Jardine S. Sta. Ana, M.D.

, DPAFP
Outline
 Ophthalmology
 Chalazion
 Hordeolum
 Blepharitis
 EOR
 Conjunctivitis
 Glaucoma
 Otorhinolaryngology
 Otitis media & otitis externa
 Sinusitis, allergic rhinitis
 Gingivitis
 Laryngitis, tonsillitis, pharyngitis, epiglottitis
 BPPV, TMJ Arthralgia
A 15 y/o female H.S. student came into your
clinic presenting with redness on the left eye
which started 2 days ago.
A. Allergic Conjunctivitis
B. Bacterial Conjunctivitis
C. Viral Conjunctivitis
D. Chlamydial Conjunctivitis
E. Fungal Conjunctivitis
Conjunctivitis
 Hyperemia (red eye)
 Chemosis (irritation)
 Epiphora (watering)
Viral Conjunctivitis (“Pink Eye”)
 Etiologic agents: adenovirus types 3, 4 & 7,
herpes simplex
 Generalized hyperemia
 profuse tearing, watery discharge
 some eye itching, eye pain, gritty sensation
 Occasionally associated with sorethroat or
fever, colds, malaise
 Preauricular lymph node
 Follicles very prominent
*Epidemic Keratoconjunctivitis
Viral Conjunctivitis
 Diagnosis: Mostly Clinical
 Treatment:
 Generally self limiting condition = 7 to 10 days
 Cold compress - initial treatment
 Artificial tears
 Topical vasoconstrictors & antihistamines for
severe itching
 Mild topical steroids for serious cases (e.g.
presence of pseudomembrane)
Bacterial Conjunctivitis

• Etiologic agents: Haemophilus influenza,

Neisseria gonorrhea & meningitides
• acute or chronic
• often bilateral irritation & injection
• marked grittiness & irritation
•Mucopurulent exudate
•Sticky lids upon waking up; severe crusting
•Lid edema occasionally (N. gonorrhea)
Bacterial Conjunctivitis
Diagnosis :
 Mostly clinicial
 Gram staining of corneal scrapings

Treatment:
 Supportive
 Antibiotic eye drops & ointment are indicated
only if there is no improvement after 3 days
 Recovery period:
 No antibiotics 4.8 days
 Immediate antibiotics 3.3 days
 Delayed antibiotics 3.9 days
 Commonly used 1st line
topical agents
 Trimethoprim with polymixin B
 Gentamycin
 Tobramycin
 Neomycin
 Ciprofloxacin
 Ofloxacin
 Gatifloxacin
 Erythromycin

Eye drops – do not interfere with vision

Ointment – prolonged contact with the ocular surface;
soothing effect
 Neonatal Chlamydial & Gonococcal
Infection
 Requires systemic treatment of the neonate, the
mother, and at risk contacts
 Chlamydia
Neonate: Erythromycin 50mkd in 4 divided doses x 2 weeks
Adult: Doxycycline 100 mg BID x 1 week
 N gonorrheae
Neonate: Pen G 100 u/kg/d in 4 divided doses x 1 week
Adult: Ceftriaxone 125 mg IM

 Prophylaxis against ophthalmia neonatorum

 1% silver nitrate solution
 1% tetracycline ointment
 0.5% erythromycin ointment
Allergic Conjunctivitis
 Severe itching very prominent
 75 % of patients report this symptom
 Moderate to profuse watery discharge
 intense burning
 Puffy eyelids especially in the morning
Diagnosis: Clinical
Stained scrapings may show eosinophils
Treatment:
 Oral antihistamines
 Cold compress
 Topical antihistamines or steroids for severe
reactions
Others

 Fungal conjunctivitis
 Inclusion conjunctivitis
 Trachoma
 Chemical conjunctivitis
 Neonatorum conjunctivitis
Diagnosis?
A. Stye
B. Chalazion
C. Blepharitis
D. Hordeolum
E. Folliculitis
Hordeolom Chalazion
- aka Stye
Hordeolum vs. Chalazion
-aka Meibomian cyst

