Etiology and Presentation of

External Otitis

Inflammatory process of ext auditory canal

Occurs when natural defenses fail or epithelium is damaged, or moisture

Presents with otalgia, otorrhea, aural fullness, decrease in hearing

Organisms of External Otitis 

Psuedomonas aeruginosa

Staphlococcus aureus

Fungal (aspergillas 90%, then candida)

Topical Treatment of Otitis Externa

Topical: Debreidment

-2% acetic acid solution (vosol)

Neomycin, polymyxin B + hydrocorisone (Cortisporin otic)

Ofloaxacin (Floxin) 0.3% soln, Cipro

Aminglyoside opthalmic solutions (Gentamycin or tobramycin sulfate)

Fungal

Oral and other Treatment of External Otitis

Oral: Cipro (500mg) BID, Levofloxacin (Levaquin) 500mg QD

Other: Wick placement, Water precautions, Pain management

Facts of Malignant otitis media

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- Severe infection of external autidiory canal

-Usually caused by psuedomonas

-Spreads to temporal bone: osteomylitis

-Most often in diabetics or immune compromised

Treatment: oral quinolone, antimicrobial drops, daily debriedment

Etiology of Otitis Media

Streptococcus penumonaie

M. Catarrhalis

Haemophilus influenza

S. aureus

Viral

Presentation of Otitis Media

Otalgia

+/- otorrhea

In child, ear pulling

recent URI

Change in Hearing

Treatment of Otitis Media

-Amox 500mg TID 10-14 days, peds 20-40 mg/kg in 3 doeses or 25 to 45mg/kg day in 2 doses

-PCN allergy Erythromycin 333mg TID 10-14 days, peds 30-50mg/kg/day 4 doses

Complications of Otitis Media

Hearing loss

TM perforation

Mastoiditis

Meningitis

Brain Abcess

Clinical presentation of Chronic Otitis Media (COM)

Usually presence of TM perforation , s/p matoidectomy

Clinical presentation of

Serous Otitis Media (SOM)

Fullness and decreased hearing, min to no pain

Recent URI or allergies

Obvious fluid or allergies

Obvious fluid on examination of TM

Treatment varies

Etiology and Presentation of TM perforation

Trauma, OM, Iatrogenic

Presentation: Otalgia, otorrhea, hearing loss, tinnitus, vertigo

Treatment and Complications of TM perforation

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Most heal on own, Tymphanoplasty

Complications: Persistance perforations, hearing loss , chronic OM

What is Mastoiditis?

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Part of Temportal bone in back of ear that contains honey comb of air cells lined with respiratory epithelium

Historically a problem prior to antibiotic development

Immune compromised or diabetic patients at risk

Treatment of immune compromised patients with Mastoiditis

Treat Otitis Externa, Acute otitis media, TM perforation more aggresively

What is a Cholesteatoma?

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Cyst of squamos epithelium which causes damage to middle ear and mastoid.

Etiology is negative middle ear pressure, eustachian tube dysfunction or TM perforation

Tympanosclerosis

Firm submucosal scarring, often appears as chalky white patch on TM

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Cerumen

Combination of desquamated eplitheium, thick sebaceuous gland secretions and thinner apocrine gland secretions

Water resistant, trapts depreis and has bacteriocidal activity

What is Barotrauma and how do yo treat it

Condition of discomfort in the ear caused by pressure differences bewteen the outside  and inside of ear drum

Pressure changes

More prone if current URI

Hearing loss, pain or discomfort, fullness of ear with dizziness

Treat: open eustachian tube to equalize pressure, rarely need surgery (tubes)

Etiology of Cauliflower Ear

Blood clot -> skin sheared from cartilage -> no other blood supply -> deprived of nutrients-> cartilage conatracts on itself

Treatment of Cauliflower Ear

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Periauricular Sinus

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Congenital Malformation/incomplete fusion of branchial arches

