HEENT Disorders and Exam

PURPOSE: The purpose of this lesson is to teach the student the proper procedure for examining and recognizing common disorders of the head, eyes, ears, nose and throat.

LEARNING OBJECTIVES:

1. TERMINAL LEARNING OBJECTIVE: Given a simulated patient with simulated symptom; the student will be able to recognize potential problems and perform the needed exam.

2. ENABLING LEARNING OBJECTIVES:
   1. The student will be able to identify different components of the eyes, ears, nose, and throat.
   2. The student will be able to identify different disorders of the eyes, ears, nose, and throat.
   3. The student will be able to identify the signs and symptoms of EENT disorders.
   4. The student will be able to identify the treatment of these disorders based upon exam.
   5. The student will be able to identify the proper techniques for a basic exam of ears, eyes, nose, and throat.

3. The instructor will give this class by lecture and demonstration.

4. This material will be covered on a daily quiz and the final oral exam.

1. Eyes, treatment and diagnosis of ocular disorders.
   1. Review of anatomy
      1. conjunctiva - mucous membrane of the eye.
      2. cornea - protective part of the eye.
      3. iris - regulates quantity of light into the eye.
      4. lens - expands/contracts in order to focus light.
      5. pupil - circular area that allows for the passage of light.
      6. retina - receives images from light and converts them into electrical impulses sent to the brain.
      7. vitreous humor - transparent liquid that gives the eye its shape.
      8. aqueous humor - fluid anterior to the lens that is used in the support of the iris and refraction of the light.

   2. Ocular disorders
      1. Refractive errors
         1. blurred vision
         2. headaches
         3. decreased visual acuity testing

      2. Types of refractive errors
         1. hyperopia - image is focused behind the retina
         2. myopia - image focused anterior to the retina
         3. presbyopia - accommodation muscles are unable to focus
         4. astigmatism - uneven focusing / displaced lens

      3. Treatment objectives
         1. obtain good history (Do they wear glasses/contacts?)
         2. refer to MO if no history of trauma or illness
         3. if positive for trauma, review procedures for various trauma’s, refer to MO
         4. do visual acuity in all cases
         5. Refer all unexplained eye pain and/or unexplained changes in visual acuity to MO.

      4. Foreign bodies / small non-penetrating
         1. signs/symptoms
            1. complaint of something in eye
            2. tearing or weeping
            3. reddened or bloodshot
            4. foreign bodies (small)

         2. diagnosis/treatment
            1. do VA
            2. complete history
            3. attempt to irrigate
            4. Examine the eye using fluorescein stain for detection of abrasion/laceration/burns/ulcerations
            5. If foreign body is hard to remove, contact MO
            6. If not improved, contact MO
            7. Corneal abrasions and scratches
               1. E-mycin ophthalmic ointment or 10% sulfacetamide sol 2 qtts q 2-3h for 2 days.
               2. Patch eye; nothing on eye except medication, i.e. no contacts.
               3. Follow-up after 24 hours SIQ
            8. Follow-up should include irrigation, VA, and restain check.
            9. If healing, continue treatment for 2 days

      5. Inflammation and infection of the eye
         1. conjunctivitis is an inflammation of the mucous membrane of the eye.
            1. bacterial conjunctivitis
               1. signs/symptoms
                  1. purulent discharge with edema
                  2. conjunctiva will appear red and inflamed
                  3. exudate
                  4. generally unilated
               2. diagnosis, prognosis, and treatment
                  1. Usually related to staph, strep, or bacillus infection.
                  2. Duration may run 10-14 days without treatment.
                  3. Never use eye drops of any kind that contain steroids without permission.
                  4. Eye should be kept free of all discharge.
                  5. No contacts.
                  6. E-mycin ophthalmic ointment QID to affected eye for 3 days.
                  7. Check culture results in 24-48 hrs
                  8. Follow-up in 3 days
                  9. If no resolution or if it worsens then check C&S
                  10. Advise pt not to rub eyes or use towels to rub eyes. It can be easily transmitted.