- infection of the glands of the eyelid, - idiopathic sterile chronic inflammation

base of the eyelashes
• Zeis’s or Moll’s glands: external
hordeolum or stye
• Meibomian glands: internal
hordeolum
*Staph aureus
- acute
-pain, redness, swelling
-maybe pointed inward (conjunctival
surface) or outward (skin)
- resorb within 7 – 10 days
- Tx: warm compress, I&D, antibiotic
ointment, systemic antibiotics if
cellulitis develops
of a blocked meibomian gland
- subacute or chronic
- painless, absence of acute
inflammatory signs; enlarging cyst may
cause pressure symptoms (even
astigmatism)
- pointed inward (conjunctival surface),
usually involves the upper eyelid
- resorb within a few months to years
-Tx: steroid injections, surgical
excision
Impression?
Blepharitis
 Chronic bilateral inflammation of the eyelids
 Sometimes can be acute (resolve within 2 – 4 weeks)
 BUT generally a long standing disease
 Can present as:
 Redness of the eyelids
 Flaking eyelids
 Scales or “granulations” clinging to the eye lashes
 Crusting at lid margins, marginal corneal infiltrates
 Gritty sensation, painful, itchy
 Blurred vision due to a poor tear film
 May be complicated by hordeolum, chalazion, epithelial
keratitis
 Can predispose to recurrent conjunctivitis
Anterior Blepharitis
 affects the outside front of the eyelid, where
the eyelashes are attached
 2 types
 Staphylococcal blepharitis
○ Staph aureus, Staph epidermidis, coagulase-
negative Staph
○ S. aureus – often ulcerative
 Seborrheic blepharitis
○ Seborrhea of scalp, brows, & ears
○ May be mixed with Staph infection
Posterior blepharitis
 Inflammation of the eyelids 20 to dysfunction of
the meibomian glands

 affects the inner eyelid and is caused by

problems with the meibomian glands in this part
of the eyelid

 May coexist with anterior blepharitis

 2 skin disorders associated:

 Acne Rosacea
 Seborrheic dermatitis
Treatment
 Keep eyelids clean – soap & water, scale
removal with damp cotton applicator, baby
shampoo, diluted soap solution

 Warm compress

 Antibiotics : Ophthalmic antibiotic ointment;

chloramphenicol, sulfonamide, tetracycline,
erythromycin
 Weak topical steroids
 Eyelid massage (for posterior blepharitis)
Hyperopic or Mypoic?
Errors of Refraction
 With increasing age, the lens loses
some of its elasticity; lens can not
round-up as it should

 Gradual loss in the ability to see close

objects; the near point gradually
recedes from the eye as we age.

Presbyopia
Errors of Refraction
 Hyperopia
– aka far-sightedness
- image is focused behind the retina
- can arise from a cornea with not enough
curvature (refractive hyperopia) or an eyeball
that is too short (axial hyperopia)
 Myopia
– aka near-sightedness
- image is focused in front of the retina
- can arise from a cornea with too much
curvature (refractive myopia) or an eyeball
that is too long (axial myopia).
Hyperopia – biconvex lens
Myopia – biconcave lens
Errors of Refraction
 Astigmatism
 rays that propagate in two
perpendicular planes have different foci;
there is a difference in degree of refraction in
different meridians.
 Quite common, one out of 3 people
 Prevalence increases with age
 Tx: Cylindrical lens
Errors of Refraction
Treatment:
Hyperopia – biconvex lens
Myopia – biconcave lens
Astigmatism – cylindrical lens
Visual Acuity (VA) Test
 VA - acuteness or clearness of vision, typically
checked at a distance of 20 feet. Visual acuity is
typically measured while fixating, i.e. as a measure
of central (or foveal) vision

 denoted by a fraction:
 Numerator = distance at which the tested eye can see
 Denominator = refers to the distance at which a normal
healthy eye can see.

 Snellen chart
Visual Acuity (VA) Test
 Cover one eye while testing the other.

 Check VA by first having the examinee wear his or her

corrective lenses (VAcc) then re-check without correction
(VAsc)
 Numbers or pictures are used for people who cannot
read, especially children.
Visual Acuity (VA) Test
 When visual acuity is below the largest optotype
on the chart, reading distance is reduced until the
patient can read it. If the patient is unable to read
the chart at any distance, he or she is tested as
follows:
Name Abbreviation Definition

Ability to count fingers at a

Counting Fingers CF
given distance.

Ability to distinguish a hand if

Hand Motion HM it is moving or not in front of
the patient's face.