Inherited autosomal dominant

Bilateral 25-50%

Increased incidence in AA and asian americans

Infections - Staph

Treatment: Antibiotics, surgery is rare

Keloid

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Scar Hypertrophy

Scar becomes raised and thickend

Extends beyone limites of original scar

Common in AA

Non Urgent complaints

Eyes Feel irritated

Bump on eyelid

Eye is red, not painful, normal vision

Urgent sounding but have been going on for weeks

Consider pt concern/anxiety

DDx of ACUTE vision loss

Optic neuritis: MS

Retinal vascular occulusion: Vein or Artery

Retinal Detachment

Diabetic Retinopathy: macular edema, vitreous hemorrhage

"Wet" macular degeneration

Cerebral Vasular Accident

Trauma (any layer)

Infections or inflammatory (any layer)

DDx of CHRONIC vision loss

Cataract

Glaucoma

Atrophic "dry" macular degeneration

Corneal degenerations

What will you see with an Orbital Floor Fracture

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Va: 20/25

IOP, Confrontation visual field WNL

EOM: Upgaze and downgaze deficit, Diplopia in upgaze

External: Eccymosis of upper lid and lower lid, sunken in eye (enophthalmos)

Slit Lamp exam: Subconjunctibal heme nasally, otherwise normal

Dilated fundus exam - Normal bilaterally

How do you treat an Orbital Floor Fx.

Oral Antibiotics

No nose blowing

Ice packs and pain medication

Surgical repair: Immediate within 24 hrs.

-If diplopia  and e/o entrapped muscle and non-resolving bradycarida, heart block, nausea vomiting, syncope

-White dyed entropion

1-2 weeks: persistant  diplopia with positive forced ductions and entrapment on CT

-Large floor fractures liekly to cause cosmetically unacceptable enophthalmos/assymetry

-Complex traume involving rim or zygomatic arch with displacement

Setting of a Hyphema

7 y/o male sutruck in the right eye with a toy airplance 15 minutes ago

Currently child is screaming in pain and mom sees blood in eye

Told to come in now

Traumatic Hyphema

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Va: 20/100, 20/20

Pupils irregular with sluggish reaction to RE, brisk LE

Timoptic 21 Bilateral eyes

SLE: Left lower lid normal

-Conj quiet

Keratometer reading (measures the curvature of the cornea) - hazy, no abrasionor stain, no laceration

Anterior chamber - deep, 2mm layered hypema, 3+ suspended RBC

Iris - irregular, little reaction, ? sphincter tear at 7:00

Lens - clear

Dilated fundus exam - hazy view

Bilateral scan - WNL

Treatment of Traumatic Hyphema

Bed rest and elevate

Shield eye (clear)

Watch for rebleed

No physical activity for at least 2 weeks

Admit kids for bed rest (not done anymore)

Topical atropine and steroid

No asprin or NSAIDS

? Sickle cell

Treat increased IOP; may need to wash out

Gonioscopy 1 month

Presentation of Corneal Abrasion

Welder got something stuck in eye and won't come out

Va: 20/25

Pupils brisk

IOP 12mm Hg

SLE: Trace injection

1mm metallic superficial foreign body

AC deep with trace cell

Clear lens

Dilated fundus exam: Normal

Treament of Cornea FB

FB rust ring removed at slit lamp

-30G needle

Golf spud

Slgerbrush/diamond burr

Don't leave any behind if you can help it

Topical Antibiotic QID

Safety Glasses

Presentation of Corneal Abrasion

10 y/o girl scratched eye with piece of paper, now if feels like something is in her eye

Mom noticed tearing, redness, photophobia, she says that her eye hurts but vision is okay

Exam findings of Corneal Abrasion

Va 20/20

Pupils, Timoptic, Extra ocular muscle, Confrontation visiual field all normal

Slit lamp exam: irregular, superficial cornieal abrasion, otherwise normal

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Cornea Abrasion Treatment

Treat with topical antibiotics until completely healed

Consider bandage corneal lens if large

-If tons of pain consider patching over corneal lens

-When in doubt, flid the lid to rule out FB

Exam findings of Ruptured Globe (besides the giant eye sticking out of head)

