HEENT

Clin Med Exam 3

subdivisions of pharynx

nasopharynx , oropharynx , laryngopharynx

pharyngitis

common cc - sore throat - 1-2% all ambulatory care visits , 12 million visits annually in U.S. , may be infectious or noninfectious

infectious pharyngitis

viral or bacterial, perform appropriate dx procedures → tx dictated by pathogen ; caused by inflammation from local destruction mucous membrane tissue by organism/pathogen , may cause edema pain redness

noninfectious pharyngitis

treat underlying cause - allergic rhinitis , sinusitis , GERD , smoking , trauma , mx side effects (ACE inhibitors , chemo) , autoimmune (Kawasaki disease)

suspect in - absence signs of infection, older pts, pts not responding to tx

viral pharyngitis

40-60% of cases , adenovirus , rhinovirus , parainfluenza , coxsackie , HSV , EBV , CMV , RSV

bacterial pharyngitis

5-40% all cases , GABHS (usually produces exudate) , n. gonorrhoeae , c. diptheriae , h. flu , m. catarrhalis , c. trochomatis

strep infection

predominantly 5-18 yo , pharyngitis under 3 yo uncommon but possible (nearly always viral)

pharyngitis sx/ clinical hx

sore throat , odynophagia , fever , chills , malaise , HA , anorexia , abd pain

pharyngitis presentation in children under 5

GAS may have atypical presentation - HA , abd pain , n/v , less incidence of exudate

pharyngitis signs/ PE

fever , tonsillopharyngeal erythema , exudates (patchy and discrete) , beefy red swollen uvula , lymphadenopathy (tender anterior cervical nodes) , petechia on palate , sandpaper scarlatiniform rash (w/ GABHS) , lack of cough

pharyngitis ddx

thrush , mono , epiglottis , diptheria

pharyngitis diagnostics

gold standard dx GABHS - throat culture - 95% sensitive (may also find less common infection)

GABHS rapid antigen detection test (RADT) - 90-99% sensitive

antistreptolysin - O (ASO) - serum titer highly sensitive denotes active GABHS infection

mono spot - up to 95% sensitive in peds

PCR - sensitive, higher cost, less insurance coverage, most check for viral and bact causes (helpful in ambiguous cases)

viral pharyngitis tx

tx symptomatically - acetaminophen/ibuprofen for pain and fever , warm saltwater gargle , soft cool foods , rest

GABHS strep tx

aimed at preventing rheumatic fever (rheumatic sequelae)

drug of choice - Pen VK (Beepen VK) , 500 mg PO BID x10 days

Pen G benzathine (Bicillin LA) - 1.2 million units IM single dose

Amoxicillin - 500 mg PO BID

Cephalexin - 500 mg PO BID x10 days

for true PCN allergy - erythromycin 500 mg PO QID F10 or Azithromycin

pharyngitis complications

acute rheumatic fever , PSGN (poststreptococcal glomerulonephritis) , pediatric autoimmune neuropsychiatric disorder associated w/ group A streptococci , throat/ tonsillar abscess , scarlet fever

role of abx in tx of pharyngitis

primarily helpful in reduce incidence acute rheumatic fever as nonsuppurative complication of GAS pharygnitis

pts who present w/ unusually severe signs/sx

secretions, drooling, muffled hot potato voice, neck swelling → evaluate for rare but serious throat infection

throat examination contraindications

never attempt when epiglottitis suspected bc of risk of precipitating resp obstruction

aspirin for peds and adolescents

do not use for tx fever due to risk of Reye’s syndrome

fever >5 days

consider kawasaki disease

indications for consultation

stridor, total dysphagia - urgent eval by epiglottitis specialist , likely in pt care

recurrent streptococcal infect w/ intact tonsils - ENT , consider tonsillectomy

Peritonsillar abscess/PTA/Quinsy

suppurative infection of tissues adjacent to palatine tonsil , develops from direct spread of inadequately treated bact tonsillitis

PTA prevalence

45,000 new cases annually U.S.

greatest incidence adolescents and YA 15-35

equal incidence male/ female

PTA sx/ clinical hx

unilateral severe throat pain , dysphagia , odynophagia , trismus (diff open mouth) , neck pain , referred ear pain , drooling , muffled voice , fever (>38C)

PTA signs/ PE

febrile , trismus, palpable fluctuant area , displaced uvula contralaterally , cervical adenopathy , halitosis , asymmetric oropharynx soft tissue swelling lateral and superior to affected tonsil , tonsil displacement medially and anteriorly

