Common Pathology of the Nose Mouth & Pharynx/Larynx

Osteomeatal Complex

drains sinus

Allergic Rhinitis

PP: exposure to indoor+outdoor allergens→immunoglobulin E (IgE) reaction

E:
seasonal allergies:
mold spores
grass/tree/weed pollen

perennial/year-round allergies:
dust mites
pet hair
dander cockroaches
mold

CM:
sneezing
rhinorrhea (runny nose)
cough
headache
fatigue
congestion
conjunctival/nasal/phayrngeal itching
excessive tearing+postnasal drip
decreased smell

PE: allergic shiners (puffy lower eyelids)
allergic salute (nose crease)
pale/congested/edematous conjunctiva

DX:
nasal speculum exam: swelling of nasal turbinates
pale+boggy nasal mucosa
wet mucosa

percutaneous/skin prick:
initial test
sensitive, not specific
results→10-20 minutes

intradermal/injection:
if skin prick is negative but clinical suspicion
more sensitive, lower specificity
higher risk of allergic rxn
results→20 minutes

serum/blood testing:
RAST/ImmunoCAP/ELIZA
detects IgE antibodies to allergen
pts who can’t do skin testing

TX:
NP:
seasonal:
outdoor: large amount of pollen→stay indoors
avoid windows
fan
hat
pollen mask
avoid eye rubbing
wash hair+body at night to remove pollen

indoor:
keep windows closed
use air conditioning

perennial:
avoid allergens
change air filters
clean carpets
keep pets out bedroom
minimize dust mite exposure
allergy testing

MX:
mild:
1st/2nd gen antihistamines:
loratadine
desloratadine
fexofenadine
cetirizine

OTC/Rx mx:
cromolyn sodium
sodium nedocromin
ipratropium bromide

antihistamine+decongestant combination:
montelukast+cetirizine/loratidine

moderate:
glucocorticoid nasal sprays:
fluticasone
mometasone furoate
beclomethasone
flunisolide budesonide

leukotriene receptor antagonist (singulair)

intranasal cromolyn

ipatroprium

severe: moderate sx+PO prednisone
tx fail→allergist referral or immunotherapy

Vasomotor Rhinitis (VMR)

PP: imbalance between sympathetic+parasympathetic inputs on nasal mucosa→increased permeability+mucous secretion

E: 20% of population
30-60 y/o
non-allergic
cigarette smoking
strong scents
fragrances

CM: perennial+seasonal exacerbations
nasal congestion
post nasal drip

PE: boggy mucosal tissue
edematous (swollen) mucosal tissue
erythematous (red) mucosal tissue

DX: allergy testing (skin testing preferred)

TX:
NP: avoid environmental triggers

MX:

topical intranasal glucocorticoids (INGCs):
Fluticasone (Flonase, Nasacort)
Beclomethasone (Qnasl, Beconase)
Triamcinolone (Nasacort Allergy 24HR)
Mometasone (Ryaltris)
Fluisolide (Dymista)

topical antihistamine:
loratidine
cetirizine
promethazine
hydrocortizone
diphenhydramine

azelastine

Acute Viral Rhinosinusitis (ARS)

PP: infected droplets inhaled into conjunctiva+nasal mucosa→inflammation of nasal cavity+paranasal sinuses→8-10 hrs→detectable viral levels in mucus secretions→sx

lasts under 10 days to 4 weeks (maximum)
peak sx: days 3-4
resolution: day 10
aka: common cold

RF: older age
smoking
air travel
exposure to changes in atmospheric pressure
swimming
asthma
allergies
dental dx
immunodeficiency

E: M/C: rhinovirus
adenovirus
RSV
coronavirus
~13.65% of population
women
45-64 y/o
children: 6-8 episodes/year
adults: 2-4 episodes/year

CM: sneezing
nasal congestion
rhinorrhea
fever
chills
malaise
watery eyes
cough
myalgia

PE:
nasal speculum exam:
erythematous+edematous nasal mucosa
watery/clear nasal discharge
purulent nasal discharge→bacterial rhinosinusitis

TX: buffered hypertonic saline nasal irrigation
pseudoephedrine q 4-6 hrs/BID
oxymetazoline
phenylephrine
antihistamines
mucolytics

C: oxymetazoline/phenylephrine chronic use→rhinitis medicamentosa
mild eustachian tube dysfunction
transient middle ear effusion
acute bacterial rhinosinusitis