            2. Viral conjunctivitis (pink eye)
               1. signs/symptoms
                  1. Eyelids may appeared reddened.
                  2. Copious amts of watery discharge with scantyexudate.
                  3. Often bilateral
               2. diagnosis and treatment
                  1. Usually associated with pharyngitis, fever or malaise. Occurs mostly with children.
                  2. Usually a week in duration
                  3. Pt should abstain from rubbing eyes
                  4. Warm water compresses, no contacts.
                  5. Sodium sulfacetamide 10% 1-2 qtts q6h X10day
                  6. Frequent hand washing to prevent spread

            3. Allergic conjunctivitis
               1. signs and symptoms
                  1. Eyes may appear reddened
                  2. May have itching and tearing
                  3. Minimal discharge
                  4. May appear chronic or reoccurring
                  5. Generally bilateral
               2. diagnosis and treatment
                  1. Treatment is symptomatic
                  2. Normally associated with hayfever, seasonal changes
                  3. Vasocon-A can be used

            4. Blepharitis - an inflammation of the eyelids.
               1. signs/symptoms
                  1. Tenderness, reddening, sore sticky exudate
                  2. Eyelids may become inverted & eyelashes fall out
               2. treatment
                  1. Antibiotics applied to eyelids
                  2. Keep scalp and eyelids clean
                  3. Scales must be removed daily with moist applicator or warm, moist wash cloth
               3. 2 Types
                  1. ulcerative - usually secondary to bacterial infection
                  2. non ulcerative - cause unknown

            5. Hordeolum (stye)
               1. signs/symptoms
                  1. Localized pain, swelling to eye lid
                  2. Often purulent discharge
               2. treatment - Hot compresses, scrub with neutral soap, topical antibiotic eyedrop q3h, and if not resolved in 2-3 days, refer to ophthalmology for I&D

2. EARS
   1. Review anatomy & physiology of the ear
      1. external or outer ear
      2. middle ear
      3. inner ear
   2. History
      1. always ask the following
         1. hearing loss
         2. tinnitus - ringing in the ear
         3. vertigo - sense of motion
         4. otalgia - ear pain
         5. otorrhea - drainage from the ear
   3. Physical exam
      1. As per lecture on physical exams of head and neck.
   4. Common disorder of the ear
      1. hearing loss - 2 types
         1. conductive - seen in people with external or middle ear problem
            1. history - Have perceived hearing loss & need things repeated
            2. physical exam
               1. Weber - in conductive hearing loss, sound lateralizes to the affected ear.
               2. Rinne - in conductive hearing loss, bone conduction (BC) > air conduction (AC)
            3. tests
               1. audiogram: normal 0-25 db.
            4. causes
               1. obstruction of external auditory canal (EAC)
               2. T.M. (tympanic membrane) perforation
               3. serous otitis media (SOM)
            5. treatment
               1. Treat underlying problem, i.e. remove cerumen, treat otitis, treat middle ear effusion.
               2. hearing aides if loss is not severe
               3. sensorineural - When the eighth cranial nerve or cochlea are damageInvolves the inner ear.
                  1. History - similar to conductive hearing loss.
                  2. PE: Weber - lateralizes to good ear
                     Rinne - AC>BC
                  3. Audiogram - both BC and AC below 25db in affectedfrequencies
                  4. Causes
                     1. noise induced - most common - occupationally involved
                     2. trauma - skull fx (basilar)
                     3. tumors
                  5. Treatment
                     1. Hearing conservation; may require baseline adjustment.
                     2. Hearing aides
                     3. Sudden hearing loss.
                        1. Usually unilateral
                        2. Sensorineural hearing loss
                        3. Causes
                           1. perilymphatic fistula
                           2. other causes - tumor, infection, environment trauma
                     4. obstruction
                        1. cerumen impaction - PE reveals wax in EAC
                        2. treatment
                           1. irrigate ear 1/2 water:1/2 hydrogen peroxide
                           2. cerumen scoop - use under direct visualization or EAC.
                              DO NOT USE BLINDLY!!!
                        3. contraindications - no irrigation if pt has a perforation

      2. Foreign bodies
         1. Common in young
         2. Objects rough/jagged edged may be irrigated
         3. Do not use forceps
         4. If object is absorbent, do not irrigate. Object may swell
         5. Insect - fill ear with mineral oil. This may kill insect.
         6. Only MO or certified corpsman can remove object
         7. If unable to remove, then ENT consult.

