decrease hearing loss. 7  General Medical Diagnosis I Acute Otitis Media (AOM) (Cont’d)** d. Bacterial causes i. Children: more important to use antibiotics 1. Child structures are not able to effectively localize / limit infection spread. ii. Adults: not as important, for adult structures are able to localize / limit infection spread. iii. Strep pneumoniae iv. Hemophilus influenzae v. Moraxella catarrhalis (M. cat.) 5. Conventional AOM treatment a. Amoxicillin is the antibiotic of choice for initial and uncomplicated otitis media. i. Don’t use zithromax. It is like shooting an ant with a cannon; too powerful. b. Topical benzocaine ear drops for pain unless TM is ruptured i. This does not treat the infection,; it just deadens the pain. 6. Naturopathic AOM treatment a. Echinacea for viruses and goldenseal for bacterial infections. b. Warm mullein oil into ear to reduce swelling and pain. DO NOT USE EAR DROPS IF EARDRUM IS BURST. c. Suppositories: Sanum i. Pleo Not, Quent, and Ut (Days 1, 2 and 3) ii. Pleo Quent and Ut (Days 5 and 6) d. Aconitum: rapid onset, anxious and restless, wakes after midnight in pain, thirsty. e. Belladonna: red face, fever, sudden onset of throbbing pain, and little thirst. f. Calcarea carbonica: related mucopurulent discharge, sweaty especially back of head, worse at night. g. Chamomilla: ears red hot, child wants to be held, then put down again and held again, … … asks for things then throws them down. h. Pulsatilla: yellow or yellow-green discharge, symptoms constantly change, not thirsty, clingy and whiny. Chronic Otitis Media (COM)** 1. Recurrent of persistent infection 2. Usually associated with conductive loss of hearing 3. May or may not be painful 4. Perforation of tympanic membrane is common Chronic Otitis Media a. May not have pain with this if fluid drains from the ear (Perforation of Tympanic Membrane) Otitis Media w/ Effusion (OME) 1. Serous effusion of middle ear (not pus) a. Common with allergic rhinitis, Eustachian tubes blocked, … …large adenoids, smokers w/ allergies 2. Conductive hearing loss 3. Tympanic membrane retracted and immobile Otitis Media w/ Effusion Notice the retracted ear drum. 4. Bubbles, air/fluid levels seen 5. No antibiotics or antibiotic prophylaxis 8  General Medical Diagnosis I Bullous Myringitis** 1. Myring/o = tympanic membrane 2. Sudden onset of severe pain a. Unaware of an infection 3. Vesicles (blisters) seen of tympanic membrane a. Clear, watery type of drainage with rupture of vesicle 4. Viral etiology usually a. Occurs acutely, symptoms are also short-lasting Bullous Myringitis Cholesteatoma** 1. “Glue ear” 2. Associated with chronic otitis media 3. Chronic negative pressure in middle ear a. Pulls and retracts eardrum inward b. Pars flaccida pulled in forming a sac c. Sac fills with debris i. Development of granulation tissue Cholesteatoma 4. Bone erosion, hearing loss, facial muscle paralysis, meningitis may occur 5. The best thing is prevention. 6. Refer to an ENT specialist. Acute Mastoiditis** 1. Sequelae of acute otitis media 2. Subperiosteal abscess a. Causes high fever, discharge from ear 3. Erythema, edema, and tenderness 4. Labs: a. Leukocytosis, increased ESR, blood c/s (to R/O bacteremia) 5. MRI to plan surgical treatment prn (if needed) Acute Mastoiditis Otosclerosis** 1. Hardening of the ear 2. Periosteal bone replaces endochondral bone a. Decreases movement of the ear ossicles 3. Ankylosis of stapes causes hearing loss a. Ankylosing spondylitis b. Most common cause of progressive hearing loss with a normal tympanic membrane 4. Onset 15-35 y/o, familial 