HEENT Exam 2 Cards Flashcards
Anatomy of the ear canal
Medial two thirds contain thin skin overlying the osseous canal and is easily traumatized
Outer third is cartilaginous with hair follicles, sebaceous, and ceruminous glands
MCC of diffuse otitis externa
Pseudomonas
Clinical presentation of diffuse acute otitis externa
Fullness, Conductive hearing loss, Pain with tragus and auricle palpation, swollen canal with moist debris
4 topical antibiotics for diffuse otitis externa
Ofloxacin, Ciprofloxacin (can be systemic), Polymixin B, Neomycin
Ear wick
Placed in swollen ear canal to help distribute medicine and keep it in the canal
Furnunculosis
Acute otitis externa that effects hair follicles in the lateral 1/3 of the canal
MCC of furnunculosis
S. aureus
Treatment for furnunculosis
Oral Dicloxacillin or Cephalexin (Keflex) with I&D if needed
Otomycosis
Chronic otitis externa caused by aspergillosis or candadiasis
Clinical presentation of otomycosis
Ear itching and foreign body sensation in ear, can arise from abx or humidity - visualized mold in ear
Treatment for otomycosis
Clean the canal and give cotrimazole BID for 10-14 days
3 causes of non-infective otitis externa
Seborrheic dermatitis, psoriasis, Contact dermatitis
Clinical presentation of non-infective otitis externa
Red, scaly, dry canal
Treatment for non-infective chronic otitis externa
Topical hydrocortisone cream or otic drops
Malignant/Necrotizing Chronic Otitis Externa
Life threatening non-cancer infection that spreads from the skin to the bone and marrow of the skull - MCC pseudomonas
3 populations in which Malignant/Necrotizing otitis externa is most common
Elderly, Diabetic, and Immune compromised patients
3 clinical presentations of malignant/necrotizing chronic otitis externa
Deep seated otalgia, Granulation tissue at bony-cartilaginous junction of ear floor, foul smelling and prurulent
Neurologic and other red flag signs of malignant/necrotizing otitis externa
Cranial nerve palsy, meningitis, thrombosis of sigmoid sinus
Workup and treatment for malignant/necrotizing Chronic otitis externa
CT to determine extent
Glucose control
IV and oral ciprofloxacin is the treatment of choice for 6-8 weeks! - may need debreidment
Presentation of Herpes Zoster Oticus
Unilateral facial nerve palsy with facial vesicular eruption
Treatment for Herpes Zoster Oticus
Prednisone and Famciclovir or Valacyclovir
Another name for Herpes Zoster Oticus facial paralysis
Ramsey-Hunt syndrome
Cause of cerumen impaction
Usually self induced - recommended to only clean ear canal opening with washcloth over index finger
3 symptoms of cerumen impaction
Ear pain, fullness, Decreased conductive hearing loss
5 contraindications for cerumen impaction removal
Presence or hx or perforated TM, Previous pain on irrigation, Mastoidectomy or middle ear surgery, Uncooperative patient, Very hard cerumen
4 techniques for cerumen removal
Irrigation - water and steam followed by drying
Mechanical/Microsuction
AT HOME
Hydrogen peroxide
Detergent ear drops
Contraindication for otic foreign body removal via irrigation
Anything organic that might expand
Extra step for removal of live insects from the ear
Immobilize with lidocaine before using alligator forceps
Auricle hematoma
“Cauliflower ear”
Collection of blood under the perichondria of the ear
Treatment of auricle hematoma
Refer if more than 7 days old
Lidocaine auricular block
I&D
Irrigate
Compression dressing for 7 days
Lidocaine auricular block procedure
2 injections diagonal from the top, 2 diagonal from the bottom - can do with 2 needles
2 goals for an auricular laceration
Cover exposed cartilage
Minimize wound hematoma
4 Exams for auricular laceration
TM and Auditory Canal
Facial nerve
Basilar skull fracture
Hearing deficit
Prophylaxis for auricular laceration
Tetanus or Antibiotics if indicated
Technique for auricular laceration surgery
Anesthetize, Debride, Irrigate, Suture, Pack, Compress, Check after 24 hours
Amount of tissue loss that should be referred to plastic surgery for an auricular laceration
5mm of tissue or more
