Med Exam 2 - Common Pathology Nose, Mouth & Pharynx/Larynx

allergic rhinitis symptoms

sneezing

rhinorrhea

cough

headache

fatigue

obstruction nasal passages

eye nose and throat itching

tearing

post nasal drip

decreased sense of smell

allergic rhinitis clinical findings

swelling of the nasal turbinates

nasal mucosa is pale and boggy

wet mucosa

conjunctiva pale / congested / edematous

allergic Shiners

allergic Salute

allergic rhinitis diagnostic testing

skin testing

- percutaneous; skin prick method

- intradermal testing

serum testing (blood)

- RAST / immunoCAP / ELIZA

- detect specific IgE antibodies

allergic rhinitis non clinical management

avoid outdoor exposure

wash hands/body/hair

keep windows closed, use AC

change air filters

clean carpets

allergy testing

allergic rhinitis treatment

mild symptoms:

- antihistamines

- can combine with decong

moderate:

- glucocorticoid nasal sprays

severe:

- oral prednisone

antihistamines

loratadine (Claritin)

desloratidine (clarinex)

fexofenafine (allegra)

cetirizine (Zyrtec)

intranasal corticosteroids

fluticasone (Flonase)

mometasone furoate (Nasonex)

beclomethasone (beconax AQ)

flunisolide budesinide

adjunctive treatments for allergic rhinitis

nasal irrigations

vasomotor rhinitis (VMR) - symptoms and triggers

nasal congestion

post nasal drip

triggered by cigarette smoking, strong scents, fragrances

patho of vasomotor rhinitis

imbalance between parasympathetic and sympathetic inputs on the nasal muscosa

leading to increased permeability and mucous secretion

vasomotor rhinitis physical exam findings

mucosal tissue boggy

edematous

erythematous

treatment/management of vasomotor rhinitis

avoid environmental triggers!

topical intranasal glucocorticouds

topical antihistamine

acute viral rhinosinusitis (ARS)

inflammation of nasal cavity and paranasal sinuses - common cold

caused by respiratory viruses, commonly rhinovirus

risk factors for acute viral rhinosinusitis

Older age

smoking

air travel

changes in atmospheric pressure

swimming

asthma and allergies

dental disease

immunodeficiency

patho of acute viral rhinosinusitis

viral particles inhaled and enter conductive/nasal mucosa

viral replication, symptoms develop

common viruses involved in acute viral rhinosinusitis

rhinovirus

adenovirus

RSV

coronavirus

acute viral rhinosinusitis symptoms

sneezing

congestion

rhinorrhea

fever

chills

malaise

watery eyes

cough

myalgia

acute viral rhinosinusitis clinical findings

red and swollen nasal mucosa

watery nasal d/c

purulent nasal d/c --> bacterial rhinosinusitis

acute viral rhinosinusitis treatment

nasal irrigation

oral decongestant

- pseudoephedrine

nasal sprays

- oxymetazoline or phenylephrine

antihistamines / mucolytics

acute viral rhinosinusitis complications

not common

Mild eustachian tube dysfunction

Transient middle ear effusion

Acute bacterial rhinosinusitis

acute bacterial rhinosinusitis (ABRS)

inflammation / infection of the mucosa of the nasal passages and at lease one of the paranasal sinuses

acute bacterial rhinosinusitis results from

impaired mucoculiary clearance

inflammation of the nasal cavity mucosa

obstruction of the ostiomeatal complex

acute bacterial rhinosinusitis patho

sinusitis trigger leads to:

swelling, blocked drainage, stagnation and infection

acute bacterial rhinosinusitis microbes

strep pneumonia

haemophilus influenza

symptoms of acute bacterial rhinosinusitis

purulent nasal d/c

nasal obstruction or congestion

facial pain/pressure

altered smell

fever

halitosis

headache

fatigue

dental pain

acute bacterial rhinosinusitis physical examination findings

facial tenderness w/ palpation

purulent nasal secretions

mucosal edema

pain in teeth

air-fluid levels on transillumination

sinus hallmark symptoms

acute maxillary sinusitis: pain in teeth

acute ethmoiditis: pain between eyes, radiate to orbit

sphenoid sinusitis: headache in middle of head

acute frontal sinusitis: pain in forehead

acute bacterial rhinosinusitis diagnostics

Non contrast, coronal CT of sinuses

MRI with gadolinium

acute bacterial rhinosinusitis management

NSAIDs

steam inhalation

oral/nasal decongestant

- pseudoephedrine

- oxymetazoline

- Nasonex or Flonase

acute bacterial rhinosinusitis treatment - first line antibiotics

amoxacillin

amoxacillin-clav

acute bacterial rhinosinusitis treatment for PCN allergies

doxycycline

levofloxicin

moxifloxicin

cefixime

acute bacterial rhinosinusitis treatment for pt with exposure to antibiotics within last 30 days

