Medicine Exam 3: Disorders of the Ears/Nose/Sinuses

Cerumen Impaction 

Definition 

• Obstruction of ear canal (full or partial) from ear wax 

Causes 

• Overproduction of cerumen

• Abnormal migration of cerumen from the canal

• External factors pushing the wax deeper

• Narrow or torturous ear canal anatomy 

Risk Factors 

• Cotton swab use

• Hearing aids 

• Older

• Developmental delays

• Hair ear canals

• Previous history 

S/S

• Conductive hearing loss

• Ear fullness/pressure

• Tinnitus

• Otalgia (ear pain)

• Dizziness

• Cough reflex 

• Complications 

  • Chronic hearing loss

  • Tympanic membrane injury

  • External otitis (retained moisture)

  • Canal stenosis from trauma

  • Perforation from irrigation

Diagnosis 

• History taking

• Physical exam with otoscope 

• Can do audiometry and/or Weber/Rinne test is hearing loss is suspected 

Management

• Cerumen removal: manual with curette, irrigation, or suction (choose based on consistency and patient factors)

• Ceruminolytics: mineral oil, H2O2, or commercial 

• Prevention education 

Conductive Hearing Loss

Definition

• Hearing impairment caused by pathology in the EAC or middle ear that prevents sound waves from reaching the inner ear 

Causes 

• Outer ear: cerumen impaction, foreign body, external otitis, congenital (aural atresia)

• Middle: otitis media, chronic otitis media, otosclerosis, ossicular chain disruption

• Tympanic membrane: perforation, scarring, retraction, cholesteatoma  

Risk factors

• Frequent URI

• Allergic rhinitis

• Cleft palate

• Down syndrome

• Chronic ear infections

• Excessive ear wax

S/S

• Mild to moderate hearing threshold 

• Sound clarity is good when loud enough 

• Bone > air conduction 

• Rare tinnitus 

• Preserved speech understanding 

• Muffled or blocked sensation that is sudden or gradual 

Diagnosis 

• History taking 

• Otoscopy, Weber (lateralizes to affected ear) and Rinne test, neurologic 

• Audiometry 

• Advanced testing: MRI or CT 

Management

• Medical: antibiotics for infection/steroids for inflammation 

• Surgical: tympanoplasty 

• Cerumen or foreign body removal

• Hearing aids 

• Bone conduction devices 

• Referral 

Sensorineural Hearing Loss

Definition

• Hearing impairment resulting from dysfunction of the cochlea, auditory nerve, or central auditory pathways 

Causes 

• Acquired

  • Presbycusis

  • Noise induced

  • Medications (ototoxic: amino-glycosides, cisplatin, loop diuretics)

  • Infectious (HSV)

  • Sudden idiopathic

  • Meniere’s

  • Acoustic neuroma  

• Genetic 

  • Mutations 

  • Congenital defects (CMV, rubella)

  • Birth trauma 

  • Premature 

Risk factors 

• Advanced age (> 65)

• Noise exposure 

• Family history 

• DM/autoimmune 

S/S

• Variable hearing threshold

• Poor sound clarity (can be distorted)

• Bone and air conduction both affected

• Common tinnitus

• Speech understanding often impaired

• Gradual and bilateral with high frequency hearing loss

• Sudden presents within 72 hours and is an emergency

Diagnosis

• History 

• Otoscopy, Weber (lateralizes to better/unaffected ear) and Rinne, neurologic, speech discrimination 

• Audiometry 

• Advanced: MRI (asymmetrical sudden) 

Management 

• Sudden: need corticosteroids

• Hearing aids

• Cochlear implants

Vertigo

Definition

• False sensation of movement, either of oneself or the environment

Types

• Peripheral

  • Originates from inner ear

  • Severe, rotary, intermittent with hearing symptoms and horizontal nystagmus

  • Also have N/V, tinnitus

  • Common causes: BPPV, Meniere’s, vestibular neuritis, labrynthitis, vestibular neuronitis

• Central

  • Originates from brainstem or cerebellum

  • Mild, non-rotatory, continuous without hearing loss, vertical nystagmus

  • Have motor, sensory, or cerebellar defects

  • Common causes: vestibular migraine, MS, stroke, tumor

Risk factors

• Older

• Female

• Prolonged recumbency

• Head trauma 

• Vitamin D deficiency

• Osteoporosis 

Diagnosis

• Dix-Hallpike test → rapid movement from sitting to head-hanging position → will have rotatory nystagmus with vertigo (BPPV)

• Supine Roll test → head rotates while supine → horizontal nystagmus (horizontal canal BPPV)

• Head impulse test → rapid head movement while fixing gaze → corrective saccade (vestibular hypo-function 

• Romberg test → standing with feet together with eyes closed → increased sway (vestibular dysfunction) 

BPPV

Definition 

• The most common cause of recurrent, brief vertigo triggered by changes in head position 

