Exam 3 Flashcards
1
Q
Obstructive Lung Diseases (3)
A
- Asthma
- Chronic Bronchitis
- COPD (emphysema)
2
Q
Characterisitics of COPD
A
- chronic airway obstruction
- airflow limitation
- generally progressive over time
- may have airway hyperactivity (reversible component)
3
Q
define Emphysema
A
a pathologic diagnosis based on a permanent abnormal dilation and destruction of the alveolar ducts and air spaces distal to the terminal bronchioles
4
Q
define Chronic Bronchitis
A
a clinical diagnosis based on the presence of a cough and sputum production occurring on most days for at least a 3-month period during 2 consecutive years without another explanation. Cough is not necessarily accompanied by airflow limitation.
5
Q
Identify this condition and describe the management:
cc: shortness of breath while exercising
exam: pt is thin, breathing through pursed lips and using accessory muscles, and has no cough or sputum production
x-ray:
A
Emphysema - Pink Puffer
managment:
- stop smoking
- inhaled beta-2 agonists (Albuterol); anticholinergic (Ipratropium)
- inhaled/oral corticosteroids
- theophylline
- oxygen therapy (end-stage)
- antibiotics
- influenza and pneumococcal vaccines
on x-ray note: hyperinflation, hyperlucency, increased retrosternal air space, flat diaphragm, small heart, bullae formation
pt will also have decreased P02 and normal or decreased PCO2
6
Q
Identify this condition and describe the management:
cc: coughing up phlegm and shortness of breath while exercising and just sitting at home
exam: you note the pt is obese
x-ray:
A
Chronic Bronchitis (ain’t no body got time for that) - Blue Bloater
managment:
- stop smoking
- inhaled beta-2 agonists (Albuterol); anticholinergic (Ipratropium)
- inhaled/oral corticosteroids
- theophylline
- oxygen therapy (end-stage)
- antibiotics
- influenza and pneumococcal vaccines
x-ray findings: normal or incrased lung markings, cardiomegaly, pulmonary HTN, cor pulmonale
pt will have reduced PO2 and elevated PCO2
7
Q
Identify this condition:
pt is a 25 year old non smoker complaining of shortness of breath on exertion
CXR shows a panacinar distribution of emphysema
A
Alpha-1-antitrypsin deficiency
management: replace alpha-1-antitrypsin, eliminate exacerbating factors, COPD management (fpnotebook.com)
8
Q
Stage 1 Mild COPD
A
FEV1/FVC < 70%
FEV1 > 80% predicted
with or without chronic symptoms
9
Q
Stage 2 Moderate COPD
A
FEV1/FVC < 70%
30 < FEV1
with or without chronic symptoms
10
Q
Stage 3 Severe COPD
A
FEV1/FVC < 70%
FEV1 < 30% predicted or < 50% predicted plus respiratory failure or clinical signs of right heart failure
11
Q
Identify this condition and describe the managment:
pt: reports shortness of breath on exertion, chronic wet cough
exam: little or no sputum production, elevated jugular venous pressure and hepatomegaly
CXR: enlarged RV and PA
A
Cor Pulmonale
RV hypertrophy and eventual failure
results from pulmonary disease: hypoxia, pulmonary vascular disease, COPD
diagnosis:
ECHO excludes LV dysfunction
ECG changes: RVH, tall peaked P waves, right axis deviation
12
Q
Chantix (varenicline)
A
targets the same receptors as nicotine and blocks nicotine from binding
helps reduce the urge to smoke
13
Q
Clinical Strategies for Smoking Cessation (5 A’s)
A
ASK - identify smokers at each visit
ADVISE - urge smokers to quit
ASSESS - readiness to make an attempt to quit
ASSIST - counseling and meds
ARRANGE - schedule follow-up contact
14
Q
Asthma Symptoms
A
- Cough - with or without expectoration of excessive mucus
- Hemoptysis - part of Churg-Strauss vasculitis or allergic bronchopulmonary aspergillosis
- Shortness of breath
- Wheeze
- Chest tightness or pain
- Hyperventilation Syndrome
15
Q
Asthma Control: Medications
A
follow-up every 1-6 months to make sure control is being maintained - use the lowest effective dose
Long-term control - medication taken daily to achieve and maintain control
- corticosteroids
- cromolyn sodium and nedocromil
- long acting beta-2-agonists
- leukotriene modulators
Quick-relief - medications taken to provide prompt relief
- short acting beta-2-agonists
- anticholinergics
- systemic corticosteroids
Complementary Alternative Medicine
- epinephrine
- ephedra
16
Q
Asthma Exam Findings
A
- wheezing (cannot be used as a predictor of severity of airflow obstruction)
- use of accessory muscles of breathing - inspiration
- eczema, atopic dermatitis or other types of allergic skin disorders
17
Q
Asthma History
A
- history of intermittent, seasonal waxing/waning of symptoms
- noctural episodes
- exacerbation of symptoms on exposure to:
- exercise
- excitement
- stress
- cold air
- aeroallergens (pollen, mold, animal dander)
- URI
- strong odors
18
Q
Pathophysiology of Asthma
A
smooth muscle dysfunction
airway inflmmation
airway remodeling
19
Q
Differential Diagnosis of Cough - Adults
A
- COPD
- Heart Failure
- PE
- Laryngeal dysfunction
- Tumor
- Pulmonary infiltration with eosinophilia
- Secondary to drugs
- Vocal cord dysfunction
- GERD
20
Q
Differential Diagnosis of Cough - Children
A
- allergic, rhinitis and sinusitis
- foreign body in trachea or bronchus
- vocal cord dysfunction
- vascular rings or laryngeal webs
- enlarged lymph nodes or tumor
- cystic fibrosis
- heart disease
- GERD
21
Q
Asthma Control Components (4)
A
- assessment and monitoring
- education for parternship in care
- control of environmental factors and comorbid conditions
- medications
22
Q
Diagnosis of Asthma
A
Spirometry
FEV1 is the most important variable - declines in direct/linear proportion with obstruction; increases after successful treatment
FEV1/FVC ratio > 75 is normal
Histamine/methacholine challenge - increase dose until FEV drops 20%
Short acting bronchodilator - increase FEV >12% of 200 mL - significant reversibility
23
Q
Definition of Asthma
A
chronic inflammation disorder
airflow obstruction
severe narrowing of the airways
wheezing, coughing, breathlessness, chest tightness
reversible
recurrent episodes
24
Q
Risk Factors of Death from Asthma
A
- past hx of sudden severe exacerbations
- prior intubations for asthma
- admission to ICU for asthma
- 2+ hospitalizations for asthma
- 3+ ER visits for asthma
- low socioeconomic status
- >2 canisters/month of inhaled short acting beta-agonist
- current use of systemic corticosteroids
- difficulty perceiving airflow obstruction
- illicit drug use
25
Asthma Assessment Measures
Spirometry
* initially
* after treament and symptoms have stabilized
* every 1-2 years - assess maintenance of airway function
Peak-Flow Monitoring
* short-term monitoring management of exacerbations
* daily long-term monitoring
26
Asthma Pathophysiology - Smooth Muscle Dysfunction
exaggerated contraction
increased smooth muscle mass
increased release of inflammatory mediators
27
Asthma Control: Control Other Factors
* environmental factors allergens and irritants
* comorbid conditions - maximize treatment of other conditions
28
Asthma Control: Assessment & Monitoring