Light Perception LP Ability to perceive any light.

Inability to see any light. Total

No Light Perception NLP
blindness.
Glaucoma
 Leading cause of preventable blindness
 Characterized by:
 Elevated intraocular pressure (IOC)
 Optic disk cupping
 Visual field loss

 Increased IOC is due to impaired outflow of aqueous

resulting from abnormalities within the drainage system.
This, in turn, leads to optic nerve damage (loss of retinal
ganglion cells)

 Risk factors:
 Family history
 Increased age
 DM and vascular factors
 Vasospastic conditions (Reynaud’s phenomenon)
 Sleep apnea
 Current or previous chronic steroid use
 History of ocular trauma
Glaucoma
 Open angle glaucoma
 Most common form of glaucoma
 Results from abnormalities (degenerative process
in the trabecular meshwork) within the drainage
system of the anterior chamber angle
 Painless, does not have acute attacks, visual field
loss is gradual but progressive

 Angle Closure Glaucoma

 Aka primary acute angle closure glaucoma, closed
angle glaucoma
 the iridocorneal angle is completely closed
because of forward displacement of the root of the
iris against the cornea
 Results in inability of the aqueous fluid to flow from
the posterior to the anterior chamber and then out
of the trabecular network.
 Angle Closure Glaucoma
 characterized by sudden ocular pain, seeing
halos around lights, red eye, very high
intraocular pressure (>30 mmHg), nausea and
vomiting, sudden decreased vision, and a
fixed, mid-dilated pupil
 considered as an ocular emergency
Glaucoma
• Diagnosis:
-*Clinical  Routine eye exam:
- tonometry – measures IOP
- gonioscopy – examines anterior
chamber
- fundoscopy – measures cup to disc ratio
- visual field exam

• Treatment Options:
•prostaglandin analogs: latanoprost
•Topical beta 2 antagonist: timolol, betaxolol
•Alpha 2 agonist & other sympathomimetics: apraclonidine
•Parasympathomimetics /Miotic agents: pilocarpine
Physostigmine, Cannabis
Glaucoma
 Treatment:
 Surgery
 Canaloplasty
 Laser surgery
 Trabeculectomy
OTORHINOLARY
NGOLOGY
 A mother comes to your clinic with her
2 year old daughter because of one
week upper respiratory infection – with
cough congestion and rhinorrhea. Two
days PTC child complained of pain in
the right ear.
On PE child has nasal congestion and
hyperemic throat. The L tympanic
membrane is normal and the right
eardrum is bulging and red. The child’s
temperature is 39.5

1. What is the diagnosis ?

2. What are the most common etiologic agent?
3. What is the drug of choice?
Acute Otitis Media (AOM)
 Less than 3 weeks
 Most often viral
 usually accompanies a viral upper respiratory tract
infection
 Viral AOM: congestion, mild ear ache, “popping”, self-
limited, resolves with viral URTI

Acute Bacterial Otitis Media

- Pneumococcus, H influenza, Moraxella catarrhalis
- Ear pain more severe & continuous
- often accompanied by pus, pressure & fever of 39 °C.
- May result in perforation
- Complications: Mastoiditis, Bacterial meningitis
Acute Otitis Media
Mild ear ache Erythematous retracted eardrum
Stage of
Ear fullness
hyperemia fever
All symptoms Red thickened bulging eardrum
Stage of aggravated Absent light reflex
exudation Tinnitus
Ear discharge Eardrum ruptures
Stage of
Fever and pain
suppuration relieved
Hearing loss
Stage of Pain and fever Mastoid tenderness
recurs
coalescence/
Mastoid
mastoiditis tenderness
Acute Otitis Media
 Treatment :
 pain management
 Observation option: (48 – 72 hours) based on illness
severity
 Antibiotics : Amoxycillin 40-50 mkd
10 days if severe and age < 6 yrs
5 – 7 days if mild to moderate in children > 6 years old