• Displaced otoconua (calcium cabronate) from utricle move into the semicircular canal → canalolithiasis (may have cupulolithiasis) → inappropriate stimualtion with head movement 

S/S

• Sudden, brief episode of vertigo that lasts less then 60 seconds 

• Accompanied by nausea, imbalance, and sometimes vomiting 

• Fatigue with repeated movements 

• No associated hearing loss or tinnitus 

Triggers 

• Looking up or down 

• Rolling over in bed/getting in and out of bed

• Tilting the head 

• Any rapid head movement 

Physical Exam 

• Full neurological exam 

• Dix-Hallpike test → induces vertigo and looking at nystagmus (fatigues with repeated testing: would go away)

Treatment 

• Epley Maneuver/Canalith Repositioning → gold standard 

• Vestibular therapy 

• Medications: vestibular suppressants (meclizine) not recommended 

• Patient education 

Vestibular Neuritis

Definition

• Acute, spontaneous and prolonged loss of vestibular function

Causes

• Viral reactivation (HSV1)

• Other: vascular compromise, immune mediated inflammation

• Common risk factor: URI

S/S

• Acute, sustained vertigo (intense rotational sensation lasting days)

• Horizontal torsional nystagmus (beating away from affected ear)

• Abnormal head impulse test

• Postural imbalance

• Absence of hearing loss

• N/V

Diagnosis

• Clinical examination

• head impulse test

Treatment

• Symptomatic care in acute phase: use vestibular suppressants (promethazine, meclizine) for a few days

• Corticosteroids may improve peripheral recovery (may not help long term)

• Vestibular rehab

• Emphasize the benign nature and recovery

• Importance of early mobilization and vestibular rehab

Tinnitus

Definition

• Perception of sound → ringing, buzzing, hissing, roaring

Types

• Subjective: sound perceived only by the patient (abnormal neural activity in the auditory pathway)

• Objective: sound that can be heard by examiner (can be from pulsatile: need to explore more)

Causes

• Hearing loss

• Ear conditions (cerumen impaction, Meniere’s)

• Ototoxic drugs: amino-glycosides, loop diuretics, chemotherapy, high dose aspirin, anti-malarial

• Acoustic neuroma

• AV malformation

Severity Assessment

• Sleep disturbance

• Social function

• Concentration issues

• Emotional impact

Diagnosis

• History taking

• Physical exam: otoscope, neurologic exam, auscultation for objective, Weber and Rinne test

• Audiometric testing

• Additional (checking for pulsatile)

Management 

• Address underlying causes

• Sound therapy 

• Behavioral interventions: cognitive behavioral for persistent 

• Medical treatment: antidepressants (severe)

Meniere Disease 

Definition 

• Chronic disorder of inner ear with recurrent episodic vertigo, fluctuating sensorineural hearing loss, and tinnitus, with aural fullness 

• Idiopathic 

• May have endolymphatic hydrops (excess fluid in labyrinths), increased pressure 

S/S

• Classic tetrad: fluctuating hearing loss (may become permanent over time), tinnitus, episodic vertigo, aural fullness 

Diagnosis 

• Clinical 

• Essential tests: audiometry (determines fluctuating hearing loss), vestibular testing, tympanometry, MRI 

Treatment 

• Dietary modifications: low Na+, limit caffeine and alcohol 

• Acute attack: antihistamines, antimimetics, benzodiazepines

• Medical: diuretics, steroid injections for refractory 

• Surgery 

Acoustic Neuroma

Definition

• Intracranial benign tumor from Schwann cells of the vestibulocochlear nerve

• Have Schwann cell proliferation → nerve compression → may have brainstem effects from large tumors

Causes/Risk factors

• Sporadic (95%)

• Neurofibromatosis type 2 with mutation on chromosome 22 → 5% of cases, bilateral, and younger age

• Radiation exposure

• Age (40-60)

S/S

• Early: unilateral progressive hearing loss, tinnitus, mild imbalance

• Intermediate: facial numbness or weakness, more balance issues, aural full sensation

• Advanced: severe ataxia, hydrocephalus symptoms, brainstem compression signs

Diagnosis

• Clinical suspicion: asymmetric sensorineural hearing loss that is sudden/rapid

• Gold standard: MRI with contrast

Treatment

• Observation

• Microsurgical resection (large tumors, young age, growing)

• Stereotactic radio-surgery (small-medium tumors and/or poor surgical candidates) → want tumor control, not removal

• Hearing loss can be permanent

Labyrinthitis

Definition

• Inflammation of the membranous or bony labyrinth of the inner ear, involving both the vestibular and cochlear structures → vertigo, hearing loss, and tinnitus

Causes

• Viral: most common type (HSV, Varicella, CMV, EBC) → acute vertigo with hearing loss

• Bacterial (meningitis, chronic otitis media complications, S. pneumoniae, H. influenzae, N. meningitides) → need urgent treatment

• Autoimmune

S/S

• Vestibular symptoms: acute onset vertigo with imbalance and ataxia, N/V

• Auditory symptoms: sudden unilateral sensorineural hearing loss with tinnitus and/or aural fullness

