HEENT Flashcards
Differential Diagnosis TMJD
1) Tooth abscess
2) Wisdom teeth eruption
3) AOM
4) Otitis Externa
5) Temporal arteritis
6) Parotitis
7) Herpes zoster/Posterhepetic neuralgia
8) Trigeminal neuralgia
TMJD Facts
May be temporary or last for years
Women > Men
Most commonly 20-40yo
TMJD Classification
1) Myofascial pain
2) Internal Derangement
3) Trauma
4) Arthritis
TMJD Causes
Bruxism
Capsule inflammation
Abnormalities in the disk or joint
Any combination of the above
TMJ S/S
- Pain in the face, TMJ area, neck, and shoulders
- Pain in or around ear when chewing, speaking, yawning
- Limited ability to open the mouth very wide
- Jaws that get “stuck” or “lock” in the open or closed position
- Clicking, popping, or grating sounds when opening or closing
- Difficulty chewing or a sudden uncomfortable bite
- swelling on ipsilateral side
- Other S/S: toothaches, headaches, neck pain, dizziness, otalgia, heaing problems, upper shoulder pain, & tinnitus
TMJD Exam
- Palpate TMJ
- ROM
- should be able to fit 3rd-5th finger into open mouth
- Limited ROM is 2 or less fingers
- Oral Exam
- Examination of ear canal and TM
TMJD Diagnostics
- After conservative therapy has failed or if internal derangement is suspected
- Panorex
- MRI to view soft tissue
- CT to see detail of bones in joint
TMJ Treatment
- Heat/cold
- Soft diet
- NSAIDs
- Muscle relaxants
- Anxiolytics
- Antidepressants
- Low level laser therapy
- Night Guard
- Corrective dental intervention
Temporal Arteritis (Giant cell arteritis [GCA]) Facts
Most commonly 50-72yo Systemic illness Symptomatic blood vessel inflammation Biggest complication = blindness Linked with Polymyalgia Rheumatica (~50%)
GCA and vision loss
- ~20% of patients develop vision loss
- May be first sign of GCA
- Usually begins suddenly with unilateral problems
- If untreated second eye can be affected (Rare)
GCA S/S
- Appears gradually
- Most common s/s: temporal HA, Jaw or arm pain/weakness, difficulty seeing clearly, new cough
- Other s/s: low-grade fever, fatigue, weight loss, scalp tenderness
- Jaw pain (claudication)
- Arm claudication
- Upper respiratory complaints
- Thoracic aortic aneurysm
GCA Diagnosis
Consider in pt >50 when: - New HA - Abrupt visual disturbance - S/S polymyalgia rheumatica - Jaw claudication - Unexplained fever/anemia high ESR and/or high serum CRP
GCA Treatment
1) Refer to rheumatologist
- Rheumatologist will confirm with a biopsy
- treat with high dose steroids, DMARDs, & biologics
Pharyngitis & common cold
- Sore throat is not usually primary symptom
- Nasal s/s tend to precede throat s/s (soreness, scratchiness, irritation)
- Non-productive cough may be present
- Low-grade fever (more common in children)
- Hoarseness
- Severe odynophagia is unusual
- Chills, malaise, and myalgia are usually not prominent
Pharyngitis & adenovirus
- Common among children and military personnel
- Present with sore throat (more than cold), high fever, dysphagia, & conjunctivitis
- AKA pharyngoconjunctival fever
- May have history of swimming within previous week
- Military personnel tend to be more ill
Pharyngitis and EBV
- More common in adolescents and young adults
- Sore throat and fatigue are most common symptoms
Pharyngitis & Influenza
- Sore throat may be CC in flu patients
- Abrupt onset with myalgias, HA, fever, chills, and dry cough
Other viral forms of pharygitis
1) Enterovirus: more common in childhood
2) RSV: s/s = rhinorrhea, sore throat, low-grade fever, & cough
3) CMV: Pts. older than those with EBV