Non response to management after 48 to 72 hours

 Increase the dose of Amoxicillin to 80 – 90 mkd/ Co
amoxiclav
 Change antibiotics
 Refer for myringotomy
Otitis Media with Effusion (OME)
 aka serous or secretory otitis media(SOM)
 a collection of fluid that occurs within the middle
ear space as a result of the negative pressure
produced by altered Eustachian tube function
 No fever, +/- mild pain, dull TM
 Viral or bacterial
 Fluid can cause conductive hearing impairment
 Risk Factors:
 feeding while lying down
 group child care
 parental smoking
 short period of breastfeeding
Otitis Media with Effusion (OME)
Diagnosis:
 Pneumatic otoscopy as primary diagnostic test
 Hearing tests required if persist longer than
3months
Treatment:
 Myringotomy and tube insertion
 Tympanostomy tube reduces recurrence for the
next 6 months
 Anti-microbials, steroids, anti histamines,
decongestants are NOT recommended due
to lack of evidence of benefit
Chronic Suppurative Otitis Media
 chronic inflammation of the middle ear and
mastoid cavity, which presents with recurrent
ear discharges or otorrhoea through a
tympanic perforation
 > 3 months
 pus may either be so abundant that it drains
to the outside of the ear (otorrhea)
 OR the purulence may be minimal enough to
only be seen on examination using a
binocular microscope
 more common in persons with poor
Eustachian tube function
 Hearing impairment
Diagnosis:
 Pure Tone Audiometry & speech testing
 CT scan or mastoid series
 C/S of ear discharge NOT routinely done

Treatment:
 Aural toilet
 Topical antibiotics for 10-14 days initial
management; not systemic antibiotics
 Systemic antibiotics maybe given if with
concomitant bacterial URTI
 Cholesteatoma - surgery
Otitis Externa
 Aka External otitis or “Swimmer’s” ear
 Inflammation of the skin of the ear canal
 Pain is very prominent, severe enough to interfere with
sleep

 Staph aureus, Pseudomonas aeruginosa

Treatment:
- Refrain from: swimming, washing hair, cleaning
vigorously with a cotton bud for a few days
- Topical ear drops: antibiotic (aminoglycosides,
fluroquinolones, polymixin B), with or without
corticosteroids, acidifying & drying solution
Sinusitis
Inflammation of paransal sinuses

 Acute (< 4 weeks)
Subacute (4 – 8 weeks)
Chronic ( > 8 weeks)
 Mostly viral, resolve within 7 – 10 days
 Bacterial: Strep pneumoniae, H. influenza, M. catarrhalis
 Signs & symptoms:
 Headache
 Congestion, fullness
 Facial pain usually localized to the affected sinus, worsened
by bending head forward or lying down
 Accompanying toothache
 By location: Frontal – headache above the eyes
Maxillary – cheeks
Ethmoid – between/behind the eyes
Sphenoid – behind the eyes but refers to the vertex
Chronic Sinusitis
 > 8 weeks
 Headache, congestion, fullness,
toothache (may lead to dental infection)
 Thick yellowish or greenish nasal
discharge, dizziness, night-time coughing,
halitosis, may exacerbate previously
minor asthma symptoms, anosmia
 Fever is not a feature
Sinusitis
 Diagnosis:
 Clinical
 X-ray of paranasal sinuses, Water’s view
 CT scan
 Nasal endoscopy
○ Tissue sample for culture
○ Biopsy
 Treatment:
 Conservative: Nasal irrigation, nasal
decongestant sprays (Oxymetazoline), steam
inhalation, warm compress, increase oral fluid
intake
Sinusitis
 Treatment:
 Antibiotics: initiated if symptoms do not resolve
by 10 days.
○ Amoxicillin – 1st line
○ Co-Amoxiclav
○ Fluoroquinolones, Clarithromycin, Doxycycline
○ Short course (3-7 days) may be just as effective
as long course (10 – 14 days)
 Intranasal corticosteroids (?)
 Referral to ENT
○ FESS – Functional Endoscopic Sinus Surgery
○ For chronic, recurring sinusitis
Allergic Rhinitis
 a symptomatic disorder of the nose induced after allergen
exposure by an IgE-mediated inflammation

 Positive identification of allergen and establishment of

causal relationship between exposure and symptom
occurrence

 Rhinorrhea, nasal obstruction, nasal itching &

sneezing
 Post-nasal drip usually accompanies profuse anterior
rhinorrhea

 Impaired daily function because of above symptoms;

impairs quality of life, sleep, school & work
classification
 PERSISTENT
 INTERMITTENT
 >4 days/ week
 <4 days/ week
 OR > 4 consecutive
 OR < 4 consecutive
weeks
weeks

