Common Pathology of the Nose Mouth & Pharynx/Larynx

Osteomeatal Complex

drains sinus

Seasonal Allergic Rhinitis

PP: exposure to indoor+outdoor allergens→immunoglobulin E (IgE) reaction→releases histamines→inflammatory rxn

E:
seasonal allergies (spring/summer/early fall):
airborne mold spores
grass/tree/weed pollen

CM:
hallmarks:

• sneezing

• rhinorrhea (runny nose)

• conjunctival/nasal/phayrngeal itching (itchy nose)

• excessive tearing+postnasal drip

• decreased smell

other sxs
cough
headache
fatigue
congestion

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

nasal speculum exam:
swollen nasal turbinates
pale+boggy nasal mucosa
wet mucosa

DX:

1st line→percutaneous/skin prick:
sensitive, not specific
results→10-20 minutes

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

can’t do skin test→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
wash hair+body at night to remove pollen
avoid windows
fan
hat
pollen mask
avoid eye rubbing

indoor:
keep windows closed
use air conditioning

MX: mild vs moderate vs severe (on other slide)

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→doesn’t follow a clear allergic pattern
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:
aka: common cold

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

lasts under 10 days to 4 weeks (maximum)

peak sx→days 3-4
resolution→day 10

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:
NP:
sx relief

MX:
buffered hypertonic saline nasal irrigation

• pseudoephedrine q 4-6 hrs/BID
  prolonged use→rhinitis medicamentosa

• 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 inflammed paranasal sinus
normal sinus drainage+mucociliary clearance disrupted

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

sinuses
most common→maxillary sinus
frontal sinus
ethmoid sinus
sphenoid sinus

CM:
hallmark triad:
prurulent nasal drainage
nasal obstruction/congestion
facial pain/pressure
dental pain→maxillary sinus infection

other sx
altered smell
cough
fever
halitosis
headache
fatigue

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

DX:

no routine imaging→clinical diagnosis

exceptions

• suspected orbital/intracranial complication

• concern for alternative dx

• complicated/refractory dx

1st line→NP:
sx management

• 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

MX:

tx indications

• 10+ days with no improvement

• severe→fever 102+°F+purulent nasal discharge/facial pain x 3-4+ days

• sxs improve→then worsen

1st line:

• amoxicillin BID/TID

• amoxicillin-clavulanate/augmentin TID

• severe sinusitis→amoxicillin-clavulanate/augmentin ER BID x 7-10 days

PCN 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:

• avoid macrolides

• avoid trimethoprim-sulfamethoxazole

• avoid 2nd/3rd gen cephalosporins

tests

• noncontrast coronal sinuses CT scan→mucosal edema+thick secretions

• MRI+gadolinium

C:
orbital cellulitis+abscess
osteomyelitis→pot puffy tumor
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
not persistent bx inflammation→chronic nasosinal inflammation

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:
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:

• intranasal corticosteroids

• nasal saline irrigations

• culture-directed abx x 3-4+ weeks

• tx not working→endoscopic sinus surgery

• air-fluid levels/retained secretions→surgical drainage

Nasal Polyps

PP: chronic inflammation→pale+edematous+mucosally covered masses with mucosal lining the sinus
benign

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

CM:
small polyps→asx

large polyps

• airway obstruction

• post nasal drip

• persistent stuffiness

• dull headaches

• snoring

• rhinorrhea

• decreased/absent smell

• chronic mouth breathing

PE:
nasal speculum exam:
benign nasal tumors→smooth+rounded+red polyps
pale/edematous/mucosally covered masses
mucosal lining of sinuses
benign nasal tumors m/c area→middle meatus

otoscopic exam→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:

Prevention/prophx:

• saline rinses/sprays

• take all allergy+asthma mx as directed

• humidifier

1st line→intranasal corticosteroids:

• fluticasone BID

• budesonide BID

• mometasone QD

more severe sx→PO corticosteroids

• prednisone PO x 6 days

big polyps/tx fail

• polypectomy/endoscopic surgery

• post-surgery→intranasal corticosteroids

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→winter months
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:
simple→not required

chronic epistaxis:

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
I: still bleeding in 30+ min

prophx/pretx
oxymetazoline x 2 sprays→prevent vasoconstriction

anterior vs posterior (on separate slide)

Deviated Septum

PP: abnormal deviation of intranasal cartilage

E: congenital
trauma

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

PE:

anterior rhinoscopy:
external deformity
unequal nostrils
postnasal drip
inflammation

DX:
clinical
further evaluation→nasal endoscopy

TX:

NP→septoplasty

MX:
decongestants

• sudafed

• mucinex-d

antihistamines

allegra

claritin

clarinex

zyrtec

xvzal

nasal steroids

• nasonex

• nasocort

• veramyst

• omnaris

• flonase

nasal antihistamines

• astepro

• patanese

Leukoplakia

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

E:
unknown
tobacco
alcohol

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

PE:
intraoral exam:
-neck
-nodes

DX:
1st line→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→infection/inflammation of salivary gland
-parotid→stensen duct
-submandibular→wharton duct
-sublingual→multiple small ducts in floor of mouth

E:
s. aureus
s. viridians
h. influenzae
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+systemic sx

TX:

1st line→NP:

• hydration

• water compress

• gland massage

• sialagogues

• duct dilation

no sx improvement

• culture drainage

• switch to broad coverage abx (augmentin/clindamycin)

• imaging

Parotitis

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

RF:
dehydration
surgery
chronic conditions

acute bacterial
-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
m/c→wharton duct
stensen duct

CM:
pain during meals
localized swelling

DX:
mouth xray:
m/c→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: infection of pharynx→inflammation of mucus membranes+lymphoid tissue of pharynx
-viral vs bx

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

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

TX:

NP:

• saline gargles

• tx upper respiratory infection symptoms

MX:

• analgesics

• antipyretics

• anesthetic troches

Bacterial Pharyngitis

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

E: m/c→group A beta hemolytic streptococcus (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 (positive sx→+1 point)
used for likliness→NOT DX
0-1→no test
2-3→yes test
4→no test

modified centor (McIsaac)→age adjustment
used with centor criteria

• 3-14 y/o→+1

• 15-44 y/o→0

• 45+ y/o→-1

culture+sensitivity
rapid antigen detection tests (RADT)

TX:

MX:

abx (must complete whole duration of abx)

• 1st line→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→strep

DX:
clinical
hx
PE

TX:
NP:
drainage→essential

• needle aspiration

• incision/drainage

• tonsillectomy

MX:

pt can swallow mx:

• PO amoxicillin-clavulanate/augmentin BID x 14 days

• PO clindamycin q 6hrs x 14 days

pt can’t swallow mx:

• IV ampicillin-sulbactam/unasyn

• IV clindamycin

tx fail/gram positive cocci:

• IV vancomycin

• IV linezolid

Epiglottitis/Supraglottitis

PP:
acute+rapidly-progressive cellulitis infxn of epiglottis+surrounding structures→airway closed off→complete+life threatening+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

iatrogenic

• intubation

• thyroid surgery

• neck surgery

• chest surgery

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

PE should be guided by Hx+DDx

Hoarseness DX+Referral

Persistent/Progressive Concerning/Unexplained→complete head+neck exam
-hoarseness Persists over 4+ weeks OR serious cause suspected+no respiratory infection
-Progressive
-Concerning sx+RFs
-no obvious Benign cause

positive findings→laryngoscope referral→visualize laryngopharynx

CT/MRI→not substitute for head+neck exam

Viral Laryngitis

PP:
acute inflammation of laryngeal mucosa→hoarseness

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

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

DX:
laryngoscope→erythema+edema

TX→symptomatic:

• voice rest

• hydration

• stop smoking

• control+tx coughing

• analgesia

• steam inhalation

• NO ABX

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 vagus/recurrent laryngeal nerve→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 folds

E:
tobacco
alcohol
chronic irritation

DX:
laryngoscopy+biopsy:

• mild/moderate/severe dysplasia

• premalignancy

• squamous cell carcinoma

TX:

• depends on patholgy

• eliminate RFs

• ENT follow up

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.