Acute Bacterial Rhinosinusitis

PP: bacterial infection/inflammation of mucosa in nasal passages+at least 1 paranasal sinus

E: impaired mucociliary clearance
inflammation of the nasal cavity mucosa
obstruction of ostiomeatal complex
S. Pneumoniae
H. Influenzae
20 million cases/year+1% office visits/year
most common: maxillary sinus
frontal sinus
ethmoid sinus
sphenoid sinus

CM: prurulent nasal drainage
nasal obstruction/congestion
facial pain/pressure
altered smell
cough
fever
halitosis
headache
fatigue
dental pain

PE: facial tenderness to palpation (sinuses hurt when touched)
purulent nasal secretions
mucosal edema
teeth pain
air-fluid levels on transillumination (inflamed+light doesn’t shine onto area)

DX:
noncontrast coronal sinuses CT scan→mucosal edema+thick secretions
MRI+gadolinium

Mgmnt:
NSAIDS
steam inhalation
pseudoephedrine q 6hrs
oxymetazoline q6-8hrs x 3 days max
nasonex 1-2 sprays/nostril daill
flonase 1-2 sprays/nostril daill

TX:
amoxicillin BID/TID
amoxicillin-clavulanate/augmentin TID
severe sinusitis→amoxicillin-clavulanate/augmentin ER BID x 7-10 days

allergy:
doxycycline BID/QD x 5-7 days
levofloxicin QD
moxifloxicin QD
cefixime daily
cefpodoxime BID ± clindamycin q 6hrs

abx in last 30 days:
amoxicillin-clavulanate/augmentin ER PO BID
moxifloxacin PO QD

avoid macrolides
avoid trimethoprim-sulfamethoxazole
avoid 2nd/3rd gen cephalosporins

C: orbital cellulitis+abscess
osteomyelitis
meningitis
cavernous sinus thrombosis
epidural+intraparenchymal brain abscess

admit to ER: face swelling+erythema (facial cellulitis)
proptosis (bulging eyes)
vision changes gaze abnormality (orbital cellulitis)
abscess/cavernous sinus involvement
altered mental status (intracranial extension)

Chronic Rhinosinusitis

PP: inflammation of paranasal sinuses that lasts over 12 weeks

RF: allergic rhintis
asthma
smoking
irritants/pollutants
nasal polyps
cystic fibrosis
viral URI
etc

E: inflammatory dx of paranasal sinuses
unknown
maybe polyfactorial
1-5% of population

CM/DX: at least 2 for 12+ consecutive weeks
nasal obstruction
nasal drainage
facial pain/pressure

hyposmia/anosmia (decreased/no sense of smell)
and
objective evidence on PE:
mucoprurulent drainage
edema
polyps in middle meatus
or
sinus CT

DX:
non-contrast sinus CT scan:
mucosal thickening
obstruction of ostiomeatal complex
sinus opacification

nasal endoscopy:
visualization/confirmation of patency of:
ostia
nasal mucosal inflammation
prurulent drainage
obstruction
ethmoid+sphenoid sinuses

bacteria+fungi→biopsy+cultures

TX:
culture guided abx x 3-4+ weeks
intranasal glucocorticoids
nasal saline irrigations
tx fail→endoscopic surgery
air-fluid levels→drainage

Nasal Polyps

PP: chronic inflammation
genetics
cystic fibrosis

E: 20-40 y/o
allergic rhinitis
asthmatics
ASA allergy
cystic fibrosis
men
rare: under 10 y/o

PE:
nasal speculum exam:
benign nasal tumors
pale/edematous/mucosally covered masses
mucosal lining of sinuses
benign nasal tumors M/C: middle meatus
smooth+rounded+red polyps
eustachian tube dysfunction

DX:
dx requirement→nose+paranasal sinuses CT scan: nasal endoscopy

MRI: better for looking at nasal tumors

allergy testing (skin)

genetic testing: cystic fibrosis (children)

TX:
1st line:
fluticasone BID
budesonide BID
mometasone QD

prednisone PO x 6 days

big polyps/tx fail→polypectomy/endoscopic surgery+intranasal corticosteroids for prophx

Prophx:
saline rinses/sprays
take all allergy+asthma mx as directed
humidifier

C: nasal polyps+asthma→DO NOT USE ASPIRIN
samter triad: nasal polyps+asthma+aspirin→bronchospasm
acute/chronic sinus infections
obstructive sleep apnea
asthma flare-ups

