ENT Flashcards
Pharyngitis has more ______ / ______ and sore throat symptoms.
chewing/swallowing
Laryngitis has more _______ and ________problems.
talking and breathing
Name the viral causes of Pharyngitis
- Coronavirus
- Rhinovirus
- Adenovirus
- Parainfluenza
- Influenza
- Epstein-Barr virus
- Cytomegalovirus
- HIV
Name the bacterial causes of pharyngitis
- Strep (GAS mainly)
- N. gonorrhea
- M. pneumonia
C. diphtheriae
name the viral causes of Laryngitis
- Adenovirus
- Influenza
- Parainfluenza
- Rhinoviruses
- Respiratory Syncytial Virus
- Enteroviruses
name the bacterial causes of Laryngitis
- S. pneumonia
- H. influenza
- M. catarrhalis
- S. aureus
The main differences b/w viral and bacterial pharyngitis / laryngitis is that:
VIRAL has a more (gradual/acute?) presentation,
cough is (common / uncommon? )
fever is (low-grade / high )
(Significant / Mild? ) odynophagia and maybe dysphagia
the child usually looks (well / sick )
and family members are usually (affected / unaffected?)
VIRAL:
gradual onset,
cough is common
fever is low grade
mild odynophagia and maybe dysphagia
well appearing
family is affected
The main differences b/w viral and bacterial pharyngitis / laryngitis is that:
BACTERIAL has a more (gradual/acute?) presentation,
cough is (common / uncommon? )
fever is (low-grade / high )
(Significant / Mild? ) odynophagia and maybe dysphagia
the child usually looks (well / sick )
and family members are usually (affected / unaffected?)
BACTERIAL
acute onset
cough is uncommon
fever is HIGH
significant odynophagia / dysphagia
child looks sick
family memebers unaffected
is exudate more common in viral or bactrial pharyngitis / laryngitis
bacterial
T/F
Adenopathy is common in viral pharyngitis / laryngitis
FALSE - common in bactrial
Dx Strep: Centor Criteria
NEED 3 of 4:
what are the 4 criteria?
- Tonsillar exudates
- Tender anterior cervical adenopathy
- Absence of cough
- History of fever
what antibiotics are appropriate when your pt is dx w bacterial strep pharyngitis?
β-lactam’s
PCN
Cefawhatever
Macrolides
Erythromycin
Azithromycin - B
Clarithromycin - C
Lincosamides
clindamycin
Glycopeptides
vancomycin
complciations of strep?
- Toxic Shock Syndrome
- PTA
- Acute Glomerulonephritis
- Parapharyngeal abscesses
- Acute Rheumatic Fever
- Scarlet Fever
- Airway compromise
pt presents to clinic 2 wks post bacterial pharyngitis that has not improves. he reports even more pain and trismus.
Open examination you notice that uvula is not midline:
Dx?
Peritonsillar Abscess (PTA) -
Usually starts as typical bacterial pharyngitis
When a pt is dx w/ PTA what MUST you always check for upon physical exam?
- Chest
- Heart exam
- Pulmonary involvement (if heart murmur 1 mo later think RF)
- Abdomen
- Organomegaly (EBV/ MONO)
- Skin
- Rashes (sandpaper rash + sore throat = strep!)
Name the 2 types of Diphtheria.
which is more common?
- Nasal diphtheria
- Milder disease
- Membrane on nasal septum
- Mucopurulent nasal discharge
- Pharyngeal (most common)
- More severe
Tx for diptheria
antitoxin (horse derived)
Erythromycin 40 mg/kg/day (max 2 gm/day) for 14 days
IM procaine penicillin G x 14 day
300,000 U/day ≤10 kg or less
600,000 U/day >10 kg for 14 days.
Giver booster vaccine
Not contagious after 48 hrs
Viral / Bacterial Parotitis is more common in neonates and elderly.
bacterial
what are some viral pathogens responsible for parotitis?
Paramyxovirus (Mumps),
(EBV),
Viral / Bacterial parotitis has a more rapid onset and presents with pain, esp with chewing.
bacterial
______ ____, pierces the buccinator muscle to enter the buccal mucosa just opposite the 2nd maxillary molar.
Stensen’s duct
what are 2 types of parotitis?
Mumps
Sialadenitis
complications of mumps
•Orchitis (inflammation of testis or ovaries)
Pancreatitis
•Unilateral Deafness
Death (rare)
Sialadenitis is pain and swelling caused by ?
obstruction to saliva flow
(•stones, strictures, scarring, foreign bodies, or tumor)
Stones seen w/ Sialadenitis are typically _____ ______ and ______.
calcium carbonate and protein
explain the anatomical reason why children are more prone to ear infections?