• Systemic symptoms: fever, malaise and fatigue, URI

Diagnosis

• Clinical history

• Otoscopy, neurologic exam, Dix-Hallpike test, head impulse

• Audiometric

• Lab: CBC if infection, MRI

Treatment

• Corticosteroids (prednisone) for hearing loss

• Vestibular rehab

• Refractory: infiximab

• Symptomatic: anti-histamines, anti-mimetics

• Antibiotic if bacterial

Eustachian Tube Dysfunction

Definition

• Does not adequately ventilate, protect, or drain the middle ear

Types

• Obstructive

  • Physical blockage preventing tube opening from mucosal inflammation (URI, allergic rhinitis) or from mechanical (alcohol tumors)

• Functional

  • Inadequate muscular opening of the tube from inefficient muscles, cleft palate

• Patulous

  • Chronically open tube from weight loss, pregnancy, medications, radiation therapy

S/S

• Pressure: ear fullness, pain with altitude changes, sensation of fluid

• Auditory: conductive hearing loss, auto phony (hearing own voice loudly), tinnitus

• Balance: mild imbalance, occasional vertigo

Diagnosis

• Clinical

• Otoscopy (TM retracted, air-fluid level )

• Audiologic

• Nasopharyngoscopy for masses

• CT for chronic 

Treatment 

• Nasal decongestants and/or corticosteroids 

• Anti-histamines 

• Valsalva 

• Autio-insufflation 

• Myringotomy with tubes for chronic 

• Balloon dilation 

• Removal of adenoids 

• Laser tuboplasty (for patulous) 

Otitis Externa 

Definition 

• Inflammation/infection of the EAC 

Causes 

• PsA 

• S. aureus

• Strep 

• Fungal: candida, Aspergillus 

Risk factors 

• Moisture and retention (swimming, humid environment)

• Trauma and infection (cotton swabs)

• Dermatologic conditions (eczema, psoriasis, allergic reactions)

• Anatomical: narrow ear canals, excessive ear hair, absence of cerumen 

• DM (can become very complicated), immunocompromised

S/S

• Primary: severe ear pain (with tragus and pinna pull), conductive hearing loss, itching and ear fullness, otorrhea 

Diagnosis 

• See erythematous, swollen canal with white, yellow, or green drainage

• + tragus/pinna pull 

• Possible lymphadenopathy 

• Canal edema: may block TM

• Must have rapid onset, otalgia and tragus tenderness, canal erythema and edema, and discharge/debris

Treatment 

• Topical antibiotics

• Oral antibiotics for immunocompromised (Neomycin/polymyxin B/hydrocortisone otic) 

• Topical amino-glycosides (tobramycin and gentamicin) effective against S. aureus and PsA

• Severe: wick placement or oral antibiotics if cellulitis extends beyond the ear canal (Cipro)

Otitis Media

Definition

• Inflammation/infection of middle ear

Types

• AOM

  • Rapid onset with signs of middle ear inflammation and effusion (usually bacterial)

• Otitis media with effusion

  • Retained fluid in middle ear without acute infection signs (often follows AOM or from Eustachian tube dysfunction, barotrauma, recent viral URI, or allergic rhinitis)

• Chronic

  • Persistent (> 3 months), often with perforation of the TM

Major risk factors

• Age 6-24 months

• Daycare attendance

• Bottle feeding

• Smoke exposure

• Craniofacial abnormalities

• Immunodeficiency

S/S

• AOM

  • Severe otalgia, fever > 38.5, tugging on ear, bulging, red tympanic membrane, decreased mobility on pneumatic, loss of landmarks, ± effusion, possible perforation 

• Otitis media with effusion

  • Usually painless, hearing loss, ear fullness, retracted or neutral TM, air fluid levels, reduced TM mobility 

• Complications

  • Intracranial: meningitis, brain abscess, sigmoid sinus thrombosis, subdural empyema

  • Local: facial nerve paralysis, chronic perforation, cholesteatoma 

  • Developmental: speech delay

Diagnosis 

• Definitive: visualization of TM with pneumatic otoscopy 

• Tympanometry if available 

• Acoustic reflectometry 

• Audiometry for severe 

Treatment 

• Observation: low risk cases in children > 6 months with mild s/s (pain control) and need reliable follow up

• AOM antibiotic: 

  • Children: amoxicillin (amoxicillin clavulanate [Augmentin] if recent antibiotic use/cephalosporins for penicillin allergy) 

  • Adults: amoxicillin clavulanate, amoxicillin, Cefednir

• OEM: waiting

  • Tympanostomy tubes considered when recurrent AOM if persistent OEM with hearing loss or development delay

Cholesteatoma

Definition

• Abnormal collection of keratinizing squamous epithelium in the middle ear: begins benign but locally destructive (have potential for bone erosion and serious complications)