Epistaxis

PP: acute hemorrhage from nostril/nasal cavity/nasopharynx
aka: nosebleed

RF: nasal trauma
rhinitis
nasal mucosa drying
septal deviation/perforation
hereditary hemorrhagic telangiectasia (HHT)
hemophilia
leukemia
thrombocytopenia
vitamin deficiencies (A/C/D/E/K)
anticoagulant/antiplatelet use

E: 60% of population
benign+spontaneous
under 10 y/o
70-79 y/o

anterior nosebleeds:
M/C: kiesselbach’s plexus
septal branch of anterior ethmoidal artery
lateral nasal branch of sphenopalatine artery
septal branch of superior labial artery

posterior nosebleeds: significant hemorrhage
posterior branch of sphenopalatine artery

PE:
check if pt is able to breathe+any significant mx hx
epistaxis tray

DX:
hemoglobin+hematocrit:
prolonged bleeding
massive hemorrhage

pt under 2 y/o→look at family hx for bleeding dx+full dx workup

TX:
NP: direct pressure to nares/close nose for 15 minutes+lean forward (prevent blood swallowing)
-no bleeding in 30 min→stop+topical abx ointment TID x 3 days

MX: still bleeding in 30+ min
pretx: oxymetazoline x 2 sprays→prevent vasoconstriction
1st line: silver nitrate cauterization
electrocautery
thrombogenic foams+gels

2nd line/tx fail: nasal balloon packing x 5 days
tampon packing x 5 days
gauze packing x 5 days

toxic shock syndrome prophx:
amoxicillin-clavulanate/augmentin
keflex QID
clindamycin QID x 5 days
topical mupurocin

posterior bleed packing:
nasal balloon catheter (epistat)
foley catheter
cotton packing
+hospitalization

surgery:
internal maxillary+facial artery→embolization
internal maxillary+ethmoid arteries→ligation

CI:
posterior packing:
very uncomfortable
bleeding may persist
nasal bone fracture
altered mental status
shock
airway blockage

Deviated Septum

PP: abnormal deviation of intranasal cartilage

E: congenital
trauma

CM: epistaxis
headaches
congestion
snoring
difficulty breathing
nasal discharge
recurrent sinusitis

PE: external deformity
unequal nostrils
postnasal drip
inflammation

DX: clinical
endoscopy

TX:
decongestants:
sudafed
mucinex-d

antihistamines:
allegra
claritin
clarinex
zyrtec
xvzal

nasal steroids:
nasonex
nasocort
veramyst
omnaris
flonase

nasal antihistamines:
astepro
patanese

septoplasty

Leukoplakia

PP: white lesion of oral mucosa on tongue/cheek/floor of mouth/lip+can’t be scraped off

E: chronic irritation
dysplasia
early invasive squamous cell carcinoma
tobacco
alcohol
unknown

CM: white patch→firm/rough/reddened/ulcerated
painless→may become sore

PE:
intraoral exam: neck
nodes

DX:
incisional biopsy
exfoliative cytologic exam

TX: resolves on own
no→abx

NP: stop tobacco/alcohol/physical irritants

Squamous cell carcinoma under 2 cm: local resection

large tumor: resection
neck dissection+radiation

MX: retinoids
beta carotene
vitamin E
COX-2 inhibitors

P: under 4mm→cure likely

Sialadentitis

PP: dehydration/immunosuppression/trauma/debilitation→salivary stasis/stricture/ductal obstruction→decreased antimicrobial activity→inflammation of salivary gland

E: s. aureus
s. viridians
h. influenza
s. pyogenes
e. coli

CM: eating→mouth/facial pain
dry mouth
facial edema
pain/erythema over area
trismus (can’t open mouth fully)
purulent drainage
fever

TX:
NP: 1st line
hydration
water compress
massage
sialagogues
duct dilation

MX: only if NP tx fail
surgical drainage+stone removal
dicloxacillin QID
or
cephalexin QID x 7-10 days
no sx improvement→culture drainage+switch to broad coverage abx (augmentin/clindamycin)+imaging

Parotitis

PP: bacteria ascends mouth→swelling of one/both parotid glands

RF: dehydration
surgery
chronic conditions
debilitation
poor oral hygiene
older postop pts

E: mumps→bilateral swelling+(fever/headache/myalgia/malaise/anorexia from painful mastication)
bacteria→unilateral swelling
sialolithiasis→blocks flow

CM: sudden pain+swelling→worsens with eating
redness
drainage (pus)

