sinusitis, rhinitis, epstaxis, oral and pharngeal disorders

an infection of the paranasal sinuses , caused by either dec function of mucocilia or narrowed/obstructed osteomeatal complex, both of which leads to an accumulation of mucus in the sinus cavity

sinusitis

sinusitis symptoms

nasal congestion/drainage, postnasal drainage, facial pain/pressure, headache, change in smell, cough, fever, malaise, toothache, fever, haliltosis

your patient presents w nasal congestion/drainage and a headache. you do a physical and see they wince in pain when you palpate their face and sinus. they have purulent rhinorrhea drainage and inflammed nasal mucosa, and they ask during the examif you can turn off the lights. what is it

sinusitis

physical presentations for pts w sinusitis

facial tenderness w palpation/percussion of sinuses, purulent or clear rhinorrhea, postnasal drainage, inflammed and/or edematous nasal mucosa, possible photophobia

how long dies viral sinusitis last

1-10 days

how long dies bacterial sinusitis last

10-30 days

how long does chronic sinusitis last (can also be recurrent)

12+wks

difference between viral and bacterial sinusitis

viral - symptoms dont worsen

bacterial - symptoms initially improve but then get worse or they just get worse the whole time

viral and bacterial sinusitis treatment

supportive care only, analgesics, decongestants, irrigation with hypertonic nasal saline, nasal steroids (fluticasone, budesonide, momesasone

for bacterial just add antibiotics

causes of bacterial sinusitis

S pneumonia, strep, H influenza, S aureus, moraxella

chronic sinusitis treatments

nasal saline irrigation, nasal steroids, check for co morbidities, do some imagine to see whats up

what normally causes chronic sinusitis

chronic inflammation (not chronic infection)

what are some red flags for really serious sinusitis or worse issues

signs of facial cellulitis or osteomyelitis (redness/swelling), signs or orbital sinusitis (pin, gaze, vision changes, ptosis), immunocomp pt (fungal sinusitis), signs of meningitis or cavernous sinus thrombosis (mental status changes), signs infection spread outside of sinuses

when do you refer a pt w sinusitis to ENT

recurrent or chronic sinusitis, no response to adequate antibiotics, previous facial trauma, previous sinus injury

rhinitis symptoms

sneezing, rhinorrhea, nasal congestion, nasal itching

most common forms of rhinitis

allergic rhinitis, various forms of nonallergic rhinitis (atrophic, rhinitis of pregnancy, occupational)

what causes atrophic rhinitis

older adults whoe done a bunch of sinus and nasal surgeries killed their nasal lining

symptoms of allergic rhinitis

mostly starts as a kid or young adult, often seen w eczema/asthma, nasal itching and congestion, watery rhinorrhea, sneexing, poor sleep, snoring, fatigue, headaches. may see transverse nasal crease, repeatedly rubbing the nose and pushing the tip of the nose up, and allergic shiners (blue/grey/purple discoloration under the eyes).

types of allergic rhinitis

intermittent (only in response to specific shit like cats), persistent (year round), seasonal (at certain times of year, most also have associated allergic conjunctivitis)

mild/episodic allergic rhinitis treatment

glucocorticoid nasal spray (better than antihistamines) (mometasone, fluticasone), cromolyn sodium (good for kids first), 2nd gen oral antihistamines (cetrizone, loratadine, fexofenadine), nasal antihistamines (azelastine, olopatadine)

persistent/moderate to severe allergic rhinitis treatment

glucocorticoid nasal sprays (mometasone, fluticasone), if need be add either antihistamine nasal spray, oral antihistamines, cromolyn nasal spray, irrigation w hypertonic nasal saline or montelukast

allergic conjunctivitis management

glucocorticoid nasal pray, eye antihistamine drops (epinastine, azelastine, olopatadine)

when to refer to ent for allergic rhinitis

kids if severe, pts w prolonged/severe symptoms or significant residual symptoms even w meds and allergen avoidance, pts w lots of comorbidities or complications or adverse effects from meds, those who want immunotherapy

nonallergic rhinitis symptoms

chronic nasal congestion, rhinorrhea and/or postnasal drainage. this is a diagnosis of ecvlusion

difference between allergic and nonallergic rhinitis

nonallergic starts at later age, has no nasal and ocular itching/sneecing, has lots of nasal congestion and postnasal drainage, and constant year round symptoms

subtypes of nonallergic rhinitis

vasomotor, gustatory

what is gustatory nonallergic rhinitis

prominent watery rhinorrhea often from hot/spicy food

what is vasomotor nonallergic rhinitis

rxn to to nonspecific irritants and temp changes

nonallergic rhinitis treatments

oral antihistamines dont work, use nasal glucocorticoids and/or nasal antihistamines, ipratropium bromide nasal, oral decongestants (pseudoephedrine, phenylephrine), daily nasal lavage/saline sprays, sedating oral antihistamines (cant sneeze if youre asleep)

a common and often uncomplicated nasal disorder that happens often in young kids and old ppl and more often in the winter

epistaxis (nose bleeds)

most common kind of epistaxis, normally self limited and mostly in the kiesselbach plexus

anterior epistaxis

less common kind of epistaxis, can result in significant hemorrhage and most pts need prompt referral to the ER/ ENT

posterior epistaxis

initial tamponade for epistaxis

blow nose to remove blood and clots, nasal oxymetazoline (vasoconstrictor), pinch nose

anterior epistaxis treatment

chemical cautery e silver nitrate, electrocautery, pack nose w tissue/tampons, ent consult after 24-48hrs

posterior epistaxis treatment

balloon catheter, foley catheter, hospitalization to monitor

nasal polyps symptoms

pale, red, muscous covered masses in nose or sinuses, often seen in pts w asthma or allergic rhinitis, diminished sense of smell, chronic nasal obstruction, salicylate sensitivity.