5. Tinnitus in 75% of patient 9  General Medical Diagnosis I External Ear Diseases 1. Obstruction 2. Acute otitis externa 3. Chronic otitis externa 4. Perichondritis 5. Relapsing perichondritis 6. Herpes zoster oticus 7. Tumors Obstruction Foreign body in ear canal Acute Otitis Externa “Swimmer’s Ear”** 1. Etiology a. Occurs often with people who swim often b. Staph, Strep, Pseudomonas 2. Pain can be severe. a. Lying on the ear hurts severely. b. Just lightly touching the pinna causes extreme pain. c. Skin becomes macerated (squishy, gushy, torn up). Acute Otitis Media 3. Cellulitis complication Notice macerated tissue. a. Extends from epidermis into deeper tissue of ear 4. Treatment a. No water in ear b. Use antibiotic eardrops to provide pain relief. Chronic Otitis Externa** 1. Associated with skin disorders a. Psoriasis b. Atopic dermatitis c. Seborrheic dermatitis 2. Intense pruritus 3. Secondary bacterial infection possible Chronic Otitis Externa a. Due to sticking things in the ear to scratch the ear. Perichondritis 1. Avascular necrosis a. Insect bites on pinna of ear b. Trauma 2. Bacterial infection (piercings) 3. Pinna may become deformed. 10 Bacterial Perichondritis  General Medical Diagnosis I Relapsing Polychondritis 1. Often in middle-aged patients 2. Multi-system, episodic inflammation a. Cartilaginous issues are common. 3. Initial symptoms a. Ear pain and erythema 4. Later symptoms a. Joint pain and weight loss Relapsing 5. Death Polychondritis a. A result of airway cartilage destruction Herpes Zoster Oticus** 1. Sequelae of shingles 2. Severe pain prior to rash 3. Loss of taste and dry eyes and mouth may occur. 4. Ramsay-Hunt syndrome: a. Facial paresis b. Paroxysmal deep ear pain c. Vertigo Herpes Zoster Oticus d. Tinnitus e. Ipsilateral hearing loss (side affected) 11  General Medical Diagnosis I Nasal Disorders Epistaxis 1. Classification a. Anterior (90%): anterior nasal septum or inferior turbinate b. Posterior: posterior nasal cavity or nasopharynx 2. Incidence bimodal a. 2-10 years old b. 50-80 years old 3. History a. Control of bleeding before lengthy history b. Duration and site of original bleeding c. Previous episodes, medications i. Aspirin, NSAIDS, Anticoagulants d. HTN, liver disease e. Easy bruising, other bleeding 4. Etiology a. Dry mucous membranes b. Acute rhinitis or chronic sinusitis c. Nose picking d. Trauma e. Allergies f. HTN g. Bleeding disorders (hemophilia, leukemia) h. Deviated septums 5. Labs a. CBC (Prolonged, profuse, recurrent bleeding? May be Leukemia) b. Bleeding time to screen for disorders c. INR/PT d. CT scan of the head if tumor is suspected Rhinitis** 1. Two main categories a. Allergic (IgE mediated) b. Non-allergic (same symptoms with less nasal itching and conjunctival irritation) 2. Statistics: a. 43% of rhinitis is allergic. b. 23% of rhinitis is non-allergic. c. 34% is a combination of both. 1  General Medical Diagnosis I Rhinitis (Cont’d)** 3. Vasomotor a. Intermittent engorgement of mm not related to allergies b. Sneezing c. Watery discharge d. Temperature changes 4. Cocaine use a. Constant runny nose b. Watery while high; congested when not c. May be chronic decongestant users d. May see chemical burns e. Septal perforation 5. Rhinitis medicamentosa a. Runny nose caused by different medications b. ACE inhibitors for hypertension c. Beta blockers d. NSAIDs Non-Allergic Rhinitis** 1. Acute – a. Common cold (URI) d. Malaise b. Watery, profuse discharge e. Swelling of nasal mucosa c. Sneezing 2. Atrophic – a. Idiopathic e. Stuffiness b. Secondary to rhinoplasty f. Painful nasal passage