4) HIV: similar presentation to EBV
Viral Pharyngitis S/S (general)
- Most: Fever, fatigue
- Edema and erythema are typical
- May have exudate, but not as much as with bacterial
- Preauricular/cervical lymphadenopathy
- Palatal petechiae, especially in EBV
Viral pharyngitis diagnostics
- CBC
- Rapid strep test
- Monospot
Viral pharyngitis treatment
- ABX do not hasten recovery
- Salt water gargle, hydration, rest
- APAP or Ibuprofen (NOT ASA, it increases viral shedding)
- Do not EVER use ASA with young children or adolescents due to risk of Reye’s Syndrome
- Anesthetic gargle/lozenges
Epstein-Barr Virus
Infectious mononucleosis
Mono Facts
Infection throughout the entire reticular endothelial system (liver, spleen, lymph nodes)
Transmitted through saliva, mucus, and coughing
Incubation = 1-2mo
Mono S/S
Early
- Fever, lymphadenopathy, pharyngitis, rash, periorbital edema, (rarely) bradycardia
Later
- Hepatomegaly, palatal petechiae, jaundice, uvular edema, splenomegaly
- (rarely) splenic rupture
Mono Labs
- Monospot (most common; may require patient to have had Dz for 1-2wk before testing positive)
- ELISA
Mono Treatment
Supportive
- Hydration, rest, ibuprofen, AVOID APAP, no physical activity for 3-6wk, No sports for 6wk+
- Closely monitor patients with extreme tonsillar edema for airway obstruction; steroid therapy may be indicated
Bacterial pharyngitis
Most common cause = Group A Beta-Hemolytic Streptococcus
GABHS S/S
- **Absence of rhinitis, conjunctivitis, cough
- Tonsillar edema/exudate
- Anterior cervical lymphadenopathy
- Palatine petechiae
GABHS Labs
- rapid strep test (95%Sp, 80-95%Sn)
- Throat culture (99%Sp, 97%Sn)
Strep Scoring
- **0-1=Probably not GABHS
- **1-3=Possible infection, rapid strep testing and treat accordingly
- **4-5=Probably infection - treat empirically with ABX if appropriate
- Fever +1
- Absence of cough +1
- Tender anterior cervical lymph nodes +1
- Tonsillar swelling and/or exudate +1
- Age 45 -1
GABHS treatment
First Line - Benzathine penicillin G IM - Penicillin V PO - Amoxicillin - Erythromycin (PCN allergy) - Cephalexin Second Line - 2nd Gen Cephalosporin ---Ceftin, Cefzil - Clarithromycin - Azithromycin
GABHS Why treat?
- Prevention of spread
- Shortens duration
- Prevents: rheumatic fever, peritonsillar abscess, poststreptococcal glomerulonephritis
Recurrent tonsillitis
- Culture when asymptomatic
- Refer to ENT
- Tonsillectomy: >6x/1yr; 5x/yr for 2yr; 3x/yr for 3yr
Allergic Rhinitis S/S
- Timing, Hx, Environmental exposure
- sneezing, clear congestion, watery eyes, HA
- Pale, pink mucosa
- cobblestoning
- serous otitis
AR Treatment
Intranasal steroids - Flonase (fluticasone) - Veramyst - Rhinocort - Nasacort AQ - Nasonex Intranasal Antihistamine - Astelin - 2sp q nostril BID - Astepro - 1-2sp BID - Patanase - 2sp BID Oral Antihistamines - Allegra - Clarinex - Claritin - Xyzal - Zyrtec Leukotriene Antagonist - Singulair Decongestants
Mild Intermittent AR
- Oral antihistamines
- Intranasal antihistamine
- Decongestant
- Intranasal decongestant (Limit use)
Moderate-to-severe intermittent AR
- Oral antihistamines
- Intranasal antihistamine
- Oral decongestant (combo)
- Intranasal steroid
Mild Persistent AR
- Oral antihistamine
- Intranasal antihistamine
- Oral decongestant
- Intranasal steroid
Moderate-to-severe persistent AR
1st-Line intranasal steroid
- oral steroid
Viral Sinusitis S/S
- Sneezing
- HA
- Fever
- Clear Mucus
- Timing
- Pink to dark pink nasal mucosa
- Swollen turbinates
- Lymphadenopathy
- PND