amox-clav ER

moxifloxacin

acute bacterial rhinosinusitis complications

orbital cellulitis and abscess

- proptosis

- gaze restriction

- abscess

osteomyelitis

intracranial complications

- meningitis

when to admit acute bacterial rhinosinusitis pt to hospital

facial cellulitis

proptosis (eye displacement)

vision changes/gaze abormalities (orbital cellulitis)

mental status change

chronic rhinosinusitis diagnosis

paranasal sinuses inflammation

presence of at least 2 of the symptoms for 12 consecutive weeks:

- nasal obstruction

- nasal drainage

- facial pain/pressure

- hyposmia/anosmia

and

objective evidence on physical exam

- mucupurulent drainage

- edema

- polyps

or radiography CT

chronic rhinosinusitis risk factors

- allergic rhinitis/asthma

- smoking

- irritants, pollutants

- nasal polyps

- defects in mucocilary clearance

- repeated viral URI

- anatomic abnormality (deviated septum)

- immunodeficiency (IgA, AIDS)

- indoor dampness, mold

- systemic diseases

patho of chronic rhinosinusitis

unclear, polyfactorial

- obstruction of sinus drainage

- impaired mucocilary clearance

- occult immunodeficiency

- odzntogenic disease

chronic rhinosinusitis diagnostics

non contrast CT

nasal endoscopy

chronic rhinosinusitis treatment

control inflammation and cause of obstruction!!

antibiotic use is challenging... use culture guided therapy

- intranasal glucocorticoids

- nasal saline irrigation

- surgery if absolutely needed

classification of rhinosinusitis by duration

acute: less than 4 weeks

subacute: 4-12 weeks

chronic: 12+ weeks

nasal polyps

benign tumors

common in allergic rhinitis, asthmatics, ASA allergy

patho of nasal polyps

chronic inflammation

genetics

disease states (CF)

when to not use aspirin

nasal polyps + asthma

polyps + asthma + aspirin = salter triad ... causes bronchospasm

nasal polyps symptoms

asymptomatic!

airway obstruction

post nasal drip

congestion

headaches

snorings

rhinorrhea

decreased smell

chronic mouth breathing

nasal polyp exam findings

smooth, round, red

middle meatus = site for benign nasal tumors

Eustachian tube dysfunction

nasal polyps diagnostics

CT scan of nose and paranasal sinuses

- endoscopy

- MRI

Lab testing

- allergy testing

- genetic testing

nasal polyps 1st line therapy

intranasal corticosteroids

- fluticasone

- budesonide

- mometasone

nasal polyps 2nd line therapy

oral corticosteroids

- prednisone

surgery if bad enough

nasal polyps complications

sinus infections

sleep apnea

asthma flare ups

nasal polyps prevention

saline rinses/sprays

allergy and asthma meds

humidifier to help moisten passages

epitaxis

nose bleeds

nostril, nasal cavity, nasopharynx

predisposing factors to epistaxis

- nasal trauma

- rhinitis

- dry nasal mucosa

- septal deviation/perforation

- hereditary hemorrhagic telangiectasias

- anticoagulant

- hemophilia

- leukemia

- thrombocytopenia

- vitamin deficiencies (A,C,D,E,K)

most common sites for nosebleeds

anterior nosebleeds

anterior nosebleeds

90% kiesselbach's plexus

- septal branch of anterior ethmoidal artery

- lateral nasal branch of sphenopalatine

- septal branch of superior labial artery

posterior nosebleeds

may result in significant hemmorhage

epistaxis assessment

airway assessment and cardiovascular stability

(severe ir normal epistaxis)

history

severe epistaxis

- airway intervention

- fluid resuscitation

- emergent otolaryngologist consult

history assessment epistaxis

check conditions predispose to bleeding

- tumors

- coag

- meds

- HIV

- drug use

timing, frequency, severity

chronic medical problems caused by blood loss

epistaxis physical diagnostic studies

check hemoglobin and hematocrit for baseline

(if bleeding is prolonged or massive hemorrhage)

anterior epistasis management

apply pressure to nares for 15 minutes

- leaning forward to prevent swallowing blood

anterior epistatic treatment if bleeding is visualized - 1st line

cauterize with silver nitrate or electrocautery

thrombogenic foams and gels

anterior epistatic treatment if bleeding is visualized - 2nd line

packaging

- nasal balloon

- gauze

- tampon

antibiotics to decrease toxic shock syndrome

posterior epistaxis management

posterior packing

- nasal balloon catheters

- foley caths

- cotton packing

- hospitalization for monitoring

surgical management

- embolization

- ligation

deviated septum

abnormal deviation of cartilage, may be congenital traumatic

deviated septum symptoms

epistaxis

headaches

congestion

snoring

difficulty breathing

nasal d/c

recurrent sinusitis

deviated septum physical exam

external deformity

unequal nostril

post nasal drip

inflammation

deviated septum diagnosis

examination

endoscopy

treatment for deviated septum

medications

- decongestants: (Sudafed)

