Medical-Surgical Nursing I

EYE and ENT DISORDERS

Mehammedamin J. (BScN, MScN)

December, 2021
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DISEASES OF THE EYE LIDS
– Blepharitis
– Hordeolum (stye)

– Chalazion
– Entropion/ Trichiasis

– Ectropion
– Ptosis

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 THE EYELIDS

skin

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1. BLEPHARITIS
• Inflammation of margins of the eye lids & skin
• Posterior blepharitis- the more common
condition
– characterized by inflammation of the inner
portion of the eyelid, at the level of the
meibomian glands
• Anterior blepharitis- less common than posterior
but serious if it occurs
– characterized by inflammation at base of
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eyelashes
1. BLEPHARITIS
• There are two main types of Anterior blepharitis
– Seborrheic Blepharitis
– Staphylococcal Blepharitis
• ETIOLOGIES
* Ulcerative: staphyloccocal infections
* nonulcerative: allergies, smoke, dust,
chemicals, seborrhea, stye, chalazion

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Blepharitis...

Anterior Posterior
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Seborrheic Blepharitis
• Associated with seborrhea of the scalp and/or
hypersecretion of the eye lid glands
• characterized by;

– dandruff-like skin changes around the base of

the eyelids
– resulting in greasy scales around the
eyelashes.

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Treatment
Non-drug treatment
• Eyelid hygiene is the primary treatment
– Use of warm compresses
– Expression of meibomian gland secretions

• Lid massage
– Cleanliness of the eyelid margins to remove crust and
debris
• with Baby shampoo or commercially available
eyelid scrub

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Topical Drug treatment
First line
• Oxytetracycline + Polymixin B +
Hydrocortisone 1 drop 2-3 times/day for 2-4wks
Alternatives
• Tetracycline single strip of ointment applied 2-3
times daily for 2-4 weeks OR
• Erythromycin single strip of ointment applied 2-
3 times daily for 2-4 weeks
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B) Staphylococcal Blepharitis
• The most common causes of anterior blepharitis
• more serious due to the involvement of the base
of hair follicles
• usually caused by staphylococcus aureus.
Symptoms and Signs:
• Irritation, itching and burning sensation,

• It has also foreign body sensation

• Fibrinous crusts and scales

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B) Staphylococcal Blepharitis
– Ulceration

– Poliosis- patch of white or gray hair

– Madarosis- deficiency of eyelashes

– Trichiasis

Diagnosis: Clinical

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Topical Drug Treatment
First line
• Dexamethasone1 drop 4-6 times a day for 3-6 weeks
Alternatives
• Oxytetracycline+Polymixin B+Hydrocortisone, 1 drop
2-3 times a day for 2-4 weeks OR
• Tetracycline, single strip of ointment applied 2-3 times
daily for 2-4 weeks OR
• Erythromycin, single strip of ointment applied 2-3 times
daily for 2-4 weeks

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Systemic Drug Treatment
for recurrent cases

First line
• Doxycycline, 100mg P.O. BID for 6 weeks

N.B: Referral: In severe and complicated cases

refer to an ophthalmologist

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2. HORDEOLUM
• Inflammatory infection of the hair follicle of
the eye lid glands
• It is the result of an acute bacterial infection
of one or more eyelid glands.
– If several eyelid glands are affected at the
same time, it is called hordeolosis

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2. HORDEOLUM...
• ETIOLOGIES

* staphylococcal infection
* usually associated with Blepharitis
• There are two main types

– External hordeolosis
– Internal hordeolosis

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a) External Hordeolum
• An acute suppurative infection of eyelash
follicles and its associated glands of zeis or moll.
Symptom and Signs
– pain & Tenderness of eyelid margins
– Eye lid is red and edematous with a small
collection of pus in the form of an abscess
– occasionally abscesses of entire lid margin
– preseptal /periorbital / cellulitis
Diagnosis: Clinical
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b) Internal Hordeolum
• Is a small abscess collection in the Meibomian
glands
Symptoms and Signs:
– Painful swelling within the eyelid
– Tender and inflamed mass within the eyelid.
– Pseudoptosis and swelling of the
preauricular lymph nodes may also occur
Diagnosis: Clinical

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 Internal Hordeolum

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 Internal Hordeolum

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Treatment
Non-drug treatment
• Warm compresses; applied for 10 minutes twice
daily for 2-4 weeks
• Epilation of the involved eyelashes - external
hordeolum

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Drug treatment
• In most cases no treatment is required,
First line
• Oxytetracycline+Polymixin
B+Hydrocortisone, 1 drop 2-3 times a day for 2-
4 weeks
Alternatives
• Tetracycline, single strip of ointment applied 2-3
times daily for 2-4 weeks OR
• Erythromycin, single strip of ointment applied
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Drug treatment...
PLUS (If associated with cellulitis)

First line
• Cloxacillin, 50mg/kg P.O. in four divided doses
for 7 days

N.B: If the above management fails referral for

surgical drainage

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3. CHALAZION (MEIBOMIAN CYST)
 Collection of fluid or soft mass cyst or granuloma in
the meibomian glands.
• ETIOLOGY
* Blockage of meibomian gland
• SYMPTOMS AND SIGNS
* Pea size cyst
* painless slow swelling of the inner part of eye lid
* Could become infected

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CHALAZION...
• DIAGNOSIS
* Visual Examination
• TREATMENT
*Warm compresses applied 3-4x/day for 10–15
minutes
*Corticosteroids
*small ones usually disappear spontaneously
after a month or two months
* large ones usually need surgical removal
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4. ENTROPION
* Inversion of eye lid into eye
• ETIOLOGY
* aging (course fibrous tissue)
• SYMPTOMS AND SIGNS
* Foreign body sensation
* Tearing / itching / redness
* Continuous rubbing causes conjunctivitis or
corneal ulcers
* Decreased visual acuity if not corrected
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ENTROPION
• DIAGNOSIS

* visual examination
• TREATMENT

* clean up on its own

* if not, minor surgery

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5. ECTROPION
* Out turned eye lids
• ETIOLOGY

* elderly (weakness of eye lid muscles)

• SYMPTOMS AND SIGNS
* dryness of the exposed part of the eye
* tears run down the cheeks
* if not treated can cause ulcers and
permanent damage to cornea

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ECTROPION
• DIAGNOSIS

* visual examination
• TREATMENT

* minor surgery if it doesn’t disappear

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 C RIM A L
F T HE LA
A SES O
DISE AT US
APP A R

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A. DACRYOCYSTITIS
• Inflammation of the lacrimal sac and duct.

a) Acute Dacryocystitis
• stenosis within the lacrimal sac.

Etiologies:
• staphylococcus, pneumococcus and
Pseudomonas

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Acute Dacryocystitis
Symptoms and Signs:
• Painful, swelling of the lacrimal sac
• Malaise, fever, and involvement of the regional
lymph nodes.
• Highly inflamed lacrimal sac
• Tender mass
• Pressure on the sac will often fail to result in
regurgitation of Mucopurulent discharge

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Acute Dacryocystitis
Diagnostic considerations
• Clinical, Gram’s stain and culture

Non-drug treatment
• Warm compresses and gentle massage to the
inner canthal region QID, because there is
stenosis of lacrimal sac

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Drug treatment for Mild Cases
First line
• Cloxacillin 500mg P.O. QID for 10-14 days for
adults; and 50-100mg/kg/day in QID for 10-14
days for children Plus
• Chloramphenicol 1 drop QID for 10-15 days

Alternatives
• Cefaclor, 250-500mg P.O. TID for 10-14 days for
adults Plus
• Gentamicin, 1 drop QID for 10 -15 days OR
• Amoxicillin/clavulanate, 20-40mg/kg/day P.O.
TID for 10-14 days for children Plus
• Gentamicin, 1 drop QID for 10 -15 days
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Drug treatment for Moderate-Severe Cases
• Hospitalize and treat with IV medications
First line
• Cefazolin, 1 g IV TID for 10-14 days for adults
Alternatives
• Cefuroxime, 50-100mg/kg/day IV TID for 10-
14 days for children OR
• Clindamycin 300mg IV QID for 10-14 days for
adults; 1mg/kg/day IV QID for 10-14 days for
children Plus
• Gentamicin 2.0mg/kg IV loading dose, and then
1 mg/kg IV TID for 10 -14 days