PTA ddx

peritonsillar cellulitis , infectious mononucleosis , diptheria , dental abscess , epiglottitis , extranodal non Hodgkins lymphoma of parapharyngeal space

PTA diagnostics

CBC c DIFF , culture and sensitivity purulent material from needle aspiration , ultrasonography for discrete abscess cavity if present , CT scan

PTA dx

can be made clinically w/out lab or imaging in pt w/ medial tonsil displacement and uvular deviation

may be needed differentiate from peritonsillar cellulitis , para/retro pharyngeal abscess , epiglottitis - ultrasound, aspiration, trial of appropriate abx therapy may help make distinction

examine anterior peritonsillar pillar (defined pillar speaks against dx)

PTA patho

often polymicrobial , predominant bact species strep pyogenes (group A strep) and oral anaerobes

PTA tx

combo IV abx, rehydration, evacuation of pus collection

empiric therapy - include coverage group a strep , s. aureus , and resp anaerobes x14 days

choice of abx depent pt degree of illness and local patterns abx resistance

needle asp/ I&D

tonsillectomy

tonsillectomy indications in PTA tx

may be performed in pt w/ hx frequent prev tonsillar infections , usually perform after infect resolved (inc risk complications) , reserved for pt who fail to respond to other drainage techniques or develop complications

surgical intervention reserved for pt not respond w/ in 24 hours med therapy

PTA complications

recurrence risk immediate (w/ in 4 days) and long term (2-3 yrs) , fatal complications w/ infection spread to deep neck spaces , adjacent structures , bloodstream

PTA in pt tx

pt w/ suspected PTA + indeterminate findings on ultrasound + no airway sx admit to hosp w/ out CT neck for 24 hrs hydration, abx, analgesia

epiglottitis prevalence

1 in 100,000 annual incidence , males 60% cases , greater in African American and Hispanic American (likely due to vacc diff) , historically peds 3-7 but success of H. flu vacc → adult incidence > pediatrics

epiglottitis etiology

HiB (H flu type B)

H parainfluenzae

strep pneumoniae

group A streptococci

staphylococcus aureus

gram + strep and staph (most cases in vacc peds)

noninfectious causes - thermal , FB trauma

epiglottitis sx/ clinical hx

abrupt onset several hrs - fever (high in peds 40C, adults may be afebrile) , sore throat , stridor (difficult labored breathing) , dysphagia , drooling , toxic appearance (agitation, anxiety)

epiglottitis signs/ PE

initial CC sore throat, odynophagia, muffled voice

triad - fever , stridor , drooling

tripod/sniffing position

no cough or hoarseness (differentiate from croup)

cyanosis , pallor , bradycardia - late signs severe airway obstruction (urgent establish artificial airway)

toxic appearing, apprehensive, ashen gray color

tripod position

neck slightly extended and chin forward, attempt to open airway

epiglottitis diagnostics

lateral neck x-ray , nasopharyngoscopy

x-ray findings in epiglottitis

enlargement of epiglottis , thickening of aryepiglottic folds (noted 80-100% pts) , thumb sign , ballooned hypopharynx , narrowed tracheal air column , prevertebral soft tissue swell , obliteraion of vallecula and piriform sinuses

epiglottitis dx

confirmed by visualization inflammation and edema supraglottic structure - should occur in setting where airway can be secured immediately if necessary

cases w/ out direct visualization - epiglottic swelling lateral neck radiographs

supraglottic stuctures

epiglottis , aryepiglottic folds , arytenoid cartilages

first step in suspection of epiglottitis

focus on interventions that may be needed for airway management ; in peds immediate tracheal intubation recommended ; adults have material on hand

intubation , cricothyroidotomy , needle jet ventilation available at bedside

epiglottitis tx

initiate abx therapy once airway secure

cefotaxime :

adults : 1-2g IV q6-8 , not exceed 12g/day

peds : 100-200mg/kg/d IV divided q8

ceftriaxone :

adults : 1-2g IV single dose

peds : 75-100mg/kg IV single dose

also antistaphylococcal - eg Vancomycin

alternatives : cefuroxime or unasyn (ampicillin-sulfabactim) , also bactrim (trimethoprim/sulfamethoxazole) and chloramphenicol if allergy pcn and cephalosporins