Three things that can cause auricular cellulitis
Minor trauma, Insect bite, or ear piercing
2 most common pathogens for auricular cellulitis
Staph aureus and Strep. spp
4 antibiotics for auricualr cellulitis
Cephalexin
Bactrim (MRSA)
Clinda (MRSA)
IV Vanc - if fever, rapid spread and tachycardia
Perichondrium
Infection of the perichondrium (where blood pools in cauliflower ear) due to local trauma surgery or burns
Area usually involved in perichondritis`
Top of ear, usually not the lobule
Clinical presentation of perichondritis
Swollen, red, tender ear
2 most common causes of perichondritis
Pseudomonas and Staph aureus
Treatment for perichondritis
Start within 5 days
Oral or IV ciprofloxacin
I&D
Normal TM color
Pearly gray
Middle ear infusion
Fluid in the middle ear
Acute otitis media
Acute infection of middle ear fluid
Otitis media with effusion
Middle ear fluid that is NOT infected also called “serous OM”
3 potential antecedent events to otitis media
Upper respiratory tract infection
Eustachian tube dysfunction with mucosal infection
Negative pressure followed by an increse in middle ear secretions
3 signs of acute otitis media
Bulging, erythema, white discoloration
3 main causes of OM
S. pneumo - MCC
H. flu
M. cat
E. coli OM
first months of life
Pseudomonas OM
Chronic, Supperative OM
Common OM cause in children with tympanostomy tubes
Staph
4 clinical findings that point to otitis media
Ear pain, Bulging TM, Poor mobility of TM, May have fever
Additional diagnostic tool for OM
Tympanometry - look for absent mobility
4 initial therapies for OM
Amoxicillin
Cefdinir
Cefuroxime
Azithromycin (not effective for H. flu)
4 secondary therapies for resistant OM
Augmentin
Cefdinir
Ceftriaxone
Clindamycin
When should secondary OM treatments be used
If they have had antibiotics in the past 30 days or treatment failure after 72 hours
Recommendation to penicillin allergic OM patients
Cephalosporin for non-anaphylaxis
Z-max or Doxy for patients w/ anaphylaxis
Length of OM antibiotic treatment
10 days under 6 yrs
5-7 days over 6 yrs
3 ways to qualify for tympanostomy tube placement
3 AOM in 6 months
4 AOM in 12 months
Unresponsive to pharmacology
3 complications of acute otitis media
Hearing loss
Mastoiditis
Meningitis
3 ways to prevent AOM
Breast feed or upright bottle feed
Avoid passive smoke exposure
Avoid pacifier use after 10 months
AOM with bullae present
Bullous Myringitis
Clinical presentation of bullous myringitis
More painful than AOM with bullae
Treatment for bullous maryngitis
Same as AOM but may need to cover for atypicals with zithromax
Clinical presentation of a tympanic membrane rupture
Sudden decrease in pain followed by otorrhea
Two topical antibiotics for ruptured TM
Ofloxacin and Ciprodex
Treatment for TM rupture
Oral and Topical abx, Audiogram now and in 3 months, Earplugs while swimming or in bath
Resolution of TM rupture
Spontaneous resolution takes weeks to months
Tympanoplasty if no resolution
3 descriptors for TM rupture documentation
Location (clock face)
Size
Signs of infection (ie. erythema)
Scar on the TM
Tympanosclerosis
Chronic suppurative OM
Perforated TM with chronic purulent drainage for 6+ weeks
Clinical presentation of chronic suppurative OM
Otorrhea, Painless, conductive hearing loss
Refer to otolaryngology
4 causes of chronic OM
Pseudomonas, Proteus, Staph, Anaerobes
Topical treatment for chronic OM
Ofloxacin or Cipro with dexamethasone for exacerbation
Oral treatment for chronic OM
Cipro for 1-6 weeks
Definitive treatment for chronic OM
Surgical in most cases
Cholesteatoma
Abnormal growth of squamous epithelium that may destroy the ossicles and cause chronic negative pressure
Often a result of eustachian tube dysfunction
4 clinical features of a cholesteatoma
White mass behind TM
Chronic infections
Ear drainage for 2 weeks despite treatment
Focal granulation at the TM periphery
Treatment for cholesteatoma
Refer to surgery
Clinical features of mastoiditis
Pain, swelling, and proptosis of the mastoid process
Look for one ear that sticks out WAY more than the other