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Drug treatment for...
N.B:
• Incision and abscess drainage
• IV antibiotics can be changed to comparable
oral antibiotics after significant improvement is
observed.
• Referral: In complicated cases refer to an
ophthalmologist

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b) Chronic Dacryocystitis
• Chronic inflammation of nasal mucosa which
leads to obstruction of nasolacrimal duct
Signs and Symptoms
• The initial characteristic is increased
lacrimation
• Non tender swelling
• Signs of inflammation are not usually present
• Mucoid or purulent discharge

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b) Chronic Dacryocystitis..
Diagnostic considerations
• Radiographic contrast studies or digital
subtraction dacryocystography
– can visualize the obstruction for preoperative
planning
Treatment
• Surgical intervention is the only effective
treatment

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 C TI V A
E CO NJUN
O FTH
SES
DISEA

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CONJUNCTIVITIS
• inflammation of the conjunctiva
• ETIOLOGIES

* Viral
* bacterial

* irritants (allergies, chemicals, UV light)

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a) Bacterial Conjunctivitis
• It is a type of Conjunctivitis,
– the transparent mucous membrane covering
the eyeball and the area under the surface of
the eyelid
– caused by bacteria

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Bacterial Conjunctivitis...
Caused:
– Staphylococcus aureus
– Streptococcus pneumonia

– Moraxella lacunata
– Staphylococcus epidermis

– Pseudomonas aeruginosa

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Bacterial Conjunctivitis...
Signs and Symptoms
• Highly sensitive to bright light, foreign-body sensation, a
sensation of pressure and burning
• Hyperemia, excessive tearing
• Eye discharge (mucoid, purulent, watery or bloody)
• Chemosis =swelling(edema) of the conjunctiva
• Papillae
• Membranes and pseudomembranes
• Swollen lymphnodes
• Different degree of corneal opacity
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Bacterial Conjunctivitis...

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Bacterial Conjunctivitis...

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Bacterial Conjunctivitis...

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Bacterial Conjunctivitis...
Papillae Arranged In Cobblestone Stone Fashion

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Bacterial Conjunctivitis cont’d

pseudomembranes

Membranes

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Bacterial Conjunctivitis...

Diagnosis

• Mostly clinical

• Gram stains and culture

Treatment

Non-drug treatment: Frequent cleaning of the

eyelids and warm compression

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Drug treatment (Topical)
• First line
– Chloramphenicol 1 drop Q 4-6hrs/d for 10-
15days
• Alternatives
– Tetracycline, single strip of ointment applied 2-
4 times per day for 10-15 days OR
– Gentamicin, 1 drop Q 4-6hrs/d for 10-15 days.
• Referral: In severe and complicated cases refer to
an ophthalmologist
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B) Viral Conjunctivitis
• It is also often referred to as epidemic
keratoconjunctivitis (EKC).
• Is inflammation of the cornea and
• Mostly associated with upper respiratory tract infection
(URTI)
• It is highly contagious,

– spread by direct contact with the patient and his or

her secretions or with contaminated objects & surface

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Viral Conjunctivitis...
Causes:

– Adenovirus

– Varicella-zoster virus and

– Coxsackie Virus

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Viral Conjunctivitis...
Signs and Symptoms:
• Irritation, Highly sensitive to bright light, foreign-body
sensation, a sensation of pressure and burning sensation
– Hyperemia
– Eye Discharge (watery or mucoserous)
– Chemosis (conjunctival edema)

– Follicles "bumpy" appearance

– Swollen lymphnodes
– Hemorrhagic Conjunctiva

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Viral Conjunctivitis...

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Viral Conjunctivitis...

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Viral Conjunctivitis...

Coxsackie Virus
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Viral Conjunctivitis...
Diagnosis
– Clinical

Treatment
– Self limiting
– special hygiene precautions should be taken
when examining patients

Non drug treatment

– Cleaning of the eyelids
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Viral Conjunctivitis...
Drug Treatment
• Treatment becomes necessary in extremely discomforting
cases
• Antihistamine eye drops
– Levocabastine, 1 drop 3-4 times per day
• Corticosteroid anti-inflammatory

– Dexamethasone 1 drop every 2-4 hours/day

 Prophylactic antibiotics,
– Chloramphenicol 500mg TID for 1 week
 Never use steroid or steroid containing antibiotics.
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Bacterial Vs Viral
Symptom & Signs Bacterial Viral
conjunctivitis conjunctiviti
s
Itching ± ±
Hyperemia ++ +
Bleeding + +
Discharge Purulent; yellow Watery
crusts, Mucopurulent
Chemosis ++ ±
Follicles - +
Papillae + -
Pseudo-membranes ± -
and membranes
Swollen lymph nodes + ++
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Allergic Conjunctivitis
• caused by airborne allergens with specific IgE,
causes
– local mast cell degranulation and the
– release of chemical mediators (histamine,
eosinophil chemotactic factors, and platelet-
activating factors)

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Clinical Manifestations
– bilateral redness
– profuse watery discharge
– itching (cardinal symptom)
– history of allergy
– conjunctival edema
– hyperemia
– burning, and
– photophobia

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Allergic Conjunctivitis
Diagnosis
– Clinical
• Rx
– instructions not to rub the eyes
– treatment of concomitant dry eye
– advice about allergen avoidance, and
– referral to an allergy or ophthalmology
specialist if indicated.

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TRACHOMA
• It is a Greek word meaning ‘rough’
• is a contagious eye infection usually as
keratoconjunctivitis caused by Chlamydia
trachomatis
• is leading infectious cause of blindness worldwide
Mode of transmission :
– Direct contact with secretions
– contact with fomites such as handkerchiefs
– Flies can be a route of mechanical transmission

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TRACHOMA...
EPIDEMIOLOGY
– Trachoma is endemic in over 50 countries

– Active infection mostly seen in young children

with a peak incidence around four to six years
– subsequent scarring and blindness is seen in
adults
– women have two to six times the rate of
trachoma than men
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TRACHOMA...
Risk factors:
– Poverty
– Poor hygiene at individual, family or
community level
– Lack of water supply
– Age
– Environmental factors (Dust, Dry, Dirty,
Discharge)

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Common Signs and symptoms
Irritation Discharge (mucopurulent)
Tearing Papillae
Foreign body sensation Conjunctival scaring
photophobia Pannus –invasion of the outer
Hyperemia layers of the cornea
Chemosis Herbert’s pit
Follicle Trichiasis
Corneal opacity

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 Pannus
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 Herbert’s pit
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WHO Grading of Trachoma
• Severity grading system for trachoma based on the
presence or absence of five key signs:
1. Trachomatous Inflammation, Follicular (TF):
• Presence of 5 or more follicles at least 0.5 mm in
diameter
• Follicular trachoma indicates active disease.
• This form is most commonly found in children
– The proportion of TF among children < 10 years
indicates how wide spread the infection is in the
community
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 Follicle
s

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TRACHOMA...
1. Trachomatous Inflammation, Intense (TI):
– Pronounced inflammatory thickening of the
upper tarsal conjunctiva
– cause is an intense inflammatory response.
– Papillae are visible
• The proportion of TI in children less than 10
years indicates how severe the disease is in the
community.

