Advanced Practice Education Associates

Eye, Ear, Nose, and

Throat Disorders
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OVERVIEW

• Sinusitis
• Allergic rhinitis
• Pharyngitis
• Epiglottitis
• Infectious mononucleosis
• Common eye conditions
• Hearing loss

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SINUSITIS
• Inflammation of the paranasal sinuses due to bacterial, viral, or fungal infection, or allergic
reaction

Question
Which med is inappropriate for treatment of a patient who has acute rhinosinusitis?
1. Analgesics
2. Saline irrigation
3. Intranasal glucocorticoids
4. Antihistamines
If bacterial, what antibiotic? _______________________________________________________

ABRS: Indications for Urgent Referral

• High persistent fever >102°F
• Periorbital edema
• Vision change
• Severe headache

ALLERGIC RHINITIS
A Day In Clinical Practice
A 30-year-old patient with allergic rhinitis has been using OTC oxymetazoline for the past 3
months. She has developed rhinitis medicamentosa. What symptom is associated with this?
1. Rhinorrhea
2. Nasal congestion
3. Cough
4. Epistaxis

• Inflammation of the mucous membranes of the nasal tract with

subsequent mucosal edema, clear discharge, sneezing, itching,
and nasal stuffiness

A Day In Clinical Practice

A patient has allergic rhinosinusitis. What would be unusual to find in
him? Image Copyright ADAM, Penn State Hershey.
http://pennstatehershey.adam.com/content.as
px?productId=10&pid=10&gid=000624
1. Infraorbital edema
2. Accentuated lower eyelid folds
3. Transverse nasal crease
4. Erythematous sclera

Pharmacologic Management
• Intranasal glucocorticoids: single most effective treatment
 Examples: budesonide, fluticasone, mometasone, ciclesonide
 Relieve nasal stuffiness, discharge, sneezing, itching, postnasal drip
 Inhibit allergic inflammation
 ***Downregulate the inflammatory response
 Onset of action: few hours but take a few days for maximal effect
• Antihistamines (nonsedating and sedating available)
 Reduce itching, sneezing, rhinorrhea, not a lot of benefit for nasal congestion
 Second-generation antihistamines safer than first generation because less sedating

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PHARYNGITIS/TONSILLITIS
• An acute inflammation of the pharynx/tonsils

Question
What is the most common bacterial cause of pharyngitis?
1. Mycoplasma pneumoniae
2. Streptococcus Group A
3. Streptococcus Group C
Image Copyright Streptococcus Pyogenes A
4. Haemophilus influenza Microbiology Project by Charlotte Reese
http://pyogenesgonewild.com/
What is THE most common cause?
_______________________________________________________

Suspect Group A Strep (GAS)

• Sudden onset sore throat
• Fever
• Tonsillopharyngeal edema
• Tonsillar exudates
• Cervical lymphadenitis
• Scarlatiniform skin rash
• History of GAS exposure

Noninfectious Pharyngitis
• Allergies (seasonal and environmental)
• GERD
• Smokers
• Secondhand smoke
• Dry environments

Question
What is the usual causative agent of mononucleosis?
1. Adenovirus
2. Coxsackie B virus
3. Epstein Barr virus
4. Herpes simplex virus

Pharyngitis
• Coinfection with Strep and a virus
 Example: mononucleosis plus Strep

A Day In Clinical Practice

A 16-year-old boy has been diagnosed with Strep throat. His monospot is positive. What plan is
appropriate?
1. Symptomatic treatment; check him in 1 week
2. Treat with penicillin; no need to recheck
3. Treat with azithromycin, no need to recheck
4. Treat with cephalexin; recheck in 1-2 weeks
Additional Notes:

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Complications: Streptococcus
• Acute rheumatic fever
• Poststreptococcal reactive arthritis
• Scarlet fever
• Acute glomerulonephritis
• PANDAS syndrome

INFECTIOUS MONONUCLEOSIS
• Viral infection caused by Epstein-Barr virus (EBV), of the
herpes family of viruses and is characterized by fever,
tonsillar pharyngitis, and lymphadenopathy

Assessment Findings
• Triad
 98%: fever
 85%: pharyngitis can be painful, severe, exudative
 100%: lymphadenopathy: anterior and posterior cervical
nodes
• Nearly 100%: fatigue can last days to weeks Image Copyright ADAM, Penn State Hershey.
http://pennstatehershey.adam.com/content.aspx?pr
oductId=112&pid=2&gid=17267
Diagnostic Studies
• Monospot used for screening of heterophil antibodies: most likely time to be positive is 2nd or
3rd week of illness.
• EBV titers
• CBC: lymphocytosis (12,000-18,000 is common) (66% of patients exhibit this)
• Atypical lymphocytes (75% of patients)
• Elevated ALT, AST (>50% of patients)

Activity Resumption
• No earlier than 21 days after illness onset
• Splenic injury risk (50% have splenomegaly): percussion, palpation vs ultrasound (ultrasound
safest before return to contact sports, but expensive). Rupture risk is negligible after the 4th
week …
• Resolution of fatigue … could take up to 3 or more months

FUNDUSCOPIC EXAM
Amelie's Tips
• Darken the room as much as possible
• Right eye to right eye, right hand
• Touch your left thumb to the patient’s right eyebrow
• Patient looks straight ahead
• Elicit red reflex
• THEN, STAY FOCUSED ON THE RED REFLEX as you
look for the optic disc

What should I see?