Types

• Congenital: present at birth and have closed TM

• Primary acquired: retraction pocket

• Secondary acquired: through TM perforation or chronic OM

Causes/Risk factors

• Negative middle ear pressure (Eustachian tube dysfunction → leads to retraction)

• Retraction pocket formation

• Epithelial accumulation

• Bone erosion from enzymatic activity and pressure

S/S

• Early: painless, progressive hearing loss with intermittent foul smelling discharge, ear fullness, and mild tinnitus

• Advanced: otorrhea, conductive hearing loss, vertigo, facial nerve weakness (rare)

• Complications

  • Facial nerve paralysis

  • Sensorineural hearing loss

  • Labyrinthitis and vertigo

  • Intracranial infection

  • Recurrent disease

Diagnosis

• Physical: white pearly mass behind TM, retraction pocket, keratin flakes, TM perforation possible

• Otoscope

• Need CT scan for surgical planning and complications (may need MRI to evaluate extention)

• Audiometric testing

Management

• Definitive: surgical removal

Otosclerosis

Definition

• Abnormal bone remodeling in the temporal bone → progressive conduction hearing loss through stapes fixation

• Have abnormal remodeling in the fissula ante fenestram → involves the oval window and stapes footplate

  • Active: increased osteoclastic activity

  • Inactive: sclerotic bone formation

  • Results in stapes immobilization

• MCC of conductive hearing loss in adults

Causes

• Genetic (AD)

• Female

• Caucasian

• Pregnancy

• Autoimmune

• Prior measles

S/S

• Slowly progressive painless hearing loss

• Bilateral

• Tinnitus

• Paracusis of Willis (hearing better in noise)

Diagnosis

• Normal otoscopic examination

• Schwartz sign (rare): pink hue behind TM

• Audiometric testing: air bone gap and Carhat notch

• Tympanometry

• Tuning fork tests

• High resolution CT

Management 

• Conservative: hearing aids, assistive devices, observe 

• Definitive is surgical (remove stapes and replace it)

TM Perforation 

Definition 

• Communication between the auditory canal and middle ear 

Causes 

• Traumatic

• Infectious (OM)

• Iatrogenic

S/S

• Acute

  • Sudden onset of pain followed by relief

  • Bloody, serous or purulent discharge

  • Immediate conductive hearing loss

  • Tinnitus or vertigo

  • Sensation of air movement in the ear

• Chronic

  • Persistent conductive hearing loss

  • Recurrent otorrhea

  • Ear fullness

• Complications

  • Chronic OM

  • Cholesteatoma 

  • Ossicular chain disruption 

  • Facial nerve injury (rare)

  • Hearing loss

  • Chronic mastoiditis 

Diagnosis

• Careful otoscopy

• Audiometry

• Tuning forks

• Culture if purulent discharge

Treatment

• Immediate care: keep ear dry, avoid nose blowing, and provide pain control (antibiotic drops only if infection suspected) with referral

• Observation period: small often heal within 6-8 weeks and monitor for signs of infection

• Surgical repair: tympanoplasty and/or myringoplasty for large and chronic perforations > 3 months with recurrent infections and/or significant hearing loss

Mastoiditis

Definition

• Serious bacterial infection of the mastoid air cells, typically caused by complicated or untreated AOM

• Mucosal edema blocks the drainage pathways → bacteria proliferate in the air cells → progressive bone destruction → intracranial extension

Types

• Acute: < 6 weeks

• Chronic: > 3 months

• Coalescent: bone destruction

Causes

• S. pneumoniae, S. pyogenes, S. aureus

• Kids under the age of 2

S/S

• Early signs

  • Persistent fever despite AOM treatment

  • Otalgia that worsens and continued purulent discharge/hearing loss

• Progressive

  • Protrusion of auricle

  • Tenderness over mastoid process

  • Post-auricular erythema and swelling

• Complications

  • Intracranial extension

  • Meningitis

  • Facial nerve paralysis

  • Labyrinthitis

  • Abscess 

Diagnosis

• Clinical

• Labs: CBC, ESR, CPR, leukocytosis 

• CT/MRI (expansion)

• Microbiology studies 

Treatment 

• Medical: IV antibiotics (ampicillin-clavulanate, add vancomycin if MRSA)

• Surgery for complications, treatment failure, or bone destruction (mastoidectomy)

Epistaxis 

Definition 

• Bleeding from the nasal cavity 

Types 

• Anterior: Kiesselbalch’s (most common)

• Posterior: sphenopalatine (can be severe enough to cause hypotension, nausea, hematemesis, anemia)

Causes 

• Nasal trauma 

• Dry air 

• Nasl infections 

• Nasal polyps 

• Cocaine 

• HTN and CVD 

• Coagulopathy and anticoagulant use 

• Liver disease 

• Risk factors 

  • Bimodal (2-10 and >50)

