Nose, Sinus, Oropharyngeal

Sneezing, clear rhinorrhea, tearing/pruritis, postnasal drip.

Exam: Pale or violaceous nasal turbinates, allergic salute, cobblestoning, allergic shiners, injected sclera.

Allergic Rhinitis (Hay Fever)

Sneezing, nasal congestion, rhinorrhea, sore throat, cough, low grade fever, malaise.

Exam: Erythematous nasal turbinates.

Viral Rhinitis (Common Cold)

Common in elderly. Clear rhinorrhea/nasal congestion in response to stimuli (cold/warm air, odors, light, alcohol).

Exam: Negative allergy workup. No specific physical findings.

Vasomotor Rhinitis

Nasal obstruction/congestion worse over the years. Due to prolonged use of OTC intranasal vasoconstrictive nasal sprays causing rebound rhinitis.

Rhinitis Medicamentosa

Recurrent mucosal edema associated with allergic rhinitis

Samter Triad: _______

Exam: Pale, boggy masses (sessile or pedunculated) on nasal mucosa

Nasal Polyps

Samter triad: Asthma, nasal polyps, aspirin sensitivity

Fever, nasal drainage, altered smell/taste, facial pain/pressure.

Exam: Inflamed/erythematous mucosa, watery nasal discharge, tenderness to sinus palpation.

Viral Rhinosinusitis (sinusitis)

Unilateral facial pain/pressure, fever, altered smell/taste.

Exam: Inflamed/erythematous mucosa, purulent nasal discharge, tenderness to sinus palpation.

Bacterial Rhinosinusitis

Enamel loss caused by streptococcus mutans metabolizing sugars into acid

Dental Caries

Inflammed gingiva

Risk factors: poor oral hygiene, smoking, diabetes

Gingivitis

"Trench Mouth". Caused by spirochetes/fusiform bacilli. Classic in young adults under stress.

Exam: Pain, ulcerations, halitosis, bleeding gingival tissue, cervical lymphadenopathy.

ANUG (Trench Mouth)

Adherent dental plaque inflaming gums. Seen in methamphetamine abuse ("Meth Mouth").

Exam: Receding gums with deep pockets (>3mm), roots exposed, loose teeth, foul breath.

Periodontitis

Exam: Located on nonkeratinized areas. Nonindurated, yellow-white lesions with sloughing base and an inflammatory erythematous halo. Painful.

Aphthous Ulcers (Canker Sore) (MC oral lesion)

Exam: Burning/pain followed by small grouped vesicles on an erythematous base.

Herpes Stomatitis (Cold Sore; HSV1)

Occurs in extremes of age, denture wearers, diabetics, immunocompromised, or post-antibiotic/steroid use.

Exam: Flaky, curd-like plaques on an erythematous base that are easily removed. Usually painless.

Oral Candidiasis (Thrush)

Swelling of loose connective tissue (face, lips, throat).

Mast Cell Mediated: Has urticaria, flushing, pruritis, bronchospasm.

Bradykinin Mediated: Prolonged (24-36h), NO urticaria/bronchospasm. Often caused by ACE-inhibitors.

Angioedema

Cough, conjunctivitis, nasal congestion, hoarseness, diarrhea.

Exam: Erythematous tonsils, oropharyngeal vesicles.

Viral pharyngitis / tonsillitis

Exam: Fever, palate petechiae, tonsillar exudate, vomiting, anterior cervical lymphadenopathy. Lack of cough.

GAS / Bacterial Pharyngitis / Tonsillitis

Pus forms between a tonsil and the wall of the throat.

Exam: Severe unilateral sore throat, "hot potato voice", trismus, uvula deviation, odynophagia.

Peritonsillar Abscess (Quinsy)

Exam: Fever, fatigue, tonsillar exudates, palatal petechiae, splenomegaly,

Hoagland sign: ____________________

Lab rx: Lymphocytosis, positive MonoSpot.

Epstein Barr Virus (Mononucleosis)

Hoagland sign: transient bilateral painless upper eyelid edema)

Acute, rapidly progressive infection.

Exam: Drooling, fever, "hot potato voice", trouble breathing. Patient in a "tripod" position (leaning forward, neck hyperextended).

Imaging: "Thumb sign" on lateral neck x-ray.

Epiglottitis

(Most common cause is GAS)

Exam: Hoarseness, postnasal drip, cough. (If h/o weight loss, smoking, alcohol use, consider laryngeal cancer).

Laryngitis

(MCC of hoarseness)

Most commonly from dental infection in lower molars.

Exam: Tender, symmetric, "woody" induration in submandibular area. Floor of mouth elevated/erythematous. Stridor, drooling.