**Severity** - intrinsic intensity of the disease process; assessed in patient not receiving long-term control
**Control** - degree to which the manifestations of asthma are minimized by therapy
**Responsiveness** - ease with which asthma control is achieved by therapy
**Impairment** - symptoms, lung function by spirometry
**Risk of Adverse Events **
29
Asthma Pathophysiology - Inflammatory Response
Acute Respone
* bronchial hyperreactivity
* mucosal edema
* airway secretions
Chronic Response
* increased inflammatory cell numbers
* epithelial damage
30
Triad of Asthma Symptoms
1. Cough
2. Shortness of breath
3. Wheeze
patients may present with only one of these symptoms
31
Asthma Pathophysiology - Airway Remodeling
cellular proliferation - smooth muscle cells, mucous glands
increased matrix protein deposition
basement membrane thickening
angiogenesis
32
Risk Factors for Asthma
* production of abnormal amounts of IGE
* gender male (10 or less)
* atopy
* family history
* wheezing on expiration
* low income populations
* minorities
* children living in inner cities
* peak expiratory flow that varies 20% or more between morning and afternoon
* obesity
* worsening of symptoms in presence of allergens
* worse symptoms at night
33
Asthma Control: Education
patient develops self-managment of their asthma
action plans
patient education
34
Characteristic Radiographic Appearance of Right-Sided Endocarditis
focal embolic lesion
35
Etiology of Community Acquried Pneumonia
Bird, Tick, Rodent Exposure; Rancher
**Bird Exposure:** Psittacosis, Histoplasmosis
**Rancher**: Q-fever, Brucellosis
**Tick Exposure/Hunter**: Tularemia
**Rodent Exposure**: sin nombre virus (hanta virus)
36
Characteristic Radiographic Appearance of Aspiration
superior segment of right middle lobe
or
posterior segment of right upper lobe
37
Outpatient Management of Community Acquired Pneumonia
Previously Healthy: macrolide or doxycycline
Comorbidities: respiratory fluoroquinolone or ß-lactam + macrolide
38
Urinary Antigen Detection
**Pneumococcal Ag:** rapid, simple, not affected by antibiotic administration, may stay positive for 2-3 months
**Legionella Ag:** detects serogroup 1
39
Characteristic Radiographic Appearance of Bacterial Pneumonia
Lobar of segmental consolidation
40
Community Acquired Pneumonia - Discharge Criteria
no more than 1 during prior 24 hours (unless it is a baseline status):
Temperature \> 37.8 C
Pulse \> 100 beats/min
Respiration \> 24 breaths/min
Systolic blood pressure \< 90 mm Hg
Blood O2 saturation \< 90%
Inability to maintain oral intake
41
Characteristic Radiographic Appearance of Pneumonia - "atypical" pathogen
Diffuse or patchy interstitial pattern
42
Characteristic Radiographic Appearance of Tuberculosis
apical infiltrates, cavitation
43
Etiology of Community Acquried Pneumonia
CF/Bronchiectasis, COPD, Influenza, Cough \> 2-3 Weeks
**CF/Bronchiectasis:** Pseudomonas, Burkholderia, S. aureus
**COPD:** H. influenzae, M. catarrhalis
**Influenza:** S. aureus, infleunza
**Cough \> 2-3 weeks:** Pertussis, TB
44
Prevention of Community Acquired Pneumonia
Get flu vaccine
Pneumococcal vaccine
Covering coughs
Hand washing
45
Etiology of Community Acquired Pneumonia
Splenectomy, HIV, IV Drug Abuse, Alcoholism
**Splenectomy:** encapsulate organisms - H. influenzae, Pneumococcus
**HIV:** Pneumococcus, PCP, TB
**IV Drug Abuse**: right sided endocarditis (S. aureus)
**Alchoholism:** Pneumococcus, Klebsiella or other g(-) bacilli aspiration
46
Community Acquired Pneumonia - Duration of Therapy
treat for a minimum of 5 days
should be afebrile for 48-72 hours
should have no more than 1 CAP associated sign of clinical instability
47
Criteria for ICU Admissions for Community Acquired Pneumonia
Major Criteria & Minor Criteria
admit to ICU with 1 major or 3 minor
Major Criteria:
* need for mechanical ventilation or pressors
Minor Criteria:
* Respiratory rate \> 30/min
* PaO2/FIO2 \< 250
* Multilobar infiltrates
* Altered mental status
* Uremia (BUN \> 20)
* Leukopenia (
* Thrombocytopenia (
* Hypothermia (
* Hypotension requiring fluid resuscitation
48
Etiology of Community Acquried Pneumonia
Travel, Hotel/Cruise Ship
**Travel:** Coccidioidmycosis, Histoplasmosis, Melioidosis
**Hotel/Cruise Ship:** Legionella
49
Inpatient Management of Community Acquired Pneumonia
Medical Ward: respiratory fluroquinolone or ß lactam
ICU: ß-lactam + either azithromycin or a respiratory fluoroquinolone
Special Concerns - could probably look this up in Sanford : )
Pseudomonas: antipneumococcal, antipseudomonal ß-lactam + cipfrofloxacin or levofloxacin ORa ntipneumococcal, antipseudomonal ß-lactam + aminoglycoside and azithromycin
Psedomonas and Penicillin Allergy: aztreonam
CA-MRSA: add linezolid or vancomycin
50
Sputum Examination in Community Acquired Pneumonia
specimen should be from deep cough, purulent
immediately transported to laboratory
examine under microscope - report semiquantitatively
performed to optimize antibiotic selection
51
CURB-65 Scoring System
C - confusion
U - BUN level \> 7 mmol/L
R - respiratory rate \> 30 breaths/min
B - low blood pressure (systolic \< 90 mmHg or diastolic \< 60 mmHg)
65 - greater risk if over 65 years of age
52
Cystic Fibrosis - Sweat Chloride Test Results
\> 6 months of age
Recommendations \> 6 months of age:
Normal \< 39 mmol/L
Intermediate 40-59 mmol/L
Abnormal \> 60 mmol/L
53
Manifestations of Cystic Fibrosis
Lungs
* Bronchiectasis
* Bronchitis
* Bronchiolitis
* Pneumonia
* Atelectasis
* Hemoptysis
* Pneumothorax
* Reactive airway disease
* Cor pulmonale
* Respiratory failure
* Muccoid impaction of the bronchi
* Allergic bronchopulomonary aspergillosis
54
Pathogenesis of Lung Disease in Cystic Fibrosis
Abnormal CFTR gene →
Abnormal CFTR protein →
Abnormal Salt Transport →
Abnormal Mucus →
Impaired Clearance →
Pseudomonas Infection →
Inflammatory Response →
Bronchiectasis
55
CFTR-Related Metabolic Syndrome (CRMS)
infants indentified by:
* hypertypsinogenemia on Newborn Screening
* sweat chloride
* up to 2 CFTR mutations, 1 of which is not clearly recognized as a CF causing mutation
56
Cystic Fibrosis - Sweat Chloride Test
\< 6 months of age
Recommendations \< 6 months of age:
CF unlikely \< 29 mmol/L
Intermediate 30-59 mmol/L
CF likely \> 60 mmol/L
57
Manifestations of Cystic Fibrosis
**Spleen:** hypersplenism
**Stomach:** GERD
**Pancreas:** pancreatitis, insulin deficiency, symptomatic hyperglycemia, diabetes
58
Manifestations of Cystic Fibrosis
General
Nose and Sinuses
Bones
**General:** growth failure, vitamin A, D, E, K deficiency
**Nose/Sinuses:** nasal polyps, sinusitis
**Bones:** hypertrophic osteoarthropathy, clubbing, arthritis, osteoporsis
59
Manifestations of Cystic Fibrosis
Heart
Reproductive System
**Heart:** right ventricular hypertrophy, pulmonary artery dilation
**Reproductive**: infertility, amenorrhea, delayed puberty
60
Manifestations of Cystic Fibrosis
Intestines
* meconium ileus
* meconium peritonitis
* rectal prolapse
* intussusception
* volvulus
* fibrosis colonopathy (strictures)
* appendicitis
* intestinal atresia
* distal intestinal obstruction syndrome
* inguinal hernia
61
How is Cystic Fibrosis diagnosed?