  • Medication induced: anticoagulants, anti-platelet, NSAID, nasal sprays

  • Environmental

S/S

• Red flags: recurrence, dizziness, N/V, heavy bleeding

• Complications 

  • Hemorrhagic shock 

  • Aspiration 

  • Nasal packing complications: septal perforation 

  • Recurrent bleeding 

  • Nasal deformity 

Diagnosis

• Good OPQRST (unilateral vs bilateral)

• Initial: vital signs, airway patency, visual inspection of nasal cavity)

• Physical exam: rhinoscopy to determine source

• Lab: CBC, PT/PTT

Treatment

• Direct pressure on soft part of nose for 10-15 minutes while sitting upright and leaning forward

• Topical: vasoconstrictors and hemostatic agents

• Advanced: cauterization with silver nitrate or electrocautery 

• Refractory → anterior nasal packing (should be prescribed amoxicillin clauvulanate)

Nasal Polyps

Definition 

• Benign, inflammatory masses from the nasal mucosa and paranasal sinuses from chronic inflammation and edema (usually from ethmoid sinus and extend into nasal cavity)

Causes 

• Chronic inflammation 

• Genetics 

• Type I hypersensitivity 

• Bacterial and fungal infections 

Risk factors 

• Asthma and aspirin sensitivity (Samter’s triad)

• Male

• Chronic rhino sinusitis

• Genetics  

• Associated conditions: CF, primary ciliary dyskinesia, Churg Strauss 

S/S

• Nasal obstruction 

• Anosmia/hyposmia 

• Rhinorrhea

• Facial pressure 

• Complications 

  • Complete nasal obstruction

  • Sleep disordered breathing

  • Secondary bacterial sinusitis

  • Permanent anosmia, altered taste

  • Rare: intracranial extension, orbital complications, malignant transformation

Diagnosis 

• Anterior rhinoscopy → pale, gray, translucent masses that are mobile and insensate 

• Nasal endoscopy: gold standard for visualization 

• CT 

Treatment 

• Topical corticosteroids 

• Systemic steroids for acute exacerbations or pre-op polyp reduction 

• Adjunctive therapies: saline irrigation, biologics 

• Surgery for severe obstruction or failure of medical therapy (relapse is common)

Rhinitis

Definition

• Inflammation of the nasal mucosa characterized by nasal congestion, rhinorrhea, sneezing, nasal itching, and/or post nasal drainage

Types

• Allergic: IgE mediated (predictable patterns)

• Non-allergic: vasomotor, hormonal, and drug induced subtypes

Allergic

• Sensitization phase (have IgE production and mast cell sensitization without s/s) → early phase response (re-exposure triggers mast cell degranulation and histamine release) → late phase response (inflammatory cell infiltration 4-12 hours later causes prolonged s/s and tissue remodeling)

Risk factors

• Genetic (atopy)

• Environmental

• Younger age

• Female

S/S

• Allergic: seasonal, clear and watery nasal discharge, sneezing and itching, triggered by allergen, excellent response to anti-histamines, allergic shiners (blue discoloration below the eyes), boggy or bluish mucosa

• Non-allergic: variable duration, clear nasal discharge, post nasal drip, triggered by changes in humidity, odor, temperature, alcohol, overuse of nasal sprays, do not have sneezing and itching)

• Complications

  • Sleep disturbances

  • Sinusitis development (impaired sinus drainage predisposes someone to bacterial superinfection)

  • Otologic complications (Eustachian tube dysfunction → OM)

  • Asthma exacerbation

Diagnosis

• Detailed history

• Nasal examination: pale/bluish

• Swollen turbinates

• May have scleral injection, infraorbital swelling with darkening, cobble stoning

• Can do skin prick tests or serum specific IgE to identify the cause

Treatment

• Environmental control

• Anti-histamines

• Intranasal corticosteroids (for moderate-severe): best for single therapy but tend to combine with anti-histamines (good prophylaxis)

• Immunotherapy (allergen specific)

• Leukotriene receptor antagonist

• Vasomotor: irritant avoidance, saline or anti-histamine spray, intranasal corticosteroids, decongestants

• Medicamentosa: d/c nasal decongestant and may need intranasal corticosteroids for withdrawal period

Acute Sinusitis

Definition

• Symptoms < 4 weeks in duration with sudden onset and complete resolution (MCC: maxillary) and often follows URI

• Chronic inflammation → tissue remodeling and dysfunction

• Mucociliary dysfunction → mucus stasis and bacterial overgrowth

• Ostial obstruction

• Secondary infection

Causes

• Most commonly caused by virus

  • Symptoms generally lasting less then 10 days

  • Lack severe or worsening s/s

  • Spontaneous resolution or improvement

• Bacterial: S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus

  • S/S last beyond 10 days without improvement

  • Severe s/s: high fever, purulent nasal discharge, facial pain for > 3 days

  • Double worsening pattern (initial improvement followed by deterioration)

Risk factors

• Predisposing: URI, allergic rhinitis, environmental, nasal polyps, dental infections

• Host factors: immunocompromised, CF and ciliary disorders, GERD, smoking

S/S

• Cardinal: purulent nasal discharge, nasal congestion, nasal obstruction, facial pain/pressure, hyposmia

