Mouth Nose and Pharynx diseases

Allergic rhinitis

§Hallmarks of Allergic Rhinitis:

§Sneezing & clear watery rhinorrhea

§Conjunctival, nasal, and pharyngeal itching

§Swollen/edematous nasal turbinates

§Nasal mucosa is pale, boggy, and edematous

§Allergic shiners – dark circles beneath the eyes caused by venous congestion

§Allergic salute – upward rubbing of the nose with the palm due to nasal itching

• May result in a transverse nasal crease from repeated rubbing

Dx: percutaneous testing (skin prick)

Tx:

non pharm:

• Avoidance

●Change air filters, clean carpets

●Keeping pets out of the bedroom and minimizing dust mite exposure

●Stay indoors as much as possible when pollen counts are high

pharm:

loratadine (mild) + decongestant (short term)

fluticasone (moderate/severe)

long term: immunotherapy

vasomotor rhinitis

◦Nasal congestion, PND

§Mucosal tissue boggy, edematous, erythematous

Dx: allergic skin testing (R/O)

Tx:

• avoidance

• azelastine (antihist)

• topical intralnasal glucocorticosteroid

acute viral rhinosinisitis

§Symptoms of the common cold last < 4 weeks

§Peak at days 3-4 & resolve by day 10

§Symptoms:

• §Sneezing, Nasal congestion, Rhinorrhea

• §Fever, Chills, Malaise, Watery eyes

• §Cough, Myalgia

• §Nasal examination —> erythematous & edematous nasal mucosa

• §Watery nasal discharge

Tx:

non pharm:

• buffered hypertonic saline nasal irrigation

• pseudoephedrine

  • 120 mg BID

• oxymetazoline (nasal spray —> short term)

acute bacterial rhinosinusitis

Sx:

§Purulent nasal drainage

§Facial pain/pressure/fullness

§Cough

§Fever

§Dental pain

§Halitosis

Tx:

uncomplicated (watch and wait):

• NSAID or acetaminophen

• fluticasone (intranasal cortico)

• pseudoephedrine (decongest)

complicated (>10 days no improv, fever >102 +purulent discharge or facial pain >3-4days, double worsening):

• amox 5-7 days

  • pen allergy: doxy 5-7 days

chronic rhinosinusitis

at least 2 of the following cardinal symptoms for 12 consecutive weeks:

• §Nasal obstruction

• §Nasal drainage

• §Facial pain/pressure

• §Hyposmia/anosmia

§and

• §Objective evidence on PE: (mucopurulent drainage, edema, polyps in middle meatus), or  radiography (sinus CT)

Dx: non contrast CT

Tx:

• fluticasone

• saline nasal irrigation

• endoscopic sinusitis surgery if persistant and prev tx not work

nasal polyp

Sx:

Small polyps → Asymptomatic

§Airway obstruction

§Snoring

§Decreased or absent sense of smell

§Chronic mouth breathing§Smooth, rounded, and red in color

Dx: CT scan

Tx:

fluticasone

surgery: if massive/failure of prev tx

Epistaxis

Tx:

initial: sit up lean slightly forward and pinch nose 10-15 min

• if resolve observe 30 min before discharge

oxymetazoline (vaso constrict)

first line if see site:

• chemical silver nitrate or electrocautery

if persist: packing (balloon, gauze, etc

for posterior: pack+admit+ent

deviated septum

§Nasal obstruction / difficulty breathing

§Recurrent epistaxis

§Recurrent sinusitis

§Snoring / sleep-disordered breathing

§Headache or facial pressure

§Asymmetric/unequal nares

Tx:

pseudaephedrine, laratadine, fluticasone

surgery: septoplasty

leukoplakia

§White patch may become firm, rough, reddened or ulcerated

Usually painless

dont scrape off

Dx: Incisional biopsy

Tx:

◦STOP tobacco & alcohol, physical irritants

If SCC – local resection if less than 2 cm

◦Large tumors – resection, neck dissection & radiation

hairy leukoplakia

White, shaggy lesions on the lateral tongue in an immunocompromised patient → EBV-associated;

sialadentitis (salivary gland inflamm and infection)

§Pain and swelling, worse with eating

§Dry mouth

§Facial or glandular swelling/tenderness

§Purulent drainage from the duct

Trismus

Tx:

if bacterial: clindamycin

hydrate

warm compress

gland massage

sialogogues

drain if not improve

parotitis

§Sudden pain & swelling worsens with eating, redness, drainage

§Bilateral parotid involvement -> mumps and inflammatory conditions

Unilateral parotid swelling, pain, and presence of fever -> Bacterial cause

Tx:

Abx

warm compress

sialagogues

sialolithiasis (salivary gland stones)

calcific concretions

§Pathognomonic pain during meals & localized swelling

Tx:

§Hydration, moist heat massage, hydration, sialagogues (lemon drops)

§Incision of duct possible to remove

pharyngitis viral

Cough/coryza, conjunctivitis, hoarseness, diarrhea, cervical lymphadenopathy, fever & chills, viral exanthem, pharyngeal edema,ulcerative lesions

§Treatment

§Saline gargles, analgesics/antipyretics, anesthetic troches

§Tx URI symptoms

pharyngitis bacterial

•Fever >38°C (100.4°F)

•Tonsillar exudate

•Tender anterior cervical lymphadenopathy

 Typically absent: Cough

Dx: rapid antigen detection test

Tx:

Penicillin V

Pen allergy = azithromycin/clinda/cephalexin

peritonsilar abcess

sx:

◦Tonsillar pain suddenly worse on one side

◦Trismus

◦Dysphagia (swallowing pain)

◦“Hot potato” voice

◦Uvula deviated away from site

◦Drooling / foul breath

Tx;

• drainage

• Abx: in pt = vanc; out pt = augmentin

epiglottis

§Sore throat, Dysphagia, Muffled voice, Stridor, Drooling, Severe pain on palpation of larynx, Tripod position

Dx:

lateral X ray = thumb print

Tx: hospitalize

Abx: ceftriaxone + vanc

viral laryngitis

§Hoarseness*

§Painful cough

§Stridor & dyspnea

edema/erythema

Hemoptysis w/ cough

Sx:

voice rest/hydrate

avoid tobacco

symptomatic (tx cough)

vocal cord nodules

Breathiness, multiple tones, loss of vocal range, vocal fatigue or loss of voice

Raspy, harsh, scratchy voice

Dx: laryngoscope

Tx:

voice modification habits

refert o speech therapist

vocal cord paralysis

§Hoarseness, breathy voice quality, coughing, loss of vocal pitch

Dx: laryngoscopy

Tx:

voice therapy/surgery

laryngeal leukoplakia

Sx: white on larynx

Dx: laryngoscopy/biopsy

Tx: eliminate risk factor and ENT referral

Laryngeal SCC

§Persistent/progressive hoarseness*

§Dysphagia/odynophagia

§Neck mass

§Hemoptysis

§Weight loss

• tobacco = huge RF

laryngeal papillomatosis

 Symptoms: Hoarseness that progress weeks -> months, lesions in throat

• §Grow quickly, issues w/ swallowing/breathing, hoarseness, coughing

 Diagnosis: Laryngoscopy

 Treatment: Repeated laser vaporizations or cold knife resections via operative laryngoscopy

laryngeal pharyngeal reflux

 Symptoms:

§Hoarseness/dysphonia, globus sensation, chronic cough, frequent throat clearing, throat irritation/sore throat, and occasional dysphagia.

§Many patients do not report classic heartburn.

Dx:

• laryngoscopy

Tx:

avpid tobacco/irritants

manage wewight

no meals close to bed