Newborn screening test: test IRT/DNA or IRT/IRT if positive parents and PCP are notified
at the CF Center: sweat chloride test
62
Manifestations of Cystic Fibrosis
Liver
Gallbladder
**Liver:** hepatic steatosis, portal hypertension
**Gallbladder:** biliary cirrhosis, neonatal obstructive jaundice, cholelithiasis
63
Genetics of Cystic Fibrosis
autosomal recessive disease
most common genotype: deltaF508/deltaF508
1000+ mutations; most common - ΔF508
64
Vicious Cycle of Cystic Fibrosis Lung Disease & Treatments for Each Stage
Inflammation: ibuprofen, corticosteroids, leukotriene modifiers
Infection: tobramycin, azithromycin
Obstruction: airway clearance, dornase alfa, hypertonic saline, bronchodilators (albuterol; xopenex), chest percussion
65
Common Infections Affecting CF Patients
Viral: RSV
Bacterial: Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Achromobacter xylosoxidans, Brukholderia cepacia, Staphylococcus aureus
Mycobacterial: M chelonae/abscessus, m avium intraceullare
Fungal: Aspergillus fumigatus
66
Cystic Fibrosis Routine Screenings
Newborn Period - checkups every 4-6 weeks + normal PCP visits
After 1st year of life -
Every 3 months
* Pulmonary Function Tests
* Sputum Culture
* Social Worker and Dietition as needed
Annually -
* CBC, CRP, Chem 14, Vitamin Levels, IgE
* Chest X-Ray
* Evaluation by Social Work and Dietitian
67
CFTR-Related Metabolic Syndrome (CRMS) - Concerning Symtpoms
lack of weight gain or unresolved acute weight loss
persistent loose stools and excessive flatus
abdominal pain
coughing or wheezing - contact CF specialist if longer than 2 weeks
68
Identify this condition and describe the management:
pt (4 yo) presents with a lesions on the attached gingiva and moveable mucosa
exam: irritable, anorexia, anterior cervical lymphadenopathy, fever (103-105)
**Primary Herpetic Gingivostomatitis (children)**
typically occurs 6 months to 5 years
MAY BE ASYMPTOMATIC
69
Primary Herpetic Infections Adult
presents as pharyngotonsillitis
watch for vessicles on tonsillar pillar
clinically similar to bacterial tonsillitis
70
Identify this condition and describe the managment:
pt presents with multiple vesicles containing clear fluid on her lower lip, she noted that the area felt tingly the day before
**Recurrent Oral Herpes (Cold Sores)**
prodromal stage: 12 hours-2 days prior to outbreak
vesicels crust over in approximately 1 week, total healing 2 weeks
subsequent eruptions triggered by: stress (UV light, malnutrition, trauma, immunological issues)
TX: Pencyclovir (Cream), Valacyclovir (capusles) - taken at the onset of the prodromal stage
71
Identify this condition and describe the management:
pt presents with 2 lesions approximately 5 mm in size on the non-keratizined tissues of his mouth, the lesions are ulcerated, erythematous macules with a red halo and very painful
**Minor Apthous Stomatitis (Canker Sore)**
immunologic cause - minor trauma + trigger
80% of all apthous stomatitis
heals over without scars in 7-10 days
tx: topical corticosteroids (triamcinolone acetonide)
72
Identify this condition and describe the management:
pt presents with a painful 3 cm lesion on the labial mucosa
**Major Apthous Stomatitis**
10% of Apthous Stomatitis
cause: immunolgic
other sites: posterior oral cavity, soft palate, tonsillar fauces
heals with scarring in 2-6 weeks
tx: topical corticosteroid (triamcinolone acetonide)
73
Identify this condition and describe the management:
pt presents with numerous lesions (2 mm in size) across the entire mucosal surface
** Herpetiform Apthous Stomatitis**
greatest number of lesions (up to 100), most frequent recurrences
predominantely nonkeratinized tissue but can occur on any oral mucosal surface
form of erythema multiforme
tx: topical corticosteroid (triamcinolone acetonide)
74
Identify this condition and describe the management:
pt presents with white, cottage cheese like plaque on his tongue and a "bad taste" in his mouth
exam: the plaque could be wiped away with a tongue blade
**Candidiasis (aka trush)**
most common oral fungal infection
caused by Candida Albicans
predisposing factors: diabetes mellitus, steroids, broad-spectrum antibiotics, dentures, iron-deficiency, immunocompromised
75
Identify this condition:
pt reports that his mouth feels "like it was scalded", he was on penicillin a week ago for strep throat
**Acute Atrophic Candidiasis**
antibiotic sore mouth
tx: clotrimazole (troche), Nystatin (ointment)
76
Identify this condition:
pt presents with an erythematous, sharply circumscribed, asymptomatic, plaque-like lesion on the dorsal midline of the tongue
**Median Rhomboid Glossitis**
tx: clotrimazole (troche), Nystatin (ointment)
77
Identify this condition:
pt presents with erythema, fissuring and scaling of the corners of the mouth
**Angular Cheilitis**
causes: C. Albicans, Mixed, Staph aureus
combined with old, worn dentures and collapsed bite
tx: clotrimazole (troche), Nystatin (ointment)
78
Identify this condition:
pt is an 80 year old female, presents with asymptomatic, red, irritated tissue below where her dentures are placed
**Denture Stomatitis**
aka Chronic Atrophic Candidiasis
tx: clotrimazole (troche), Nystatin (ointment)
79
define Leukoplakia
not a disease but a clinical term
white patch or plaque that cannot be attributed to any other disease
pre-malignant lesion (4% lifetime risk of malignant transformation
risk of lesion increases with age
80
etiology of Leukoplakia
tobacco: (80% of smokers)
alcohol: synergistic effect with tobacco
UV: low lip vermillion
microbes: C. albicans and HPV
81
define Erythroleukoplakia
speckled leukoplakia
red and white mixed colored lesion
28% transformation to malignancy
82
define Erythroplakia
pre-malignant lesion
50% are already invasive carcinoma by time of biopsy
typically found of floor of mouth, tongue and soft palate (all high risk locations)
83
What are the 4 clinical variants of oral Squamous Cell Carcinoma?
leukoplakia (erythroleukoplakia)
erythroplakia
exophytic (mass-forming)
endophytic (ulcerating)
84
Oral Squamous Cell Carcinoma
90% of oral malignancies
far more deadly than SCC of skin
85
Tooth Anatomy - Cliff's Note's Edition
Enamel - hard outer covering, brittle, thin
Dentin - has dentinal tubules and odontoblastic processes, continues to form throughout life
Cementum - covers only the root has Sharpey's fibers in it
Peridontal Ligament - attach tooth, cushion force, made of collagen-rich Sharpey's fibers
Dental Pulp - contains blood vessels, lymphatic vessels, myelenated and unmyelanated nerve fibers
86
Primary Dentition
| (baby teeth)
20 teeth - 10 in each arch
4 incisors, 2 canines, 4 molars
87
Adult Dentition
32 teeth total, 16 per arch
each arch: 4 incisors, 2 canines, 2 pre-molars, 3 molars
88
Eruption Milestones:
age 1st tooth appears:
completion of primary dentition:
age 1st permanent tooth appears:
completion of permanent dentition:
**Eruption Milestones:**
**1st tooth:** roughly 6 months (mandibular, central)
**completion of primary dentition:** 2-2.5 years
**1st permanent tooth:** 6 years (mandibular 1st molar)
**completion of permanent dentition:** 12-13 years (no 3rd molars)
\*from ages 8-10 "classic mixed dentition" 1/2 primary, 1/2 permanent
89
Identify the condition and describe the management:
pt is a newborn presenting for a 2 week check up
exam: you note 2 teeth, and ulceration of the lower lip
**Neonatal Teeth -\>**
**Riga Fede Disease** (ulceration)
seen at birth or within 30 days
prematurely erupted portion of deciduous dentition can interfere with nursing
tx: if supernumerary remove the tooth, if not smoother it
90
Hyperdontia
Supernumerary Teeth
extra tooth in addtion to the 20 primary or 32 permanent teeth
can impede eruption of other teeth
**most common:**
* anterior maxillary incisor region
* 4th molar
91
Hypodontia
**Congenitally Missing Teeth** - alveolar housing is deficient locally
more common in females
multiple missing teeth can be a component of several syndromes
**most likely**
1. 3rd molar
2. lateral incisior
3. 2nd premolar
92
Identify this condition and describe the management:
pt is a 7 year old and is pretty pumped to be getting his adult teeth and money from the tooth fairy
mom however is worried about this vesicle that has appeared:
**Eruption Cyst**
* remnant of developmental dental follicle
* occurs after the erupting tooth has emerged through bone
tx: once the tooth penetrates the gingiva, cyst drains and heals uneventfully - may require enucleation
**Eruption Hematoma**
blood filled cyst (see below)
tx: same
93
Enameloblast Insult
causes: fever, medications (TETRACYCLINES), trauma
imperfect enamel "hypoplastic" can be localized or generalized
active: 14 weeks I.U. to approx 8 (2nd molars), 14 (3rd molars)
94
Describe the dentition changes that can occur from thumb sucking and pacifiers.