NSAIDS

stridor

high pitched inspiratory squeaking sound , may signal impending airway collapse , medical emergency

young peds vs older, adolescents, and adults epiglottitis presentation

young - fever, stridor, drooling, resp distress, anxiety, sniffing/tripod posture

older - severe sore throat, relatively mild resp sx, anterior neck pain, relatively normal oropharyngeal exam

things to avoid in acute management of epiglottitis

agitating the pt, therapy such as sedation or inhalers

administer supp O2 if possible but do not force in case of agitation

thrush prevalence

oral candidiasis , 37% of newborns may develop , universal but more common in poorly nourished , equal male female prevalence

newborn thrush

usually mild and self limited but may cause discomfort sufficient to disrupt newborn feeding , rare during 1st wk of life , incidence peaks around 4th wk life , uncommon in infants older than 6-9 mo

candidiasis

most common fungal infection of mouth , opportunistic , candida species - oral thrush , esophageal candidiasis

esophageal candidiasis

indicator condition for AIDS in 16% pts w/ HIV , uncommon until CD4+ count below 50 , oropharyngeal thrush common in acute HIV infection and increasingly common late in disease as CD4+ count falls

candidiasis risk factors

general causes compromised host defense : neutropenia , glucocorticoid therapy , malnutrition

oropharyngeal thrush risk factors

DM, HIV, dentures, inhaled/oral glucocorticoids, neonatal period, iron deficiency

candidiasis sx/ clinical hx

frequently asymptomatic but may have sore/painful mouth, burning mouth/tongue, dysphagia, whitish thick patches oral mucosa

usually hx HIV, wear dentures, DM, or exposed broad spectrum abx or inhaled steroids

candidiasis signs/ PE

diffuse erythema, white patches buccal mucosa throat tongue gums

types of oropharyngeal candidiasis

1. membranous candidiasis

2. erythematous candidiasis

3. chronic atrophic candidiasis (denture stomatitis)

4. angular cheilitis

5. mixed

membranous candidiasis

one of most common types , characterized by creamy white curd like patches on mucosal surfaces

erythematous candidiasis

associated w/ erythemaous patch on hard and soft palates

chronic atrophic candidiasis

also thought to be one of most common forms , denture wearers

angular cheilitis

inflammatory rxn, characterized by soreness erythema fissuring corners of mouth

mixed candidiasis

combination of any other 4 types of candidiasis

oral thrush ddx

leukoplakia , hairy leukoplakia , lichen planus , secondary syphilis , condylomata lata

esophageal candidiasis ddx

herpes simplex esophagitis , cytomegalovirus esophagitis , reflux esophagitis , barret’s esophagus , acute caustic ingestion

candidiasis dx

usually made clinically ; KOH positive wet smear , endoscopy

oropharyngeal candidiasis tx

clotrimazole troche - 5x/d 7-14 days

fluconazole tablet - 100mg/d 7-14 days

itraconazole solution - 200mg/d 7-14 days

alternatives :

nystatin suspension - 15mL swish&spit QID 7-14 days

for azole unresponsive disease :

caspofungin IV - 50mg/d until resolved or

amphotericin B IV - 0.3-0.5mg/kg qd until resolved

esophageal candidiasis tx

fluconazole (diflucan) tablet - 400 mg loading dose followed by 200-400 mg/d 7-21 days or

voriconazole 200mg/ BID 14 days

sialadenitis and parotitis

inflammation of salivary glands, can be due to number of factors - mumps infection , coxsacki virus , parainfluenza , systemic disease ; may be infectious, non infectious, post surgical, pharmacological, architectural

infectious sialadenitis/parotitis

may be bacterial or viral

non infectious sialadenitis/parotitis

may be caused by systemic disease such as sjogren’s or sarcoidosis or even by radiation therapy

post surgical sialadenitis/parotitis

called surgical mumps, pt kept w/out fluid and given atropine → xerostomia predisposing to inflammation

pharmacological sialadenitis/parotitis

drugs causing xerostomia

architectual sialadenitis/parotitis

blockage of salivary gland due to stone

sialadenitis/parotitis tx

most often out pt, single dose parenteral abx in ED followed by oral, adequate hydration, correct electrolyte imbalance

clindamycin - 900mg IV q*h or 300mg PO q8h

pt w/ significant morbidity, significant dehydration, or sepsis admit to in pt and CT

sialogogues (hard candies)

in cases refractory to abx, consider viral and atypical bact causes

parotitis

inflammation of parotid gland, may be infectious or non, common causes - mumps , sjogren’s , bact infection parotid gland (usually staph aureus) , blocked salivary duct , stone in salivary duct

parotitis sx

pain/tenderness and enlargement parotid glands

infectious parotitis

acute bacterial , acute viral , HIV

acute bacterial parotitis

pt report progressive painful swelling gland aggravated w/ chewing

acute viral parotitis

“mumps” , pain swelling gland lasts 5-9 days , moderate malaise anorexia fever , bilateral involvement most instances