c. Thinning of nasal mucosa g. Dry / shiny membranes d. Nasal crust formation h. Fetid odor Left nasal cavity Nasal septum to the left, medial Inferior turbinate to the right Less mucous than normal Atrophic Rhinitis 2  General Medical Diagnosis I Differential Diagnosis for Rhinorrhea 1. Trauma a. Ominous sign for possible skull fracture; may be CNS fluid, b. Check with Benedict’s sol’n for sugar c. Clear nasal drainage, but history of skull fracture 2. Foreign body a. Discharge b. Odor (unilateral) 3. Neoplasm – Bloody discharge 4. Choanal atresia a. Atresia = not well formed b. Congenital defect in septal development with obstruction of nasopharynx on one or both sides c. Both sides (bilateral obstruction) = Infant is unable to breath through the nose while eating. i. Crying allows inhalation of air with this condition. ii. Preferred breathing of an infant is normally through the nose. Allergic Rhinitis** 1. General information a. Allergic rhinitis affects 20-40 million people annually b. Most prevalent chronic illness < 18 y/o c. 3.8 million days of work and school are lost annually d. Direct costs are 2.7 billion dollars/yr. Normal Nasal Mucosa e. Seasonal or perennial 2. Pathogenesis a. Recognition of allergen by IgE i. Asthma, atopic dermatitis, rhinitis b. Ag/Ab complex binds to mast cells in nasal mucosa or circulating basophils c. Histamine and leukotrienes released d. Inflammatory cells attracted i. Sneezing, rhinorrhea, post-nasal drip Allergic Rhinitis 3. Risk factors a. Family history of atopy (genetic predisposition for allergic reaction) b. Exposure to tobacco or indoor allergens such as animals or dust mites, high pollution areas, farms c. Less common in those exposed to common childhood illnesses d. Onset can be anytime, and symptoms often wane in older adults e. Can contribute to or be misdiagnosed as other conditions e.g. sleep disorders, learning disabilities 4. Some botanicals may have a cross-allergenicity with ragweed. 5. Asteracae family (may cause rhinitis in individuals with ragweed allergy) a. Chamomille, Echinacea, Goldenrod, Tansy and Tarragon 3  General Medical Diagnosis I Nasal Polyps** 1. Definition: a pedunculated tumor (stalk) a. A manifestation of chronic inflammation b. Multiple polyps are often associated with other conditions (i.e: Cystic fibrosis) c. 85% patients with fungal sinusitis have multiple nasal polyps d. 50% with polyps have ETOH intolerance 2. All children with multiple polyps should be evaluated for cystic fibrosis and asthma 3. Theories of the development of polyps a. Inflammation increases Na reabsorption by mucosal cells which increases H2O retention b. Increased vascular permeability increases edema Nasal Polyps 4. Symptoms (if large) a. Nasal obstruction b. Congestion or rhinorrhea c. Decreased sense of smell d. Dull headache (H/A) e. Snoring f. Epistaxis may be a sign of malignancy 5. Physical examination Blue arrow: Nasal Septum a. Use otoscope with speculum. Red Arrow: Inferior Nasal Turbinate b. Anterior septum and inferior turbinate Teal Arrow: Polyp c. Middle of septum and middle turbinate d. May see middle meatus e. Most polyps arise at middle meatus f. Blockage of middle meatus i. Chronic sinusitis or… … sinusitis that is difficult to treat Nasal Septum 1. Important to examine for: a. Deviation due to trauma – i. May present with nasal stuffiness and “constant colds” 2. Perforation due to: a. Chronic infection, cocaine snorting, crusting from atrophic rhinitis b. Previous nasal surgery, TB, syphilis 3. Abscess – rare, but dangerous a. Dangerous due to location; close to the