ENT Flashcards
Major functions of upper airway structures
Allow air to and from lungs Heat and humidify air Remove particles Immune surveillance Smell Speech
Schneiderian mucosa
Mucosa lining nasal cavity and rhinonasal sinuses
Three types of epithelial cells
Ciliated pseudostratified columnar cells
Goblet cells that produce mucin
Basal cells that replenish layers
Characteristics of lamina propria
Lots of vasculature
Subepithelial seromucous glands
Coryza
Common cold
Profuse catarrhal discharge
Rhinorrhea
Runny nose
Transmission of acute rhinitis
Direct contact:
Infected skin or environmental surface
Aerosolization
Acute rhinitis can induce and produce
Pharyngitis
Sinusitis
Otitis media
Acute Rhinitis
Self limited disease
Can include conjunctivitis
Not effected by treatment
Runny nose, HA, fever, anorexia, tired, muscle aches
Causes of acute rhinitis
40% rhinoviruses (picornaviruses, ss-RNA, **genus-enterovirus)
Adenoviruses Echoviruses Coronaviruses Parainfluenza Respiratory syncytial (RSV)
Allergic rhinitis
Hay fever Children, young adults, 30-40s (continues throughout life) Watery rhinorrhea (with sneezing, itching, congestion)
Seasonal rhinitis
Occurs a particular time of year
Tree, grass, weed pollen
Perennial rhinitis
Occurs year round
Fungi, household items
Occupational
Episodic rhinitis
Symptoms occur at irregular intervals
Could be anything
Allergic rhinitis pathophysiology
Type I hypersensitivity
Allergen stimulate Th2 -> IgE
IgE binds Fc on mast cells
Subsequent exposure activates mast cells
Immediate phase of hypersensitivity reaction
Vasodilation, congestion, edema
Late phase of hypersensitivity reaction
Eosinophils, neutrophils, and T cells infiltrate
Chronic rhinitis
**More than 1 month: sneezing, rhinorrhea, nasal congestion, and postnasal drainage
Follows acute rhinitis
May be due to altered anatomy (polyps, septum)
May have superimposed bacterial infection
Chronic rhinitis vs recurrent allergic rhinitis
Onset after age 20
Aeroallergen cannot be identified
Nasal polyps
Seen with recurrent rhinitis but patients **not atopic
Multiple, 3-4 cm
May cause obstruction or get infected
Edematous loose stroma with mixed inflammatory infiltrate
Lots of eosinophils
Mucocele of sinus
Accumulation of mucus but no bacterial involvement
Sinusitis can rarely occur from
Oral lesions: periapical infection, periodontal disease, or perforation of the antral floor and antral mucosa at the time of dental extraction
Major findings of sinusitis
Facial pain and pressure Nasal obstruction Nasal discharge Reduced ability to smell Congestion Purulence in nasal cavity Fever (acute only)
Minor factors
HA Halitosis Fatigue Dental pain Cough Ear symptoms Fever (non acute)
Serious complications of sinusitis
Spread to orbit -> orbital cellulitis
Osteomyelitis
Cranial vault extension
Septic thrombophlebitis of dural venous sinus
Acute sinusitis
Empyema of sinus
Less than 4 weeks
Purulent rhinorrhea, nasal congestion, facial pain
Can be viral or bacterial
Acute viral sinusitis
AVRS
Associated with common cold, clears in 7 days
Rhinoviruses, influenzavirus, parainfluenzavirus
Acute bacterial sinusitis
ABRS
Can be complication of AVRS
Streptococcus pneumoniae, haemophilus influenzae, moraxella catarrhalis (mainly children)
Presence of symptoms for seven or more days
Symptoms initially improve and then worsen
Sinusitis associated with dental disease
**Can’t differentiate from viral initially
Chronic bacterial sinusitis
More than 12 weeks
Recurrent acute attacks
Fungal sinus disorders
**Obstructive
Anatomic predisposing factors for chronic sinusitis
Deviated septum, trauma, foreign body, mass/neoplasm, previous surgery
Genetic/medical predisposing factors for chronic sinusitis
ASA triad, immunodeficiency, immotile cilia syndrome, cystic fibrosis, DM, ICU
Environmental/allergic predisposing factors for chronic sinusitis
Allergic and nonallergic rhinitis, microorganisms, sick building syndrome, smoking/pollution, dry indoor heating
ASA triad
Aspirin induced chronic rhinosinusitis, nasal polyps, and severe bronchial asthma
Immotile cilia syndrome
Kartagener syndrome
Cilia don’t work and patient has situs inversus
Sick building syndrome
No specific illness or cause can be identified
Ostiomeatal complex
Needs to be patent for normal ventilation and drainage