Complications of mastoiditis
Subperiosteal abcess
Deep neck abcess
Septic thrombosis of lateral sinus
Diagnostic for mastoiditis
CT scan - compare with other mastoid
Treatment for mastoiditis
IV Rocephin or Ancef for 7-10 days
PO Augmentin or cefdinir
Myringotomy (I&D)
2 things that open the eustachian tube
Yawning or swallowing
3 causes of eustacian tube dysfunction
Viral URI - MCC
Allergies
Edema of tubal lining
3 symptoms and one sign of eustachian tube dysfunction
Ear fullness
Mild/moderate hearing impairment
Popping or crackling sound with yawning/swallowing
TM retraction with decreased mobility
4 treatments for eustachian tube dysfunction
Decongestants
Autoinflation
Steroids for allergies
Avoid air travel and diving
How barotrauma happens
Negative middle ear pressure tends to collapse and lock the auditory tube - can be painful
Treatment and Prevention for barotrauma
Decongestants can help, VT tubes, autoinflation and myringotomy can also be useful treatments
When should decongestants be used on a flight to prevent barotrauma
1 hour before arrival for topical
Several hours for oral
Perilympatic fistula
Rupture of oval or round window leading to vertigo, hearing loss, and emesis
2 conditions you should not dive with
URI or perforated TM
Common presentation of diving related barotrauma
Hemotympanum
Exosteses/Osteomas
Bony overgrowth of ear canal d/t benign tumors
Significance of osteomas
Usually not significant if solitary, multiple can be from cold water exposure and may require surgery
2 ear canal neoplasias
Squamous cell - more aggressive can be life threatening if it goes lymphatic
Adenomatous - ceruminous glands - more indolent
Rhinorrhea
Runny nose
Coryza
Describes cold symptoms such as mucous membrane inflammation
Rhinitis
Symptomatic disorder of the nose characterized by itching, nasal discharge, sneezing, and nasal airway obstruction
Rhinosinusitis
Symptomatic inflammation of the nasal cavity and paranasal sinuses
MCC of the common cold
Rhinoviruses
Upper respiratory tract infection
Usually refers to the common cold
URI transmission
Hands, droplets, fomites
Usual clinical course of URIs
10-14 days
3 weeks in kids
Peak viral shedding on days 2 and 3 but may persist
Three most common features of a URI
Rhinitis, Nasal congestion, Rhinorrhea
3 complications from a URI
Rhinosinusitis, Otitis media, Pneumonia
Sinuses present at 1 year old
Maxillary and Ethmoid
Sinus that develops after 2
Sphenoid sinus
Treatment for URI
NO ANTIBIOTICS
NSAIDs, Fluids, decongestants, irrigation
Sinus that develops after 12
Frontal sinus (develops with frontal lobe??)
Most common sinus infected in bacterial rhinosinusitis
Maxillary sinus
4 precursors to bacterial rhinosinusitis
Viral URI, Allergic Rhinitis, NG-Tube, Dental infections
2 most common pathogens that cause bacterial rhinosinusitis
Strep pneumo
H. flu
Pathophysiology of bacterial rhinosinusitis
Pathway is obstructed from edema leading to buildup of muscous that becomes infected
Maxillary sinus pain
Unilateral facial fullness with pressure and tenderness over the cheek
Ethmoid sinus pain
Usually referred to the orbits
Sphenoid sinus pain
associated with pansinusitis (all cavities on ONE side) refers to vertex (top) of the head
Frontal sinus pain
Pain on the forehead and on palpation below the medial end of the eyebrow
Location of sphenoid sinus
Behind the bottom of the nose
Diagnostic criteria for acute bacterial rhinosinusitis
s/s of acute rhinitis lasting 10+ days
OR
Onset of high fever with purulent discharge and facial pain 3-4 days
OR
Symptoms of viral URI that slowly improve but than worsen to more severe after 5-6 days
Diagnostics for acute bacterial rhinosinusitis
Clinical
CT can be done but not necessary for routine cases
Nasal culture NOT useful
Treatment for acute bacterial rhinosinusitis
Observation for 7-10 days
Can use oxymetazoline spray for symptomatic relief or flonase
Rhinitis medicamentosa
rebound congestion with ABRS when Afarin is administered
Treatment for ABRS that lasts more than 10 days
Augmentin is first line