      3. Otitis externa
         1. Infection of external ear
         2. Caused by bacteria, fungi, or may be a dermatitis
         3. Common in swimmers
         4. Results from wax in ear that absorbs water, macerates the skin & canal, which affords a basis for infection.
         5. signs/symptoms
            1. Itching followed by pain.
            2. Eear swollen, pale in color.
            3. Lymphadenopathy in pre-auricular area,post-auricular area or neck.
            4. Pain with movement of auricle.
            5. Discharge may be present.
         6. Treatment
            1. mild to moderate
               1. cortisporin otic solution 4 qtts QID
               2. keep ear dry
               3. if ear swollen shut, may need placement of a wick
               4. Tylenol, NSAID’s for pain
            2. severe (lymphadenopathy, fever, severe pain)
               1. as above but in addition may require systemic antibiotics (Augmentin or Amoxicillin 500mg TID)
               2. refer to MO
               3. may need narcotic analgesics
            3. try to visualize T.M. to R/O concurrent otitis media or perforated T.M.
            4. Otitis Media (OM)
               1. infection of middle ear
               2. bacterial or viral
               3. most common bacterial
               4. common in children 3 months to 3 yrs
               5. starts as URI. Organisms enter into the middle ear via eustachian tube, swell, become inflammed and eventuallyobstructs. Results in bacteria trapped in the middle ear.
               6. signs/symptoms
                  1. otalgia (ear pain)
                  2. fever, nausea, vomiting
                  3. general malaise
                  4. decrease in hearing
                  5. may have vertigo
               7. physical exam
                  1. T.M. erythematous, edematous, dull, bulging, decreased mobility (use pneumatic bulb or valsalva maneuver)
                  2. No landmarks, or distorted landmarks.
                  3. Purulent material behind T.M.
               8. treatment
                  1. antibiotics - Amoxacillin 250 mg tid x 10days, if PCN sensitive, give Septra D.S. BID X 10 days
                  2. Oral decongestants
                  3. Analgesics
                  4. Recheck in 2 weeks
         7. Complications
            1. Serous otitis media - sterile fluid behind T.M., immobility ofT.M. usually treated with decongestants such as Entex LA BI May persist for 4-6 weeks.
            2. Acute mastoiditis - seen about 10-14 days after untreated or poorly treated acute OM. Develops thick, purulent otorrhea, dull post-auricular pain, low grade fever, post-auricular swelling and erythema, displacement of auricle outward, pain most intense over mastoid.
            3. If you see acute OM in elderly pts, must R/O nasopharyngeal cancer blocking eustachian tube and causing OM
            4. Chronic otitis media
               1. T.M. perforation, usually central perforation
               2. mucoid, oderless drainage
               3. acute exacerbation
               4. conductive hearing loss
               5. treatment - irrigate with saline, then dry ear. Cortisporin otic susp. 4qtts QID, & may need oral antibiotics
            5. Cholesteatoma
               1. collection of desquamated epithelial cells in the middle ear
               2. foul smelling discharge
               3. marginal perforation
               4. proteolytic enzymes causes destruction to bone
               5. PE - retracted T.M. with marginal perforation and pearly white material in superior part of T.M.
               6. treatment - mastoidectomy (surgical)
               7. causes - eustachian tube dysfunction causes retraction ofT.M.
               8. refer to ENT

      4. Trauma
         1. traumatic
            1. causes - blunt trauma, explosions, etc.
            2. Treatment - refer to MO or ENT
               1. Secondary to foreign body - ear should be cleaned and suctioned. Avoid ear drops. Perforations will heal spontaneously. Follow-up in 1-2 weeks. If not healed, refer to ENT.
               2. blast injury
                  1. refer to ENT
                  2. May have hearing loss & most will complain of pain

      5. Eustachian tube dysfunction
         1. Fullness in ear, loss of hearing, T.M. retracted
         2. Decongestants may help

3. The Nose
   1. Review anatomy
   2. Common disorders
      1. Epistaxis (nose bleed)
         1. Kiesselbach’s plexus - located anterior septum, supplied by four arteries
         2. Usually bleed from one nostril
         3. Most nose bleeds are anterior
         4. Causes - trauma, foriegn body, etc.
         5. PE & TX:
            1. Use nasal speculum and light to see bleeding and location
            2. May use cautery to stop bleeding (silver nitrate stick for nose cautery). May apply bacitracin-ointment to nares TID after cautery.
            3. Have pt sit straight up and pinch nostrils for 5 minutes
            4. If not stopped, use nosepack (1/4 gauze with bacitracian-ointment). Have them return to clinic next day.
            5. If bleeder not seen and pt complains of blood running down throat, may be a posterior nose bleed.
               1. Need referral to ENT for nasal pack, and admission to ICU for airway watch.
               2. Posterior nose bleeds not caused by trauma, seen more In elderly
               3. If bleeding continues, surgery may be needed.
         6. other causes
            1. If chronic, get good family history
            2. May have bleeding disorder
            3. Labs - pt/ptt, cbc with platelets, bleeding time
            4. Check BP
            5. Dry environment may cause epistaxis
               1. Nasal mucosa becomes brittle and bleeds easily
               2. Use ocean spray mist (NACL) 2 sprays to ea nostril q4-6hrs or ointment for moisturizing effect.

