What do you expect to find on Weber and Rinne tests in sensorineural hearing loss (SSNHL)?




Both of these tests are easy bedside maneuvers to perform in the early evaluation of hearing loss and only require a 256 Hz tuning fork.  The main thing to remember is that in the Rinne test, air conduction is supposed to be greater than bone conduction….but because the problem with SSNHL is the conversion of sound waves to neural impulses, AC will still be greater than BC because the sound waves can still travel through the canal uninhibited.  So AC>BC can be both normal and abnormal, which is why it always done in tandem with the Weber to help figure out which side is affected.


Epstein’s Pearls


Other Known Aliasesnone

DefinitionSmall, fluid filled cysts on the hard palate of newborns that are most commonly found along the median palatal raphae.

Image result for epstein's pearls


Clinical SignificanceNone.  These are completely normal and occur in 65-80% of newborns.  The are formed by epithelium that becomes trapped during palatal development.

Image result for epstein's pearls


History – Named after Alois Epstein (1849-1918), who was a Czechoslovakian pediatrician, graduating from the University of Prague in 1873.  His career was highlighted by becoming the first physician-in-chief for the University of Prague hospital in 1873 and being appointed to professor at the University of Prague in 1884.  He first described these findings in 1880.


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Lewis DM. Bohn’s nodules, Epstein’s pearls, and gingival cysts of the newborn: a new etiology and classification. Journal – Oklahoma Dental Association. ; 101(3):32-3. [pubmed]
  6. Singh RK, Kumar R, Pandey RK, Singh K. Dental lamina cysts in a newborn infant. BMJ case reports. 2012; 2012:. [pubmed]
  7. Epstein A. Ueber die Gelbsucht bei Neugeborenen Kindern. Leipsic. 1880. [book]


For HEENT block, lets talk a little about about hearing loss:



Tullio’s Phenomenon


Other Known AliasesSound-induced vestibular activation.

Definition – Vertigo, dizziness, nausea, and nystagmus caused by a load noise.

Clinical Significance This pathology is due to a communication between the middle and inner ear classically associated with congenital syphilis.  Recently, it has been associated with superior canal dehiscence syndrome (SCDS).  This can also be elicited with nose-blowing, valsalva, and heavy lifting.

History – Named after Italian biologist Pietro Tullio, Ph.D. (1881-1941), who originally studied this finding in pigeons and published it in 1929. 

Tullio blowing a whistle in the ear of rabbit test subject


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Tullio, Pietro: Das Ohr und die Entstehung der Sprache und Schrift. Berlin, Germany: Urban & Schwarzenberg; 1929.
  6. Kaski D, Davies R, Luxon L, Bronstein AM, Rudge P. The Tullio phenomenon: a neurologically neglected presentation. Journal of Neurology. 2012; 259(1):4-21. [pubmed]
  7. Halmagyi GM, Curthoys IS, Colebatch JG, Aw ST. Vestibular responses to sound. Annals of the New York Academy of Sciences. 2005; 1039:54-67. [pubmed]


Argyll Robertson Pupils


Other Known Aliases – Prostitute’s Pupil

Definition – Small, bilateral pupils with an absence of miotic reaction to light, both direct and consensual, with preservation of miotic reaction to near stimulus.  In other words, they accommodate, but do not react light (light-near dissociation).

Clinical Significance Classically associated with tabes dorsalis of neurosyphylis, but can also be seen in diabetic neuropathy.  Rare now due to the widespread of antibiotics and treating early syphilis infections

History – Named after Douglas Moray Cooper Lamb Argyll Robertson (1837-1909), who was a Scottish surgeon and ophthalmologist and one of the first to specialize in the eye.  He published his findings of several case reports in two articles in the “Edinburgh Medical Journal” in 1869.  Previous to this however, he was also the first to discover and use the extract of the Calabar bean (otherwise known as physostigmine) for treatment of various eye disorders.

“Dougie”, as his friends called him****


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Robertson DA. On an interesting series of eye symptoms in a case of spinal disease, with remarks on the action of belladonna on the iris. Edinb Med J. 1869;14:696–708.
  6. Robertson DA. Four cases of spinal myosis with remarks on the action of light on the pupil. Edinb Med J. 1869;15:487–493
  7. Robertson, D. A.:  On the Calabar Bean as a New Agent in Ophthalmic Medicine.  Edinb Med J. 1863;93:815-820.

****I have no source for this but he looks like a Dougie….plus with a name like Douglas Moray Cooper Lamb Argyll Robertson, you have to have a nickname, right?