Macrolides, Bactrim, and Ceph not recommended
Treatment for 7-10 days
Antibiotics for penicillin allergic pts
FQ or Zmax if the patient cannot tolerate a cephalosporin
Clindamycin and cefixime or cefpodoxime if the patient CAN tolerate a cephalosporin
Treatment for orbital cellulitis
CT
I&D
Vanc and Ceftriaxone
Treatment for subperiosteal abcess (Pott’s puffy tumor)
Tender doughy swelling over forehead
I&D
6 weeks of antibiotics depending on sensitivity
Intracranial complications that can result from ABRS
Cavernous sinus thrombosis
Meningitis
Invasive fungal sinusitis
Invasive opportunistic infection of the sinuses caused by saprophytic fungi in the immune compromised - can be life-threatening
Clinical findings of invasive fungal sinusitis
Severe facial pain
Black eschar on middle turbinate - necrosis
Orbital cellulitis
Diagnosis and treatment of invasive fungal sinusitis
Nasal endoscopy with biopsy to diagnose
IV amphotericin B for 3-6 months
Switch to oral itraconazole
Chronic sinusitis
Sinusitis that persists for more than 12 weeks
Diagnose with CT and refer for culture guided antibiotics
Indication for sinus surgery
When antibiotics fail to clear infection - open up the passageway
Chronic fungal sinusitis
Non invasive, more insidius aspergillis infection of the sinuses, biopsy to diagnose
IV amphotericin followed itraconazole to treat
Poor prognosis
Chronic fungal sinusitis
Allergy induced, treated with surgery to remove drainage and debris
Wegners granulomatosis
Condition that causes inflammation of the blood vessels and reduced blood flow to the nose- sinus pain. cough fever, hematuria, and hearing loss
Clinical presentation of wegners granulomatosis
Smell disturbances, Nasal crusting Saddle nose defomity, Purulent/bloody discharge
Diagnosis and treatment of wegner’s granulomatosis
Rheumatologic work-up
Imaging and biopsy
Treat with steroids and immunosuppressants
Cause of perennial vs. seasonal allergic rhinitis
Perennial = Chronic (ie. household)
Seasonal = Pollens
Tree to grass to weeds
Fungi full growing season
Immunoglobulin that mediates allergic responses
IgE
Clinical presentation of allergic rhinitis
Similar to viral but with persistent and seasonal variation, pruritis
3 phisical signs of allergic rhinitis
Shiners under eyes, Salute and crease, Allergic faces, pharyngeal cobblestoning, boggy nasal mucosa
Diagnosis of allergic rhinitis
Accurate hx
Allergy skin testing
Eosinophils in nasal discharge
Prick puncture method of allergy testing
Intrademal - must be off antihistamines for 5 days
Allergen specific IgE serum testing
No antihistamine cessation necessary, just as good as prick puncture
4 symptoms that qualify allergic rhinitis as severe
Sleep disturbance
Impairment of daily activities
Impairment of school or work
Troublesome symptoms
Only need 1
Persistent allergic rhinitis
More than four days a week for more than four weeks
Treatment for allergic rhinitis
Clean nose if crusted
IN Glucocorticoids for persistent and moderate-severe
Flucatisone, mometasone, beclomethasone
Topical nasal spray use
NOT PRN
Can cause local irritation and epistaxis
Tilt head forward pointing bottle to ipsillateral ear
H1 antagonists
Antihistamines that antagonize the H1 receptor
Allergic rhinitis, conjunctivitis, Angioedema, Pruritis and uticaria
1st generation antihistamines
Sedating can cause weight gain
Benadryl
Atarax
Vistaril
2nd generation antihistamines
Preferred because they don’t have sedative properties
Zyrtec and Claritin
Allegram Carinex, Xyzall
Can rotate medication if tolerance occurs
Decongestant use for Allergic rhinitis
Sudafed, zicam are options
Can cause insomnia and anti-cholinergic symptoms
Other treatment options for allergic rhinitis
Cromolyn
Leukotriene antagonists
Ipratropium bromide (anticholinergic)
SQ allergy shots if very severe
Vasomotor rhinitis
Non allergic sneezing rhinorrhea and post nasal drip
Worse with weather changes but no allergy symptoms
May be gustatory in response to eating
Rhinitis medicamentosa
Nasal obstruction due to overuse of decongestants
Switch to steroids to treat