-aka: recurrent respiratory papillomatosis (RBP)

E:
HPV 6
HPV 11

CM:
hoarseness that progresses weeks→months

DX:
larynogscopy→pink bumps on vocal cords

TX:

Prophx→gardasil

NP:

• 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 larygnopharyngeal region->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

• omerazole

• prilosec

• etc.

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

Perrenial Allergic Rhinitis

PP:
exposure to indoor+outdoor allergens→immunoglobulin E (IgE) reaction→releases histamines→inflammatory rxn

E:
perennial (year-round allergies):
dust mites
pet hair
dander cockroaches
mold

CM:
hallmarks:

• sneezing

• rhinorrhea (runny nose)

• conjunctival/nasal/phayrngeal itching

• excessive tearing+postnasal drip

• decreased smell

• itchy nose

other sxs
cough
headache
fatigue
congestion

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

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

DX:

1st line→percutaneous/skin prick:
sensitive, not specific
results→10-20 minutes

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

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

TX:
NP:

perennial:

• avoid allergens

• change air filters

• clean carpets

• keep pets out bedroom

• minimize dust mite exposure

• allergy testing

MX→mild vs moderate vs severe (on other slide)

Allergic Rhinitis→Mild Tx

1st/2nd gen antihistamines:

• loratadine

• desloratadine

• fexofenadine

• cetirizine

OTC/Rx mx:

• cromolyn sodium

• sodium nedocromin

• ipratropium bromide

antihistamine+decongestant combination:

• montelukast+cetirizine

• montelukast+loratidine

Allergic Rhinitis→Moderate/Severe Tx

moderate:

glucocorticoid nasal sprays:

• fluticasone

• mometasone furoate

• beclomethasone

• flunisolide budesonide

• leukotriene receptor antagonist (singulair)

• intranasal cromolyn

• ipatroprium

severe:

• moderate sx tx+PO prednisone

tx fail+too intense for regular tx

• allergist referral

• immunotherapy

Epistaxis Assessment

assess airway+hemodynamic stabiltiy

hemodynamically stable

• normal vitals+respiratory status→proceed with focused evalution

severe/unstable epistaxis

• airway managment

• IV/fluid resuscitation

• emergent ENT consultation

focused history

bleeding characteristics

• onset

• duation

• frequency

• severity

predisposing conditions

• coagulopathies/other hematological dxs

• nasal tumors

• structural nasal abnormalities

• HIV/immunocompromised state

medications

• anticoagulants

• antiplatelets

• NSAIDS

substance use

• intranasal mx

comorbidities

• conditions worsened by acute blood loss

Anterior Epistaxis 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:
I: still bleeding in 30+ min

prophx/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 Epistaxis 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:
I: still bleeding in 30+ min

prophx/pretx
oxymetazoline x 2 sprays→prevent vasoconstriction

posterior bleed packing:

• with hospitalization+ENT consultation

• nasal balloon catheter (epistat)

• foley catheter

• cotton packing

surgery:

• internal maxillary+facial artery→embolization

• internal maxillary+ethmoid arteries→ligation

C:
posterior packing:

• very uncomfortable

• bleeding may persist

• nasal bone fracture

• altered mental status

• shock

• airway blockage

Adult Hoarseness Red Flags

persistent dysphonia x4+ weeks

progressive voice change

tobacco

heavy alcohol exposure

hemoptysis

dysphagia

odynophagia

neck mass

unexplained weight loss

unexplained otalgia

stridor/respiratory distress

recent head/neck/chest surgery

recent intubation

neurologic deficits