Child: ET is flat
Adult: ET is more oblique so ear infections less common
Acute Otitis Media (AOM) = Rapid onset (≤48 hours) of signs and symptoms of inflammation in the _____ ear.
middle
Otitis Media with Effusion (OME), aka Chronic Otitis Media = inflammation of the middle ear with liquid collected in the middle ear; the signs and symptoms of acute infection are (present / absent)?
absent
define Otorrhea
discharge from the ear, originating at 1 or more of the following sites: the external auditory canal, middle ear, mastoid, inner ear, or intracranial cavity.
3 most common pathogens responsible for AOM
- Strep pneumoniae
- H. influenzae
- M. catarrhalis
can you dx otitis media without middle ear effusion (MEE)?
NO
MEE without signs or symptoms of acute ear infection. DX?
OME chronic otitis media
AOM prophylaxis
- Vaccines!!!
- Breast feeding
- Smoke-free environment
- No bottles in crib/bed
antibiotics NOT reccommended for prophylax
Tx of choice for AOM:
amoxicillin 80-90 mg/kg/bid to max of 1000mg/dose*.
secod line tx for AOM
amox/clavulanate (Augmentin) ES 80-90 mg/kg/bid based on amoxicillin component
should you give cold meds to children under 2 y/o?
NO
how should a normal TM look upon examination?
pearly grey
gone of light at 4 oclock
Dx?
pt has pain
AOM
Dx?
OME (chronic) - pt will present w/out pain
Dx?
Normal
pathogens responsible for Otitis Externa
- Bacteria
- P. aeruginosa
- P. vulgaris
- S. aureus
- E. coli
- Fungal
- Aspergillus
- Candida spp.
- Furuncles
- S. aureus (maybe MRSA).
pt presents w/ red, swollen ear canal littered with moist, purulent debris and desquamated epithelium. Their outer ear appears as pictured.
Pt complains of pain and no itching. she is a diabetic.
Dx
Tx?
Otitis Externa “Swimmers Ear”
Topical antibiotics to cover suspected pathogens
Quinolone drops
Nystatin
Clotrimazole
Oral (and topical) antibiotics when symptoms are more severe or there are comorbidities (DM!!)
Quinolone’s, ceph’s
antifungals
How does the repeated presence of water lead to otitis externa?
decreased canal acidity
can you treat otitis media w/ acetic acid if the pt has a perforated ear drum?
NO ! eardrum must be in tact
pt presents with the classic signs of otitis externa. Their chief complain is INTENSE pruritis!
is this likely bacterial or fungal?
what are the likely pathogens?
fungal
•Aspergillus
Candida spp
what is the most common cause of perforated TM?
improper attempts at wax removal or ear cleaning.
Pt reports to clinic for yearly physical. Upon examination of the ear canal you notice a perforated TM.
when you ask the pt if they are experiencing any symptoms in that ear they report otorrhea (drainage).
How do we treat?
Systemic antibiotics if otorrhea from a TMP.
When treating a perforated TM you should AVOID eardrops containing: (3 things)
gentamicin
neomycin sulfate,
tobramycin.
Dx?
what causes this?
Auricular Hematoma
- Results from direct trauma
- Shearing forces - separation of the anterior auricular perichondrium from the cartilage
what is a MAJOR complication of untreated bacterial OM or otitis externa?
mastoiditis
what is Mastoiditis
bacterial infection of the mastoid air cells surrounding the inner and middle ear.
Most common oral cavity lesion is?
squamous cell carcinoma
is this lesion exophytic or ulcerative?
Exophytic
is this lesion exophytic or ulcerative?
ulcerative
Patients with oral lesions can be categorized into three clinical groups:
- Those with local disease
- Those with locally or regionally advanced disease (lymph node positive)
- Those with recurrent and/or metastatic disease
(Localized / Advanced) disease is T1 and T2 lesions without lymph node positive.
(Localized / Advanced) disease is T3-T4b with lymph node positive.
local - T1 and T2 (1/3 of cases)
Advanced - T3-T4b positive (50% of cases)
Pt comes to clinic complaining of Sore throat and Dysphagia. Upon inital exam you find a neck mass.
when you conduct an oral exam you notice an ulcerated mass at the base of their tongue.
Dx?
where is the MOST common area to find this type of lesion
SCC
tongue ( lateral aspect)
where are the 2 locations you may find SCC
Develops most frequently in the tonsillar region and base of tongue
•Most common chief complaint of pts w/ SCC
- Presence of a neck mass
- Sore throat
- Dysphagia
Usually presents at more advanced stage
A recent study found patients with oropharyngeal cancer, 63.8% had _____-positive tumors
HPV
HPV-positive tumors had an overall (worse / better) 3-year survival rate then those with HPV-negative tumors
better
what is the name of the HPV vaccine?
at what age should kids recieve the vaccine?
Gardasil
11-12 (3 dose series)
Young women can get HPV vaccine through the age of ____
Young men can get the HPV vaccine through the age of ___.
F (26)
M (21)
men who have sex w/ men or men w/ compromised immune systems can recieve vaccine up to age 26
Dx?