Ludwig Angina

Exam: High fever, neck/throat pain, stridor. Septic arthritis (hip or knee), respiratory distress.

Lemierre's Syndrome

- Septic thrombophlebitis of internal jugular vein.

- Most common pathogen: Fusobacterium necrophorum.

Risk factors: dehydration, sialolithiasis.

Exam: Postprandial cheek pain, unilateral swelling, tenderness/erythema of duct opening (+/- pus).

Sialadentits

- Infection/inflammation of the salivary gland

- MC pathogen S. aureus

Exam: Prodrome (fever/malaise/HA) followed by bilateral parotid swelling (may not occur synchronously), trismus, eyelid swelling.

Parotitis

- Highly contagious myxovirus / Mumps

Thick, white plaques on oral mucosa.

Exam: Usually asymptomatic. Cannot be removed or scraped away easily.

Leukoplakia

Abnormal red patches or lesions. ~90% are dysplasia or carcinoma.

Erythroplakia

Exam: White, lacy patches or red, swollen tissues, autoimmune.

Oral lichen planus

- Chronic inflammatory autoimmune disease

Triggered by EBV. Common in HIV/immunocompromised.

Exam: White patches on the lateral tongue that may appear hairy and do not wipe off.

Hairy Leukoplakia

Most common head/neck cancer. Associated with tobacco, ETOH, HPV.

Exam: Raised, firm, white lesions with ulcerations at the base. Painful to palpation. Unilateral odynophagia, weight loss.

Squamous Cell Carcinoma (Oral Cavity & Oropharyngeal)

Diagnostic test: Oral Candidiasis

KOH prep

Fungal Cx if resistance (generally not indicated)

*HIV testing if no risk factors for Candidia

Diagnostic testing: Angioedema (not typical)

C4 level if suspected undiagnosed hereditary or acquired angioedema

Diagnostic tests: Pharyngitis / Tonsillitis

- Rapid Strep Ag test

- Throat culture (Gold standard)

- Antistreptococcal Ab titers (if managing complications like RF or glomerulonephritis)

Diagnostic testing/labs/imaging: Peritonsillar Abscess

- Rapid Strep Ag test

- Throat culture

- Aspiration Cx

- CBC, BMP

Imaging: CT of soft tissue of neck (with contrast) or US

Diagnostic testing/imaging: EBV (Mono)

- EVB Ab tests (MonoSpot)

- CBC (+lymphocytosis)

- Rapid Strep Ag test

- Throat Cx

Imaging: US if concern for splenomegaly

Labs/Imaging: Epiglottitis

Labs:

- CBC

- CRP, ESR

- Blood cultures

- Throat Cx

Imaging: Lateral neck films ("thumb sign" 90% sensitive)

Labs/Imaging: Laryngitis (if cancer is suspected)

Flexible laryngoscopy

Biopsy

Labs/Imaging: Ludwig Angina

Labs:

- CBC, BMP

- +/- Blood cultures

Imaging: CT scan

Labs/Imaging: Lemierre's Syndrome

Labs:

- CBC, BMP

- Throat cx

- Blood cx

Imaging: CT or MRI

Labs/Imaging: Sialadenitis

Labs:

- Culture of duct purulence

- FNA / bx (if mass or neoplasm suspected)

Imaging: CT or US (to eval for calculus or dilated duct)

Labs: Parotitis

Virologic: RT-PCR or viral cx

Serologic: Mumps-specific IgM Ab

Labs: Leukoplakia or Erythroplakia (Gold standard)

Bx for histopathologic eval

Labs: Oral Lichen Planus

Exfoliative cytology or small biopsy

Treatment: Allergic Rhinitis

- Avoid allergen

- Oral antihistamines

- Intranasal corticosteroids (Fluticasone, budesonide, mometasone)

- Combo spray: Azelastine/fluticasone propionate

- Oral leukotriene-RA: Montelukast

- Allergen immunotherapy

Treatment: Viral Rhinitis

- Symptomatic relief

- Pt EDU: Benign, self-limited syndrome

- Best prevention: hand washing!

Treatment: Rhinitis Medicamentosa

- Intranasal corticosteroid: Fluticasone while weaning off the decongestant.

- Oral steroids may be necessary if severe.

Treatment: Nasal Polyps

- Intranasal corticosteroid (1-3mo): Fluticasone, beclomethasone, mometasone, budesonide, flunisolide.

+/- short course Oral steroids.

- Surgical removal (Referral to ENT) if large/symptomatic.