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 Papillae

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TRACHOMA...
1. Trachomatous Conjunctival Scarring (TS)
– The presence of easily visible scars in the upper tarsal
conjunctiva.
– The more severe the scarring, the higher the risk of
subsequent trichiasis.
– This form may be associated with the development of
dry eye syndrome
• The proportion of conjunctival scarring (TS) among
adults indicates how common trachoma was in the past

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 Scarring

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TRACHOMA...
4. Trachomatous Trichiasis (TT)
– At least 1 eyelash rubs on the eyeball or evidence of
recent removal of in-turned eyelashes.
– This is a potentially blinding lesion that can lead to
corneal opacification.
• The number of people with Trichiasis indicates the
immediate need to provide surgical services for lid
correction

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TRACHOMA...
5. Corneal opacity/CO/
– Easily visible corneal opacity over the pupil
• Corneal opacity or scarring reflects the
prevalence of vision loss and blindness
resulting from trachoma.
• The proportion of people with corneal opacity
indicate the impact of trachoma in the
community in terms of visual loss

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TRACHOMA...
Diagnosis
– Clinical, culture
– WHO severity grading system of trachoma
Prevention
• WHO advocates SAFE strategy.
– S = Surgery for complications (TT & CO)
– A = Antibiotics for active (inflammatory) trachoma
(TF & TI)
– F = Face washing, particularly in children
– E = Environmental improvement including provision
of clean
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Drug treatment
• Trachomatous Inflammation–Follicular (TF)
First line
– Tetracycline single strip of ointment applied BID
for 6 weeks
Alternative
– Erythromycin, single strip of ointment applied BID
for 6 weeks 

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Drug treatment
• Trachomatous Inflammation – Intense (TI)
 Topical First line & Alternative used for TF Plus
• Doxycycline 100mg P.O. QD for 3 weeks (only for
children over 7 years of age and adults) OR
• Erythromycin, 250mg P.O. QID for 3 weeks.
– For children of less than 25kg, 30mg/kg daily in
4 divided doses OR
• Sulfamethoxazole + trimethoprim , 160 + 800mg
P.O. BID for 3 weeks.
– For children of 6-12 years: half of the above
dose. Children of < 6 years: mixture (syrup) as
prescribed
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Drug treatment
• TS - No treatment
• TT - surgical correction called tarsotomy
• CO - may benefit from corneal transplant
N.B: Mass treatment recommended by WHO
 when prevalence of active trachoma among 1-9yrs-old
children is <10%
 Subsequent annual treatment should be administered for 3
years
 Annual treatment continued until prevalence <5%
 Azithromycin 20 mg/kg PO single dose or
 Topical tetracycline 1%eye ointment BID for 6 wks
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GLAUCOMA
• refer to a group of ocular conditions
characterized by optic nerve damage
• It is a condition in which the intra ocular
pressure(IOP) is sufficiently high to cause optic
nerve damage followed by visual field changes
• The average IOP is 15 mmHg (Range of IOP is
10 to 21 mm Hg.)
• If untreated, glaucoma can result in blindness.

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GLAUCOMA...
• It is accurately referred to as a “thief in the
night” because in its most common forms, vision
is lost gradually without the person’s being
aware of it.
• Glaucoma is broadly classified as
– Open angle glaucoma (chronic)
– Angle closed glaucoma (acute)

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Physiology of Aqueous Humor
• Aqueous humor produced by ciliary body
• flows between iris &lens, nourishing cornea& lens
• Most (90%) of the fluid then flows out of anterior
chamber, draining through trabecular meshwork
into canal of Schlemm & episcleral veins
• Rest 10% exits through the ciliary body into the
suprachoroidal space & then drains into venous
circulation of ciliary body, choroid & sclera

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 Circulation Of Aqueous Fluid

Posterior Anterior
Chamber Chamber angle

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 Angle closed Glaucoma

-Blockage is on pupillary area

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 Open angle glaucoma- blockage to trabecular meshwork

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A) Open angle glaucoma (chronic)
• It is as a disorder of IOP, degeneration of the optic nerve &
visual field loss.
• Characterized by;
– Repeated IOP < 21mmHg
– Incidence increases with age
– Incidence over 95% of glaucomas
Signs and Symptoms
• Usually asymptomatic
• In advanced cases there will be
– V/A reduced
– Abnormal visual fields
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PATHOPHYSIOLOGY & ETIOLOGY
Degenerative changes occur in the trabecular meshwork &
canal of schelm, causing microscopic obstruction.
Aques fluid cannot be emptied from the anterior chamber,
leading to increase IOP.
IOP varies with activity & some people tolerates increased
IOP without optic nerve damage (ocular hypertension),
whereas others exhibits visual field defects & optic
nerve damage with minimal or transient IOP elevation.

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A) Open angle glaucoma (chronic)
Diagnosis
• clinical
• Visual fields testing
• Gonioscopy, tonometry, ophthalmoscopy
Management
• Urgent referral for medical and surgical
treatment to ophthalmic center

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b) Angle Closed Glaucoma(Acute)
• is an elevation of IOP as a result of obstruction
of aqueous outflow.
– About 5% of glaucomas
• IOP is normal when the anterior chamber angle
is open, & glaucoma occurs when a significant
portion of that angle is closed.
Glaucoma is associated with progressive visual
field loss & eventual blindness if allowed to
progress.
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PATHOPHYSIOLOGY & ETIOLOGY
 Mechanical blockage of anterior chamber angle
result in accumulation of aqueous humor
 Anterior chamber is anatomically shallow in
most cases.
 The shallow chamber with narrow anterior angle
is more prone to physiologic events that result in
closure.
 Angle closure occurs in sub acute, acute or
chronic forms.
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PATHOPHYSIOLOGY & ETIOLOGY...
 Episodes of sub-acute closure may preside acute attack &
cause transient blurred vision & pain but no increased IOP
 Acute angle closure causes a dramatic response with
sudden elevation of IOP & permanent eye damage within
several hours if untreated.
 Within several days, scar tissue forms between the iris &
cornea, closing the angle.
 iris & ciliary’s body begin to atrophy, cornea degenerates
because of edema & the optic nerve begins to atrophy.

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b) Angle Closed Glaucoma(Acute)
Symptoms
– Painful red eye
– Sudden reduction of vision or Rapid
progressive visual impairment
– Periocular pain
– Nausea and vomiting, headache

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b) Angle Closed Glaucoma(Acute)
Signs
– V/A is decreased
– Firm to hard eyeball
– Anterior chamber will be shallow

– Pupil is mid dilated & fixed.

– visual impairment

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b) Angle Closed Glaucoma(Acute)
Diagnosis
– Clinical
– Tonometery –Elevated IOP, usually <24mmHg.
– ophthalmoscopy examination may reveal a pale
optic disc.
– Gonioscopy- special instrument used to study
the angle of the anterior chamber of the eye

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b) Angle Closed Glaucoma(Acute)

Management
• Therapeutic medications for glaucoma are used
to lower IOP
– by decreasing aqueous production or
– increasing aqueous outflow
• Urgent referral for medical and surgical
treatment to ophthalmic center

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Medical Management

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Medical Management...

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Surgical management
Surgery is indicated if:
 IOP is not maintained within normal limits by
medical regimen.
there is progressive visual field loss with optic
nerve damage.
 TYPES OF SURGERY
Laser trabeculoplasty
Trabeculectomy
Laser iridotomy
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 Tonometry

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Nursing Assessment
 Evaluate patient for severe pain, nausea & vomiting &
signs of increase IOP.
 Assess visual symptoms.
 Assess frequency, duration & severity of visual
symptoms
 Assess patient’s knowledge of disease process &
anxiety.
 Assess patient’s motivation to participate in long term
treatment.