DX: hx+PE+further dx studies

TX:
NP: warm compress
sialogogues

MX: abx
analgesics

Sialolithiasis

PP: forms calcified blocks in wharton/stensen ducts of the salivary glands

E: 30-60 y/o

CM: pain during meals
localized swelling

DX:
mouth xray:
wharton duct stones→large+radiopaque
stensen duct stones→small+radiolucent

TX: hydration
moist heat massage
hydration
sialogogues (lemon drops)
ductal incision+stone removal
sx persist→specialist referral

C: secondary infection
dysfunctional gland

Viral Pharyngitis

PP: viral infection of pharynx→inflammation of mucus membranes+lymphoid tissue of pharynx

E: rhinovirus
coronavirus
adenovirus
coxsackie a virus
herpes simplex virus
influenza virus
respiratory syncytial virus (RSV)
adults: 90%
children: 60%

CM: cough
conjunctivitis
hoarseness
diarrhea
cervical lymphadenopathy
fever
chills
viral exanthem/viral rash
pharyngeal edema
ulcerative lesions

TX: tx upper respiratory infection symptoms
NP: saline gargles

MX: analgesics
antipyretics
anesthetic troches

Bacterial Pharyngitis

PP: bacterial infection of pharynx→inflammation of mucus membranes+lymphoid tissue of pharynx

E: strep pharyngitis
group A beta hemolytic streptococci (GABHS)
n. gonorrheae
chlamydia pneumonia
mycoplasma pneumonia
corynebacterium diptheria
meningococci

CM:
centor criteria (memorize):
sore throat
and
tender anterior cervical adenopathy
fever over 100.4°F/38°C
pharyngotonsillar exudate
no cough

tonsillar edema+hyperemia
pharynx erythema
scarlatiniform rash (red rash on mouth)
petechiae on palate (spots on palate)

pediatric: headache
vomiting

DX:
centor criteria score:
0-1→no test
2-3→yes test
4→no test

culture+sensitivity
rapid antigen detection tests (RADT)

TX:
PenVK BID x 10 days
amoxicillin BID x 10 days
amoxicillin IR QD x 10 days
cefuroxime BID x 10 days
IM PCN G benzathine single injection

allergy: azithromycin QD x 3 days

C: peritonsillar abscess
septic arthritis
rheumatic fever
post-streptococcal glomerulonephritis
scarlet fever
sinusitis
otitis media
mastoiditis

Peritonsillar Abscess

PP: deep infection of head+neck→penetrates tonsillar capsule/surrounding tissue→cellulitis→abscess

E: 20-40 y/o
s. pyogenes
fusobacterium

CM: unilateral tonsil pain
fever
trismus (can’t open mouth fully)
dysphagia
odynophagia
“hot potato voice”
tonsillar pillar+soft palate swelling
uvula deviated away from site
drooling
foul breath

DX: clinical
hx
PE

TX:
NP:
drainage→essential
needle aspiration
incision/drainage
tonsillectomy

MX:
IV ampicillin-sulbactam/unasyn
IV clindamycin
tx fail→IV vancomycin/IV linezolid
gram-positive cocci→IV vancomycin/IV linezolid x afebrile+clinical improvement

amoxicillin-clavulanate/augmentin PO BID x 14 days
clindamycin PO q 6hrs x 14 days

Epiglottitis/Supraglottitis

PP: acute+rapidly-progressive cellulitis of epiglottis+surrounding structures→airway closed off→complete+fatal airway obstruction

E: h. influnezae type b
bacterial
viral
fungi

CM: sore throat
dysphagia
odynophagia
muffled voice
stridor
fever
drooling
palpation of larynx→severe pain
tripod position

DX:
lateral neck xray: “thumbprint” sign
laryngoscopy

TX:
NP: hospitalization
oral intubation+airway management

MX: ceftriaxone+vancomycin
cefotaxin+vancomycin

Laryngopharynx Anatomy+Functions

anatomy:

• cartilage framework

• vocal folds

• intrinsic+extrinsic muscles

• neurovascular supply→vagus nerve

• overlying soft tissues

functions:

• phonation

• valsalva maneuver

• airway patency during respiration

• airway protection during swallowing

Hoarseness Common Causes

physical+neoplastic lesions:

• vocal cord trauma

• laryngeal papillomatosis

• squamous cell carcinoma

• mx

irritant/inflammatory causes:

• alcohol/tobacco

• laryngopharyngeal reflux (LPR)

