EENT Precision & Pearls #3 (Nose & Throat) Flashcards
Anterior epistaxis:
-Causes
-MC Location
-Order of treatment options
-Nasal trauma (nose picking), dry weather, alcohol, antiplatelet medications, cocaine use
-Kiesselbach Plexus
-Direct pressure 5-15 minutes (leaning forward) + Topical Vasodilators (Oxymetazoline, Lidocaine)
–Cauterization
–Nasal packing
Posterior epistaxis
-Causes
-MC Location
-Order of treatment options
-Hypertension, atherosclerosis, older age, neoplasms
-Sphenopalatine artery and Woodruff’s Plexus
-Balloon catheters
-Posterior packing and admission
Rhinitis is inflammation of the nasal mucosa. Symptoms of this condition include…
There are three types. Name them.
Allergic: MC type (IgE mediated)
Infectious: Rhinovirus
Vasomotor: due to temp or smells
Allergic: pale, boggy turbinates, nasal polyps. Cobblestone mucosa of conjunctiva. Allergic shiners, allergic salute
Viral/Infectious: Erythematous turbinates
What is the treatment for allergic rhinitis?
Intranasal corticosteroids (Mometasone, Fluticasone)
Antihistamines or decongestants
Treatment for vasomotor rhinitis
-Oral antihistamines, decongestants, intranasal steroids
What should you be aware of when using intranasal corticosteroids most than 3-5 days
Rhinitis medicamentosa = rebound congestion
Common causes of nasal polyps
Allergic rhinitis and cystic fibrosis
Explain what a nasal polyp looks like and the treatment
Pale, boggy mass on nasal mucosa
Intranasal glucocorticoids
What are nasal polyps associated with?
Samter’s Triad: nasal polyps + asthma + aspirin sensitivity
Acute sinusitis has viral and bacterial causes. What are the MCC in both categories?
Viral: Rhinovirus
Bacterial: Strep Pneumo
Symptoms of acute sinusitis
Facial pain worse with bending or leaning
Headache, fever, purulent nasal discharge
Worsening symptoms after period of improvement (especially bacterial)
What diagnostics are done for acute sinusitis?
CT scan without contrast (DOC)
XR Sinus: Water’s View
Biopsy: definitive
Treatment for acute sinusitis
-Supportive, decongestants
-ABX only if symptoms > 10 days, worsening symptoms
–Augmentin, Amoxicillin are first line
–Doxy or Bactrim 2nd line
Chronic sinusitis is when the symptoms last ________ and the diagnostic that should be done is
> 12 weeks
Biopsy or histology to determine causative organism
MC bacterial cause of chronic sinusitis
MC fungal cause of chronic sinusitis
Staph A
Aspergillus
Mucormycosis (Zygomycosis) is an invasive fungal infection of the sinuses, lungs, and CNS. Who is this MC seen in?
Name some symptoms of this rare condition.
Immunocompromised or Diabetics
Sinusitis progressing to orbit and brain involvement. May have black eschar on palate, nasal mucosa, or face
Diagnostics for mucormycosis
-Biopsy: non-septate broad hyphae with irregular right angle branching
Treatment for mucormycosis
-IV Amphotericin B and debridement of necrotic areas
Symptoms of a nasal foreign body
Epistaxis with purulent discharge, foul odor, and nasal obstruction (mouth breathing)
Name two ways you can remove a nasal foreign body
-Positive pressure
–blow nose with obstructing opposite nostril
–parent blows into the mouth while obstructing opposite nostril
Aphthous ulcers are canker sores, essentially. What conditions are these associated with?
Describe a canker sore
Associated with IBD, Celiac, SLE, HIV
Small, painful shallow round/oval (yellow, white, grey exudates) with erythematous halo
What is the treatment for an aphthous ulcer?
Topical oral glucocorticoids (Clobetasol, Dexamethasone)
2% viscous lidocaine for analgesia
Risk factors for oral candidiasis (thrush)
Symptoms of this condition
Immunocompromised states, ABX use, denture use, use of inhaled corticosteroids without a spacer
Loss of taste. White curd-like plaques in mouth that are easily friable and bleed easily
Diagnostic done for thrush and what is seen
KOH prep: budding yeast and pseudohyphae of scrapings
Treatment for Thrush
-Nystatin liquid, Clotrimazole troches
-Oral Fluconazole if severe
Oral leukoplakia is ______ and risk factors associated with this are
Hyperkeratosis due to chronic irritation
-Smoking, alcohol, dentures, HPV infections
Symptoms of oral leukoplakia
-Painless, white patchy lesions that CAN’T be scraped off
You should perform what diagnostic and why for oral leukoplakia?