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Nursing Intervention
 Providing information about Glaucoma.
 Teach the action, dosage & side effects of all medications

 Ensure adequate administration of eye drops by watching

return demonstration.
 Discuss visual defects with patient & ways to
compensate.
 Inform patient that surgery is done on outpatient basis &
recovery is quick, usually prolonged restrictions are not
required.
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Nursing Intervention...
 After surgery elevation of head 30 degree will promote
aqueous humor drainage after a trabeculectomy.
 Additional medication after surgery will include topical
steroids & cyclopleges to decrease inflammation & to dilate
pupils.
 Relieving pain.
 Patch will be worn for several hours & sun glasses may be
used to avoid photophobia.
 Vision will be blurred for first few days after the procedure.
 Frequent initial follow-up will be necessary.
 Relieving fear & anxiety of patient.
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 Refractive Errors

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Refraction of Light
• The normal eye creates a clear image by bending
(refracting) light rays to focus on to the retina.
– Emmetropia

• Refractive errors occur when the parallel rays of

light are not focused exactly upon the retina
– Ametropia

01/03/2022 120
Normal Refraction

01/03/2022 121
Ametropia

• Can be;

– Myopia (nearsightedness)

– Hyperopia/Hypermetropia

(farsightedness)

– Astigmatism

01/03/2022 122
Myopia (nearsightedness)
• is a common refractive disorder in which
principal focus is formed in front of the retina
• Patients are nearsighted and; excellent near
vision
• But have blurred distance vision

01/03/2022 123
Causes
 too long axial length (pts have deeper eyeballs)
 The eyeball is elongated and thus the light rays
do not reach the retina
 too great refractive power of the eye's optical
system
 due to a steep cornea (too curved cornea)
 N.B: axial length is the distance from the
posterior corneal surface to the retina

01/03/2022 124
Myopia (nearsightedness)

01/03/2022 125
Sign and Symptoms
• Vision getting blurry when looking at distant
objects
• Persons need to hold things close to their eyes to
see them better
• Eyestrain leading to headaches

01/03/2022 126
Management
• Treatments for refractive errors include glasses,
contact lenses, and refractive surgery.
• Optical Management
– Spectacle Correction glasses containing a
spherical surface (Concave Lens)
– Contact lens
• Surgical Management
– LASIK (laser assisted in situ keratomileusis)

01/03/2022 127
Management
Myopia corrected with refractive device that
provides concave (divergent) refracting
surface
decrease the excess focusing power of the eye's
optical system

01/03/2022 128
Hyperopia (farsightedness)

01/03/2022 129
 Hyperopia
• is a refractive disorder in which principal focus is
formed behind the retina
• Patients are farsighted; have excellent distance
vision
• but blurry in near vision.

01/03/2022 130
Causes
 too short axial length of the eye (patients have
shallower eyeballs)
 the globe or eyeball is too short from the
front to the back
 insufficient refractive power of the eye's optical
system
 due to a flat cornea

01/03/2022 131
Hyperopia

01/03/2022 132
Management
• Optical management
– Spectacles or glasses containing a spherical
surface ( Convex Lens )
– Contact lens
• Surgical management
– LASIK (laser assisted in situ keratomileusis)

01/03/2022 133
Management
Hyperopia corrected with refractive device that provides
convex (convergent) refracting surface
increase the deficient focusing power of the eye's optical
system

01/03/2022 134
Hyperopia Vs Myopia

(A) Hyperopia (C) Myopia (nearsighted)

(farsighted)

(B) Corrected hyperopia

(D) Corrected myopia
01/03/2022 135
Astigmatism
• Due to an irregularity in the curve of the cornea.
– results in multiple focus points in front of or
behind the retina.
– This can result in either myopic or hyperopic
astigmatism
– Patient has blurred vision with distortion of
the visual image
– results in blurry in distance and near vision.

01/03/2022 136
Astigmatism...

• The irregularity of corneal curvature can be

caused by;
– injury
– inflammation
– corneal surgery

– inherited autosomal dominant trait.

01/03/2022 137
Astigmatism

01/03/2022 138
Management
is corrected by spectacles containing a cylindrical
optical surface lenses
bring multiple points of focus on to the retina.

01/03/2022 139
Lense Types
• Minus (concave) lenses
– lenses that increase divergence
– decrease the eye's focusing power
• Plus (convex) lenses
– lenses that increase convergence
– increase focusing power
• Spherical lenses
– is a device with optical symmetry which can either
converge or scatter light rays
• Cylindrical lenses- does not have optical symmetry

01/03/2022 140
Presbyopia ("aging sight")
• is a non-refractive error that affects visual acuity.
• is a condition in which the crystalline lenses lose
their elasticity resulting;
– decrease in ability to focus on close objects at
arm's length or closer
– lens loses its normal accommodating power
• usually is associated with aging and generally
occurs after age 40
01/03/2022 141
Presbyopia...
• Reading materials must be held at increasing
distance in order to focus
• Patient reports, “Arms are too short!”; need for
increased light;
– reading glasses or bifocals needed
• Complaints of eyestrain and mild frontal
headache are common.
– relieved with eye rest and corrective lenses

01/03/2022 142
 Lenses Disorder

01/03/2022 143
Cataract
 is an opacity or cloudiness in the lens of the eye
that may cause a loss of visual acuity

 Vision is diminished because light rays are

unable to get the retina through the clouded lens.

 caused by opacification and degeneration of lens

fibers or deposition of protein materials in the
lens.

01/03/2022 144
01/03/2022 145
Risk Factors
Aging- leads for;
– Loss of lens transparency
– Clumping or aggregation of lens protein
(which leads to light scattering)
– Accumulation of a yellow-brown pigment
due to the breakdown of lens protein

01/03/2022 146
Risk Factors
Associated Ocular Conditions
– Myopia

– Retinal detachment and retinal surgery

– Infection (eg, herpes zoster, uveitis)

Nutritional Factors
– Reduced levels of antioxidants

– Poor nutrition
– Obesity
01/03/2022 147
Risk Factors

Toxic Factors
• Corticosteroids, especially at high doses and in
long-term use
• Alkaline chemical eye burns, poisoning

• Calcium, copper, iron, gold, silver, and mercury,

which tend to deposit in the pupillary area of the
lens

01/03/2022 148
PATHOGENESIS
 Cataract occurs when there is either of the
following conditions in the lens
– DEGENERATION
– OPACIFICATION
– DEPOSITION OF OTHER MATERIALs
– ABNORMALITY OF LENS PROTEIN
– DISORGANISATION OF FIBROUS
TISSUES

01/03/2022 149
Signs and Symptoms
– Painless, blurry vision
– Light scattering and reduced light transmission
– myopic shift and astigmatism
– Polyopia and diplopia (double vision)
– increased sensitivity to glare and bright light
• eg. Trouble in driving at night (Glare)
– decreased color vision (yellow, orange, & red
appear brighter and WHITE appears dull)

01/03/2022 150
BLURRED VISION DUE TO SCATTERING
OF LIGHT ON THE RETINA

01/03/2022 151
01/03/2022 152
GLARED VIEW (TROUBLE DRIVING
AT NIGHT)

01/03/2022 153
CHANGE IN COLOUR VISION(DIMNESS)

01/03/2022 154
CLASSIFICATION
BASED ON :
– MORPHOLOGY
– AGE OF ONSET
– MATURITY

01/03/2022 155
MORPHOLOGIC
1. CAPSULAR CATARACT
 ANTERIOR CAPSULAR CATARACT
 POSTERIOR CAPSULAR CATARACT
 reveals an opaque nucleus, manifested as a
yellow-brown hazy structure at the center of
the lens

01/03/2022 156
MORPHOLOGIC...
2. SUB CAPSULAR CATARACT
 ANTERIOR SUBCAPSULAR CATARACT
POSTERIOR SUBCAPSULAR CATARACT
 reveals a "frost-like" haze just in front of the
posterior capsule

01/03/2022 157
MORPHOLOGIC...
3.NUCLEAR CATARACT
caused by central opacity in th lens
4.CORTICAL CATARACT
involves the anterior, posterior, or equatorial
cortex of the lens

01/03/2022 158
01/03/2022 159
01/03/2022 160
AGE OF ONSET
1. CONGENITAL

2. INFANTILE

3. JUVINILE

4. PRE-SENILE

5. SENILE

01/03/2022 161
CONGENITAL CATARACT
• Occur due to maternal infection, malnutrition,
perinatal hypoxia or hereditary