• GERD

• viral laryngitis

• intubation trauma

neuromuscular/psychiatric issues:

• multiple sclerosis

• myasthenia gravis

• Parkinson’s disease

• stroke

• nerve injury

• vocal atrophy

• conversion aphasia

Hoarseness Hx

ask:

• vocal quality

• speech

• effort

• sx of pain with speaking/swallowing

evaluate:

• timing

• onset

• duration

• exacerbating/remitting factors

  associated sx:
  -GERD
  -laryngopharyngeal reflux (LPR)
  -postnasal drip

review of mx

acute onset→infection/inflammation/injury/vocal abuse

chronic/progressive change→severe dx

Hoarseness PE

clinical clues:

• hoarseness

• breathlessness

• vocal fatigue

• voice quality

• voice with tremulous quality/tremor

pay special attention to head+neck exam

additional inspections:

• ears

• upper airway mucosa

• oral cavity

• cranial nerve function

• respiration

Hoarseness DX

hoarseness over 4 weeks+no respiratory infection→complete head+neck exam

laryngoscope→visualize laryngopharynx

CT not substitute for head+neck exam

Viral Laryngitis

PP: acute inflammation of laryngeal mucosa→hoarseness

E: M/C of hoarseness
m. catararhalis
h. influenza
viral

CM: hoarseness
painful cough
marked edema→stridor+dyspnea
ruptured small vessels→hemoptysis (coughing blood)

DX: laryngoscope→erythema+edema

TX:
voice rest
stop smoking
control coughing
analgesia
steam inhalation

C: continuation→polyps/cysts/vocal cord hemorrhage

Traumatic Lesions of the Vocal Folds

PP/E: vocal cord abuse→nodules on vocal cords

children: “screamer’s nodules”
adults: “singer’s nodules”

CM: breathiness
multiple tones
loss of vocal range
vocal fatigue
loss of voice
raspy/harsh/scratchy voice

DX:
laryngoscope: smooth+benign paired lesions
callous-like growth
form at anterior 1/3+posterior 2/3 of vocal cords

TX: voice modification habits
speech therapist

P: behavior modification→resolve
recalcitrant nodules (get calcification again)→surgical excision

Vocal Cord Paralysis

PP: nerve impulses to larynx disrupted→vocal cord muscle paralysis

E: surgery injury (thyroid/parathyroid surgery)
neck/chest injury
stroke
tumors
infections
neurological dx
idiopathic
iatrogenic

unilateral vs bilateral fold paralysis

CM: hoarseness
breathy voice wuality
coughing
loss of vocal pitch

DX: laryngoscopy

TX: voice therapy
surgery

Laryngeal Leukoplakia

PP: white plaque-like formation on vocal cords

E: smokers+hoarseness

DX:
laryngoscopy+biopsy: mild/moderate/severe dysplasia
squamous cell carcinoma

TX:
NP: mild/moderate dysplasia→smoking cessation→reverse/stabilize
serial resections
external beam radiation

MX: proton pump inhibitors

P: close follow up→laryngovideostroboscopy

Laryngeal Papillomatosis (LP)

PP: lesions at junction of ciliated+squamous epithelial cells→grow quickly→issues with swallowing/breathing/hoarseness/coughing/etc.

E: HPV 6+11

CM: hoarseness progresses weeks→months

DX: larynogscopy→pink bumps on vocal cords

Prophx: gardasil

TX: repeat laser vaporizations
operative laryngoscopy+cold knife resections

P: benign
high recurrence rate

C: airway obstruction

Laryngeal Pharyngeal Reflux (LPR)

PP: dysnfunctional upper esophageal sphincter→abnormal reflux of acid into esophagus->mucosa damage

CM: daytime+upright position occurrence
50%→no heartburn
hoarseness
globus pharyngitis (feeling invisible lump in throat)
cough
frequent throat clearing

DX: no gold standard
exclusion of other dx→laryngoscopy

TX:
NP: lifestyle modifications
surgery

MX: empiric proton pump inhibitors trial x 3 months

P: lifestyle modifications→controlled

CM:
untreated LPR: sore throat
chronic cough
vocal cord swelling
vocal cord ulcers
asthma exacerbations
emphysema
bronchitis

GERD vs. LPR

GERD:

• nightime/supine

• lower esophageal

• heart burn sx

LPR:

• daytime/upright

• upper esophageal

• no esophagitis/occasional heartburn