6-year-old boy is brought in my his mother to the office for evaluation of a 3-day history of irritability, fever, and ear pain.  She also says that his older sister has had a cold the past week, but it doesn’t seem to be that bad.  He is up to date on his immunizations.  She also report she has had an intermittent, non-productive cough, but denies any decrease in eating/drinking, diarrhea, or vomiting.


Vital signs show a BP-117/72, HR-94, RR-16, O2-100%, and T-99.2.  Physical exam reveals:

  • General – Non-toxic appearing, NAD, WN/WD
  • Skin – no rash
  • Eye – sclera white, conjunctiva clear
  • Ear – (below)


  • Throat – OP clear, no erythema or tonsillar swelling
  • Neck – no LAD
  • Heart – RRR without M/G/R
  • Lung – CTA without adventitial sounds
  • Abdomen – S/NT/ND
  • PV – 2+ pulses throughout, BCR < 2s
  • Neuro – No focal deficits


Mother is wanting an antibiotic because the holiday season is here and she can’t afford to have him sick.

  1. What is your diagnosis?
  2. What is your treatment?
  3. What do you tell the mother?


  1. Diagnosis
    1. Viral Otitis Media
      1. Based on the 2013 consensus guidelines from Pediatrics, the following findings suggests a viral etiology:
        1. Non-toxic appearance
        2. Non-bulging tympanic membrane
        3. > 48hr onset of symptoms
        4. Temperature < 39°C (102.2°F)
        5. No middle ear effusion
  2. Treatment
    1. Given the patient’s age (6yo), there are 2 acceptable options:
      1. Observation
        1. This is the ideal patient for close observation as it is most likely viral, immunocompetant, no ottorhea, no severe symptoms, and non-toxic appearing.  Treatment should be directed towards pain control and recommendations should be given to the parents on how to treat:
          1. Ibuprofen – 10mg/kg TID
          2. Acetaminophen – 10mg/kg TID
          3. Topic antipyrine/benzocaine – no longer available
          4. Topical lidocaine – off label, but can be used
      2. Antibiotic Therapy
        1. If the patient fails to improve in 48-72hr, then antibiotics are warranted. Duration of therapy for children > 2yo is 5-7 days.


Case Resolution

After examination of the patient and discussion with the mother, you recommend a course of MICOS:

Masterful Inactivity with Catlike Observations

You explain that his symptoms are likely viral and self-limiting and the best thing for him now is to control his pain.  You give the dosing guidelines for ibuprofen and acetaminophen and offer a prescription of topical lidocaine.  You encourage the mother to call back to the clinic in 3 days time if he is not improving, at which time you will call in a prescription for antibiotics.



  1. Lieberthal AS, Carroll AE, Chonmaitree T. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-99. [pubmed]
  2. Bolt P, Barnett P, Babl FE, Sharwood LN. Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial. Archives of Disease in Childhood. 2008;93(1):40-4.  [pubmed]

#24 – Retinal Detachment



A retinal detachment is defined as a separation of the multilayer neurosensory retina from the underlying retinal pigment epithelium and choroid.



Retinal detachments have been reported to occur in 6-20 per 100,000 population worldwide, but there is wide variability in incidence between the types.  Risk factors include:

  • Myopia (most common)
  • Age (50-75yr)
  • Previous eye surgery or injury
  • Use of fluoroquinolones
  • History of glaucoma
  • Family history of retinal detachment
  • Diabetes
  • Hypertension

Pathophysiology and Types

There are 2 main types of retinal types and the pathophysiology is slightly different.

  • Rhegmatogenous (most common)
    • Full-thickness tear caused by vitreous traction on the retina
      • Not to be confused with tractional detachment
        • RRD à tear 1st, then vitreous traction forces fluid in
        • TRD à traction pulls the layers away, but no tear
      • Most common site is a posterior vitreous detachment
        • Typically take weeks to months to fully develop
      • Traumatic retinal detachment can occur from surgery or injury
  • Nonrhegmatogenous
    • Tractional
      • Vitreous traction separates the layers and neovascularization from DM, HTN, sickle cell causes fluid to accumulate
    • Exudative
      • Fluid accumulation from inflammatory states or ocular malignancies causes the separation of layers


Signs and Symptoms

  • Mostly slow onset (weeks to months), but can be acute if traumatic
  • Increase, or worsening of floaters
    • Multiple, cob-web like
    • Single, large
      • Romans called this “mosca volante” –> large housefly
  • Gradual loss of peripheral vision (“curtain pulled over eye”)
  • Decrease in visual acuity once the macula is involved

Physical Exam

All patients with any eye complaint should have visual acuity checked and documented.  If you suspect a detachment from the history, visual fields should be assessed.  Fundoscopic exam should be performed to look for any gross retinal defects.  All patients with a suspected retinal detachment should be referred for urgent evaluation by an ophthalmologist for dilated retinal exam with slitlamp.  The test of choice is a 360o scleral depressed examination using an indirect ophthalmoscope.