01/03/2022 162
INFANTILE AND JUVINILE CATARACT

01/03/2022 163
Senile Cataract
• Age related cataract
• By the age of 70 years, <90% of
individuals develop senile cataract

01/03/2022 164
MATURITY
1. IMMATURE CATARCT
 A cataract that still allows a view of the retina
and transmits a red reflex
2. MATURE CATARACT
• a cataract that never allows view of the retina
and transmits a red reflex

Immature cataract Mature cataract

01/03/2022 165
MATURE AND IMMATURE CATARACT

01/03/2022 166
IMMATURE
CATARACT

01/03/2022 167
Diagnostic Evaluation
Visual acuity measurement
Ophthalmoscopy (direct and indirect)
darkening or opacities of the red reflex
Slit lamp microscopy
Glare testing
Other tests (e.g., visual field test)
N.B: Cataract should suspected in pt with complain
a painless & progressive decline in vision

01/03/2022 168
Management
• Nonsurgical

Change prescription of glasses

Strong reading glasses or magnifiers
Increased lighting

Lifestyle adjustment
Reassurance

N.B: No nonsurgical (medications, eyedrops,

eyeglasses) treatment cures cataracts
01/03/2022 169
Surgical Management
1. Intracapsular Cataract Extraction (ICCE)
– entire lens (nucleus, cortex, and capsule) is
removed, and fine sutures close the incision.
2. Extracapsular Cataract Extraction (ECCE)
– portion of anterior capsule is removed,
allowing extraction of lens nucleus & cortex.
– posterior capsule & zonular support left intact.
– A rigid plastic lens is inserted instead

01/03/2022 170
Surgical Management...
3. Phacoemulsification (small incision surgery)
 uses ultrasonic device that liquefies nucleus &
cortex, then suctioned out through a tube.
The posterior capsule is left intact.

Because the incision is even smaller than the

standard ECCE, the wound heals more rapidly

01/03/2022 171
Surgical Management...
4. Lens Replacement (intraocular lens
implantation)
After removal of the crystalline lens, the
patient is referred to as aphakic (without lens).
• lens replaced by either of the following options:

– aphakic eyeglasses

– contact lenses
– Intra-Ocular Lens (IOL) implants.
01/03/2022 172
Surgical Management...
 Aphakic glasses- are effective but heavy
– Objects are magnified by 25%, making them
appear closer than they actually are.
– Objects are magnified unequally, creating
distortion.
– Peripheral vision is also limited, and
binocular vision is impossible if the other
eye is phakic (normal).
01/03/2022 173
Surgical Management...
 Contact lenses- provide patients with almost
normal vision, but because contact lenses need to
be removed occasionally, the patient also needs a
pair of aphakic glasses.
– are not advised for patients who have difficulty
inserting, removing & cleaning them.
– Frequent handling and improper disinfection
increase the risk for infection.
01/03/2022 174
Surgical Management...
 Insertion of IOLs- during cataract surgery is the
usual approach to lens replacement.
 After ICCE, the surgeon implants an anterior
chamber IOL in front of the iris.
 Posterior chamber lenses, generally used in
ECCE, are implanted behind the iris.

01/03/2022 175
 Disease of the uveal tract

01/03/2022 176
Uveitis
• Inflammation of the uveal tract (iris, ciliary body,
choriod)
• ETIOLOGIES
 autoimmune
 infections (syphilis, tuberculosis, toxoplasmosis,
histoplasmosis)
 unknown etiology
• There are two types of uveitis:
– Non-granulomatous
– Granulomatous
01/03/2022 177
Non-granulomatous
• more common type of uveitis
• Clinical manifestations
– acute pain and photophobia
– pattern of conjunctival injection/redness
– Pupillary constriction
– blurred vision
– In severe cases
• hypopyon (accumulation of pus in the
anterior chamber)
01/03/2022 178
Granulomatous uveitis
• It tends to be chronic and can involve any
portion of the uveal tract
• Clinical manifestations
– minimal photophobia and pain
– Markedly and adversely affected vision
– Diffuse Conjunctival injection
– Vitreous clouding
– In sever cases
• retinal and choroidal hemorrhages
01/03/2022 179
Management
– wear dark glasses outdoors for photophobia
– cyclopentolate (Cyclogyl) and atropine to
avoid Ciliary spasm and synechia
– Local corticosteroid drops to decrease
inflammations
– Systemic corticosteroids in severe cases
– Vitrectomy- removal of excessive vitreous

01/03/2022 180
Diseases of the cornea
–Keratitis

01/03/2022 181
KERATITIS
 inflammation and ulceration of the cornea

• ETIOLOGIES
herpes simplex virus (cold sores)

bacteria
fungi

trauma
dry air or intense light (welding)

01/03/2022 182
KERATITIS...
• SYMPTOMS AND SIGNS
pain or numbness of the cornea
decreased visual acuity
irritation
tearing
photophobia
mild conjunctivitis
blepharospasm (spasm of the eyelids)

01/03/2022 183
KERATITIS...
• DIAGNOSIS
 examination of cornea using slit lamp
 medical history and upper respiratory tract infections
• TREATMENT
– topical antibiotics
– antiviral medications for herpes simplex
– cycloplegic agents (to keep iris & ciliary body at rest)
– eye patch to protect from photophobia & decrease
amount of eyelid movement over the cornea
– warm compresses.
01/03/2022 184
 Muscular eye disorders
 Nystagmus

 Strabismus

01/03/2022 185
Nystagmus
• an involuntary rhythmic movement of the eyes.
• occurs normally when a person watches a rapidly
moving object (eg, through the side window of a
moving car or train)
• However, pathologically it is an ocular disorder
associated with vestibular dysfunction.
• can be caused by a disorder in the central or
peripheral nervous system or phenytoin toxicity

01/03/2022 186
Nystagmus...
• can be horizontal, vertical, or rotary

• Horizontal nystagmus is the most common

• distinguished from other abnormal involuntary
eye movements by:
– The rhythmic nature

– slow speeds of nystagmus

01/03/2022 187
Nystagmus...

• Clinical symptoms
– vertigo- misperception or illusion of motion of
the person or the surroundings
– oscillopsia- a to-and-fro illusion of
environmental motion
– abnormal head position
– blurred vision

01/03/2022 188
Normal eye movement
• upward- superior rectus & inferior oblique

• downward- inferior rectus and superior oblique

• horizontally laterally (abduction)- lateral rectus

• horizontally medially (adduction)- medial

rectus muscle

• incyclotort- superior oblique muscle

• excyclotorts- inferior oblique muscle

01/03/2022 189
Strabismus (Crossed Eyes)

• deviation in ocular alignment

• deviation of the visual axis of one eye toward
that of the other eye, resulting in diplopia.
• can occur in one or both eyes, and in any
direction.
• Represents misaligned eyes pointing in different
directions

01/03/2022 190
Forms of strabismus

1. Esotropia- when one eye fixates on an object,

while the other eye turns in
2. Exotropia- when one eye fixates on an object,
while the other eye turns out
3. Hypotropia- when one eye fixates on an object,
while the other eye turns down
4. Hypertropia- when one eye fixates on an
object, while the other eye turns up

01/03/2022 191
Signs and Symptoms

• Double vision

• Eyes' inability to focus on a particular point at

the same time
• Uncoordinated eye movement
• Loss of depth perception

01/03/2022 192
Diagnosis of strabismus
• Clinical History
• Corneal light reflex

• Cover test

• Cover/uncover test
• Brückner red reflex test

• Extra-ocular muscle movement test

01/03/2022 193
Corneal light reflex
Normal corneal
reflex

Corneal light
reflex in esotropia

Corneal light
reflex in exotropia

01/03/2022 194
Cover/uncover test

01/03/2022 195
Red reflex test

Normal reflex Unequal reflex

No reflex (cataract) Strabismus

01/03/2022 196
Management
For Children For Adults
Eye patching Optical approaches
Eye glasses Prism correction
Atropine drops Eye muscle surgery
Eye muscle surgery
Tightening or loosening
of muscle