Sphenoethmoid recess and nasolacrimal duct most important
Chronic obstructive sinusitis
Facial pain, pressure, fullness
Nasal obstruction/congestion
Nasal drainage/postnasal drip
Decreased sense of smell
Opacity can be seen on CT
Non-infected obstructive sinusitis
Mucocele
Infected obstructive sinusitis
Empyema
Obstructive sinusitis bacteriology
**Staph aureus
Gram negative rods
H. flu, Group A strep, strep p, diptheriae
**Increasing mixed infections with anaerobes
Allergic mucus
Eosinophilic mucus with Charcot-Leyden crystals but no fungi
Recurrent symptoms, polyps
May need debridement or steroids
Allergic fungal sinusitis
Eosinophilic mucus with Charcot-Leyden crystals WITH fungi
Recurrent symptoms, polyps
May need debridement or steroids
Fungus ball
Myecytoma
Can see mass lesion on xray
Fungal organisms with little mucus or inflammation
Surgical debridement
Invasive fungal sinusitis
Severe sinusitis with possible neuro deficit
Fungal organisms invade tissue and vessels
Aggressive surgical debridement and anti-fungal drugs
Vascular necrotizing lesions of upper airways
Granulomatosis with polyangitis
Cocaine
Vasospasm
Infectious necrotizing lesions of upper airways
**Rhinocerebral mucormycosis/Rhinocerebral zygomycosis
**Hansen disease/lepromatous leprosy
Several fungi
Syphilis
Malignant necrotizing lesions of upper airways
**Extranodal NK/T cell lymphoma - lethal midline granuloma
Blocks blood flow -> ischemia
Squamous cell
Adenocarcinoma
Rhinocerebral Mucormycosis
Saprophytic mold fungi (Mucoromycotina)
Irregular hyphae with no septa
**Usually in uncontrolled DM ketoacidosis - mucor loves iron
Can invade oral, brain, and eye areas
Nasopharyngeal angiofibroma
RARE
Almost all young males age 10-20
**Epistaxis, unilateral blockage, swelling
Posterolateral wall origin, usually benign but can be aggressive
Have androgen receptors, very vascular
Surgically remove - prognosis depends on resectability
Schneiderian benign neoplasms
Derived from epithelium of embryonic membrane, benign
Epistaxis, nasal obstruction, asymptomatic mass
3 types:
Exophytic
Inverted
Oncocytic
Squamous papilloma
Verruca vulgaris or wart
More common than schneiderian benign neoplasms
Squamous mucosa - towards nares
Exophytic sinonasal papilloma
**Septal, squamous, fungiform Often HPV Rarely becomes carcinoma Looks like little fingers More men than women
Inverted sinonasal papilloma
Lateral wall
Associated with HPV
5-10% develop invasive carcinoma within 5 years
Cells grow downward and inward -> inverted
Looks much more rounded
More difficult to get rid of
More men than women
Oncocytic sinonasal papilloma
Cylindrical, columnar
Later wall
NO association with HPV
**Bright pink cytoplasm
Olfactory neuroblastoma
Neuroendocrine cells Neurosecretory granules \+ IHC markers Extensive polypoid mass, obstruction, epistaxis, anosmia, visual disturbance Looks like blue cell tumor 5-year Survival 40-90%
Nasopharynx mucosa
60% NK squamous
40% Respiratory epithelium
Oropharynx and Laryngopharynx mucosa
100% NK squamous
Upper airway lymphoid structures
Diffuse submucosal aggregates
Tonsils: palatine, lingual, adenoids, tubal
Lymphocytes in the lamina propria -> follicle
Disorders secondary to lymphoid hyperplasia
Obstruction: sleep apnea and recurrent otitis media
Difficult to arouse Daytime sleepiness Poor attention span Poor school performance Snoring Observed episodes of sleep apnea
Infectious and inflammatory conditions of nasopharynx
Same as nasal mucosa
Pertussis (Whooping cough)
Bordetella pertussis Gram neg coccobacilli Spread via droplets DTaP and Tdap vaccine Attaches to pharygneal and tracheal surfaces Diagnose with swab and PCR
Catarrhal phase of pertussis
Most infectious this stage
Looks like any other URI
Paroxysmal phase of pertussis
Bouts of intense coughing
Post cough vomiting and turning red is common
Coughing has characteristic whoop sound (not seen in under 6 mo old)
Convalescent phase of pertussis
Chronic cough lasting for weeks
Nasopharyngeal carcinoma
Three types: K and NK SqCC, undifferentiated with lymphoid component **EBV-related Africa - common in children Asia - common in adults USA - rare Often metastases Associated with smoking and diet Undifferentiated is most aggressive but has best prognosis
NUT Midline Carcinoma
Mostly mediastinum
Highly aggressive (median survival 7 mo.)