- Conjunctivitis
VS Treatment
- Decongestant
- Antihistamine
- Intranasal anticholinergic (Atrovent/Ipratropium IN)
- Short term intranasal decongestant (Vicks, Sinex, Afrin)
- Pain relief (IBU, APAP)
Bacterial Sinusitis S/S
- Duration of Sx
- Unilateral sinus pressure
- Fever
- Periorbital edema
- Congestion
- Tooth pain
- Tenderness with percussion
- Erythematous, edematous turbinates
- Mucopurulent drainage
BS Diagnostics
- Sinus X-ray
- CT scan
- ** Refer when: no response to Tx, fever, pain with EOM, periorbital cellulitis
BS Treatment
If no ABX in previous month - Amoxicillin - Augmentin XR - Omnicef - Cefzil ABX in previous month - Augmentin XR - Levaquin - Avelox
BS Alternative treatment
- Biaxin
- Zithromax
- Bactrim
BS 1st Choice Tx
If Seriously ill or if initial treatment has failed:
High dose augmentin
More BS TX
- Afrin
- Topical nasal steroids
- Oral steroids
- Decongestants
- Guaifenesin
Chronic Rhinosinusitis
- Nasal Lavage
- Neti pot
sterile H2O
URI
- Non-specific term
- Acute infection of sinuses, pharynx, trachea, and/or bronchi
- Causes: Viral, bacterial (pharyngitis/tonsillitis, sinusitis, bronchitis
Viral URI S/S
- Onset
- Congestion, sneezing, sore throat
- Exposure
- Transmission (aerosol, droplet, direct contact)
Viral URI Tx
- Pain relief/antipyretic
- Nasal steroids
- Decongestant
- Expectorant
- Fluids
- Rest
- If not resolved in 7-10d, return
Influenza S/S
RAPID onset
- Fever, malaise, HA, cough, sore throat
Flu Dx
Rapid antigen test
viral culture
Flu Tx
- Only lessens duration by 1-2d
- Tamiflu
- – Diagnosed with Influenza A or B
- – Very expensive
- Relenza (zanamivir)
- – Treats A or B
- – Inhalation
- – Contraindicated with Hx of lung Dz
- Symmetrel (amantadine) & Flumadine (rimantadine)
- – only effective against A
- – High rates of resistance
- – Not usually prescribed
Flu Who to treat
- Age
- Timing
- Chronic Dz
- Pregnancy
Flu Shot
- Indication: >6mo
- Contraindications: severe egg allergy, reaction to previous vaccine, <6mo
- Takes 2wk to develop antibodies
- Killed virus
- Contains 2A and 1B virus
Flu Nasal inhalation
Indications: age 5-49yo
Contraindications: Lung Dz, Pregnancy, 49yo
Red Eye
Conjunctivitis - Viral=more common - Bacterial=more common in children Subconjunctival hemorrhage Foreign body/abrasion Acute angle glaucoma Iritis
Red eye pertinent negatives
- No Photophobia
- No eye pain
- No change in acuity
- May c/o irritation but can open eye
Ophthalmology referral
1) Reduction in acuity
2) Ciliary flush
3) Photophobia
4) Severe foreign body sensation
5) Corneal opacity
6) Fixed pupil
7) Severe HA with nausea
Viral conjunctivitis
- Self-limiting
- Topical antihistamines if allergic component (Naphcon-A, Ocuhist)
- Topical lubricants
- Avoid spreading to other eye
- NO steroids –> if needed, refer
- VERY contagious
Bacterial Conjunctivitis
Common organisms: S. pneumoniae, H. influenzae, S. Aureus, M. catarrhalis
- S. aureus more common in adults, others more common in children
- Do not overlook possibility of chlamydial conjunctivitis
BC Tx
Topical ABX
- Erythromycin
- Polytrim
- Bleph 10 (contains sulfa)
- Fluoroquinolones
Allergic Conjunctivitis
Symptomatic relief Topical Gtts - Antihistamine/Mast cell stabilizer --- Patanol --- Optivar --- OTC Zaditor (combo) --- OTC Alamast (MCS) - Oral antihistamines
Subconjunctival hemorrhage
- Reassurance
- Cool compress
- Lubricating ointment
Foreign Body/Abrasion
Conjunctival - Removal if visualized and can be washed out - Topical ABX for 2-3d Corneal - Refer