01/03/2022 197
 EAR DISORDERS
External Ear
Middle Ear
Inner Ear

01/03/2022 NT 198
01/03/2022 NT ENT 199 199
01/03/2022 NT ENT 200 200
Conditions of the External Ear
Ear Impaction
Otitis Externa
Malignant OE

01/03/2022 NT 201
Ear Impaction/Cerumen Impaction/Ear Blockage
A condition in which wax can build up & block ear canal.
Wax blockage is one of the most common causes of hearing
loss
Causes
Too much production of earwax
The extra wax harden and block the ear
obstruction due to ear canal disease
Home based trial to remove the blockage

01/03/2022 NT ENT 202 202

Ear Impaction...
Symptoms
Otalgia (earache)
Tinnitus- ringin or buzzing in the ear
Sudden or Partial hearing loss
Feeling of fullness in the ear
Dx : clinical and otoscopic examination

01/03/2022 NT ENT 203 203

01/03/2022 NT ENT 204 204
 In Cerumen obstructing TM

01/03/2022 NT ENT 205 205

Management
three recommended therapeutic options:
1. cerumenolytic agents
should be avoided if pt has history of infections,
perforations, otologic surgery & TM damage
Retention of cerumenolytic drops behind cerumen
results irritation in skin of external auditory canal.
 recommend usage no more than 3 to 5 days
 Carbamide peroxide 5-10drops BID for 4
days
01/03/2022 NT ENT 206 206
Management
2. irrigation- Instilling with cerumen softners
 warmed glycerin or mineral oil or
 half-strength (3%) hydrogen peroxide into the
ear canal for 30 minutes
 Eg. dilute hydrogen peroxide and warm
water as 1:10
 Irrigation tends not to be effective for hard
impaction
 cerumenolytic agent may assist with
01/03/2022 NT 207
irrigation
Management
3. manual removal (Instrumentation)
Performed by trained clinicians
preferred for patients with abnormal otologic
findings (eg, perforated tympanic membrane) or
patients with immunodeficiency
Attempts to clear with matches, hairpins or others
are dangerous
because trauma to the skin, infection, and
damage to TM can occur.
01/03/2022 NT 208
Ear Impaction...
Complications
Infection in the ear canal
Damage to the eardrum
Hearing loss

01/03/2022 NT ENT 209 209

Otitis Externa (External otitis)
an inflammation of the external auditory canal.
Etiologies
water in the ear canal (swimmer’s ear);
trauma to the skin of the ear canal,
Bacterial infections
Staphylococcus aureus and Pseudomonas species
fungal infections
Aspergillus, Candida and other organisms

01/03/2022 NT ENT 210 210

Otitis Externa...
Classification:
Acute diffuse OE: typically seen in swimmers
characterized by rapid onset (generally within 48
hours)
Acute localized OE: associated with infection of a
hair follicle
Chronic OE: is the same as acute diffuse OE but
is of longer duration (<6 weeks)

01/03/2022 NT ENT 211 211

Otitis Externa...
Eczematous (eczematoid) OE: associated with
various dermatologic conditions
Otomycosis: associated with fungal infection
Necrotizing (malignant) OE:
occurs mainly in elderly, diabetics,
immunocompromised or in those who have
received skull base radiotherapy or in advanced
case of all type of OE

01/03/2022 NT ENT 212 212

Clinical Manifestations
Otalgia, Tinnitus and Itching
aural Tenderness
Hearing loss

Erythematous and edematous ear canal

hair like black spores (In fungal infections)
Otorrhea (yellow or green and foul-smelling)
Systemic symptoms Absent
Tympanic membrane may appear normal

01/03/2022 NT ENT 213 213

01/03/2022 NT 214 214
ENT
01/03/2022 NT ENT 215 215
 In Otomycosis: Fungal
Infection TM looks

01/03/2022 NT ENT 216 216

Otitis Externa...
Dx:
Clinical and Otoscopic examination
Culture may identify the bacteria or fungus
causing infection

01/03/2022 NT ENT 217 217

Management
• There are five fundamental steps
– Thoroughly clean the ear canal

– Treat inflammation and infection

– Control pain
– Avoid promoting factors

– Follow-up

01/03/2022 NT 218
Bacterial Management
Oxytetracycline hydrochloride + polymyxin B

sulphate + hydrocortizone acetate 2 drops 2-3

times daily for 7 days OR

Ciprofloxacin 4 drops BID for 7 days OR

Hydrocortison 3 drops BID for 7days

01/03/2022 NT ENT 219 219

Management...
For Fungal OE
• Clotrimazole 4 drops QID for 7 days OR
• Fluconazole 200 mg PO for 1 dose, then 100
mg PO for 3-5 days
For Malignant OE
• Ciprofloxacin 400 mg IV BID or 750 mg PO
BID for 4-6weeks OR
• Ceftriaxone 2 g IV TID for 4-6 weeks

01/03/2022 NT ENT 220 220

Complications
Complications of OE are rare and may include the
following:
– Necrotizing OE- most significant complication

– Mastoiditis
– skull base osteomyelitis

– Cellulitis of the face or neck

– AOM

01/03/2022 NT ENT 221 221

Malignant OE
• A more serious, although rare, external ear infection

• is a progressive, debilitating, and occasionally fatal

infection of;
– external auditory canal
– the surrounding tissue and
– base of the skull

• Usually caused by Pseudomonas aeruginosa in

patients with low resistance to infection

01/03/2022 NT 222
Clinical manifestations
• Sever pain
• Otorrhea

• Visible granulation tissue

• In advanced cases osteomyelitis of;

– base of the skull
– temporomandibular joint- resulting pain while
chewing

01/03/2022 NT 223
Management
• Control of immunosuppressing conditions

– Eg. Diabetics control

• Intravenous administration of antibiotics
– antipseudomonal agents and aminoglycosides

– Ciprofloxacin 400mg IV TID

• Aggressive local wound care

– Eg. debridement

01/03/2022 NT 224
 Conditions of the Middle Ear
Otitis media
Mastoiditis
Otosclerosis)

01/03/2022 NT 225
ACUTE OTITIS MEDIA (AOM)
It is an acute infection of the middle ear usually
lasting less than 6 weeks
More common in children
The second most common cause of otalgia
Causes
Usually by: S pneumoniae, H influenzae,
Moraxella catarrhalis

01/03/2022 NT ENT 226 226

Clinical Manifestations
Irritability or feeding difficulties
Otalgia and Fever
Hearing loss
no pain with movement of the auricle.

Signs of inflammation On otoscopic exam.;

Reddening of the mucosa and formation of purulent middle ear effusion
Bulging & reddening of TM
The external auditory canal appears normal

01/03/2022 NT ENT 227 227

 Bulged TM
01/03/2022 NT ENT 228 228
01/03/2022 NT 229
AOM...