anterior maxillary teeth flare outward & mandibular retroclination - open bite
if it continues past eruption of permanent teeth, may permanently change skeletal form of anterior maxilla
95
What is tooth decay?
demineralization of tooth structure by lactic acid
dental plaque: biofilm of bacteria, proteins, and glycoproteins
normal flora: streptococcus mutans and lactobacillus
96
Baby Bottle Decay
Early Childhood Caries
typically seen 1-3 year olds
due to having control of drinks throughout day and or night - bottle at bedtime, sippy cups - child holding fluid for extended period of time against teeth
97
Differentiate between:
Pit and Fissure Decay
&
Smooth Surface Decay
Pit and Fissure Decay -
* pits and fissures can be too narrow for toothbrush bristles to clean
* usually develops 0-3 years after eruption of tooth
Smooth Surface Decay
* between teeth (interproximal surfaces) or near gingival margin on the buccal surface
* 2-5 years after eruption of tooth
98
Gingivitis
**marginal gingiva swells** due to irritation from normal flora bacteria in dental plaque and calculus
**REVERSIBLE** but can progress to periodontitis
**increased probing depth** in gingival sulcus
99
Periodontitis
begins as gingivitis
deepest part of gingival sulcus has less oxygen and nutrients
*anaerobic bacteria: Actinobacillus actinmycetemcomitans; Porphymonas gingivalis, Bacteroides forsythus -* produce* *collagenase
**collagenase: breaks down peridontal ligament**
affects hard and soft tissue
without treatment: tooth loss
100
Describe the managment and complications of tooth displacement:
damage to peridontal ligament - stabilization for 2 weeks
if pulpal tissues damaged or severed: root canal
time out of correct position is critical, if more than 2 hours reimplantation will fail
can have resorption
* external destroy tooth from PDL
* internal destroy tooth from nerve chamber
101
Dentoalveolar Fracture
requires replacement and stabilization for 2-8 weeks
pulpal tissue damages requries treatment (root canal)
102
Dental Trauma Management:
if the tooth is chipped and patient has no pain, blood, mobility
no hurry
103
Dental Trauma Management:
if tooth is fractured with sensitivity
go to dentist
104
Dental Trauma Management:
if tooth avulsed
replace the tooth NOW and refer to dentist ASAP
105
Identify the condition and describe the management:
pt is a rugby player and recieved a blow to the ear, he has an accumulation of blood in the subperichondrial space
**Auricular Hematoma -**
**aka cauliflower ear**
complications: cartilaginous necrosis, permanent disfigurment
tx: within 7 days, surgical evacuation refer to ENT
106
Identify the condition and describe the management:
pt's ear appears pale and cyanotic
pt was sledding with some friends and didn't wear a hat
upon rewarming pt reports pain; erythema and blisters are noted
**Auricular Frostbite**
due to prolonged exposure to cold, vasoconstriction, dehydration and freezing of auricular tissue
early on reversible, increased time necorsis results
tx: rapid rewarming, refer to ENT
107
Identify the condition and describe the management:
pt complains of otalagia, aural fullness, pruritus and tenderness upon palpation
otoscopic exam shows:
**Otitis Externa**
**Staph aureus and Pseudomonas aeruginosa**
**pathogenesis:** heat, humidity, maceration result in edema and occlusion of apopliosebaceous units
**other findings:** can also have otorrhea and occlusion of EAC
**management:**
1. clean EAC - irrigation, enhances drop penetration
2. treat inflamamtion and infection -
* acidifying agents, antiseptics, topical steroids and antibiotics (Cipro HC, Corticosporin, Tobrdex, Pred-G)
* systemic antibiotics - quinolones
3. control pain - oral analgesics, oral anti-inflammatories
4. culture in severe cases
5. avoid promoting factors
* keep ear dry during recovery
**follow up:** 1-2 weeks, should improve 36-48 hours
108
Describe the causes, managment, and complications of a perforated Tympanic Membrane.
**Causes:**
* trauma
* barotrauma
* AOM
**Management:**
* protect from moisture
* small perforations can heal on own
* surgery for larger perforations
**Complications:**
* can have hearing loss depending on the location of perforation
* cholesteatoma
* chronic perforation
109
Eustachian Tube Dysfunction
causes, symtpoms, treatment
**causes:**
* URI
* allergies
* inflammatory causes
**symptoms:**
* aural fullness
* fluctuating hearing
* discomfort
**treatment:**
* meds
* autoinflation techniques
110
Barotrauma
causes, treatment
**Causes**
* poor eustachain tube function
* flying, driving, abrupt altitude changes
**Treatment**
* preventative medications
* autoinflation
* myringotomy
111
Describe the complications of Acute Otitis Media:
**Extracranial**
* acute mastoiditis
* labyrinthitis
* petrositis
* CN VII paresis or paralysis
* cholesteatoma
* perforation & tympanosclerosis
**Intracranial**
* meningitis
* epidural abscess
* subdural abscess
* brain abscess
* otitic hydrochephalus
* sigmoid sinus thrombosis
112
Identify the condition and describe the management:
pt was seen last week for AOM
pt presents with fever 38 C, postauricular pain and erythema
**Mastoiditis**
cause: inadequately treated otitis
management:
* CT scan
* admit and treat aggressively
* surgery may be required
113
Identify the condition and describe the management:
pt was seen last week for AOM
pt is lethargic, presents with a fever, headache and nausea
ophthalmoscopic examination shows papilledema
**Sigmoid Sinus Thrombosis**
septic thrombophlebitis of sigmoid sinus
diagnosis: MR venography
tx: IV antibiotics, surgical debridement
114
Identify the condition and describe the management:
pt complains of tinnitus, hearing loss and purulent otorrhea
otoscopic exam shows TM retraction with a small perforation, purulent otorrhea, some ossicle erosion
**Cholesteatoma**
**pathophysiology:** chronic negative middle ear pressure leads to retraction of TM, disrupting migratory pattern of squamous epithelium resulting in the accumulation of keratin debris - cholesteatoma sac
**diagnosis:** imaging can help but is not definitive
**managment:**
* non-surgical: otopical antibiotics/steroids
* pseudomonas, strep, staph, proteus
* surgical: removal, high rate of recurrence, yearly follow up
115
Indications for Cerumen Removal
* hearing loss
* poorly functioning hearing aid
* ear pain
* ear fullness
* unexplained fever
* unexplained facial paralysis
* unexplained dizziness
116
Complications of Cerumen Removal
* lacerations
* further impaction
* otitis externa
* perforation
* pain
* hearing loss
* vertigo
117
Nasal and Paranasal Anatomy
channel your inner Dr. Keim : ) you know this stuff . . . if you neeed a little review: slides 3-22 serve as a good review
118
Common Patholgoy of the Nasal and Paranasal Sinus
hint: KITTENS
K = Congenital
I = Inflammatory, Infectious, Immune, Idiopathic.