• Associated: fever, maxillary dental pain, ear pressure, fatigue

• Complications

  • Orbital: cellulitis, abscess, orbital apex syndrome 

  • Intracranial: meningitis, epidural/brain abscess, cavernous sinus thrombosis 

  • Bone: osteomyelitis of frontal bone, mucocele

Diagnosis

• Physical findings: purulent discharge, facial tenderness to palpation, decreased transillumination

• CT not indicated 

Treatment 

• Viral: symptomatic (saline irrigation, intranasal steroids)

• Bacterial: amoxicillin clavulanate 

• Penicillin allergy: doxycycline or RFQs  

Chronic Sinusitis 

Definition 

• >12 weeks duration with persistent s/s despite medical therapy 

• Multifactorial: persistent inflammation, infection, allergy, and sometimes structural 

S/S

• Major criteria (>= 2 required): nasal obstruction/blockage, nasal discharge/postnasal drip, facial pain/pressure/fullness, reduced sense of smell

• Minor criteria: HA, ear pain/pressure/fullness, halitosis, dental pain

Diagnosis 

• Need objective data on nasal endoscopy/CT imaging 

Treatment 

• Intranasal corticosteroids and saline irrigation (systemic antibiotics and steroids reserved for acute exacerbations 

• Referral to ENT 

• Biologics 

• Unresponsive: surgery 

Pharyngitis

Definition

• Inflammation

Causes

• Viral (most common → flu, rhinovirus)

• Bacterial (GABHS)

• Other: allergic, GERD, trauma

Risk factors

• Environmental (close contact, seasonal, poor hand hygiene)

• Individual: younger age, smoking, allergies, recent URI

S/S

• Primary: sore throat with swallowing, scratchy throat sensation (pain usually worsens throughout the day)

• Viral: cough, conjunctivitis, nasal congestion, oropharyngeal vesicles (Coxsackie)

• GAS/bacterial: sudden onset of fever, palate petechiae, tonsillar exudate, vomiting, absence of cough, tender cervical lymph nodes

  • Complications: rheumatic fever, peritonsillar abscess, mastoiditis, glomerulonephritis, PANDAS

Diagnosis

• Physical: red pharynx and uvula, tonsillar exudate, cervical lymphadenopathy, soft palate petechiae, rashes (usually suggests bacterial)

• Centor criteria: tonsillar exudate, tender anterior cervical nodes, fever history, absence of cough (>=3: suggests bacterial)

• Rapid antigen test (high specificity)

• Throat culture: gold standard for GABHS (consider for negative rapid with high clinical suspicion)

Management

• Viral: supportive with analgesics and avoid aspirin in kids

• Bacterial: penicillin/amoxicillin (1-2 generation cephalosporin if penicillin allergy)

• Macrolides used for severe allergy

Tonsillitis 

Definition 

• Inflammation of palatine tonsils 

Causes 

• Viral: adenovirus, EBV, rhinovirus

• Bacterial: GA strep 

• Chronic changes: recurrent infections lead to tonsillar hypertrophy, cryptic debris accumulation, and potential airway obstruction 

S/S

• Mild: sore throat, minimal exudate, mild redness

• Moderate: odynophagia, tonsillar exudate, fever, cervical lymphadenopathy (may need antibiotics) 

• Severe: high fever, severe pain, limited oral intake, marked tonsillar enlargement, potential airway complication 

• Chronic: >= 7 in 1 year, >= 5 in 2 years, >= 3 in 3 years, antibiotic failure

Diagnosis 

• Physical Exam 

  • Grade the tonsils

• Lab: rapid strep test, CBC and heterophile antibody is suspected EBV

Treatment

• Surgical: tonsillectomy for recurrent/sleep disordered breathing/abscess

Peritonsillar Abscess (Qinsy)

Definition 

• Collection of pus between the tonsillar capsule and pharyngeal muscles (most common deep space neck infections in adults)

• Usually form posterior to the upper tonsillar pole (supra-tonsillar space)

Causes 

• Complication of acute tonsillitis 

• Infection of Weber’s gland (less common)

• Usually poly-microbial: Strep pyogenes dominant 

Risk factors 

• 20-40 y/o

• Male 

• Smoking 

S/S

• Classic triad: severe unilateral throat pain, fever and chills, difficulty swallowing 

• Emergency: drooling or inability to swallow, respiratory distress, neck stiffness, systemic toxicity 

Diagnosis 

• Physical exam: muffled voice, trismus, uvular deviation away from the abscess, unilateral tonsillar enlargement, enlarged cervical nodes, referred ear pain 

• Uncertain: intraoral or transcutaneous ultrasound 

• CT reserved for deep space extension

• Lab: CBC may show leukocytosis, needle aspiration confirms diagnosis

Treatment 

• Needle aspiration: first line 

• Incision and drainage 

•  Antibiotics (IV ampicillin sulbactam then transition to oral therapy after improvement: add vancomycin if concerned about MRSA)