Biopsy to rule out squamous cell carcinoma
High chance of SCC with this
Treatment for oral leukoplakia
-Cessation of irritants
-Cryotherapy or laser ablation if high risk for SCC
On the other hand, oral hairy leukoplakia is a mucocutaneous manifestation of _______. The symptom of this condition are
-EBV (HHV4)
Painless, white, smooth or corrugated “hairy” plaque along lateral tongue border that can’t be scraped off
Oral hairy leukoplakia occurs almost exclusively in this with what condition?
HIV
Treatment for oral hairy leukoplakia
No specific treatment
Antiretrovirals for HIV treatment
Erythroplakia is uncommon and has a high risk of malignancy. 90% are either dysplastic or SCC. The risk factors are the same (chronic irritation); however, what does this look like?
Painless, erythematous soft velvety patch in the oral cavity (floor MC)
Treatment after biopsy for erythroplakia
Complete excision if SCC
Oral Lichen Planus is an idiopathic cell-mediated autoimmune response. It is associated with what condition?
Explain what this looks like MC
Hepatitis C infection
Lacy reticular leukoplakia of oral mucosa (Wickham Striae)
Diagnostics for oral lichen planus and treatment
-Biopsy to rule out SCC
-Treatment: local glucocorticoids (Betameth, Clobetasol)
–Topical 2nd line
–Systemic 3rd line
Parotitis is inflammation of the parotid glands. Risk factors for this include
Causes…
Risks: Dehydration, meds, malnutrition (anything that causes increased salivation)
Bacterial, Viral (Mumps), Autoimmune (Sjogren’s, SLE), Obstruction (Stone)
If the parotitis is associated with mumps, what will occur?
If associated with bacterial, what will occur?
Mumps: Bilateral swelling
Bacterial: unilateral swelling
Treatment for parotitis
-Symptomatic
-Sialogogues, Hydration
-Stone removal
-Bacterial IV ABX
What vaccine can prevent parotitis?
MMR (Mumps)
at 12-15 months and 4-6 years old (in two doses)
Acute bacterial sialadenitis (Suppurative) is a bacterial infection of the parotid or submandibular glands MCC by ________, but risk factors are ________
Staph A
Dehydration, stone, Sjogren’s, Autoimmune
Symptoms of sialadenitis
-Sudden onset of firm, tender gland swelling with purulent discharge (pus) if duct massaged
-Dysphagia, Trismus, Fever, chills
What diagnostic can be done to diagnose sialadenitis and what is the treatment?
CT scan
Sialogogues and ABX (Nafcillin or Dicloxacillin)
What are other things you can remind the patient to avoid sialadenitis?
Maintain good oral hygiene, smoking cessation, increase water intake
Sialolithiasis (Salivary Gland Stone) MC occurs in what locations?
Wharton’s Duct (submandibular gland) or Stensen’s Duct (parotid gland)
Symptoms of a salivary gland stone and treatment for it
Sudden onset of salivary gland pain and swelling with eating or in anticipation of eating
Sialogogues, increase fluid intake, moist heat
-Laser surgery or sialoadenectomy if no relief
Epiglottitis is a life threatening inflammation of epiglottis. It is MC in kids, but Diabetes is a risk factor in adults. What are the common causes (MC overall and if immunized)?
Symptoms of this condition?
H. Influenza B (MC)
Strep (GABSH) if immunized
Drooling, Dysphagia, Distress
Inspiratory stridor, dyspnea, hot potato voice, tripod position
What two diagnostics can be done for epiglottitis and what is seen on each? What should you NOT do?
Lateral cervical XR: Thumbprint sign
Laryngoscopy: definitive: cherry red epiglottis with swelling
DO NOT VISUALIZE WITH TONGUE DEPRESSOR
Treatment for epiglottitis
-maintain airway
-OR best for intubation, ENT consult
-IVF AND IV ABX
–Ceftriaxone or Cefotaxime
-Can add PCN or Vanco
What can you give to close contacts of those with epiglottis?
Rifampin
or get the HiB vaccine
Laryngitis, MC after a viral URI, can also be caused by what things?
What are some symptoms?
What is the treatment?
Vocal strain, irritations (GERD, Polyps
Hoarseness, aphonia, scratchy throat
Supportive, vocal rest, fluids
A peritonsillar abscess (Quinsy) is MCC by what organism?
What are the symptoms?
Strep Pyogenes (GABHS)
-Dysphagia, hot potato voice, drooling, trismus, swollen or fluctuant tonsil
-Uvula deviation to the contralateral side
Treatment for a peritonsillar abscess
Drainage (needle aspiration preferred) or I&D
-ABX: Oral Augmentin or Clindamycin
What is angular cheilitis?