Treatment: Viral Rhinosinusitis

- Supportive care: rest, hydration, saline rinse

- OTC analgesics

- OTC decongestants: Pseudoephedrine (C/I HTN), phenylephrine

Treatment: Bacterial Rhinosinusitis

- Supportive care: NSAIDs, saline rinse, acetaminophen

- OTC decongestants:

- Pseudoephedrine PO

- Oxymetazoline nasal spray

- Sx >10days, severe, immunodef: Amox/Clav

- PCN allerg: Doxycycline or Clindamycin

Treatment: Dental caries (Definitive, pain, infection)

Definitive: refer to dentist

Pain: Topical anesthetic, NSAIDs, Acetaminophen

Infected: Penicillin or Clindamycin

Treatment: Gingivitis

- Oral hygiene

- Chlorhexidine mouthwash

- D/C EtOH and tobacco

Treatment: ANUG

- Oral ABX: Metronidazole, PCN, Doxy, Clindamycin

- Half-strength peroxide rinses

- NSAIDs (Ibuprofen, naproxen)

- Topical pain relief: Lidocaine

Treatment: Periodontitis

Refer to dentist

Treatment: Aphthous Ulcers

- Supportive care

- Avoid irritants

- Oral chlorhexidine rinse

- Topical corticosteroids: Triamcinolone dental paste

- Severe: Short course tapered systemic corticosteroids (Prednisone)

Treatment: Herpes Stomatitis

Antivirals (24-48hr of onset to shorten course)

- Acyclovir, Valacyclovir PO

- Acyclovir topical 5% oint/cream

Treatment: Oral Candidiasis (PO, Topical, Resistant)

- Oral antifungal: Fluconazole, Ketoconazole, Clotrimazole troches.

- Topical: Nystatin mouth rinses

- Resistant: Voriconazole

*Note: Tx dentures with Nystatin powder

Treatment: Angioedema (Mast Cell, Bradykinin)

For all types: Maintain airway!!

- Acute allergic:

- Anaphylaxis: EpiPen, IV Fluids, O2

- Antihistamines (Cetirizine)

- Glucocorticoids (prenisone or methylprenisolone)

- ACE-Inhibitor Induced: D/C medication immediately

Treatment: Viral Pharyngitis / Tonsillitis

Supportive care:

- Saltwater gargles

- Hydration

- Humidification

- Analgesics: NSAIDs, Acetaminophen

+/- corticosteroids

Treatment: GAS Pharyngitis / Tonsillitis

Oral ABX (5-10d): PCN, Amox, Cephalexin

If PCN allergy: Erythromycin, Clindamycin, Azithromycin

Treatment: Peritonsillar Abscess

1. Airway stabilization

2. IV ABX (broad-spectrum): Ampicillin/sulbactam

PCN allergy: Clindamycin

3. Transition to PO ABX (or if mild): Amox/Clav or Clindamycin

*Needle aspiraiton or I&D

*Dexamethasone 10mg IV can reduce severity

Treatment: EBV (Mono)

- Supportive care (saltwater gargles, NSAIDs, Acetaminophen)

- Corticosteroids (if severe)

- No contact sports (21-28d)

Treatment: Epiglottitis

1. Secure airway!

2. Emergent ENT consult, continuous puls ox

3. IV ABX: Ceftriaxone or Ampicillin/sulbactam

If PCN allergy: Levofloxacin

Supportive care:

- Humidified air

- Glucocorticoids

- Nebulized epinephrine

Treatment: Laryngitis

Supportive care: hydrate, humidify, vocal rest

If bacterial: PCN

Treatment: Ludwig Angina

1. Secure airway!

2. IV broad-spectrum ABX: Ampicillin/sulbactam

- or Clindamycin

- or Ceftriaxone + metronidazole

IV steroids

3. Consult ENT (+/- I&D)

Treatment: Lemierre's Syndrome

Prolonged ABX course: PCN + Metronidazole or Clindamycin

+/- Anticoagulants

Treatment: Sialadentitis

Bacterial: Amox/Clav

- or Cephalexin AND metronidazole

- or Clindamycin

Supportive: warm compress, sialagogues

Large sialoliths/tumors: surgery

Treatment: Parotitis (+ Prevention)

- Supportive care

- Males: Gamma globulin to prevent orchitis

- Prevention: MMR vaccine

Treatment: Leukoplakia and Erythroplakia

1. Gold standard: Biopsy

2. Surgical intervention (excision or laser)

3. Frequent monitoring

4. D/C EtOH and tobacco

! No approved medical therapy !

Treatment: Oral Lichen Planus

Sx MGMT:

- Daily topical corticosteroids (Clobetasol, fluocinonide, betamethasone, triamcinolone)

Treatment: Hairy Leukoplakia

Oral antivirals: Acyclovir, valacyclovir, famciclovir

Treatment: Oral cavity and Oropharyngeal SCC

Local resection if <2cm

Positive margins/metastatic = radiation or chemo