Appearance similar to nasopharyngeal and squamous cell carcinoma
BRD4/BRD3-NUT fusion gene
Acute pharyngitis
"Beefy red" **Adenovirus (ds-DNA) HSV, EBV and CMV Some bacterial (strep) Same things that cause tonsilitis
Group A Strep
Age 5-15
Winter and spring
Sore throat and fever
Absence of cough, coryza, hoarseness, conjunctivitis
Tender anterior cervical lymph nodes
Tonsils are enlarged, erythematous and have patchy exudate
Symptoms suggestive of viral not bacterial sore throat
Cough, coryza, hoarseness, conjunctivitis
Fusobacterium necrophorum
Common cause of bacterial pharyngitis
Part of normal flora
10% acute pharyngitis cases
>20% in recurring cases and in peritonsillar abscesses
Jugular vein with thrombophlebitis (Lemierre syndrome)
Thrombi break off and seed to different sites
Diptheria
Corynebacterium diphtheriae
Strains carrying tox gene -> gene encoded within a lysogenic bacteriophage
Sudden pharyngitis that worsens over a few days
**Pseudomembrane
Vaccine
Rhinovirus pharyngitis
Indirect infection -> grow in nasal mucosa
Adenovirus pharyngitis
Pharyngoconjunctival fever (fever, sore throat, conjunctivitis)
EBV pharyngitis
Infectious mononucleosis - can be chronically tired
Can develop lymphadenitis and hepatosplenomegaly
Monospot test
HSV type 1 and 2 pharyngitis
Gingivitis, stomatitis and pharyngitis
Painful vesicles
Pharyngitis common part of
Flu and common cold
Enterovirus pharyngitis
Secondary to upper GI infection and then dissemination
CMV and HIV pharyngitis
Mononucleosis-type illness with acute infection
HIV>CMV
Reinke’s space
Space between vocal ligament and overlying mucosa
Epiglottitis
Swelling of epiglottis secondary to **infections, chemical, and traumatic agents -> may lead to suffocation
H. flu used to be most common now group B strep
Now more common in adults
More of a problem in children
Acute laryngitis
Hoarseness, decreased speech volume, painful speech
Infections, overuse, trauma, smoking
Allergic rxns and GERD are rare
Infectious laryngitis
Abrupt and self-limited and 3-5 years of age
Progressive hoarseness with URI
Viruses > 90% cases: Rhinoviruses, Parainfluenza, RSV, Adenoviruses
Bacteria causes: H. influenzae, S. pneumonia
Viral better than bacterial
Infectious laryngitis in children may lead to
life-threatening laryngoepiglottitis
Croup/Laryngotracheitis/Laryngotracheobronchitis
Inspiratory stridor Seal-like barking Mainly caused by parainfluenza Treat with steroids May see Steeple sign - subglottic narrowing
Reinke edema
Polypod corditis
Usually occurs in middle-aged females who are heavy smokers
Can also occur with heavy, recurrent voice strain
Develop husky low-pitched weak voices
Can be reversed
Vocal Cord Nodules and Polyps
Reaction to injury of vocal cord Usually at junction anterior and middle third of cord Nodules - small and bilateral Polyps - large and unilateral Sustained injury: singing, smoking Almost never give rise to cancer
Vocal Cord Papilloma and Papillomatosis
Benign neoplasms Looks like a raspberry Single in adults but can be recurrent Multiple in children HPV
SqCC of larynx
**Prolonged hoarseness
Dysphagia, SOB, other evidence of obstruction
Enlarged cervical lymph nodes
90% have history of smoking and alcohol abuse
SqCC progression
Hyperplasia -> hyperkeratosis -> dysplasia -> carcinoma in situ -> cancer
Location of laryngeal carcinomas
Glottic, involving vocal cords - 50%
Supraglottic, higher stage at diagnosis - 30%
Subglottic - 5%
Transglottic
Glottic has better survival
Most are squamous
Otitis Externa
Marked tenderness after gentle traction of pinna
Peak age between 7-12
Physical Findings: erythema, swelling, moist debris, pus
Causes of otitis externa
Trauma, contaminated water 90% bacterial: **pseudomonas Staph Gram - rods 10% fungal
Neoplasms of external ear
Simple skin tumors:
Squamous and basil cell
Cholesteatoma
Squamous epithelium trapped within the temporal bone
Usually secondary to injury
Can erode tissue in middle ear
Hearing loss, facial nerve paralysis, labrynthitis, meningitis, epidural or brain abscess
Requires surgery
Acute otitis media
Eustachian tube blocked
Otalgia, fever, otorrhea, irritability, vomiting, diarrhea
Tympanic membrane opacity, bulging, erythema, effusion and decreased motility
Associated with bacterial conjunctivitis and concurrent URI
Bacteria causing acute otitis media
S. pneumoniae, H. influenzae, and Moraxella catarrhalis
Chronic otitis media
Recurrent otitis media with adenoid hypertrophy
**Conductive hearing loss
Perforation tympanic membrane, scarring, mastoiditis and bone erosion, cysts
Bacteria causing chronic otitis media
Pseudomonas aeruginosa, S. aureus
Middle ear cysts
Squamous epithelium: large amounts keratin produced
Metaplastic columnar epithelium: mucin-secreting
Otosclerosis
Autosomal dominant
Begin unilateral, most become bilateral
Hearing loss begins late adolescence/young adults
Progressive ankylosis/immobilization over decades -> severe conductive hearing loss
Bone callus builds up on stapes
Branchial cleft defects
Sinus tracts
Fistulas
Lymphoepithelial cyst: lateral neck, usually unilateral
Most arise from 2nd branchial cleft
Thyroglossal duct cysts
Cyst in midline
Portion of hyoid bone is removed along with cyst and tract
Carotid body tumor
Parasympathetic tumor
Bruit on auscultation
Neuroendocrine cells
Genetic factor if multiple or bilateral