• Supportive care 

Epiglottitis

Definition

• Inflammation and edema of the epiglottis

Causes

• H. influenzae used to be main pathogen → now have vaccine and is mainly S. pneumoniae, GAS, S. aureus, or viral (HSV, varicella zoster)

Risk factors

• Host: male, immunocompromised, DM, chronic renal failure, lack of vaccination

• Environmental exposure: smoking and alcohol, thermal injury, foreign body

S/S

• Adult: gradual onset over days with severe sore throat, odynophagia, fever, muffled voice (less common to have drooling and respiratory distress initially)

• Pediatric: rapid onset with high fever, drooling, limited oral intake, tripod, stridor, thumb sign on lateral neck X-ray, respiratory distress

• Waning: progressive respiratory distress, cyanosis, altered mental status

Diagnosis

• Physical

  • Pediatric: toxic, febrile, tachycardia and tachypnea, tongue protruding

  • Adult: toxic, febrile, cervical lymphadenopathy, erythema and warmth over anterior neck (can signify cellulitis)

• Primarily clinical

• Direct visualization of epiglottis: cherry red, swollen

  • Laryngoscopy gold standard in safe and stable adults but do not use in unstable patients or children

• Labs: CRP, leukocytosis (respiratory and blood cultures should be obtained to guide antibiotic treatment)

Treatment

• Airway

• Antibiotics: ceftriaxone (add vancomycin for MRSA)

• Supportive: IV corticosteroids, humidified O2

Laryngitis 

Definition 

• Inflammation of larynx and vocal cords 

Causes 

• Viral (most common) 

• Bacterial: often secondary to viral 

• Chronic: > 3 weeks (seen with laryngopharyngeal reflux: may include vocal cord polyps, nodules, or malignancy) → want referral to r/o malignancy 

• Non-infectious: voice overuse, laryngopharyngeal reflux, allergies, smoking, environmental

Risk factors 

• High risk occupation (public speakers, teachers)

• Smoking/alcohol 

• GERD 

• Allergic rhinitis 

• ET history 

S/S

• Hoarseness 

• Complete aphonia: severe inflammation 

• Throat irritation 

• Fever suggests concurrent URI 

Diagnosis 

• Physical exam: normal in viral

• Acute: < 3 weeks 

• Concerning: hemoptysis, dysphagia, unintentional weight loss, neck mass, smoking, progressive voice changes 

• Use laryngoscopy is hoarseness < 2-3 weeks, recurrent laryngitis, high risk patient, red flag s/s

Treatment 

• Voice rest

• Hydration and humidification 

• Analgesics for pain

• Address underlying cause 

Sialadenitis

Definition

• Inflammation of the salivary glands (most commonly parotid and submandibular)

Causes

• Acute viral: mumps (bilateral), EBV, parainfluenza, CMV

• Acute bacterial: S. aureus, Strep. viridian, anaerobic

• Chronic: Sjogrens, IgG4 related, sialolithiasis, radiation

Risk factors

• Patient factors: dehydration and poor oral hygiene, advanced age, immunocompromised

• Medications: anticholinergics, anti-histamines, diuretics

S/S

• Acute onset

• Erythema over skin and purulent discharge

• Pain related symptoms

Diagnosis

• Physical: unilateral swelling, erythema over gland, express saliva or discharge, induration or fluctuance, stones, tumors, facial paresis (facial nerve affected)

• Imaging: ultrasound first line, CT for ductal anatomy, MRI for soft tissue detail and masses

• Lab: CBC, amylase, autoimmune markers, culture for purulent

Treatment

• Conservative: hydration

• Medical: antibiotics for bacterial (amoxicillin clavulanate)

• NSAIDs

• Ductal dilation, stone removal, steroid injection

• Gland excision

Parotitis

Definition

• Inflammation of parotid glands

Causes

• Majority are viral (mumps) (usually bilateral)

• Other causes: influenzae A, EBV, human herpes virus 6

S/S

• Acute viral: bilateral swelling, fever, malaise, prodrome of HA, low grade fever

• Acute bacterial: unilateral swelling, high fever, purulent discharge (elderly)

• Chronic: Sjogren;s

Definition 

• Small, shallow ulcers that develop on soft tissue of the mouth 

Causes 

• Immune system 

• Genetic 

• Vitamin B12 deficiency

• Stress

• Human herpes virus 6 

• Autoimmune/Celiac 

Types 

• Minor (most common): < 1cm, heal in 7-10 days w/out scarring 

• Major: deeper and larger, >1cm, >4weeks , may scar

• Herpetiform: multiple clusters 

S/S

• Round or oval ulcers with well defined borders 

• Yellow gray base with red halo 

• Severe pain disproportionate: usually peaks 2-3 days and subsides 7-14 days 

Diagnosis 

• Clinical history and physical exam 

• Lab: usually not necessary (CBC and autoimmune if recurrent)