T = Trauma, Tumor
T = Toxic
E = Endocrine
N = Neurologic
S = Systemic, Psychogenic
119
Rhinitis vs. Rhinorrhea
rhinitis: nasal hyperfunction, tissue inflammation
rhinorrhea: tissue transudate (hypersecretion)
120
Causes of Acute Viral Rhinitis
most common cause: Rhinovirus
others: Corona viruses, respiratory syncytial virus (RSV), parainfluenza viruses, Coxsackie virus, adenovirus
121
Acute Viral Rhinitis: Prodromal Stage
hours
local invasion and nasal ischemia
hot, tickling sensation
"unusually clear nose"
122
Acute Viral Rhinitis: Catarrhal Stage
hours to days
infection spreads over the mucousal surface via lymphatics
sneezing, profuse watery discharge nasal obstruction
mucousal erythema and edema, mild fever
123
Acute Viral Rhinitis: Mucous Stage
days
venous stasis/secondary infection
nasal discharge thickness/"mucopurulent"
mucosa becomes dusky
nasal obstruction at its worst
124
Acute Viral Rhinitis: Resolution
regression of signs and symptoms within 10 days
125
Identify the condition and describe the managment:
pt reports nasal obstruction, sneezing, head feeling full and itchy eyes and nose, clear nasal discharge
exam: pale-bluish, boggy nasal mucosa, inferior turbinates are swollen
**Allergic Rhinitis**
Type 1 Hypersensitivity reaction: antigen binds to IGE, mediators (histamine) is released producing symptoms
causal tx: avoidance, immunotherapy
symptomatic: antihistamines, steroids, decongestants
126
Identify this condition and describe the management:
pt complains periods of congestion and a runny nose that come on after eating the spicy salsa that Zemogs put on his burrito
exam shows bilateral watery secretion, deep red mucosa and turbinate swelling
**Vasomotor Rhinitis**
**idiopathic nasal congestion and rhinorrhea not associated with sneezing or pruritus**
triggers: chemical, climatic, and emotional factors
medical tx: steroid, ipratropium bromide
surgical: directed to the inferior turbinate
127
Identify this condition and describe the management:
pt complains of:
facial pain and fulless, sinus pain
nasal blockage, post nasal drainage, mucopurulent smelly discharge
headache and fatigue
exam:
nose: mucous red, edmatous; purulent discharge noted
sinuses: tender to palpation
**Acute Sinusitis**
predisposition: subsequent inflammation, blockage, deviated septum, trauma, excessive dryness, impaired cilia, immunocrompomised states
micrbiology: Strep pneumo, H. flu, Moraxella catarrhalis (rare - Staph aureus, Strep pyogenes)
tx:
* antibiotics if symptoms persit for 7-10 days
* decongestant
* steam, saline, irrigations
* mucolytic decongestants
* antihistamines
128
Symptoms of Acute Sinusitis
Major Symptoms:
* facial pain/pressure
* facial congestion/fullness
* nasal obstruction/blockage
* nasal discharge/purulence/discolored postnasal drainage
* hyposmia/anosmia
* purulence in nasal cavity
* fever (acute rhinosinusitis only)
Minor Symptoms
* headache
* fever (all non-acute)
* halitosis
* fatigue
* dental pain
* cough
* ear pain/pressure/fullnes
129
Identify this condition and describe the management:
pt compalins of nasal obstruction, postnasal drainage and occasional pain/pressure for the past 3.5 months
**Chronic Sinusitis**
microbial causes: anaerobic gram positive cocci, Fusarium species, alpha-strep, H. Flu, Staph a.
tx:
* antibiotics
* saline irrigation
* steroid spray
* allergen densitization
* envrionmental controls
* antihistamines if allergic
* Functional Endoscopic Sinus Surgery (FESS) to open drainage pathways and aerate the sinuses
130
Chronic Rhinosinusitis Types
* Aspirin Exacerbated Respiratory Disease
* Allergic Fungal Sinusitis
* Asthmatic Sinusitis
* Allergic Sinusitis
* Cystic Fibrosis
* Chronic Rhinosinusitis with/without polyposis
* Chronic Rhinosinusitis with/without biofilm
* Chronic Eosinophilic Rhinosinusitis
131
Treatment of Chronic Rhinosinusitis
**Inflammation:** corticosteroids, antifungals, macrolides
**Fungus:** topical antifungal
**Allergy:** immunotherapy
**Bacterial Biofilm**: topical antibiotics, surfactants, mechanical debridement, probiotics
**Bacterial Superantigen:** antibiotics
**Other:** saline, irrigation
132
Identify this condition and describe the management:
pt complains of increasing nasal obstruction, inability to smell and a feeling of head fullness
pt is taking aspirin to prevent MI, and has hx of seasonal allergies
exam shows a sessile mass, it is soft and mobile on probing
**Nasal Polyposis**
Sampter's Triad: polyps, asthma, aspirin sensitivity
TX:
* diet if allergy due to specific foods
* immunotherapy
* decongestants
* antihistamines
* steroids
* avoiding NSAIDS if a trigger
* leukotriene-receptor antagonists
* SURGICAL: endoscopic polypectamy and FESS
133
Conductive Hearing Loss
Sound conduction is impeded through the external ear, middle ear, or both
134
Identify the condition and describe the management:
pt complains of ringing in his ears, full feeling ears and occasionally has some hearing loss in just the left ear. the pt also complains of periods of vertigo with nausea that lasts a couple of hours.
**Meniere's Disease**
labrynthine disorder, uncertain etiology, thought to be caused by increased fluid pressure within the ear
usually self limited
**diagnostic work-up: **audiometry, vestibular testing, MRI to rule out acoustic neuroma
**tx: symptomatic treatment - **antiemetic (compazine, tigan), vestibular suppressant (meclizine), diuretics, decrease sodium intake
135
Identify the condition and describe the management:
pt complains of vertigo that lasts for a few seconds after he rolls over in bed or gets up quickly from a chair
**Benign Paroxysmal Positional Vertigo (BPPV)**
caused by otoconia particles from the utricle or sacccule lodging in the posterior semicircular canal
exam: ENT, orthostatic hypotension, ocular exam, balance tests, assess gait, CN assessment
**Dix-Hallpike Manuever**
symptomatic tx: meclizine
136
Common Ototoxins
salicylates
aminoglycosides
chemotherapeutics
137
Identify the condition and describe the management:
pt presents with white patches on the TM (see below) and has reduced movement on pneumatic otoscopy
pt has a prior hx of recurrent otitis media and tympanostomy tube
**Tympanosclerosis**
clacium patches on the TM in response to infection
involves the TM, ossicles, middle ear mucosa - stiffens system
tx: ENT referral
138
Rinne Test
Tuning Fork **(512)** at mastoid, when pt no longers hears sound, place tuning fork adjacent to ear canal to check air conduction
Air conduction better than bone conduction (AC \> BC)
**Abnormal in Conductive Hearing Loss**
139
Whisper Test
Patient occludes opposite ear
Examiner whispers questions or commands
Patient answers or follows commands
Avoid testing with finger snapping or ticking watch
Not accurate for Hearing Testing
140
Identify the condition and describe the management:
pt is a 45 yo female
she complains of ringing in her ears, and that she has slowly lost hearing in her right ear
Weber: + Left ear
Rinne: negative
**Accoustic Neuroma**
* benign tumor that arises from the Schwann cells of CN 8
* most common in middle age
* symptoms: tinnitus and hearing loss
* hearing loss is usually gradual, progressive, unilateral
diagnostics: MRI
tx: srugery or radiothrapy
141
Identify the condition and describe the management:
pt reports reduced ability to hear in his R ear
Weber: lateralizes to R side RInne: R BC\>AC
exam shows: pt has a bony overgrowth in the EAC
**Exostoses / Osteoma**
tx: surgery, rarely necessary
can cause impared cerumen migration
142
Tinnitis
"ringing" in the ears, preceived internal noise heard by patient with associated hearing loss
can be secondary to vascular problem, intracranial mass, metabolic disorders, medications
if "blood rushing" or "heartbeat" - vascular problem
if bilateral, NOT pulsatile, not instrusive and mild hearing loss - secondary to hearing loss
tx: find the underlying cause and manage that
143
What is the most common PREVENTABLE cause of sensorineural hearing loss?