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Va: No Light perception

Pupils - no view of eye

SLE - typical features

Massive 360 hemorrhagic chemosis

Prolapsed uvea

Full thickness corneal laceration

Flat anterior chamber

Hazy view of lens

Irregular or peaked pupil

Treatment of Ruptured Globe

Shield eye quickly after exam

Do no check pressure

Do not check extraocular motility

No drops

Perform complete exam of other eye

Olain cilams/CT scan of orbits to rule out FB

Bed rest

No oral meds, IV antibiotics

Tetnus shot

To OR ASAP for exploration and repair

Prognosis variable

History of Retinal Detatchment

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Sudden flashes and floaters

Curtain Coming Down

Exam Findings of Retinal Detachment

Central vision good if macula is attached

"macula on detatchment"

Visual field defect

May have IOP

May see Retinal pigment epithelium in vitreous

Perform 360 deg scleral depression to find tears

Requires urgent surgical treatment, sooner if macula

History of Central Retinal Artery Occlusion

Sudden painless visual loss

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Usually count fingers to light perception

Marked APD

Cherry Red Spot

Treatment of Central Retinal Artery Occlusion

If within 90 minutes:

Occular massage, Anterior Chamber paracentesis, diamox or beta blocker

Consider ESR, PCP for further testing

History of Corneal Ulcer

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Pain, photophobia, vision loss

"white spot on eye"

Slept in Contact Lens

Exam Findings of Corneal Ulcer

Variable VA, poor if central

Conj injection

Corneal inflitrate with overlying epithelial defect, edema

Anterior chamber reaction, +/- hypopyon

Culture, broad spectrum/fortified abx

History of Orbital Cellulitis

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Recent adjacent infection (sinus) or preseptal cellulitis

Rapid swelling of lids, eye popping out of head, double and blurry vision, feels sore

Exam findings and treatment of Orbital Cellulitis

Fever, looks ill

+/- poor vision, +/- afferent puupillary defect

May have elevated IOP

Proptosis, poor motility

Lid edema, chemosis, injection, discharge

+/- optic nerve edema

Treat: aggresively with IV Abx, may need surgical treatment

History of Acute Angle Closure Glaucoma

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Sudden pressure like pain, blurry vision

Nausea/Vomiting

Exam findings for Acute Angle Closure Glaucoma

Poor vision

Pupil fixed, mid dilated

IOP elevated (40-70)

Injected conj

Hazy/edematous cornea

Closed angle; shallow AC/occludable angle in non-affected eye

Lower IOP, laser Pl?

History of Pupil Involving Third Nerve Palsy

Double vision and droopy eyelid

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Exam Findings of Pupil Involving Third Nerve Palsy

Ptosis (drooping eyelid)

dilated pupil (difference greater in light)

Impaired motility with eye "down and out"

What do you do with a Pupil involiving third nerve palsy?

Immediate imaging with CT angio or MRI to rule out aneursym

Neurosurgical consult for further evaluation and treatment

History of Temporal Arteritis

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Elderly patient

Sudden, painless visual loss

HA, jaw claudication, scalp tenderness, fatigue, myalgias

Exam findings of Temporal Arteritis

Very poor acuity with afferent pupillary defect

Pale disc edema, cotton wool spots

Treatment of Temporal Arteritis

Immediate IV steroids

Temporal artery biopsy

ESR may be elevated

History of Acute Post/Op Endopthalmitis

Few days post op

Sudden onset worsening vision and pain

Exam findings of Acute Post Op Endophthalmitis

Injection, corneal edema, AC reaction with hypopyon, fibrin, vitresou opacities

Treatment: Vitreous tap and injection of abx

Possible vitrectomy