brain A: Frontal sinus B: Sphenoid Sinus C: Superior concha (turbinate) E: Inferior concha (turbinate) F: Auditory tube opening 4  General Medical Diagnosis I Sinusitis** 1. Development of the sinuses a. Ethmoid and maxillary sinuses are very tiny at birth. b. Sphenoid sinus is pneumatized by 5 years old. c. Frontal sinuses appear at 7-8 years of age, … …but are not developed until late adolescence. d. All sinuses are not developed until about 18 years of age. e. “Catch all diagnosis” 2. Difficult to distinguish between simple URI and acute sinusitis a. Most viral URI’s involve both the nose and sinuses. i. Antibiotics do no good in viral infection. b. Bacterial infections of sinuses do not involve the nose. c. When thick and purulent discharge is present, it is coming from the sinuses via the nose. i. This is likely a sinus infection. 3. Incidence a. 80% of acute bacterial sinusitis follows viral URI. b. 20% are associated with allergic rhinitis. c. Children have 5-10 viral URIs per year. d. Acute bacterial otitis media and acute bacterial sinusitis i. The most common sequelae of viral URIs (similar organisms) 1. Hemophilus influenzae 2. Moraxella catarrhalis, 3. Pseudomonas 4. Acute bacterial sinusitis = infection lasting < 30 day with resolution of symptoms 5. Subacute = infection lasting between 30 – 90 days with resolution of symptoms 6. Recurrent acute bacterial sinusitis = episodes of infection lasting < 30 days and separated by 10 days a. Patient is asymptomatic during the 10-day period. 7. Chronic sinusitis = infections lasting > 90 days with symptoms continuing 8. Acute bacterial sinusitis superimposed on chronic sinusitis = a. Patients with residual symptoms develop new respiratory symptoms. b. These new symptoms resolve with therapy, but the underlying residual symptoms do not. 9. Presentation a. Uncomplicated viral URIs generally last 5-7 days; although the respiratory symptoms may not have completely resolved by the 10th day, they have, however, peaked in severity and are improving. b. The persistence of symptoms without evidence of improvement suggests secondary bacterial infection. c. Constitutional symptoms resolve in 48 hours and purulent discharge does not occur in viral URI. d. If the patient has fever and purulent discharge for 3-4 days, consider bacterial sinusitis. e. Nasal mucosa is swollen. f. Pain / tenderness over sinuses or behind orbit (not necessarily bacterial) g. Periorbital swelling or proptosis (eyeballs are bulging out) is an alarming finding. h. Transillumination of the sinuses can be helpful, but is controversial. i. Cough is present in subacute and chronic sinusitis and may be worse at night. 5  General Medical Diagnosis I Diagnosis & Treatment of Sinusitis** 1. Diagnosis a. In children, the clinical diagnosis correlated with x-ray diagnosis in 80% of cases. i. Imaging studies are not recommended. b. In adults, coronal CT of the sinuses should be done if chronic or recurrent episodes are suspected. 2. Conventional Treatment a. Causative organisms may be resistant to ampicillin b. Most patients treated should respond within 72 hours when bacteria is sensitive to antibiotic. 3. Alternative Treatment a. H1 antihistamines do not help in non-allergic patients. b. Intranasal steroids do not help. c. Antibiotic prophylaxis is not recommended. d. Homeopathic medicine and Vitamin C therapy works very well… …both in prevention of sinus infection and recovery from sinus infection. X-ray on Left: Opacification of left maxillary sinus (indicating infection) X-ray on Right was done 3 weeks after treatment. Complications with Sinusitis** 1. Orbital or periorbital cellulitis a. Edema, pain moving the eye, very sick patient 2. Cavernous sinus thrombosis a. Fever, deep eye pain, ocular palsy (extra ocular movements not intact), edema b. Death can occur in 2-3 days, mortality is 50%. 