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Head, Ears, Eyes, Nose, Throat


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What is the most common cause of epistaxis?
nose picking
A child has a button battery lodged in his nose. You cannot retrieve it. Is it safe for him to follow up with ENT in the morning?
No. Button batteries can erode and destroy the septum or nasal bridge. He requires emergent ENT consultation.
A child has a bead lodged in her ear. You cannot retrieve it. Is it safe for her to follow up with ENT in the morning?
When you pack someone's nose for epistaxis, why do you then put them on antibiotics?
To prevent staph toxic shock syndrome.

If you see this finding in someone less than 40, what kind of work-up should you initiate?
This is arcus, and it is common in the elderly. In people less than 40, you should initiate a hyperlipidemia evaluation, as it is a common finding with very high lipids.

This patient has eye pain and vomiting. What is the appropriate treatment?
This patient has acute glaucoma, with a mid-dilated fixed pupil and chemosis. It is treated with diamox, intraocular beta blockers, mannitol, hypertonic saline, and sometimes, surgery.

What is the appropriate therapy for this?
this is angular blepharoconjunctivitis, and it is treated with topical antibiotics, as it is often bacterial in origin.

What is this called and how is it treated?
This is blepharitis, and it is common with autoimmune disease or with infectious processes. It is treated with warm packs, topical steroids, and in severe cases, topical antibiotics.

What is the difference between this lesion and a hordeolum?
This is a chalazion, and it differs from a hordeolum in that it is chronic. It is treated with warm packs, sometimes with topical antibiotics, and sometimes with surgical drainage.

What is this pathognomonic for?
This is CMV retinitis, characterized by white retinal patches. it is common in immunosuppressed individuals, especially those with transplants or HIV. It is treated with IV ganciclovir or intraocular ganciclovir.

What causes this, and how is it treated?
These are conjunctival concretions, and they are a normal finding as people age. they are generally asymptomatic. if they are large enough to cause corneal irritation, they are treated with removal under local anesthesia with a needle.

What is this, and how do you treat it?
this is a conjunctival foreign body, and it is removed with a cotton swab. the patient's Td should be updated.

What is this, and what is its significance?
this is conjunctivalization of the cornea, and it is often a sign of graft versus host disease in bone marrow transplant patients.

What is this?
This is conjunctivitis, with significant conjunctival edema.

What is this, and how is it treated?
this is a conjunctival laceration, and if small it is treated with simple observation, but if large, needs to be sewn up by ophthamology. Td should be updated, and a careful eye exam and potentially a CT and U/S should be done to rule out globe rupture or other injuries.

What is this, and how is it treated?
This is a corneal foreign body, and it can be removed with a swab, a burr, or a needle. Td should be updated. There is no proven role for patching or for antibiotics.

How should you remove this?
This is a corneal foreign body, and it looks like it is metallic, likely from welding. it will probably need to be removed with a needle or a burr.

What is this, and how is it treated?
this is a corneal abrasion, and it is treated by time. Td should be updated. Contacts should not be worn.

What is this, and why should it concern you?
This is a corneal ulcer, and it involves the visual axis. in addition, ulcers can cause globe perforation, scarring, and blindness. they are often caused by pseudomonas. unlike abrasions, ulcers need to be treated with topical antibiotics.

What is this?
Dacroadenitis. often viral, and also associated with crohn's disease and some other systemic diseases. you should evaluate the patient for bacterial source.

What is this called?

What is this, and how is it treated?
This is called entropion, and it can be caused by scarring of the lid margin. it is treated with surgery.

What is the etiology of this?
This is epidemic keratoconjunctivitis, or pink eye. it is caused by adenovirus.

What is a possible cause of this?
this is exposure keratoconjunctivitis, often caused by not closing the eyes during sleep, commonly from a bells palsy.

How is this treated?
This is a hordeolum, and it is treated with hot packs and topical antibiotics. if it is refractory, it can be drained.

What kind of suture should you use to sew this?
6-0 non-absorbable.

What is this?
This is globe perforation with iris extrusion.

What is this?
iris laceration from trauma.

what is this, and how is it treated?
corneal laceration with extrusion of the iris. it is treated with tetanus, antibiotics, and surgery.

What is this?
fungal keratitis

What does this funduscopic exam show?
retinal hemorrhages and cotton wool spots, common with elevated intracranial pressure

What is this?
uveitis with a hypopion.

How is this treated?
These are retinal hemorrhages secondary to central retinal vein occlusion. it is treated with manual eye compression and heparin.

What is this and how is it treated?
This is herpes zoster blepharitis. It is treated symptomatically and with topical antivirals to prevent ocular spread.

What is this finding?
corneal dendritic lesions from herpes infection.

What is this?
corneal dendritic lesion from HSV

What is this and how is it treated?
This is HSV blepharitis, and it is treated with antivirals.