HPV
Pt presents with a white mucosal change that can not be removed by rubbing surface.
Dx?
Leukoplakia
Pathophysiology of leukoplakia
Hyperplasia -> dysplasia -> carcinoma in situ -> invasive malignant lesions
where would you commonly find Leukoplakia
•trauma prone regions (cheek or dorsum of tongue) where mucosa is normally thicker
disorder common in smokeless tobacco ?
Leukoplakia
Pt presents to clinic with hairy outgrowth on tongue that can not be removed.
Dx?
what is this associated w/ and what pt population does this condition occur almost entirely in?
Oral Hairy Leukoplakia (Hairy Tongue) - NOT premalignant
associated w/ EBV
see in ONLY HIV infected pts
is leukoplakia considered pre-malignant?
yes - Considered “potentially malignant disorder”
what is the most common acute oral lesion?
Aphthous Ulcer (canker sore)
pt presents w/ painful, small round ulcerations with yellow-gray fibrinoid centers surrounded by red halos. the ucler appears on the pts tongue and measures 0.2 cm.
Dx?
- Minor aphthous ulcers are <1cm
- Major aphthous ulcers are >1 cm
what are the 3 classifications of aphthous ulcers?
- Minor aphthous ulcers are <1cm
- Major aphthous ulcers are >1 cm
- Herpetiform - multiple
Tx options for aphthous ulcers
- Topical corticosteroids provide symptomatic relief:
- Triamcinolone acetonide 0.1%
- Fluocinonide 0.05%
- Other alternative options:
- Diclofenac 3% in hyaluronan 2.5%
- Doxymycine-cyanoacrylate mouthwash
- One week taper of Prednisone has been found to be effective
Tx options for RECURRENT aphthous ulcers
•Maintenance therapy with Cimetidine
Most common ulcerative condition in the US?
Recurrent Aphthous Stomatitis
Classifications of Recurrent Aphthous Stomatitis
- Simple aphthous (most common)
- Several episode a year
- Lasting up to 14 days
- Limited to oral mucosa
- Complex aphthous
- Oral and genital
- Multiple grouped lesions that are larger than 1cm
- Lasting 4-6 weeks
- So frequent that patients almost always have them
Pt arrives to clinic complaining of a painful lesion in their mouth. They said they have had this occur prior and want to know how to treat them.
Upon exam you note recurrent, well-defined, shallow, round to oval ulcerations on the oral mucosa. A necrotic center with a yellow-gray pseudo-membrane and a surrounding halo of erythema.
Dx?
Recurrent Aphthous Stomatitis
Tx of Recurrent Aphthous Stomatitis
- Oral hygiene – non alcohol mouth wash and soft toothbrush
- Pain control – viscous lidocaine 2%
- Diphenhydramine liquid swish and spit
- Dyclonine lozenges
- Topical steroids
- Dexamethasone swish and spit
- Clobetasol gel •
- Triamcinolone paste
Pathogens responsible for Oral Candida
- Candida albicans
- Candida glabrata
- C. krusei
- C. tropicalis
2 classifications of oral candida
- Pseudomembranous – most common
- White plaques on buccal mucosa, palate, tongue and oropharynx
- Atrophic (denture stomatitis)
- Found under upper dentures
- Erythema without plaques
Tx of Oral Candida?
- Nystatin suspension swish and swallow
- Clotrimazole troches
- Miconazole buccal tabs
- Diflucan PO
A pt comes to clinic complaining of dry mouth and difficulty swallowing. Upon examination you notice 2 things:
He wears partial dentures (upper) and erythema without plaques.
Dx? (be specific)
Oral Candida - Atrophic (denture stomatitis)
what is the most common type of oral candida>
how does it present?
Pseudomembranous
•White plaques on buccal mucosa, palate, tongue and oropharynx
pt arrives to clinic with what appears to be oral candida what cultures / swabs should you make sure are part of the workup?
- Fungal culture
- KOH prep
- Refractory thrush – HIV testing
Pt comes to clinic complaning of a rash on perioral area. Upon exam you note multiple oral vesicular lesions and erosions surrounded by erythematous base.
Dx?
HSV-1
how would primary HSV-1 present?
(think systemic)
- Fevers
- Lymphadenopathy
- Decrease oral intake
- Poor ability to manage oral secretions due to pain
how would you work-up HSV?
- Tzanck smear – immunofluorescence smear of viral culture
- Un-roof vesicle
- Serology for HSV by PCP
Pt is dx w/ HSV-1 and you prescribe “Magic Mouthwash”.
what are the components of this mouthwash?
- Diphendydramine
- Viscous lidocaine
- Antacid or mucosal coating agent (magnesium hydroxide, sucralfate, or aluminum hydroxide)
How would we tx HSV systemically?
- Systemic antivirals
- Acyclovir
- Valacyclovir
- Famciclovir