6  General Medical Diagnosis I Disorders of the Mouth & Throat Leukoplakia** 1. White patch or plaque 2. Cannot be scraped off 3. Etiology a. Chronic irritation (i.e. smokers) 4. Peak age 40-60 y/o 5. Usually asymptomatic 6. 2-6% are early squamous cell carcinomoa 7. Homogenous oral leukoplakia vs. verrucous oral leukoplakia Homogenous vs. Verrucous Leukoplakia** 1. Homogenous oral leukoplakia a. Most common type b. Uniform white plaques on buccal mucosa 2. Verrucous oral leukoplakia a. White plaques on an erythematous base Homogenous Verrucous Oral Leukoplakia Oral Leukoplakia Erythroplakia** 1. Marked erythema 2. Usually asymptomatic 3. 90% are early squamous cell carcinoma 4. Smokeless tobacco, ETOH, any irritant Erythroplakia Candidiasis “Thrush” ** 1. Infection with candida albicans 2. White patches, painful and raw at base 3. Can be scraped off 4. Tongue, pharynx, buccal mucosa 5. Infants, immunocompromised patients 6. Denture wearers, broad spectrum antibiotics 7. KOH prep shows pseudohyphae Oral Candidiasis Glossitis** 1. Loss of papillae (slick tongue) 2. Painless Glossodynia** 1. Pain/burning of the tongue 2. Associated with irritants, menopause, nutritional deficiencies Glossitis 1  General Medical Diagnosis I Geographic Tongue** 1. Causes erythema 2. Loss of papillae 3. Not painful 4. Surpiginous (Snakelike) border 5. Hyperkeratotic 6. Benign, migratory; shape changes 7. Predisposed to spicy foods, etc. Geographic Tongue 8. Asymptomatic Necrotizing Ulcerative Gingivitis** 1. “Vincent’s infection” or “trench mouth” 2. Associated with a fusiform bacillus (normal flora) 3. Normal flora becomes pathogenic. 4. Abrupt onset of painful, bleeding gingiva 5. “Punched out lesions” with a grayish membrane on gingiva 6. No fever; not usually contagious Necrotizing Ulcerative 7. Factors Gingivitis a. Eating rodents during the war in the trenches b. Poor oral hygiene c. Smoking Aphthous Stomatitis Aphthous Stomatitis “Canker Sores” ** 1. Unkeratinized mucosa a. Under the tongue, inside the cheeks (buccal mucosa), inside of the lips 2. 1-5 painful, discrete ulcers (1-10mm) 3. Healing may take 1-3 weeks 4. Foods may cause flare-ups 5. Possible autoimmune etiology a. Association with inflammatory bowel diseases (Crohn’s, ulcerative colitis, mononucleosis) Herpetic Stomatitis “Fever Blisters” ** 1. HSV-1 2. Usually recurrent (with sickness, fever, sunburn) 3. Occurs in 90% patients before 10 y/o 4. Initial illness with systemic symptoms 5. Occurs on keratinized mucosa and unkeratinized mucosa Herpetic Stomatitis 2  General Medical Diagnosis I Herpangina** 1. Coxsackie virus types A and B 2. Children < 6y/o in the summer 3. Abrupt onset of fever and dysphagia (difficulty of swallowing) 4. White/gray vesicles and ulcers 5. 1-2 mm in diameter with red halos Herpangina 6. Typically on tonsilar fossa Hand-Foot-Mouth Disease** 1. Coxsackie virus A-16 2. Spring and summer, young children 3. Vesicles and small ulcers 4. Often on lips and buccal mucosa 5. Lesions on soles and palms 6. Transient rash; macular (trunk or extremities) Hand-Foot-Mouth Disease 7. Mild systemic set of symptoms (Low grade fever) Sialedenitis 1. Acute inflammation 2. Parotid or salivary gland 3. Usually due to infection 4. Swollen and tender gland 5. Probing the ducts may reveal a plug or stenosis Oral Cancer** 1. Tongue is the most common site. 2. Over 90% are squamous cell cancers. 