Acute angle glaucoma
EMERGENCY
- Usually older and in distress
- Slumped over, covering the eye or clutching to frontal/temporal area
- C/O HA and malaise
- As pressure rises N/V
- “The worst HA of my life”
- Visual acuity rapidly deteriorates; photophobia; NO FB sensation
- Red eye w/o discharge; pupil becomes fixed
- Within hours –> cornea becomes hazy
- rapid Tx is critical
AAG Evaluation
- Snellen chart
- Near vision test
- – Exact acuity is not important
- Document in crude categories (reading vision, form vision, light perception)
- Assess acuity before checking pupils or placing drops
Blepharitis
Inflammation of lid margin
- Staph infection, seborrhea, meibomian gland abnormality
Bleph Tx
Lid hygiene - Warm compress - wash with q-tip, water, and baby shampoo Topical ABX - Eythromycin oint - Bleph 10 - Tobrex - Polytrim (limited effectiveness against staph) Topical lubricants
Hordeolum
Obstruction of meibomian glands
- Staph infection
- Difficult to differentiate from acute/inflamed chalazion
Hordeolum Tx
Lid Hygiene
Topical ABX
If unresolved - Refer
Chalazion
Blockage of meibomian gland
- Chronic
- Tx=referral
Otitis Media
- Analgesics
- Treatment of URI S/S
- Amoxicillin HD (Fever, significant hearing loss, severe pain, and/or marked erythema)
Alternative - Augmentin
- Cefdinir
- cefpodoxima
- Macrolide (erythromycin/sulfisoxazole, azithromycin, clindamycin)
Serous Otitis (SO)
Otitis media with effusion = the presence of middle-ear effusion in the absence of acute s/s of infection - Allergies - URI Obstruction of ET - Refer
SO S/S
- No clinical signs of acute illness
- Hearing loss (~weeks to months)
- Insomnia
- Vertigo
SO Tx
- Majority resolve without intervention
- Watchful waiting, pharmacologic Tx, & surgery
- – Tx depends on the risk for speech, language, or learning development problems
Conductive Hearing Loss
Outer ear canal
- Cerumen (warm water irrigation, cerumen spoon, Debrox/Cerumenex)
- Foreign body (warm water irrigation, removal with tweezers, referral)
- Insect (instill warm oil, then extract)
Otitis Externa
Topical gtts - Floxin otic - Ciprodex otic - Cortisporin otic Oral ABX
Perforated TM
- 2mm refer
Myringosclerosis
Scarring of TM in response to infection of inflammation
- Refer
Sensorineural Hearing Loss
More common in children and elderly refer for audiology Possible causes: - Presbycusis (older adults) - Ototoxic drugs Tumors (Acoustic neuroma) - Meniere's disease
Tinnitus
Character
- High pitched (sensorineural hearing loss)
- Low pitched (Idiopathic, Meniere’s)
- Pulsatile (vascular)
- Ocean sounds (Eustachian tube dysfunction)
- Popping or clicking (ETD, TMJ)
Laryngitis Treatment: Croup
- Humidified air
- Oxygen
- Racemic epinephrine
- Steroids
Laryngitis Tx: Acute epiglottitis
- Intubation
- ABX: 2nd gen. Cephalosporin; Bactrim
- Steroid
Laryngitis Tx: Diptheria
- ETT
- ABX: PCN
- Antitoxin
Laryngitis Tx: Pertussis
- Erythromycin
Laryngitis Tx: Candidiasis
- clotrimazole
- oral fluconazole
Laryngitis Tx: Blastomycosis, Histoplasmosis, Coccidioidomycosis, Cryptococcosis
- Amphotericin B IV
- Ketoconazole PO
- Itroconazole
Laryngitis Tx: Reflux
- PPI
Bronchitis S/S
- ** Cough w/o nasal congestion or rhinorrhea
- s/s last ~3wk
- r/o PNA with absence of fever, tachypnea, tachycardia
Bronchitis Causes
- Viral
- Adenovirus, coronavirus, Influenza, metapneumovirus, parainlfuenza, RSV, rhinovirus
- Bacterial
- bordatella pertussis (macrolide)
- Chlamydia pneumonia
- Mycoplasma pneumonia
Bronchitis Tx
*** Antitussives