Fissures at the side of the mouth
What is the first line diagnostic to use for a peritonsillar abscess?
CT scan to differentiate abscess from cellulitis
MCC Of acute pharyngitis
Viral: Adenovirus, Rhinovirus, etc.
Strep Pharyngitis, MCC by ______, has symptoms such as _______. Think of the Centor Criteria.
GABHS
Fever, Absence of cough, tonsillar exudates, anterior cervical LAD
What diagnostics can be done for GABHS Pharyngitis?
What is one complication that should be remembered with this condition?
Rapid antigen detection test (best initial)
–If negative, get throat culture (definitive)
Rheumatic Fever!
Treatment for Strep Pharyngitis
-Penicillin G or VK (First line), Amoxcillin
–Macrolides if PCN allergic
What is Ludwig’s Angina?
What is it commonly from?
Symptoms of this condition?
Cellulitis of the floor of the mouth
Dental infections, HIV, DM
Fever, stiff neck, dysphagia, drooling, woody induration of the upper neck and chin
What diagnostic is done for Ludwig’s Angina?
CT scan of the neck
Treatment for Ludwig’s Angina?
IV Augmentin or Ceftriaxone + Metro
–Add Vanco if MRSA suspected
What is acute herpetic gingivostomatitis?
Symptoms of this?
Treatment?
-Primary manifestation of HSV-1 in kids
Ulcerative lesions on gingiva (gum swelling, friable, bleeding)
-Perioral vesiular lesions clustered on an erythematous base with a halo
Oral Acyclovir if within 3 days of onset. Otherwise, supportive
What are symptoms of a retropharyngeal abscess?
Torticollis, stiff neck with extension, fever, drooling, dysphagia
Midline/unilateral posterior pharyngeal wall edema
Anterior Cervical LAD
What diagnostics are done for a retropharyngeal abscess, what is seen and what is the treatment?
Lateral neck XR: increased prevertebral space ( >50%)
CT with contrast is DOC
I&D and IV ABX: Augmentin or Clindamycin
What is acute herpetic pharyngotonsillitis?
Symptoms and treatment
Primary manifestation of HSV-1 in adults
Vesicles that rupture and lead to ulcerative lesions with grayish exudate in mouth
Oral hygiene
Respiratory Diphtheria is caused by what bacteria?
Transmission?
Symptoms?
Corynebacterium diphtheriae (gram positive bacillus)
Laryngitis (sore throat, fever, malaise)
Myocarditis (arrhythmias, or heart failure)
-Friable, gray to white membrane on pharynx that bleeds if scraped.
Cervical LAD (bull neck)
Although Diphtheria is a clinical diagnosis, what can be done?
Culture (using Loffler medium or tellurite agar)
Treatment for Diphtheria
Diphtheria antitoxin (horse serum) + Erythromycin or Penicillin x 2 weeks
What are some things to remember about treating Diphtheria?
Patient in respiratory droplet isolation until 2 cultures 24 hours apart are negative
Prophylaxis for close contacts: Erythromycin or Penicillin G x 1 dose
DTaP schedule with booster
5 doses at 2, 4, 6 month , between 15-18 months, and between 4-6 years old
Booster: at 11-12 years old
Nasopharyngeal carcinoma MC type and risk factors
-Squamous Cell Carcinoma
-EBV, hereditary, diet rich in salted fish
Symptoms of nasopharyngeal carcinoma
-Lump in neck (palpable LAD due to metastasis late in disease)
-unilateral hearing loss
-nasal obstruction
-blood tinged nasal discharge
-facial numbness
-unintentional weight loss
One important thing to remember about naspopharyngeal carcinoma should you remember to associated with?
EBV –> nasopharyngeal carcinoma
What is a mucocele?
Mucus filled cyst caused by trauma –> obstruction of salivary gland flow
Located on lower lip. Painless swelling in oral cavity. Bluish color.
They usually spontaneously resolve.
More than 90% of oropharyngeal cancer/larynx cancer are _______.
Risk factors include….
SCC
HPV, Smoking, exposure to paint, asbestos, gasoline fumes, radiation
Larynx Cancer symptoms
-Hoarseness!
-Odynophagia
-Referred ear pain
-Firm, painless mass in neck
-Weight loss
-Aspiration
-Airway compromise
Treatment for larynx cancer
Surgical resection +/- chemo/radiation
Malignant neoplasm of the mouth is almost always associated with
oral tobacco
What is torus palatinus?
Treatment?
Harmless, painless bony growth located on the roof of the mouth (hard palate)
Only needs to be referred to maxofacial surgeon if problematic. Observation for most cases.