When should you admit people with this finding?
This is a hyphema. It is treated with elevation of the head of the bed and bedrest. You should admit people who cannot comply with that, including children, hyphemas that involve the visual field, and sickle cell patients as well as sickle trait patients with this finding.

What is wrong with this man?
He has an inferior blow out fracture with entrapment causing an upward gaze palsy.

What is the diagnosis?
Iritis. this is evident from the irregular pupil.

What disease this person have?
Wilson's disease

What's wrong with this patient?
this patient has narrow-angle glaucoma, as evidenced by the narrow anterior chamber.

what's this and what causes it?
pinguecula, caused by dry eyes and exposure to UV radiation, wind, and other stuff outside.

What is this and what causes it?
Posterior synechiae, usually caused from irits.

what's this and how should it be treated?
This is a corneal ulcer, probably from pseudomonas, and an accompanying hypopion. Needs antipseudomonal antibiotics.

What is this?

What is this and how do you treat it?
subconjunctival hemorrhage, and there is no specific treatment.

What causes this?
This is trichiasis, and it is often caused by chronic blepharitis or scarring. it is treated with hair removal in a variety of ways.

What is this, and what other evaluation should you consider?
This is scleritis and is common in people with autoimmune disease. You should consider an autoimmune evaluation.

What is this?
Retinal hemorrhages with retinal central vein occlusion

What is this?
This is retinal artery occlusion, as evidenced by the darkened (cherry red) macula and the lack of hemorrhaging.

What is this?
Retinal detachment

What is this?
retinal detachment

What is this?
Retinal detachment
In the case of a bug in someone's ear in the setting of a perfed TM, it is safe to use mineral oil to kill the insect. true or false.
true. lidocaine is not safe.
a patient has suffered a crush to the ear and has several pieces of loose cartilage in the ear laceration. should you remove them?
no. never debride cartilage. it can be used in the future for reconstruction.
a patient has a captive bead earring in her tragus, and needs an MRI. should you cut it off?
no. most earrings are surgical grade steel or titanium, and will not be cut easily. many are safe for MRI. research the jewelry, then use kelleys to remove it if necessary.
a patient has a full-thickness ear laceration which is not gaping. do you need to sew the cartilage back together?
no. only with gaping or large wounds is it necessary to sew cartilage.
with perichondritis, what bacteria do you need to cover for?
staph and pseudomonas

What kind of injury is depicted here?
Large corneal burn

What is this and how do you use it?

This is a Morgan lens, which is an irrigation system for the eye. Attach Morgan Lens Delivery Set, IV, or syringe using solution and rate of choice. Start flow so the Morgan Lens floats on the fluid (it does not rest on the cornea). Release the lower lid over lens and adjust flow. Tape tubing to patient's forehead to prevent accidental lens removal. Absorb outflow. DO NOT RUN DRY.
Why is Lactated Ringer’s solution generally preferred over normal saline for irrigation in ocular injury?
Higher pH of 6-7.5 better approximates physiologic pH of eye (pH of tears is 7.1). The pH of normal saline pH is 4.5 to 7.
Which ocular burns are worse – acid or alkali? Why?
Alkali because they
a.) rapidly penetrate through cornea/anterior chamber
b.) combine with cell membrane lipids, causing cell disruption and concomitant tissue softening
c.) continue destruction after superficial removal
d.) coagulation necrosis after acid injury limits penetration of acid into
ocular tissue
How are ocular burns classified?
Classification of severity by Roper-Hall
Grade I: prognosis good, corneal epithelial damage only, no limbal ischemia
Grade II: prognosis good, Corneal haze, iris details visible, <1/3 limbal ischemia
Grade III: prognosis guarded, total epithelial loss, stromal haze, Iris details obscured, 1/3-1/2 ischemia
Grade IV: Prognosis poor, Cornea opaque, iris and pupil obscured, >1/2 limbal ischemia
When should ocular burn irrigation be initiated – at the scene by EMS or at the hospital?
Treatment of eye burns should begin immediately, utilizing non-sterile or tap water if needed. Immediate treatment is copious and continuous irrigation at the scene, en route, and at the hospital.
The goal for decontamination of ocular burns should be to achieve an ocular pH of _____
At least 7.2, preferably 7.4

What grade ocular burn is this?
Grade 3 burn, 4.5 clock hrs of limbus involvement with 30% conjunctival involvement. Injury sustained from bleach.
If pH paper is not available, an adequate guideline for irrigation of ocular burns is _____
A minimum of 1-2 L per eye of continuous irrigation fluid over 30-60 minutes. Complete removal of caustic agent and proper neutralization may require several hours of irrigation.
Ocular pH is best obtained in which area of the eye?
Lateral cul-de-sac

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