- antihistamines: (allegra, Claritin, zyrtect)

- nasal steroids: (Flonase)

- nasal antihistamines

surgery: septoplasty

leukoplakia

white lesion of oral mucosa; tongue, cheek, floor of mouth, lip

may be from chronic irritation

clinical features of leukoplakia

white patch, may become firm, rough, reddened, or ulcerated

usually painless, may become sore

cannot be scraped off!

leukoplakia diagnostic studies

- full intramural, neck, and nodes exam

- incisional biopsy

- exfoliative cytologic exam

leukoplakia treatment

stop alcohol, tobacco, and other physical irritants

for squamous cell carcinoma- remove if less than 2cm

cure likely if less than 4mm in depth

for large tumors - remove, neck dissection and radiation

salivary gland infection

sialadenitis; inflammation of salivary gland

3 pairs of salivary glands

parotid

- stensen duct

submandibular

- Wharton duct

sublingual

- joins submandibular duct

salivary gland infection microbes

staph aureus **

h. influenza

s. pyogenes

patho of salivary gland infection

begins with salivary stasis, restriction/obstruction of duct follows

stasis decreases saliva's ability to promote antimicrobial activity

predisposing factors

- dehydration

- immunosuppression

- trauma

- debilitation

sialadentis symptoms

mouth/facial pain with eating

dry mouth

edema face

pain/erythema of area

spasm of jaw muscle

purulent drainage

fever

sialadenitis management

hydration

warm compress

promote drainage

- massages

- dilation of duct

- sialagogues

sialadenitis treatment

antibiotics

- dicloxacillin

- clindamycin

- cephs

parotitis

swelling of paranoid glands

parotitis microbes

virus (mumps)

bacteria

sialothiasis (blocks flow)

parotitis risk factors

dehydration

surgery

chronic conditions

parotitis clinical presentation

sudden pain and swelling

- worsens with eating

redness + drainage

bilateral parotid swelling assocations

mumps and inflammatory conditions

unilateral parotid swelling associations

bacterial cause

also presents with fever

mumps parotitis clinical presentation

fever

headache

myalgia

malaise

anorexia due to painful chewing

treatment and prevention for parotitis

antibiotics

analgesics

warm compress

sialagogues (promotes secretion of saliva)

prevention: good oral hygiene

sailolithiasis + mostly found where?

salivary gland stones

- calcific concentrations

most common in Wharton's duct

- also in stensen duct

Wharton duct stones

large & radiopaque

Stensen duct stones

small & radiolucent

treatment for sialolithiasis

hydration, moist heat massage, sialagogues

incision of duct if possible to remove

sialolithiasis complications

secondary infection

dysfunctional gland

pharyngitis

Inflammation of mucus membranes and lymphoid tissue of pharynx

usually a result of infection, most commonly viral

viral pharyngitis microbes

Rhinoviruses

Coronaviruses

Adenovirus

Coxsackie A virus

Herpes simplex

Influenza virus

RSV

viral pharyngitis symptoms

cough

conjuctivitis

hoarseness

diarrhea

fever and chills

cervical lymph node swelling

viral rash

edema

ulcers/lesions

viral pharyngitis treatment

saline gargle

analgesics/antipyretics

anesthetic troches

treat URI symptoms

bacterial pharyngitis microbes

group A beta hemolytic streptococci (GABHS)***

neiserria gonorrheae

chlamydia pneumonia

mycoplasma pneumonia

corynebacyeroim diphtheria

meninococci

centor criteria + when to treat

sore throat

PLUS

fever >100.4

anterior cervical lymph node swelling

pharyngotonsillar exudate

no cough

.... test for 2/4 symptoms

3/4 symptoms = rapid strep test

4/4 = treat

symptoms of strep pharyngitis

swelling and redness of tonsils

pharyngeal redness

rash

petechiae on palate

headache

vomiting

bacterial pharyngitis - strep treatment

PenVK

Erythromycin for PCN allergies