   C-1. Acute sinusitis

   1. Inflammation of paranasal sinuses by bacteria, viruses, or fungi
   2. Accompanied by or follows colds
   3. signs/symptoms
      1. pain over affected sinus
      2. headache
      3. purulent rhinorrhea
      4. fever and other systemic disease
   4. physical exam
      1. Mucosa is hyperemic and edematous
      2. Turbinates are enlarged and often about the septum
      3. Purulent drainage
      4. Pain elicited from pressure over involved sinuses
      5. Transillumination may reveal air-fluid level.

   5. sinus X-rays
      1. Four views - Caldwells, Water’s, lateral & base.
      2. See air-fluid level in involved sinus or may just be clouded.
      3. Not required for diagnosis; more useful in chronic cases.

   6. treatment
      1. Augmentin 500mg TID X 14-21 days
      2. Entex LA
      3. Topical vasoconstrictors/decongestants (Afrin) for 3 days only.
      4. Analgesics
      5. Avoid antihistamines

   7. If frontal sinusitis, or if diagnosed by X-ray, consult ENT doctor, as IV antibiotics and hospitalization may be required (could develop into brain abcess).

   8. complications
      1. periorbital cellulitis
      2. orbital cellulitis
      3. orbital abcess
      4. cavernous sinus thrombosis
      5. intracranial abscess
      6. sinus mucocele
      7. osteomyelitis

   C-2. Chronic sinusitis

   1. Irreversible tissue changes have occurred in lining membrane of one or more of the paranasal sinuses, mucosal thickening becomes apparent.
   2. Causes - repeated bacterial sinusitis
   3. signs/symptoms
      1. Purulent material in nose. Enlarged turbinates.
      2. Similar to acute sinusitis.
      3. Should not have pain or headache
   4. physical exam
      1. Purulent material in nose. Enlarged turbinates.
      2. May notice nasal polyps
   5. X-rays
      1. Sinus series
   6. Treatment
      1. Treat like acute sinusitis
      2. Antral lavage with culture of turbinates
      3. May require ENT referral if recurrent or refractory
      4. Rhinitis

   C-3. Allergic (hay fever)

   1. seasonal or perennial
      1. sneezing, lacrimation, itching, nasal discharge etc.
      2. must obtain good history; key to diagnosis.
      3. caused by pollen, grasses, dust/house mites etc.
      4. c/o frontal headache
      5. trouble breathing through nose
   2. physical exam
      1. pale mucosa
      2. turbinates (inferior) enlarged
      3. clear/thin secretions
      4. possible deviated septum
      5. nasal polyps
   3. labs/allergy testing (in severe cases)
      1. intradermal allergy testing
      2. rast test (blood test)
   4. treatment
      1. avoidance of allergen
      2. nasal steroid inhaler
      3. antihistamine
      4. may use topical vasoconstrictor

   C-4. Acute Rhinitis

   1. common cold
   2. cause - rhinovirus
   3. signs/symptoms - fatigue, sore throat, nasal discharge, headache, fever, nasal obstruction, sneezing
   4. physical exam
      1. nasal mucosa red
      2. inferior turbinates enlarged and erythematous
      3. clear watery discharge
   5. treatment - symptomatic

   C-5. Foreign body

   1. common in younger children
   2. foul smelling, bloody, unilateral discharge
   3. consult MO or ENT for removal

   C-6. Trauma

   1. nasal fracture
      1. result of blunt trauma
      2. signs/symptoms
         1. epistaxis, nasal dyspnea, edema, pain, ecchymosis.
      3. physical exam - crepitus, mobile nose, deviation, edema, ecchymosis. Must look into nose to R/O septal hematoma. If found, refer to ENT.
      4. Look for and rule out other facial fractures.
      5. X-rays of little valve
      6. treatment - reduction, anesthesia, Denver splint, antibiotics if open Fx, refer to MO or ENT.
   2. Blow out fracture
      1. When force is applied to the orbit causing contents to spill either medially or inferiorly. If inferiorly, will end up in maxillary sinus.
      2. signs/symptoms
         1. epistaxis
         2. enophthalmus
         3. entrapment
         4. dypesthesia
         5. diplopia
      3. fracture over infraorbital rim
      4. X-rays needed; CT scan is definitive.
      5. If there is entrapment of EOM, need surgery soon otherwise must wait5-7 days
      6. Must R/O ocular injury
      7. refer to ENT