Noise Trauma
high-frequency affected first
tx: aggressive use of noise protection
144
Identify the condition and describe the management:
pt presents with otorrhea from the right ear and complains of hearing loss in the right ear
Weber lateralizes to the right, Rinne: BC\>AC
otoscopic exam:
**TM Perforation**
reduces surface area available for sound transmission
usually secondary to chronic OM or trauma
tx: surgery for large perforations
keep ear dry
145
Meniere's Disease Triad of Symptoms
episodic vertigo (Hours)
tinnitis
fluctuating hearing loss - LOW frequency, unilateral
146
Identify the condition and describe the management:
pt complains of unilateral hearing loss
otoscopic exam shows effusion in the middle ear and decreased TM mobility
**Otitis Media**
most common cause of conductive hearing loss in children
TX: treat the OM, possible myringotomy tubes
147
Common Causes of Conductive Hearing Loss
* Cerumen Impaction
* Foreign Body
* Otitis Externa
* Exostoses and Osteomas
* Otosclerosis
* Tympanic Membrane Perforation
* Otitis Media
* Tympanosclerosis
* Tumors/cysts of the auditory canal
148
What type of hearing loss is this, and which ear is affected?
weber: lateralizes to the right ear
rinne: R: BC\>AC; L: AC\>BC
conductive hearing loss of the right ear
Weber: lateralizes to the ipsilateral ear in conductive loss
Rinne: bone conduction is greater than air conduction
149
Weber Test
Tuning Fork **(256)** at midline forehead
Sound radiates **TO Conductive Hearing Loss ear**
Sound radiates **AWAY from Sensorineural Hearing Loss ear**
150
Identify the condition and describe the management:
pt had a cold last week and now complains of sudden vertigo that lasts for days, she also notes some hearing loss
**Acute Labrynthitis**
inflammation of the inner ear - often after viral URI
tx: symptomatic tx: antiemetic (compazine) and vestibular suppresent (meclizine)
151
Common Causes of Senorineural Hearing Loss
* Presbycusis
* Noise Trauma
* Ototoxin Exposure
* Meniere's Disease
* Acoustic Neuroma
* Acute Labrynthitis
* Tinnitis
152
Sensorineural Hearing Loss
Occurs with dysfunction of the inner ear
problem with cochlea or neural pathway to auditory cortex
mainly affects adults; children can be affected usually secondary to congenital hearing loss
sudden sensorineural hearing loss requires **urgent ENT referral** if cause cannot be found on exam
153
Identify the condition and describe the management:
pt is a 49 year old female
presents with bilateral hearing loss (less than 50 DB) that has gotten worse
family hx: father had something similar
**Otosclerosis**
abnormal bone deposition at the base of the stapes
leads to fixation of the stapes, preventing vibration
tx: hearing aids or surgery (stapedectomy)
154
Tumors/Cysts of the Auditory Canal
Uncommon
refer to ENT or surgical removal
155
What type of hearing loss is this and which ear is affected?
Weber: sound lateralizes to the right ear
Rinne: R: AC\>BC; L: AC\>BC
left ear sensorinueral hearing loss
Weber: sound will latealize the the contralateral ear in sensironeural hearing loss
Rinne: normal hearing or sensorineural loss result in AC\>BC (2:1)
156
Identify the condition and describe the management:
pt complains of vertigo that lasts for 3-4 days, but has no hearing loss
**Vestibular Neuritis:**
occurs spontaneously or after a URI
symptomatic tx: antiemetic, vestibular suppressant, antihistamines, benzodiazepines, anticholinergics
157
Identify the condition and describe the management:
pt is a 75 yo male brought in by his wife, he reports increased difficulty hearing the tv and difficulty understanding speech with both ears
audiometry testing shows high pitched hearing loss
**Presbycusis**
* **symmetric, progressive deterioration of hearing** - usually in adults and elderly
* loss of cochlear hair cell function
* combination of genetic disposition and envrionmental factors
* secondary to neurovascular injury: HTN, DM
* **high frequency hearing and speech discrimination** are affected
TX: audiology consult, hearing aids
158
Identify this condition:
pt presents with a collar of edema and infection of the submandibular, sublingual and submental compartments bilaterally, tongue is pushed superiorly and posteriorly
**Ludwig's Angina**
tx: manage airway, I&D may be required
159
Identify and describe the management:
pt is a 22 yo acapella singer
Larygnoscope shows: bilateral distinct masses on the anterior vocal cords involving the mucosa and submucosa
**Nodules**
* bilateral can occur in children and young adults
* no sex predilection
* biphasic, early and mature
* occur at the "striking zone"
TX: voice therapy
160
Identify and describe the management:
Larygnoscope shows: a sessile mass on the mid anterior cord
**Unilateral Polyp**
can be pendunculated or sessile
tx: voice therapy or surgery
161
Grade these tonsils:
**Grade 4**
162
Identify this condition:
pt reports recurrent oral apthous ulcers, gential ulcers, and uveitis
**Bechet's**
rare immune-mediated small vessel systemic vasculitis
163
Grade these tonsils:
**Grade 2**
164
Identify this condition:
20 yo pt presents with small, round circumscribed ulcers that has a gray floor with an erythmatous halo in her mouth
pt reports prior history and that these typically occur 3-6 times a year and only last a week or so
pt says her brother has something similar
**Aphthous Stomatitis**
* restricted to the mouth
* typically resolves in the third decade of life
* affects 20% of population
* ulcers last 7-10 days
* 3-6 episodes a year
* result of T cell mediated immune response
165
associated conditions with: Aphthous-Like Stomatitis
* Behcet's Disease
* Celiac Disease
* Cyclic Neutropenia (every 21 days)
* Nutritional Deficiencies (B12, folic acid, & iron)
* IgA deficiency
* Immunocompromised States
* IBD - Chron's
* MAGIC Syndrome (Mouth & Genital Ulcers with inflammed cartilage)
* PFAPA Syndrome (Periodic Fever, Aphthas, Pharyngitis, Adenopathy)
* Reiter's Disease
* Erythema Multiforme
* Toothpastes - Sodium Lauryl Sulfate
166
Recurrent Respiratory Papillomatosis
* affects mucous membrane of the respiratory tract
* infection only in keratinocytes of the skin or mucous membrane
* viral etiology: **HPV 6, 11**
* vertical transmission
* juvenile and adult onset
167
Identify this condition and describe the management:
pt presents with an occluded salivary gland on the mucosa
**Mucocele**
tx: drainage and excision
168
Identify this condition and describe the management:
pt presents with a midline anterior neck mass
examination reveals the mass elevates when the patient swallows and sticks out her tongue
**Thyroglossal Duct Cyst**
remnant of connection between foramen cecum and thyroid
tx: surgical excision
169
Identify this condition:
pt presents with a lace like pattern in her oral cavity
Lichen planus
* not contagious
* unknown triggers
* maybe autoimmune
TX: steroids helpful, no known cure
170
Identify this condition:
lateral neck mass, anterior to the SCM
exam reveals the mass opens into the tonsillar fossa
**Branchiogenic Cyst - second arch**
Superficial to CN IX and XII
Superficial to Cartoid Sheath
171
Granulomas
Contact - posterior glottis
* auctioneers, bass singers, throat clearing/coughing
* GERD
TX:
* steroids, proton pump inhibitors
* surgical management
172
Identify this condition:
pt is an adolescent with a sore throat, fever, malasie,
exam: lymphadenopathy over the posterior cervical and occipital nodes, elevated AST/ALT (liver tests)
**Infectious Mononucleosis**
Primary cause: Epstein Barr Virus
Can be detected with the monospot test
173
Identify this condition and describe the management:
pt presents with a mass in the floor of his mouth, it extends inferiorly into the neck
**Ranula**
**occlusion of sublingual gland**
_simple_ type: lies in the mouth floor
_plunging or diving type_: pierces mylohyoid muscle and presents as a neck mass
174
Identify this condition:
neck mass, anterior to the SCM
**Branchiogenic Cyst - first arch**
Type 1 - duplication of EAC
Type 2 - intimate association with facial nerve
175
Identify and describe the management:
pt is a female smoker with a very raspy voice
Larygnoscope shows: bilateral masses spread across the cord
**Bilateral Diffuse Polyposis**
common with vocal abuse - leads to edema, vascular congestion and stasis
176
Grade these tonsils:
**Grade 1**
177
Identify this condition:
pt complains of trismus, dysphagia, odynophagia
exam: see below, temp: 100 F
CBC: increased WBC
**Peritonsillar Abscess**
178
Identify this condition:
pt presents with painful, ulcerated, bleeding gums
culture shows polymicrobial anaerobic infection (Borrelia vinventii)
Acute Necrotizing Ulcerative Gingivitis (aka Trench Mouth, Vincen'ts Angina)
more common in young adults
predisposing factors: poor nutrition, debilitating disease
tx: antibiotics, surgical debridement
179
Identify this condition:
pt complains of mouth pain, exam shows a cheesy appearance with an ulcerative base
**Fungal Infection**
Candida most common
180
Identify this condition:
pt presents with vesicles in her mouth
exam findings: ulcerated lesions on a hyperemic rim (see below)
**Herpes Virus**
type 1 primarily oral
tx: antivirals
other presentations see below:
181
Leukoplakia
* white patch
* pre-cancerous lesion
* need biopsy to rule out carcinoma
* 0-20% turn into cancer (see image of vocal cord carcinoma below)
182
Grade these tonsils:
**Grade 3**
183
Identify this condition:
5 yo pt presents in the ER, he is bent forward and drooling with stridor
**Acute Epiglottitis/Supraglottitis**
often pediatric presentation
H. flu
examine in O.R. with intubation equipment readily available
184
Identify this condition:
pt presents with a candidal infection at the corner of her mouth
**Angular Chelitis**
associated with decreased vertical height between the mandible and maxilla
tx: restore height, use antifungals
185
describe Otitis Media with Effusion (OME)
* presence of effusion in an **asymptomatic patient**
* TM's appear
* non-bulging
* translucent or opaque
* bubbles or air/fluid levels apparent
* Tympanoscopy - **compliance decrased pressure can be positive or negative**
186
describe Bullous Myringitis
* **"blisters"** on the ear drum
* caused by: Strep. pneumo or Mycoplasma
* if pt has chronic nagging cough - more suspicious of mycoplasma
* antibiotics: **Erythromycin or Azithromycin**
187
Describe what you see through your otoscope:
**Retraction**
188
Identify this condition and describe the management:
pt presents with severe ear pain that is made worse with chewing and pressure on the tragus
no sxs of fever or URI
otoscopy shows erythematous external auditory canal with moist, white exudate in the canal (see image)
**Otitis Externa "Swimmer's Ear"**
* inflammation of th external auditory canal
* high humidity, frequent or prolonged immersion in water, local trauma can compromise local defenses - leading to inflammation and infection
**Causative Organisms:**
* **P. aeruginosa**
* children with tympanostomy tubes: S. aureus, S. pneumo, M. cat, Proteus, Klebsiella
TX:
* Topical Antibiotic Drops
* Cortisporin otic suspension if TM is intact
* Acetic Acid Preparations - restore pH
* Tympanostomy Tube: Quinolone otic drops
189
Identify this condition and describe the management:
pt complains of slight hearing loss, has some itching, denies pain and other symptoms
pt has been utilizing q-tips to clean out her ears
**Cerumen Impaction**
* usually from mechanical attempts to remove ear wax
* pt should be educated to leave the ear wax alone
TX:
* curettage
* suction (if soft)
* lavage/irrigation
* cerumenolytic agents (Debrox, Cerumenex)
190
How do you distinguish Acute Otitis Media (AOM) from Otitis Media with Effusion (OME)?
AOM
* symptoms of acute infection
* symptoms of TM inflammation
OME
* no signs of acute infection or TM inflammation
191
Otitis Media has increased frequency in . . .
* Boys
* Native American/Alaskan Natives
* HIV
* Cleft Palate
* Trisomy 21
* January/February
192
describe Acute Otitis Media (AOM)
* rapid onset of local and or systemic illness: otalagia, fever, irritability, anorexia or vomiting
* TM's are
* bulging
* opaque
* erythematous
* Tympanometry - **compliance decreased**, **positive pressure**
193
Identify this condition and describe the management:
Three days ago you treated a patient for AOM with amoxicillin. Her fever and pain has persisted, and presents swelling and redness behind her ear. Upon examination you notice the ear lobe pushed superiorly and laterally.
**Mastoiditis**
* rare but serious complication of OM
* infection of the periosteum of the mastoid bone
* severe cases: bony destruction and resorption of mastoid air cells
DX: diagnosesd by CT scan
TX:
* Myringotomy - culture and sensitivity
* IV abx: Ceftriaxone with nafcillin or clindamycin
* Surgery for I&D and mastoidectomy if:
* failure of abx after 24-48 hrs
* signs of intracranial complications
Complications: meningitis, brain abscess, facial palsy
194
Describe what you see through your otoscope:
**Scarring** on the TM
195
*What are the 3 most common infectious organisms that cause Otitis Media?*
1. Streptococcus pneumoniae
2. Haemophilus influenzae
3. Moraxella catarrhalis
196
Use this card to test your knowledge of surface landmarks on a normal tympanic membrane.
197
When is watchful waiting for an otitis media contraindicated?
* children under 2 years old
* ear symptoms greater than 48 hours
* fever present
* severe pain (pain not managed by analgesics)
198
*What are the risk factors for Otitis Media in children?*
* Bacterial Colonization (S. pneumo, H. flu, M. cat, GAS)
* Reccurent viral URI's
* Eustachian tube dysfunction
* Smoke Exposure
* Immunocompromised
* Bottle Feeding
* Young Age
* Genetic Susceptibility/parental history
* Sibling at home/share room with a sibling
* Daycare
199
Otoscope Practice
An annulus fibrosus
Lpi long process of incus - sometimes visible through a healthy translucent drum
Um umbo - the end of the malleus handle and the center of the drum
Lr light reflex - antero-inferioirly
Lp Lateral process of the malleus
At Attic also known as pars flaccida
Hm handle of the malleus
200
Describe what you see through your otoscope:
**Chronic Perforation**
201
Identify this condition and describe the management:
pt is a 3 year old. hx of a cold last week and now says "my ear hurts." temp: 99 F
mom reports little Tommy has been irritable lately and is not sleeping well
see otoscope exam photo below & tympanometry results
**Acute Otitis Media**
* Tympanogram results: positive pressure, decreased compliance
TX:
* Watchful Waiting
* Pain Management
* Antibiotics - Acute course
* Myringotomy Tubes
202
Identify this condition and describe the management:
A mother brings in her four year old son. Mom has noticed that he is tugging on his ear and itching it a lot. Mom suspects he has decreased hearing on one side. PT does not report pain and does not have any other symptoms.
**Ear Foregin Body**
removal with a bayonette forceps or ear currette under direct visualization
lavage (DON'T lavage vegetable matter)
mineral oil or lidocaine - insect removal
**if not easily removed - refer to ENT**
complications: laceration, otitis externa, TM perforation
antibiotic drops should be perscribed after removal
\*\*Alkaline batteries can cause liquefying necrosis\*\*
203
Treatment Options for Otitis Media
**watchful waiting**
* first option
* educate parents, give the child 48 hours if no improvement or fever develops call back
* unless
* child under age 2
* ear symptoms \>48 hours
* fever present
* severe pain not managed by analgesics
pain management
* acetaminophen or ibuprofen
* topical anesthetic drops (Auralgan/ AB otic)
* tympanoscentesis
Antibiotics (7-10 days)
* Amoxicillin (day care, recurrent cases, recent antibiotic useage)
* Augmentin (amoxicillin/calvulanate)
* Cephalosporins (cefuroxime, cefpodoxime, cefdinir)
* Prophylactic antiboitic use in recurrent otitis media is rare!
Myringotomy Tubes
204
What is Recurrent Otitis Media?
**3** Otitis Media in **6 months **
or
**4** Otitis Media in **1 year**
205
Identify this condition and describe the management:
cc: some hearing loss
hx: of chronic ear disease and draining that has been unresponsive to treatment
otoscopic examination shows a middle ear cyst with some retraction
**Cholesteatoma**
* epithelial cyst behind the TM in the middle ear
* associated with TM retraction or perforation
* can be destructive and erosive - produces osteolytic enzymes (will errode ossicles, may invade other structures)
DX: CT to make definitive diagnosis
TX: ENT referral
206
A look through the otoscope shows . . . what type of pathology is present?