• Red reflex: should be present
• Optic disc: sharp outline Image Copyright Stanford Medicine.
• Cup: disc ratio should be <0.5 https://stanfordmedicine25.stanford.edu/the25/fundoscop
ic.html
• Retinal circulation: venous pulsations; follow vessels
peripherally in all directions
• Arteries are narrower than veins. Veins pulsate!

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Can't forget!
• The microvasculature of the eyes is VERY SENSITIVE to elevated blood pressures and
elevated blood glucose
• Hence, retinopathy common in these patients!

Retinopathy
• Cotton Wool Spots
 HTN, DM, other causes: microinfarction occurs
 Considered “moderate retinopathy”
• Flame Hemorrhages
 HTN, DM, other causes: microinfarction occurs
 Considered “moderate retinopathy”
 Blot and dot hemorrhages, hard exudates, microaneurysms are considered “moderate
retinopathy”
• AV Nicking
 HTN stiffens vessels
 Arteries indent and displace veins
 Considered “mild retinopathy”
Cotton Wool Spots Flame Hemorrhages AV Nicking

Image Copyright Stanford Medicine. Image Copyright Retina Image Bank. Image Copyright Stanford Medicine.
https://stanfordmedicine25.stanford.edu http://imagebank.asrs.org/discover- https://stanfordmedicine25.stanford.edu
/the25/fundoscopic.html new/files/4/25?q=retinal%20hemorrhage /the25/fundoscopic.html

SENSORY IMPAIRMENTS IN OLDER ADULTS

Visual Impairment
• Common in older adults
• Age-related macular degeneration, presbyopia, cataracts, glaucoma, diabetic retinopathy
• Increases risk of falls, hip fractures

Age-Related Macular Degeneration (AMD)

• Most common cause of permanent vision loss in older adults
• Central vision needed for driving, watching TV, reading, ADLs
• Symptom: loss of central vision over years
• Degeneration of the central portion of the retina (macula)

Assessment of Vision Changes

• Rate of vision loss (RED FLAG: days or weeks)
• One eye or both
• Vision loss: distance, near, both

Cataract
• Opacity in the lens of the eye
• AGE related
• Not age-related: trauma, use of topical steroids, uveitis, scleritis
• Complains of: glare, difficulty seeing at nighttime, difficulty with distant vision

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Open Angle Glaucoma

• Elevated intraocular pressure (IOP): normal is 8-20 mm Hg
• Optic neuropathy caused by high pressure
• Irreversible blindness if untreated
• “Cupping”: hollowed out appearance of the optic nerve (disc)
• Abnormal cupping (cup diameter >50% of vertical disc diameter)

Question
What is the instrument used to measure intraocular pressure?
1. Dermatoscope
2. Ophthalmoscope
3. Tonometer
4. Pachymeter

OCULAR FOREIGN BODY

Presence of substance, material, object adhering to the eye or embedded in the eye

Four-Step Assessment of all Eye Complaints

Image Copyright Low Vision
1. Always start by assessing visual acuity!!! and Legal Blindness Terms
DOCUMENT it for both eyes!! and Descriptions by Maureen
A. Duffy, M.S. CVRT
http://www.visionaware.org/inf
o/your-eye-condition/eye-
health/low-vision/low-vision-
terms-and-descriptions/1235

2. Examination with slit lamp or binocular loupe Image Copyright St Mungo's-Ed

Ophthalmology Eye Examination
AFTER Snellen examination or penlight for PDF
most of us! https://static1.squarespace.com/st
atic/5871553a3e00be90c79a68cd/
t/590b29b3cd0f6826f9f18c5c/1493
903797554/O3.pdf

Image Copyright St Mungo's-Ed

3. Fluorescein staining is used to assess for Ophthalmology Eye Examination
corneal defects (should be done as last part of PDF
https://static1.squarespace.com/stat
examination) ic/5871553a3e00be90c79a68cd/t/5
90b29b3cd0f6826f9f18c5c/1493903
797554/O3.pdf