4. Throat
   1. pharyngitis - inflammation of pharynx
      1. causes
         1. viral - Epstein-Barr virus (mono), adenovirus, etc.
         2. bacterial - group A & B strep
      2. signs/symptoms
         1. odynophagia
         2. sore throat
         3. dysphagia
         4. fever, fatigue, otalgia
      3. physical exam
         1. tender anterior cervical adenopathy
         2. erythmatous posterior pharynx
         3. exudate
         4. palatal petechiae
      4. differentiation
         1. throat C&S
         2. severe symptoms suggest bacterial etiology
      5. Often have concurrent tonsillitis
      6. Treatment
         1. throat C&S
         2. Pen V-K 500 mg QID x 10 days
         3. increase/force fluids, analgesics
   2. Tonsillitis - inflammation of tonsils.
      1. causes - similar to pharyngitis
      2. signs/symptoms - more odynophagia and dysphagia due to increase of tonsil size.
      3. Physical exam - similar to pharyngitis.
         1. tonsils enlarged, red, and exudate (white patchy)
         2. palatal erythema and edema
         3. cervical nodes may be tender, usually palpable
      4. treatment - similar to pharyngitis
      5. tonsillitis rare without pharyngitis but can have vice-versa
   3. Peritonsillar abcess
      1. abcess of peritonsillar region, pus within surrounding tissues
      2. signs/symptoms
         1. hot potato voice
         2. trismus - inability to open mouth fully
         3. increased odynophagia
         4. foul odor from mouth
         5. unilateral pain
      3. physical exam
         1. uvular deviation
         2. tender over anterior fauces arch
         3. tonsils red, swollen
         4. protuding and flunctuant on one side
      4. treatment
         1. I&D of abcess, ENT consult
         2. antibiotics - Cleocin 300mg TID x 10 days to cover anaerobic bacteria

5. Larynx
   1. Review anatomy
   2. Laryngitis
      1. Signs/symptoms
         1. hoarsness
         2. aphasia
         3. pain in larynx
         4. coughing attack
      2. Physical exam - indirect (mirror) laryngoscopy reveals vocal cords to be red and swollen
      3. Treatment - symptomatic; voice rest, vaporization, do not whisper, antibiotics rarely needed.

6. Special Topics
   1. Otalgia
      1. Ear pain caused by other than infection.
      2. Temporomandibular joint (TMJ) dysfyunction
         1. often causes ear pain located pre-auricular
         2. often hear pop, click, or crepitus in joint
         3. physical exam - palpate TMJ by putting finger in ear and pressing anteriorly. Have pt open and close mouth.
         4. treatment
            1. Motrin
            2. soft, mechanical diet
            3. warm compresses
            4. refer to ENT
      3. Cancer to head and /or neck
         1. Cancer of oral cavity (CNV), base of tongue (CNIX) or (CNX). Can have referred pain to ear.
         2. Obtain good history of smoking, radiation, change in voice or hoarseness.
         3. Refer to ENT
   2. Vertigo
      1. Sense of motion - not the same as dizziness must differentiate between the two.
      2. Causes
         1. External & middle ear - impaction or foreign body
         2. Inner ear and CNS
            1. benign positional - caused by otoconia that trigger cells in the vestibular sense organ
            2. perilymphatic fistula
            3. acoustic neuroma
            4. acute suppurative labyrinthitis - bacterial infection of inner ear causes permanent hearing loss.
            5. vestibular neuronitis - viral infection of inner ear. No permanent hearing loss.
            6. Meniere’s disease - triad of low frequency hearing loss, vertigo and tinnitus.
            7. Vestibulobasilar insufficiency - seen in elderly patients, AJD of cervical spine can impinge vertebral artery.
      3. Tests
         1. MRI< EMG< brain stem evoked potentials

   3. Neck Mass (differential diagnosis)
      1. lymph node
         1. if node is tender, its reactive from an infection
         2. non-tender, rubbery, hard, R/O neoplasm
         3. over 50% of lymphadenopathy is unknown
         4. give 2 weeks course of antibiotics
         5. if not resolved in 2 weeks, refer to ENT for further work up
      2. epidermal inclusion cyst, dermoid cyst, lipoma
      3. 0-15 age, inflammatory - congenital - neoplasm (malignant-benign)
         16-40 age, inflammatory - congenital - neoplasm - (benign-malignant)
         40 & up - (neoplasia) malignant - benign - inflammatory - congenital
   4. Human and animal bites of head and neck.
      1. Human bites are more dirty than animals.
      2. Irrigate with saline and betadine (1:1) use jet stream irrigation.
      3. Clean non-human bites can be closed primarily if seen in 5 hrs or less.
      4. Human bites closed in a delayed manner. Use wet to dry dressing changes for 2-5 days then close primarily.
      5. Treat avulsions with delayed manner.
      6. Antibiotics - oral, Augmentin 500mg TID x 14 days. IV Timentin 3.1g q6hrs
      7. Refer all bites to MO or ENT.

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Naval Hospital, Great Lakes

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