Diagnosis

Otoscopic examination

Clinical and Culture

Audiological assessments

01/03/2022 NT ENT 230 230

AOM...
Prevention:
Control of nasal inflammation in children, whether
caused by an allergy or by recurrent infection,
appears to decrease the recurrence of AOM

01/03/2022 NT ENT 231 231

Treatment (First line)
Amoxicillin 500mg P.O. TID for 10 days for adults; 250 mg P.O.
TID for 10 days for children <6 years; 125mg/5ml, 250mg/5ml
P.O. TID for 10 days for children <6 yrs OR
Sulfamethoxazole+trimethoprim, Adults; 160+800mg. P.O. BID
for 10 days. Children 6-12 years of age; 80+400mg P.O. BID for
10 days OR
Amoxicillin/Clavulanate 375mg P.O. TID for 10 days OR 625mg
P.O. BID for 10 days for adults, 312mg/5ml suspension P.O. TID
for 10 days OR 156mg/5ml suspension P.O. TID for 10 days for
children OR
Ceftriaxone1 g IM every other day for 3 doses
01/03/2022 NT ENT 232 232
Complications
Perforation of the tympanic membrane,
mastoiditis
facial nerve palsy or acute labyrinthitis
Meningitis
encephalitis
brain abscess
Bactaeremia or bacterial endocarditis

01/03/2022 NT ENT 233 233

AOE Vs AOM
Features AOE AOM
May or may not Present if TM
Otorrhea
present perforated
Persistent, may Relieved if TM
Otalgia
awaken at night ruptures
Aural tenderness Present Usually absent
Systenic
Absent Fever, URIs, rhinitis
symptoms
Edema of external
Present Absent
auditory canal
Tympanic May appear Erythema, bulging,
membrane normal may be perforated

Hearing loss Conductive type Conductive type

01/03/2022 NT 234
Chronic Otitis Media (COM)
is the result of recurrent AOM causing damage of
the tympanic membrane, destroy the ossicles,
and involve the mastoid process
Causes
AOM
Eustachian tube obstruction
Trauma

01/03/2022 NT ENT 235 235

COM...
Types
Benign (inactive) COM
characterized by dry TM perforation
Chronic serous otitis media
characterized by continuous serous drainage
(typically straw-colored).
Chronic suppurative otitis media
characterized by persistent purulent drainage

01/03/2022 NT ENT 236 236

COM...
Signs and symptoms
– Hearing loss
– Painless except in cases of acute mastoiditis
– purulent otorrhea, may be foul smelling
– Otoscopic examination may show perforation
and cholesteatoma
– Defect of the tympanic membrane

01/03/2022 NT 237
Perforated TM

01/03/2022 NT ENT 238 238

Non-drug treatment
Conservative measures
To dry up the middle ear.
Clean the external meatus periodically with 3%
H2O2; it may be irrigated with saline at body
temperature.
Pus is taken for culture and sensitivity test and
appropriate systemic antibiotics are given

01/03/2022 NT ENT 239 239

Medical Treatment
• Topical antibiotics- first line for uncomplicated
otorrhea
– Ciprofloxacin drops BID for 02 weeks OR
– Ofloxacin drops BID for 02 weeks
• Systemic antibiotics- in case of risk for
complications

01/03/2022 NT 240
Surgical Treatment
Patient should be treated as early as possible by
tympanoplasty, ossiculoplasty and
mastoidectomy to prevent potential infections
 tympanoplasty- surgical repair of the TM
 ossiculoplasty- surgical repair of Ossicle bones
 mastoidectomy- surgical removal of mastoid
process

01/03/2022 NT 241
Complications
Cranial Complications
Labyrinthitis
Facial paralysis
Mastoiditis
Intracranial complications
Meningitis, brain abscess
Extracranial Complications
OE, Retropharyngeal abscess

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Mastoiditis
• is a suppurative infection of the mastoid air cells
• Causes swelling in the postauricular area which
may brust leading formation of mastoid fistula
• is a complication of acute otitis media
• Acute mastoiditis- with symptoms of less than
one month's duration
• Chronic mastoiditis- with symptoms of long-
standing duration (months to years)
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Clinical manifestations
• Ear pain and fever

• Postauricular tenderness and erythema

• swelling or mass over the mastoid
• Displacement of the auricle

– usually downward and outward in children <2

years
– upward and outward in children < 2yrs

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 Mastoiditis ear is displaced
downward & outward
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Otosclerosis
• a disease of middle ear characterized by
conductive hearing loss due to
– fixation of footplate of stapes
– formation of new & abnormal spongy bone

• Resulting the stapes not to vibrate and carry the

sound to the inner ear

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Otosclerosis Anatomy

Arrow points to sclerotic

Normal anatomy process at the foot of stapes
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Clinical Manifestations
• progressive conductive or mixed hearing loss.
• Tinnitus

• Otoscopic examination usually reveals a normal

tympanic membrane.
• Bone conduction is better than air conduction
on Rinne testing

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Management
• sodium fluoride- believed as it;
– mature the abnormal spongy bone growth
– prevent the breakdown of the bone tissue

– But ineffective
• stapedectomy- remove stapes superstructure
and part of footplate
– insert a tissue graft and a suitable prosthesis
• Hearing aids

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Stapedectomy for otosclerosis

Stapes broken Robinson

footplate is stainless steel
away surgically removed from its
from its diseased base prosthesis in
base position
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 Conditions of the Inner Ear
Labyrinthitis
Ménière’s disease

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Labyrinthitis
Is an ear disorder that involves inflammation of the
inner ear, labyrinth.
It derives its name from the labyrinths that house
the vestibular system, which senses changes in
head position
The infection can enter the inner ear by penetrating
the membranes of the oval or round windows as a
complication of otitis media.

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Causes
Most commonly result from bacterial and viral

Taking certain drugs that are dangerous to the

inner ear

Head injury

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Potential viral causes
Mumps virus
Rubeola virus
Influenza virus
Rubella virus
Varicella-zoster virus
Parainfluenza virus
Cytomegalovirus
Herpes simplex virus 1

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Potential bacterial causes
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Neisseria meningitidis
Streptococcus species
Staphylococcus species
Escherichia coli
Mycobacterium tuberculosis

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Symptoms and Signs
Vertigo- Abnormal sensation of movement
Loss of balance
Nausea and vomiting
Nystagmus
Hearing loss
Tinnitus.
Anxiety, dizziness and a general ill feeling

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Diagnosis
The otologic examination :
External inspection for signs of mastoiditis,
cellulitis, or prior ear surgery
Inspect the ear canal for otitis externa, otorrhea,
or vesicles
Inspect TM & other structures for presence of
AOM, middle ear effusion or perforation
Culture

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Management
IV antibiotics therapy, fluid replacement,
antihistamine and antiemetic medications.
Vestibular rehabilitation therapy (VRT) is a
highly effective way to substantially reduce or
eliminate residual dizziness from labyrinthitis.
VRT works by causing the brain to use already
existing neural mechanisms for adaptation
Aimed to restore vestibulo- ocular reflex

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Management...
For Bacterial labyrinthitis: antibiotic treatment is
selected based on culture & sensitivity results
Viral labyrinthitis: The initial treatment consists
of bed rest, hydration and antiviral agents
Example: Acyclovir, Valacyclovir
Patients with severe nausea and vomiting may
benefit from antiemetic medications

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Vestibular rehabilitation therapy
most commonly used Rehabilitation strategies:
Eye exercises and Head exercises
a) Eye exercises: sitting
Oculomotor:
Holding a single target, keep eyes fixed on target
Slowly move it side-to-side/up-down/diagonally
while head stays in focus point.
Repeat cycle , 15 times per day for 14 days.

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Vestibular rehabilitation therapy
b) Head exercises
Gaze stabilization: Sitting
moving the head from side to side while fixated
on a stationary object
Repeat cycle , 15 times per day for 14 days.

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Vestibular rehabilitation therapy
Gaze stabilization: Standing feet apart
moving the head from side to side while fixated
on a stationary object
Repeat cycle , 15 times per day for 14 days.

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Gaze stabilization:
Sitting

Gaze stabilization:
Standing feet apart

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Vestibular rehabilitation therapy
Head/eyes moving in same direction
Holding a single target, keep eyes fixed on target.
Slowly move target, head and eyes in same
direction up-down/ side to side/diagonally
Repeat cycle , 15 times per day for 14 days

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Visuo-vestibular: eyes/Head
moving

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Vestibular rehabilitation therapy
N.B: If the client use glasses, wear them while
performing exercises.
exercises may provoke symptoms of dizziness or
nausea. Work through these symptoms.
If too dizzy, slow eye movement down slightly and
rest between each exercise.
Exercises demand concentration; avoid distractions.