3. Increased risk with ETOH and tobacco 4. 5 year survival rate is 50% Squamous Cell Carcinoma 3  General Medical Diagnosis I Pharyngitis / Tonsillitis** 1. Usually viral etiology 2. May or may not have exudate a. Exudate: “I have pus pockets on my tonsils.” i. Actually, these may be food particles for they turn white in the mouth. ii. Exudate is much more liquid-like (and may be bacterial or viral). 3. May or may not have LAO 4. R/O strep and infectious mononucleosis a. Carditis is a risk occurrence via Strep throat. b. Splenomegaly may occur with mononucleosis so do not play contact sports with this condition. 5. Scarlet fever is strep pharyngitis with a rash. a. Toxins are released from bacteria. b. Sand-paper feeling; red papules 6. Observation is not enough and symptoms are not always sufficient. Using a strep test kit can determine if the person is positive for strep. Signs and Symptoms of Strep Pharyngitis** 1. Strawberry tongue and cirucumoral pallor 2. Pastia’s lines in antecubital fossa a. Horizontal, linear rash 3. Sandpapery rash develops. a. Occurs when endotoxins are released from the bacteria as they are destroyed. 4. Hot potato voice Strep Pharyngitis a. Change in voice while talking to avoid rubbing together of throat structures Rheumatic Fever** 1. A possible sequelae of strep pharyngitis 2. Peak age 5-15 y/o 3. Jones criteria for diagnosis: a. Patient must have 2 major manifestations or … … 1 major and 2 minor plus evidence of prior strep pharyngitis 4. Major Manifestations a. Carditis: i. High fever and chest pain ii. Valvular defects due to vegetation occur years later iii. Most serious complication b. Migratory polyarthritis: lasts 6-12 wks i. Usually larger joints 4  General Medical Diagnosis I Rheumatic Fever (Cont’d)** c. Erythema marginatum: lasts < 1 day i. Short-lived rash; surpiginous, macular rash d. Sydenham’s chorea (St. Vitus’ Dance) i. Lasts 3-6 months ii. Inappropriate bizarre movements like a seizure (but awake) iii. Laughing randomly, jerky movements e. Subcutaneous nodules on extensor surfaces of larger joints Peritonsillar Abscess** 1. AKA “Quincy” 2. Infection between tonsil and superior pharyngeal muscle a. Moves tonsil medially b. Uvula displaced to nonaffected side 3. Group A Strep a. The most common cause 4. Symptoms: Peritonsillar Abscess a. Sever pain and fever 5. Referral to ENT a. I&D (irrigation and drainage) may need to be done. Epiglottitis** 1. Peak age 2-5 y/o, onset 6-8 hours a. Go down for nap, then wakes up and is unable to breath b. Drooling, looking at you, unable to breath 2. Sudden, severe airway obstruction 3. Etiology: Haemophilus influenaze type B a. Vaccination for this…if vaccinated, then the condition may not be epiglottitis, but instead may be Croup. 4. Symptoms: a. High fever b. Inspiratory stridor (indicates upper airway obstruction) c. Drooling, tachypnia, d. Severe respiratory distress, life threatening 5. DO NOT visualize pharynx until patient is in a controlled environment (operating room). a. Almost all caes require an artificial airway. b. Endotracheal tube c. Antibiotics and mechanical ventilation 5  General Medical Diagnosis I Thyroglossal Duct Cyst 1. Usually dx in infancy or childhood 2. Cystic lesion in anterior midline of neck 3. Painless unless infected 4. Failure of tract to involute after embryonic descent of the thyroid Branchial Cleft Cyst 1. May not present until adulthood 2. Often discovered with ear or dental infection 3. Area of the lower pole of the parotid Congenital Neck Masses 6