 MODERATE to
 MILD
 Normal sleep
 Normal daily activity
 Normal work/ school
 No troublesome
symptom
SEVERE
 Sleep disturbance
 Impairment of daily
activity
 Problems at work.
School
 Troublesome symptoms

Environmental modification Antihistamines

Steroids - inhaled
And lifestyle changes antileukotrienes
Treatment
 Environmental
 Impermeable covers for beddings
 Wash with warm water (55-60 deg C)
 Vacuums w/ HEPA filters
 Pharmacologic
 Oral H1 antihistamines, 2nd gen > 1st gen
 Intranasal antihistamines
 Intranasal glucocorticoids
 Oral/IM glucocorticoids
 Anti-leukotrienes
 Intranasal anticholinergics
NON ALLERGIC RHINITIS
 Infectious rhinitis  Non allergic rhinits
 Vasomotor rhinitis with eosinophilia
 Food induced rhinitis syndrome
 Mucosal  Structural
abnormalities abnormalities (nasal
septal deviation,
 Hormonal rhinitis adenoidal
 Intranasal foreign hypertrophy)
bodies  Benign and
malignant tumors
Acute Tonsillopharyngitis
 BACTERIAL  VIRAL
CENTOR CRITERIA  Conjunctivitis
 Fever  Coryza
 Patchy discrete  Cough
exudates  Hoarseness
 Tender, enlarged  Diarrhea
anterior cervical
nodes
 Absence of cough

*Age > 44 y/o

*Age < 15 y/o
 • Gold standard: Throat
culture
• Sensitivity : 90 – 95 %

• Drug of Choice: ? Penicilin V

Cephalosporins: cephalexin, cefadroxil, cefuroxime,
cefixime 10 day course.

• Failure to resolve the infection within 3 – 4 days

justifies shifting to co-amoxiclav, clindamycin, 3rd
gen cephalosporin, higher generation macrolides
 OBSTRUCTIVE TONSILLAR
HYPERTROPHY
Enlarged tonsils enough to cause
symptoms of functional obstruction
of the air and food passages such
as snoring and dysphagia

TONSILLECTOMY maybe recommended for tonsillar hyperplasia

accompanied by any of the following:
upper airway obstruction
dysphagia
speech impairment
halitosis
American Academy of Otolaryngology-Head
and Neck Surgery Foundation CPG

Indications for Tonsillectomy:

 7 episodes of tonsillitis in the past year
 5 episodes per year in the past 2 years
 3 episodes per year for the past 3 years
 Each episode should have documented…
○ T = 38.3 C
○ Cervical adenopathy
○ Tonsillar exudates
○ Positive test for Group A Beta-hemolytic strep
American Academy of Otolaryngology-Head
and Neck Surgery Foundation CPG

 Modifying factors that may favor

tonsillectomy:
 Multiple antibiotic allergy/intolerance
 Periodic fever
 Aphthous stomatitis
 Pharyngitis and adenitis
 History of peritonsillar abscess
Epiglottitis
 a potentially life-threatening condition that
occurs when the epiglottis swells, blocking
the flow of air into your lungs.

 Possible causes: burns from hot liquids,

direct injury to throat, and various
infections
 Haemophilus influenza type B – most common
cause of epiglotitis in children in the past
 Others: Streptococcus pneumonia,
Streptococcus A, B & C
Symptoms:
CHILDREN
- Develop within hours
- Fever
- Severe sore throat
- Abnormal, high-pitched sound
when breathing in (stridor)
- Difficult and painful swallowing
- Drooling
- Anxious, restless behavior
- Greater comfort when sitting up
or leaning forward
TREATMENT:
- Epiglottitis is a MEDICAL EMERGENCY
- Establish airway: O2 mask, intubation, tracheostomy
- Broad-spectrum antibiotics
ADULTS
- Develop more slowly; may take
days
- Severe sore throat
- Fever
- A muffled or hoarse voice
- Abnormal, high-pitched sound
when breathing in (stridor)
- Difficulty breathing
- Difficulty swallowing
Benign Positional Paroxysmal
Vertigo
 Positional vertigo - defined as a spinning
sensation produced by changes in head
position relative to gravity.