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Ménière’s disease
• abnormal inner ear fluid balance due to
– malabsorption in the endolymphatic sac or
– blockage in the endolymphatic duct

• named for Prospere Meniere, a French physician

Signs and Symptoms

– Episodic vertigo (have onset and offset conditions)
– Tinnitus initially reversible
– Hearing loss but later on permanent
– Nausea and vomiting

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Management
• Dietary modification (low salt, high fruits...)
• antihistamines (meclizine)

– suppress the vestibular system

• Tranquilizers (diazepam)- control vertigo

• Diuretic therapy (hydrochlorothiazide)
• Endolymphatic Sac Decompression (shunting)

• Vestibular Nerve Sectioning

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 Nose Conditions
Sinusitis
Rhinitis
Epistaxis

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Sinusitis
 an inflammation in any of the paranasal sinuses
 Inflammation of most or all of the paranasal sinuses
simultaneously is known as pansinusitis
Causes
 Viral infection

 Bacterial infection- usually S. pneumoniae, H.

influenza (nontypable), M. catarrhalis, Beta-

hemolytic Streptococci
 allergy
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Sinusitis...
• Maxillary/ethmoid sinuses are commonly
involved
• Preceding URI blocks clearing/draining of
mucus
• Onset may be sudden or gradual in children

• Can be acute or chronic

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Clinical features (Acute)
• sense of pressure, pain, or fullness in the
affected sinus
• may be accompanied by

– facial swelling
– erythema, fever, malaise and
– drainage of foul-smelling mucopurulent
material

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Clinical features (Chronic)
• It is usually a result of bacterial or fungal
infections that are low-grade and recurrent in
nature, obstructive nasal disease, or allergy.
• It is characterized by episodes of sinus disease
that respond initially to treatment only to return,
or that remain symptomatic inspite of treatment.

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Management
• Decongestants Ex. 2% ephedrine
– to decrease mucosal edema and inflammation
• Supportive Measures (Fluids, ice pack)
• Antibiotics
– Amoxicillin for mild-moderate cases
– Augmentin 625mg PO TID 07days for sever cases
• Analgesics (acetaminophen/ibuprofen)
• Night time cough suppressant –e.g codeine syrup

• Surgical drainage of the sinus is indicated

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Rhinitis
• inflammation of mucous membrane in the nose
(i)Allergic rhinitis  
• characterized by nasal itching, swelling and
watery discharge
• other symptoms like itching and watering of eye,
swelling of eyelid, sneezing and rash
• Triggered by pollen, mold, animal dust and other
similar inhaled allergens.

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Management
 Otroxin nasal drop #1bottle 3drops/day
 Celestamine PO 2tabs /day
 If there is pus norfloxacin 400mg bid for 07days
 Topical decongestants - nasal sprays that constrict
blood vessels in the lining of the nose.
oxymetazolinephenylephrine, xylometazoline &
naphazoline 
 Advise patient to avoid allergens

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(ii) Non allergic (vasomotor) rhinitis
• non allergic, non infective rhinitis in which the
patient suffers from clear watery discharge.
• Causes could be
 Medication (rhinitis medicamentosa)
 Atrophy
 Hormonal factors
 Warm or cold air
 Light or particulate matter
 Trauma, Emotions
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Causes of Non-allergic Rhinitis...
 Local irritants (dust, tobacco, war gases,
irritating chemicals, chlorinated water of
swimming pool)
 Structural abnormalities (deviated nasal septum,
turbinate hypertrophy, polyps,)
 Neoplasm (papilloma, angiofibroma,
malignancy)
 Substance abuse(alcohol, cocaine, nicotine

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Rhinitis medicamentosa
• Is drug induced rhinitis
• It is often associated with prolonged use of
topical decongestants.
Mgt
• Discontinue topical treatment/systemic
decongestant
• Oral prednisalone

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Atrophic rhinitis (Ozena)
• associated with atrophy of nasal mucosa and
turbinate
• in association with excessive crusting and
offending smell mucopurulent discharge
• Patient usually present with complain of
epistaxis, nasal obstruction, headaches and foul
smell.

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Management of Atrophic rhinitis
• Saline irrigation
• Topical antibiotics

• Kemeticine anti ozena solution prepared

with CAF

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iii)Infective Rhinitis
1. Viral cause (common cold, measles, small pox)
Symptoms
Clear mucus secretion
Decreased ability to smell
Nasal congestion
Malaise, headache, and cough
Nasal mucosa seems red and swollen on
examination.

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iii)Infective Rhinitis...
2. Bacterial cause (typhoid fever, syphilis)
It usually follows viral infection.
Symptoms
thick, yellow-green nasal discharge.
loss of sensation
blocked nose
bad breath.
Fever, cough &headache,some times facial pain

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iii)Infective Rhinitis...
3. Fungal Cause
 It is rare and affects only patients with reduce
immune system like DM, kidney diseases and
taking cancer treatment.
 Patient complain of facial pain and some times
visual symptoms.

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Epistaxis (Nose Bleeding)
• a hemorrhage from the nose

• Occurs when there is rupture of;

– tiny and distended blood vessels in the mucous
membrane of any area of the nose

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Etiologies
Trauma
Infection
 Foreign body
Extreme hot or cold
Tumor eg. hemangioma
Systemic diseases like HTN
Hormonal factors
Medications
Idiophatic
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Epistaxis...
Anterior
 Accounts about 80% of causes.
 Occurs mostly in children and young.
 Usually cause by trauma and drying
Posterior
 Accounts about 20% of cases.
 Occur mostly in adults <49

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Management
 Sit up and lean forward.
 Pinch nose firmly for 5 or 10 minutes continuously
 Keep nose moist with nasal spray or NS after it stops
 Application of nasal decongestants (phenylephrine)-
vasoconstrictors
 Check V/S
 Nasal packing with adrenaline
 Cauterizations with silver nitrate or electrocautery
(high-frequency electrical current)
 Resusciatative measures

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Throat and mouth conditions
Tonsillitis
Stomatitis

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Tonsillitis
• is inflammation of the tonsillar structures in the
oropharynx.
• More common in children

Causes
– viral

– bacterial
• Most common bacterial cause is Group A
β-hemolytic streptococci.
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Signs and Symptoms
– Difficulty swallowing and breathing
– Nasal, muffled voice
– Persistent cough
– Often associated with otitis media and
hearing difficulty
– Enlargement visible on throat examination,
may be red or covered with white exudate.
– Recurrent sore throat
– Fever
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Management
• supportive measures
– increased fluid intake
– analgesics
– salt-water gargles and rest.
• Bacterial infections
– treated with penicillin (first-line therapy) or
cephalosporins
• Tonsillectomy

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Stomatitis
- inflammation of tissues of the mouth, including
lips, buccal mucosa, gingiva and posterior
pharyngeal wall
• Causes
• Herpes simplex virus

• Coxsackie virus

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Signs and Symptoms
 Fever (very high with herpes infection)
 Painful ulcers
 Drooling
 Difficulty swallowing
 Decreased fluid/nutritional intake
 Associated respiratory or GI symptoms
 Associated skin rash
 Erythema (herpangina) and Vesicles

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Complications
– Pain

– Dehydration
– Secondary infection (e.g., gangrenous
stomatitis)
– Ludwig’s angina (Sub-mandibular space
infections)

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Management
 Maintenance of hydration is important

 Increase oral intake of fluids

 Counsel parents or caregivers about the signs and
symptoms of dehydration
 Recommend dietary adjustments:

 bland, non-acidic fluids (such as milk and water);

 older children may eat popsicles, ice cream and
similar food items;
 avoid citrus foods, such as orange juice

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Management...
 Recommend local mouthwashes (1:1 hydrogen
peroxide and water), especially after eating
 To prevent spread of infection, recommend
avoidance of direct contact with infected
individuals (e.g., kissing, sharing glasses and
utensils, hand contact)
 Provide support to parents or caregivers to help
them cope with a “cranky” child
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Management...
 Acetaminophen (Tylenol) for fever and pain

10–15 mg/kg PO or PR q4h prn

 Reassess the young child (<2 years of age) in
24–48 hours to ensure maintenance of hydration
 The disease is self-limiting, so consultation and
referral are usually unnecessary, unless there are
complications.

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 THANK YOU!!!

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