4. Lid eversion: flip the eyelid with cotton swab to Image Copyright St Mungo's-Ed
look for suspected foreign body; remove visible Ophthalmology Eye Examination
PDF
object using wet cotton swab https://static1.squarespace.com/stat
ic/5871553a3e00be90c79a68cd/t/5
90b29b3cd0f6826f9f18c5c/1493903
797554/O3.pdf

Management
• Removal of the foreign body/object/material if it is superficial and NOT embedded
• A patch or metal shield to protect the eye if referred to ophthalmologist
• Keep patient NPO if patient is referred to ophthalmologist (in case surgery is needed to
remove embedded object)
• Tetanus prophylaxis

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A Day In Clinical Practice Image Copyright Ento Key

Fastest otolaryngology &
A 75-year-old patient presents for a routine Ophthalmology Insight Engine
Ophthalmologic Laboratory and
exam. The NP notices these changes in both Diagnostic Tests
eyes. How should this be managed? Laurence Freier Sep 28, 2016
https://entokey.com/ophthalmol
ogic-laboratory-and-diagnostic-
1. Ophthalmology referral tests-2/
2. Order an ANA, sed rate
3. Order a lipid panel
4. This is a normal finding

HEARING LOSS
Question
Which agent used to treat otitis externa is associated with the most allergic reactions?
1. Ofloxacin
2. Levofloxacin
3. Neomycin-polymyxin B
4. Acetic acid
What MUST be checked before prescribing a topical otic product?
_____________________________________________________________________________

A patient who has been diagnosed with otitis externa (OE) should be taught:
1. to avoid swimming with active OE.
2. that hearing will be diminished for about 1 week after OE resolution.
3. that tinnitus is common with OE.
4. this rarely occurs unilaterally.

Hearing Loss
• Can be acute, temporary
• Can be permanent
• Examples:
 Flying in airplane
 Traveling up a mountain C-126 C-256 C-512
 Otitis externa, media Image Copyright McKesson.
https://mms.mckesson.com/product/478943/Sklar-67-7605
 Sensorineural, conductive

Hearing Assessment
• Conductive hearing loss: involves the external canal or
middle ear
• Sensorineural hearing loss: involves the inner ear or 8th
CN
• Weber and Rinne compare air and bone conduction.

Weber and Rinne Tests

Weber Lateralizes Rinne Test
Conductive Loss
Good ear AC>BC
Bad ear To bad ear BC>AC
Sensorineural Loss
Good ear To good ear AC>BC
Bad ear AC>BC
Image Copyright UpToDate.
http://cursoenarm.net/UPTODATE/contents/mob
ipreview.htm?31/34/32298

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Conductive Hearing Loss (Involves the external canal or middle ear)

• Examples:
 Cerumen impaction
 Ear plugs
 Fluid in the middle ear
 Wearing of headphones

Sensorineural Hearing Loss (Involves the inner ear or 8th CN)

• Examples:
 Hereditary hearing loss
 Presbycusis
 Noise exposure
 Ménière disease
 Acoustic tumors
 Trauma

Presbycusis
• Progressive, symmetric loss of high-frequency sounds over many years in older patient
• Results in diminished nonverbal executive function and decreased psychomotor speed
• TREAT!!!!
• Common complaints:
 Difficulty understanding speech in large, crowded rooms, difficulty understanding
consonants, loss of high-pitched tones
 Tinnitus: sounds like crickets, bells, ringing in ears
Additional Notes:

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CHECK YOUR KNOWLEDGE

A 36-year-old woman complains of, irritated, dry, itchy eyes.
What is your diagnosis?
1. Conjunctivitis
2. Blepharitis
3. Iritis
4. Chalazion

Image Copyright UpToDate. www.uptodate.com

Exam Checklist:
• Acute sinusitis ✓ Know clinical presentation (subj, obj findings)
• Epistaxis ✓ Know how to diagnose
• Hearing assessment ✓ What’s in diff dx?
• Pharyngitis/epiglottitis ✓ Pharm, nonpharm management
• Mononucleosis ✓ Follow-up care
• Otitis media/externa ✓ Recognize normal course
• Periorbital cellulitis ✓ When to refer
• Conjunctivitis, blepharitis
• Retinopathy
• Macular degeneration

Resources for Eye, Ear, Nose and Throat Disorders

• CareOnPoint, a mobile clinical reference tool developed by NPs; available by subscription

(provides contact hours): http://www.apea.com/careonpoint/about-careonpoint
• Hollier, A. (2018). Clinical Guidelines in Primary Care, 3rd ed. Lafayette, LA: APEA.
• Amelie’s Antibiotic Cards (2018); APEA
• To view this lecture again, visit the APEA CE Library and purchase the Fundamentals of
Otorhinolaryngology on video: https://www.apea.com/ce-library
Additional Notes:

194 Copyright 2020 Advanced Practice Education Associates