• Biopsy consideration if it does not heal

Treatment 

• Topical corticosteroids, anesthetics

• Systemic for severe, frequent, or refractory 

• Supportive 

Oral Candidiasis

Definition

• Fungal infection

Causes

• Candida albicans (normal flora but becomes pathogenic when there is disruption of microbiome)

Risk factors

• Age extremes

• Medications (broad spectrum antibiotics, corticosteroids, immunosuppressants)

• DM

• HIV/AIDS

Types

• Pseudomembranous: classic thrush with removable white, curd like plaque with a red base

• Erythematous: red, flat lesions without white plaques, often seen on tongue and palate with burning mouth and taste changes

• Chronic hyperplastic: white patches that cannot be wiped away, requiring biopsy

• Angular chelitis: cracks and fissures on the corners of the mouth (usually bilateral)

• Complications: esophageal or systemic spread

Diagnosis

• Clinical

• KOH and/or fungal culture

• Biopsy

Treatment

• First line → topical antifungals

• Refractory or severe → systemic antifungals

Dental Abscess

Definition

• Localized collection of pus from bacterial infection of tooth or surrounding tissues

Types

• Periapical: infection at tooth root apex, usually from untreated dental caries extending to the pulp

• Peridontal: infection in gum tissues, often associated with deep peridontal pockets and plaque accumulation

• Pericoronitis: infection around partially erupted tooth, commonly affecting wisdom teeth with food and bacteria

• Complications: spread of infection (Ludwig’s angina), cavernous sinus thrombosis, sepsis

Risk factors

• Poor dentition

S/S

• Severe, throbbing tooth pain, often radiating

• Purulent discharge near the affected tooth

• Swelling of the gum or face

• Fever, malaise, enlarged local nodes

Diagnosis

• Clinical

Treatment

• Antibiotic: amoxicillin

• Pain control

• Urgent dental referral: definitive (I and D)

Gingivitis

Definition

• Reversible inflammation of the gums

Causes

• Bacterial plaque accumulation (Strep) due to poor oral hygiene

• Risk factors: smoking, phenytoin, DM, hormonal, crowded teeth, mouth breathing

S/S

• Red, swollen, and tender gums that bleed easily

• Halitosis

• No loss of tooth attachment

• Complications

  • Periodontitis → bone and tissue loss → loss of tooth

Diagnosis

• Bleeding on probing

Treatment

• Professional dental cleaning

• Antimicrobial mouth rinses

• Stop smoking

Leukoplakia 

Definition 

• Painless white patches or plaques on oral mucosa that cannot be rubbed off 

Types 

• Homogenous: thin, uniform, smooth, slightly wrinkled, well defined, lower malignancy

• Non-homogenous: mixed white and red areas 

• Proliferative: highest malignant potential 

Risk factors 

• Tobacco use 

• Alcohol 

• Immunosuppression

S/S

• High risk sites: lateral tongue border, buccal mucosa, floor of mouth 

• Low risk sites: gingiva and hard palate 

• White patches that cannot be wiped off 

• Usually no symptoms 

Diagnosis 

• Clinical exam 

• Risk assessment 

• Biopsy for persistent lesions to determine degree of dysplasia 

Treatment

• Risk factor elimination

• Surgical removal

• Long term monitoring

Benign Neoplasms

Oral

• Fibroma

  • Most common benign oral tumor

  • Smooth, pink, painless nodule

  • Usually from chronic irritation

  • Simple excision

• Papilloma

  • Caused by HPV: cauliflower like

• Pyogenic

• Lipoma

Nasal and Sinus

• Inverted

Laryngeal

• Vocal cord polyps

• Nodules

• Papillomas (HPV related)

Malignant neoplasms 

Oral Squamous Cell Carcinoma (most common)

• Greatest risk factor: tobacco use, alcohol consumption, age 60 y/o, HPV

• Common sites: lateral tongue, floor or mouth, soft palate 

• S/S: non-healing ulcers, persistent white-red patch w/ or w/out pain, loose teeth, weight loss, bleeding, subtle changes in surface texture, induration of papillae 

• Diagnosis: need to biopsy (may need CT/MRI/PET if worried about extension)

• Treatment: excision/chemo/radiation (depends on size)

Nasopharyngeal carcinoma 

• Strong association with EBV

• Tobacco/consumption of preserved foods/HBV

• See nasal obstruction, cranial nerve palsy, painless node swelling

• Usually present with advanced stage 

• Need to biopsy and stage with CT/MRI

• Management depends on stage (radiation/chemo/surgery)

Laryngeal cancer 

• Laryngitis greater than 3 weeks 

• Risk factors: smoking, alcohol, occupation, prior radiation GERD. HPV

• S/S: persistent hoarseness (> 2-3 weeks), dysphagia, weight loss, neck mass, airway compromise

• Need laryngoscopy and biopsy to diagnose with CT, MRI, PET

Takeaways: Tobacco cessation, alcohol moderation, HPV vaccine, regular screening