samter triad

nasal polyps, history of asthma, salicylate sensitivity (can cause severe episode of bronchospasm)

what should you consider if you see nasal polyps in kids

cystic fibrosis

nasal polyps treatment

refer to ent, glucocorticoids (intranasal are first line- fluticasone, budesonide, mometasone)

what is the most common cause of oral ulcers (idiopathic)

aphthous ulcers (canker sores)

symptoms of aphthous ulcers (canker sores)

painful, shallow, localized, small, clearly defined round or oval ulcers that heal within 10-14 days on its own and w/o scarring. some pts get 2-4 a year, some get them continuously

aphthous ulcers (canker sore) treatment

symptomatic relief only (topical triamcinolone, sucralfate suspension, topical analgesics like benzocaine)

pseudomembranous oral candidas symptoms (most common form of thrush)

white plaques that can be scraped off on buccal mucosa, palate, tongue, or oropharynx

atrophic oral candidas symptoms

often under dentures, redness w/o plaques

general (????) candidas symptoms

beefy red tongue and associated soreness, angular cheilitis (aka perleche aka painful fissuring at the corners of the mouth

candidas treatments

nyastatin, miconazole, clotrimazole

an inflammation of the salivary glands usually due to an obstructive, infectious, or inflammatory etiology. mostly the parotid or submandibular glands

sialadentitis

what can cause/make sialadentitis worse

dehydration, chronic illness (renal failure, diabetes, sarcoid, sjogrens syndrome), poor oral hygiene

sialadentitis pathogenesis

reduction in salivary flow, salivary stasis, pathogen from mouth (S. aureus)

sialadentitis symptoms

tender swollen gland, worse w meals, red ductal opening that may have pus, red swollenoverlying skin, trismus (lock jaw), auricle may protrude if its the parotid thats fucked

sialadentitis treatment

refer to ent, treat underlying disorder, rehydration, antibiotics, sialagogues (stuff that makes you salivate like sour lemon drops or vit c tabs), massage, I&D for abscess

a calculus formation in the salivary ducts

sialolithiasis

sialolithiasis symtpoms

history of sialadentitis and stricture (abnormally narrowed structures or passages), postprandial pain, local edema, stone may be palpable if its close to the duct opening, one little white dot under tongue or at other gland openings

sialolithiasis treatment

surgery from ENT (dilate the duct and excise the duct and gland)

a bilateral infection of the submandibular, sublingual and submaxillary space that commonly comes from an infected 2nd or 4rd bottom molar

ludwig angina

ludwig angina symptoms

aggressive and rapidly spreading cellulitis w/o lymphadenopathy. redness and swelling of upper neck, displacement of tongue up and backwards, respiratory distress. fever, chills, mouth pain, stiff neck, drooling, dysphagia, muffled voice

ludwig angina treatment

EMERGENCY potential airway obstruction, broad spectrum IV antibiotics w coverage for MRSA

a common self limited inflammation of the vocal cords often lasting less than 3wks

acute laryngitis

acute laryngitis symptoms

hoarseness (bad voice quality), rhinorrhea, cough, mild sore throat

what can cause acute laryngitis

acute vocal strain, upper respiratory infection (viral, morazella cat, H influenza, S pneumonia), gerd, alc/tobacco use, other harsh chemicals

acute laryngitis treatment

COMPLETE voice rest, hydration, humidification, oral glucocorticoids for pts who need to use their voice, macrolide (antibiotic) if bacterial, fix reflux if needed

when do you need to see ent for hoarseness

if it lasts over 2wks (need laryngoscopy)

causes of infectious pharyngitis

viral (most common)- adenovirus, rhinovirus, covid

bacterial- group A strep

symptoms of viral pharyngitis

minimal signs and symptoms. cough, congestion, ear pain, rhinorrhea, hoarseness, minimal exudate except w mononucleosis

symptoms of bacterial pharyngitis

acute onset and more severe, fever, dysphagia/odynophagia, anterior cervical lymphadenopathy, patchy tonsullar exudate, palatial petechiae, strawberry tongue

pharyngitis treatments

supportive care (oral NSAIDS and acetaminophen, rest, fluids, soft diet, avoid respiratory irritants.

if you get a positive strep test do oral antibiotics (penicillin or cephalosporin/clindamycin/macrolides if allergic)

when would you need urgent management of pharyngitis

muffled “hot potato” voice, drooling/spit pooling, stridor, respiratory distress, sitting in sniffing/tripod positions, severe one sided sore throat, bulging of pharyngeal wall/soft palate/oropharynx floor, neck pain/swelling, crepitus, stiff neck, trismus, toxic appearance

when should you refere pharyngitis to ent

if you have 5-7 episodes of it in 1 yr (may need tonsillectomy)

an infection/collection of pus in the tonsillar fossa often preceded by tonsilitis or pharyngitis

peritonsillar abscess

what is the first step in evaluating a pt w peritonsillar abscess

rapid assessment of the degree of upper airway obstruction

peritonsillar abscess symptoms

severe one sides sore throat, “hot potato” or muffled voice, trismus (lock jaw), fever, pooling of saliva, drooling, ipsilateral ear pain, extremely swollen and/or fluctuant tonsil w deviation of the uvular on the opposite side

peritonsillar abscess treatment

refer to ent, drain w needle aspiration and culture, antibiotics (amoxicillin-clavulanate, clindamycin), supportive care