Rhegmatogenous Retinal Detachment

Rhegmatogenous Retinal Detachment


Tractional Retinal Detachment


Exudative Retinal Detachment


Ultrasound technology is getting better and better and ocular scanning can see detachments at the bedside in the hands of a competent provider.


  • Detachment without tear
    • Reassurance that floaters with resolve over 3-12 months
  • Tear without detachment
    • Risk of detachment is around 30% if left untreated
    • 2 options
      • Laser Retinopexy
      • picture1

      • Cryoretinopexy
        • (see below scleral buckling video)
      • Both take approximately 2 weeks to form strong adhesions
    • Tear with detachment
      • Without treatment, will progress to complete vision loss
      • Small tears
        • Laser or cryoretinoplexy
      • Large tears
        • Pneumatic retinopexy (office)
          • Cryoretinopexy with injection of gas bubble and head position to tamponade the tear
          • 24-48hr for fluid reabsorption and retinal re-attachment
          • 70-80% 1st time success
        • Scleral buckle (OR)
          • Cryoretinopexy with suturing of an exoplant to the outside of the sclera, which causes an indentation in the wall of the eye
          • picture1
          • 80-90% 1st time success
        • Vitrectomy
          • Removal of central and peripheral vitreous humor with gas or liquid injection
          • 80-90% 1st time success


  1. Mitry D, Charteris DG, Fleck BW, Campbell H, Singh J. The epidemiology of rhegmatogenous retinal detachment: geographical variation and clinical associations. The British Journal of Ophthalmology. 2010;94(6):678-84. [pubmed]
  2. Wilkes SR, Beard CM, Kurland LT, Robertson DM, O’Fallon WM. The incidence of retinal detachment in Rochester, Minnesota, 1970-1978. American Journal of Ophthalmology. 1982;94(5):670-3. [pubmed]
  3. Haimann MH, Burton TC, Brown CK. Epidemiology of retinal detachment. Archives of Ophthalmology (Chicago, Ill. : 1960). 1982; 100(2):289-92. [pubmed]
  4. Risk factors for idiopathic rhegmatogenous retinal detachment. The Eye Disease Case-Control Study Group. American Journal of Epidemiology. 1993;137(7):749-57. [pubmed]
  5. Pasternak B, Svanström H, Melbye M, Hviid A. Association between oral fluoroquinolone use and retinal detachment. JAMA. 2013;310(20):2184-90. [pubmed]
  6. Go SL, Hoyng CB, Klaver CC. Genetic risk of rhegmatogenous retinal detachment: a familial aggregation study. Archives of Ophthalmology (Chicago, Ill. : 1960). 2005;123(9):1237-41. [pubmed]
  7. Hikichi T, Trempe CL, Schepens CL. Posterior vitreous detachment as a risk factor for retinal detachment. Ophthalmology. 1995;102(4):527-8. [pubmed]
  8. Wolfensberger TJ, Tufail A. Systemic disorders associated with detachment of the neurosensory retina and retinal pigment epithelium. Current Opinion in Ophthalmology. 2000;11(6):455-61. [pubmed]
  9. Hollands H, Johnson D, Brox AC, Almeida D, Simel DL, Sharma S. Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA. 2009;302(20):2243-9. [pubmed]
  10. Byer NE. Natural history of posterior vitreous detachment with early management as the premier line of defense against retinal detachment. Ophthalmology. 1994;101(9):1503-13. [pubmed]
  11. Coffee RE, Westfall AC, Davis GH, Mieler WF, Holz ER. Symptomatic posterior vitreous detachment and the incidence of delayed retinal breaks: case series and meta-analysis. American Journal of Ophthalmology. 2007;144(3):409-413. [pubmed]
  12. D’Amico DJ. Clinical practice. Primary retinal detachment. The New England Journal of Medicine. 2008;359(22):2346-54. [pubmed]
  13. Hilton GF, Tornambe PE. Pneumatic retinopexy. An analysis of intraoperative and postoperative complications. The Retinal Detachment Study Group. Retina (Philadelphia, Pa.). 1991;11(3):285-94. [pubmed]
  14. Tornambe PE, Hilton GF. Pneumatic retinopexy. A multicenter randomized controlled clinical trial comparing pneumatic retinopexy with scleral buckling. The Retinal Detachment Study Group. Ophthalmology. 1989;96(6):772-83. [pubmed]