 Benign paroxysmal positional vertigo – a

disorder of the inner ear characterized
by repeated episodes of positional
vertigo.
 Benign Positional Paroxysmal
Vertigo
 Benign - not due to any serious CNS disorder
- overall prognosis is favorable

 Paroxysmal – episodic with rapid & sudden onset

2 Variants:
1. Posterior canal BPPV (85 - 95%) – posterior semi-
circular canal affected; rotational or spinning sensation
when patient changes head position relative to gravity
(+) Dix-Hallpike maneuver

2. Horizontal canal BPPV – lateral semicircular canal

affected; (+) Supine Roll Test
Dix-Hallpike Maneuver
 considered the gold standard test for the
diagnosis of posterior canal BPPV

 performed by moving the patient through

a set of specified head-positioning
maneuvers to elicit the expected
characteristic nystagmus
Dix-Hallpike Maneuver

 rotate patient’s head 45 degrees to the right.

 move patient, whose eyes are open, to the supine right-ear-
down position and extend patient’s neck slightly so that the
chin is pointed slightly upward.
Dix-Hallpike Maneuver
 Observe for the latency, duration, and
direction of nystagmus
 The provoked nystagmus is described as a mixed
torsional and vertical movement with the upper
pole of the eye beating toward the dependent ear

 Patient should also be asked for the presence

of subjective vertigo.
Dix-Hallpike Maneuver
 After resolution of the subjective vertigo
and the nystagmus, if present, the
patient may be slowly returned to the
upright position.

 Observe for the reversal of the

nystagmus and wait for it to resolve.

 Repeat steps for the left side.

Benign Positional Paroxysmal
Vertigo
Diagnosis:
- Hx & PE (e.g. Dix-Hallpike) will suffice
- NO radiographic imaging needed
- NO vestibular function testing needed (unless considering
other diagnoses or failure to respond to treatment)

TREATMENT OPTIONS
- Education/information/counseling
- Medical therapy
 vestibular suppressant medications
 antihistamines
 benzodiazepines
- Treatment with canalith repositioning procedure (Epley’s)
- Vestibular rehabilitation exercises
Epley’s Maneuver
 Seated upright, position the patient’s
head 45 degrees towards the affected
side.

 Lay patient back to the supine head-

hanging position and maintain the
position for 20 - 30 seconds.
Epley’s Maneuver
 Turn the head 90 degress
toward the opposite
(unaffected) side and hold
for 30 seconds.

 Turn the head a further 90

degrees (necessitating the patient
to turn from supine to lateral
decubitus position) such that
patient’s head is nearly in the
facedown position.
 Hold for 20 – 30 seconds.
Epley’s Maneuver

 Bring patient back to

upright seated position.
Temporomandibular Joint Dysfunction
(TMJD)
 Considered as a syndrome of pain
and dysfunction of the muscles of
mastication and the
temporomandibular joints.
 Usually affects persons 20 – 40 y/o
and more common in women.

• 2nd most common cause of orofacial pain after dental

pain.
Temporomandibular Joint Dysfunction
(TMJD)
3 cardinal signs symptoms of TMJD:
1. Pain and tenderness on palpation in the muscles of
mastication, or of the joint itself
2. Limited range of mandibular movement
3. Noises from the joint during mandibular movement
(clicking, popping or grating)

Other signs & symptoms:

- Headache (occipital & frontal), diminished hearing,
tinnitus, dizziness, pain or feeling of pressure behind the
eyes, sensation of malocclusion, tight neck muscles,
shoulder pain
Temporomandibular Joint Dysfunction
(TMJD)
 Risk factors:
 Misalignment or malocclusion of teeth
 Trauma to the jaw
 Teeth grinding
 Poor posture
 Emotional stress
 Arthritis & other inflammatory musculoskeletal disorders

 Diagnosis:
 Mainly thru Hx & PE
 Imaging studies (e.g. standard TMJ x-rays, CT, MRI)
Temporomandibular Joint Dysfunction
(TMJD)
 Treatment options:
 Medications: NSAIDs, muscle relaxants, sedatives,
antidepressants, trigger point injections
 Orthotic appliance – occlusal splints

 Physical therapy, dietary modifications

 Psychological counseling
 Surgical: manipulation under anesthesia (e.g.
brisement), open arthroplasty, coronoidectomy,
condyloplasty
Good afternoon and
thank you for your kind attention!

Good Luck!