HIV parotitis

nonpainful swelling gland , otherwise asymptomatic pt

acute parotitis tx

abx , rehydration (stimulating salivary flow) , possible I&D

chronic parotitis tx

eliminate causative agent (salivary stone/other blockage) , warm compress , sialogogues , possible surgical resection , ligation of duct in hopes of atrophy

parotitis in TB

chronic nontender swelling of one parotid gland or lump noted w/in gland

sjogren’s syndrome parotitis

recurrent or chronic swelling one or both parotid glands w/ no apparent cause noted ; modest discomfort ; related to dry eyes and mouth

recurrent parotitis of childhood

repetitious episodes unilateral or bilateral mump like episodes in young children

sarcoidosis parotitis

chronic nontender swelling of parotid gland

mumps

viral parotitis , acute sialadenitis caused by RNA virus - paramyxovirus

pt considered infectious 3 days before onset and up to 4 days after start of active parotitis

orchitis may occur in 50% post pubertal males (cause testicular atrophy in as many as 50% but rarely sterility)

other viruses causing salivary gland infection

cytomegalovirus , coxsackie virus , echovirus

mumps vaccine

vaccine introduced 1967, nationally reportable 1968

prior to vacc about 50% children contracted

leading cause viral meningitis and encephalitis , most common cause of acquired sensorineural hearing loss in peds

clinical features of mumps

transmitted via airborne droplets , mainly affects parotid gland , mainly children 5-18 yo , 2-3 wk incubation period , rapid swelling parotids bilaterally , acute pain when salivating

most commonly reported sx : parotitis (83%), submaxillary/submandibular gland swelling (40%), fever (36%), sore throat (32%)

mumps PE

ear lobe elevated due to glandular enlargement , may be purulent discharge from parotid duct but usually clear and unremarkable

mumps diagnostics

positive IgM mumps antibody , significant rise in IgG titers btwn acute and convalescent specimens , isolation of mumps virus or nucleic acid from clinical specimen

mumps tx

conservative therapy indicated , fluids essential (hydration and alimentation) , food and liquid that contain acid may cause swallowing difficulty as well as gastric irritation , rx analgesics for severe HA or discomfot due to parotitis , in orchitis stronger analgesic may be needed , no antiviral agent is indicated mumps (self limited disease)

causes of hoarseness

acute laryngitis , chronic laryngitis , benign vocal fold lesions , malignancy , neurologic dysfunction , non organic (functional) issues , systemic conditions and rare causes

acute laryngitis

<3wks, self limited, URI or acute vocal strain, mostly viral but M. catarrhalis , H. influenzae , and streptococcus pneumonia also been implicated , URI associated w/ rhinorrhea cough mild sore throat

chronic laryngitis

related to irritants, reflux, chronic infection, habitual vocal misuse/ muscle tension dysphonia, benign or malignant lesions

benign and malignant lesions that may lead to chronic laryngitis

benign - polypoid corditis , polyps , nodules

malignant - laryngeal cancer

laryngitis sx/ clinical hx

hoarseness , +/ - sore throat , cough , SOB , stridor , cough , hemoptysis , throat pain , dysphagia , odynophagia , referred ear pain , weight loss , hx smoking and/ or etoh

laryngitis presentation red flags for malignancy

smoking / etoh social hx , SOB , stridor , cough , hemoptysis , throat pain , dysphagia , odynophagia , referred ear pain , weight loss

laryngitis signs / PE

coarse scratchy/ tremulous quality voice

laryngitis diagnostics

usually not necessary for acute unless concerns for deep neck space infection

laryngoscopy may visualize lesions (not usually done in primary care setting)

chronic investigation - indirect laryngoscopy using mirror or direct transnasal/ transoral w/ digital/ fiberoptic endoscope ; CT or MRI to look for masses , upper GI endoscopy

ENT referral w/ concern for malignancy or chronic of unknown origin