**Otits Media**
207
A look through the otoscope shows . . . what type of pathology is present?
**Perforated TM**
208
A look through the otoscope shows . . . what type of pathology is present?
**TM Scarring**
209
A look through the otoscope shows . . . what type of pathology is present?
**Tympanostomy Tube**
210
Describe the sinus development of children.
* BORN with ethmoid and maxillary sinuses that continue to develop
* frontal sinuses APPEAR around age 4
* not fully developed until adolescence
211
define - referred otalgia
otalgia secondary to a problem unrelated to the ear
remember the ear has innervations from: CN V, VII, IX, X and cervical sensory nerves
212
Identify this condition and describe the management:
pt: is a high school wrestler who hates to wear his headgear
**Auricular Hematoma (Cauliflower Ear)**
* secondary to trauma to the auricle which causes the hematoma
* can lead to necrosis and resoprtion, possible infection
TX: needle aspiration (high recurrence), definitive treatment: I & D
213
A look through the otoscope shows . . . what type of pathology is present?
**Normal **
214
What is this instrument used for?
**Pneumatic Otoscope**
* utilized to check the movement of the TM
* TM should move equally back and forth if normal pressure is present
215
A look through the otoscope shows . . . what type of pathology is present?
**Otitis Media**
\*note from Erin in lecture - this could also be from a child crying
216
Identify this condition:
pt has a midline mass just below her chin
exam: mass does not move when pt swallows or sticks out her tongue
**Dermoid Cyst**
located in the submental area
endoderm and mesoderm remnants
does NOT move with swallowing or tongue protrusion
217
Identify and describe the management of this condition:
pt: has enlarged parotid and submandibular glands that are tender to palpation, ducts have a purulent discharge
**Sialoadenitis**
tx: antibiotics, hydration, massage of gland, warm compress
218
Benign Neoplastic Salivary Gland Enlargement - Differential Diagnosis
* Pleomorphic adenoma
* Warthin's tumor
* Oncocytoma
* Hemangioma
219
Benign Neck Masses: Schwannoma
solid, slow growing, neurogenic tumor, painless
most common in 25-50 year olds
220
Identify this condition and describe the managment:
pt: reports pain on the left side of her mouth/cheek right before sitting down to eat dinner
exam: observed swelling of salivary gland, palpation of a stone in Wharton's duct
**Sialolithiasis**
tx: removal of stone by massage or milking the gland
refer: ENT if stone does not pass within 5-7 days
221
Benign Neck Masses: Sebacous Cyst
cyst sac, slow growing, painless, moveable
possibly infammed and tender
tx: incision and drainage, excision
222
Benign Neoplasia Neck Mass Differential Diagnosis
* Lipomas
* Fibromas
* Sebaceous Cyst
* Epidermoid Inclusion Cysts
* Paragangliomas
* Schwannomas
* Neurofibromas
223
Identify this condition and describe the management:
pt has a 3 cm (midline) mass on his anterior neck, the mass moves when the patient swallows or sticks out his tongue
**Thyroglossal Duct Cyst**
remnant of descending tract of thyroid
may intermittenly become infected
_Management:_ surgical excision of cyst, tract
224
Malignant Neoplasia Differential Diagnosis
* Metastatic squamous cell carcinoma
* Lymphoma
* Rhabdmyosarcoma
* Neurofibrosarcomas
* Thyroid Carcinoma
* Salivary Carcinoma
225
Malignant Neck Masses - Lymphoma
occurs in pediatrics and adults
enlarged lymph nodes, non-tender
addtional sxs: weight loss, night sweats
226
Identify this condition and describe the management:
pt complains of mass on her neck
reports s/s of cough, fever, nasal drainage, tonsillar enlargment with exudates
exam shows: enlarged, tender/painful submandibular and anterior cervical lymph nodes
Inflammatory Neck Mass: **Reactive lymphadenitis **
secondary to viral or bacterial illness
* most common bacterial casue: strep and staph infection
* most common viral: Mononucleosis (EBV)
* less common causes: Mycobacterium, Tuberculosis, Cat Scratch Disease, Toxoplasmosis, HIV
diagnosis can utilize labs - rapid strep test, CBC, PPD, HIV test, Bartonella, EBV titer, etc.
tx: 10-14 days of antibiotic unless viral (self-limited) - follow up in 2-3 weeks
managment: further work-up if doesn't resolve in 2-3 weeks
227
Benign Neck Masses: Lipoma
soft mass, ill-defined borders, painless
tx: excision if needed
228
Malignant Neck Mass: Rhabdomyosarcoma
pediatrics - peak incidence age 5
painless, enlarging mass
229
Congenital Lateral Neck Masses - Differential Diagnosis
* Branchial cleft cysts
* Lymphangiomas (cystic hygromas)
* Hemangiomas
230
Identify this condition and describe the management:
pt has a cyst on the anterior border of the his left SCM, it has increased in size over the past year
pt had a cold last week and now the mass is infected
exam: palpation reveals the mass is soft, and does not elicit pain
**Branchial Cleft Cyst**
can be a cyst, sinus or fistula anywhere on the SCM
2nd cleft most common, 1st cleft less common
* First Branchial Cleft - associated with EAC, Parotid Gland
* Second Branchial Cleft - associated with Superior pole of tonsil, located on the anterior border of the SCM, between the internal and external carotid arteries, opens into tonsilar fossa
* Third Branchial Cleft - associated with Pyriform Sinus, located on the anterior border of the SCM, posterior to common carotic, opens into Pyiriform sinus
_management_: surgical excision of cyst and sinus tract
231
Malignant Neoplastic Salivary Gland Enlargment
* Muccoepidermoid carcinoma
* Adenoid cystic carcinoma
* Adenocarcinoma
* Squamous cell carcinoma
* Lymphoma
* Metastasis
232
Inflammatory Salivary Gland Differential Diagnosis
* Acute or chronic sialoadenitis
* Mumps
* Sialolithiasis
* HIV
* Tuberculosis
* Cat Scratch Disease
* Cytomegalovirus
* First branchial arch cysts/sinus
233
Benign Thyroid Neoplasm Differential Diagnosis
Follicular Adenoma
234
Malignant Neck Masses: Metastatic Squamous Cell Carcinoma
most common cause of malignant neck mass in adults
primary tumor most likely in aerodigestive tract
235
Benign Neck Masses: Fibroma
fibrous or connective tissue, painless
tx: excision if needed
236
Thyroiditis - Thyroid Masses Differential Diagnosis
* Acute thyoiditis
* Subacute thyroiditis (granulomatous, lymphocytic)
* Chronic lymphocyte thyroitis (Hashimoto's)
* Fibrous thyroiditis (Riedel's)
237
Metabolic Salivary Gland Enlargment Differential Diagnosis
* Sjogren's Syndrome
* Medications
* Sarcoidosis
238
Identify this condition:
pt presents with a cystic lesion on the floor of his mouth, it plunges through muscle planes into the upper neck
**Ranula**
occurs from mucus extravasation from blocked salivary duct
239
Degenerative Thyroid Masses - Differential Diagnosis
* nontoxic multinodular goiter
* Graves' disease
240
Congenital Midline Neck Masses - Differential Diagnosis
* thyroglossal duct cyst
* dermoid cysts
* Ranulas (plunging)
241
Inflammatory Neck Mass - Differential Diagnosis
* Cervical adenitis (viral or bacterial)
* Infectious mononucleosis
* Atypical mycobacteria
* Cat scratch disease
* Tuberculosis
* Histoplasmosis
* Toxoplasmosis
* Accquired immunodeficiency syndrome
* Granulomatous (sarcoidosis)
242
Malignant Thyroid Neoplasms
* Papillary Carcinoma
* Follicular Carcinoma
* Medullary Carcinoma
* Anaplastic Carcinoma
* Lymphoma