Area where 95% of nosebleeds originate
Keisselbach’s plexus - anterior epistaxis
Signs of posterior epistaxis
Source not visualized
Bleeding from BOTH nares
Blood in posterior pharynx
4 perdisposing factors for epistaxis
Trauma (including picking), Deviated septum, Alcohol, Neoplasms
Management for anterior epistaxis
pressure on sight for 15 minutes
Sit leaning forward
Phenyephrine for vasoconstriction or nasal congestants
Management of anterior epistaxis if the bleeding will not stop
Topical 4% cocain, or lidocaine and epinephrine
Silver nitrate if ID on bleeding point
Nasal packing or baloon
Management of posterior epistaxis
Associated with hypertension and atherosclerosis
ENT consultation for packing, narcotic analgesics, ligation
Antibiotic prophylaxis for epistaxis w/packing and patient education
Augmentin, Clindamycin, Keflex w/ 48-72 hour follow up
Avoid intense exercise, spicy food, nasal trauma and lubricate
Nasal polyps
Pale edematous mucosally covered masses
See with allergies due to prolonged irritation
May suggest cystic fibrosis in children
Treatment for nasal polyps
Topical nasal steroids for 1-3 months with surgical removal if unsuccessful
Clinical presentation of a nasal foreign body
Unilateral obstruction, foul smelling rhinorrhea, Persistent unilateral epistaxis
Removal tools for nasal foreign body
Suction catheter, slligator forceps, positive pressure
2 workup considerations for nasal fractures
Consider the airway and exclude cervical spinal injuries
Septal hematoma
Widening of the nasal septum
Needs I&D and anti staph abx
Cribriform plate fracture
Can cause CSF leakage - test
Aphthous stomatitis
Canker sore - often caused by stress - may be associated with herpes 6 virus
Treatment for Aphthous stomatitis
No definitive treatment
Can use viscous lidocaine or steroids for supportive care
Herpes gingivostomatitis
HSV 1 cold sore triggered by stress, 2-3 day prodromal phase with fever following in initial infection
Clinical presentation of gingivostomatitis
Initial burning followed by vescicle formation and crusting around the lips. May have cervical adenopathy
Diagnosis for Herpes gingivostomatitis
PCR is definitive, Tzanck smear for multinucleated cells is less so
Treatment for herpes gingivostomatitis
Antivirals started within 24-48 hours
Acyclovir or Valacyclovir
2% viscous lidocaine
Oral candidiasis
Thrush, scrapes off with a tongue blade
Infants, dentures, diabetes, immune compromised
Clinical findings of oral candidiasis
Painful burning tongue, beefy with white patches that can be scraped off
Diagnosis for oral candidiasis
Wet KOH prep looking for budding yeasts with or without pseudohyphae
Treatment for oral candidiasis
Nystatin, fluconazole, magic mouthwash
May need to sanitize bottles for babies and treat mothers breasts if breastfeeding
Angular cheilitis
Inflammatory lesion of the corner of the lips, usually breakdown due to excessive moisture due to thumb sucking, etc. invaded by candida albicans
Treatment and prevention for angular cheilitis
Clotrimazole or Miconazole BID topical
Stop licking lips, wear lip balm, ensure dentures fit properly to prevent drooling
Glossitis
Inflammation of the tongue and loss of filiform papillae resulting in a red smooth surface - rarely painful
Usual cause of glossitis
Nutritional deficiencies, Dehydration, drug reaction
Treatment of glossitis
Treat primary cause or begin empiric nutritional replacement therapy
Glossodynia
Intraoral burning sensation in the mouth
without glossitis in postmenopausal women
With glossitis in other causes
Treatment Treatment for glossdynia
Treat underlying cause
Clonazepam, TCAs, Behavioral therapy help
Oral leukoplakia
Hyperkeratosis in response to chronic irritation. White patchy lesion that cannot be scraped off the tongue
Management and treatment for leukplakia
Always biopsy for carcinoma
Surgical removal with elimination of irritating factos
Follow up in 3 months
Erythroplakia
Like leukoplakia but erythematous, sharply demarcated firey red patch - HIGH risk of malignancy
Management of erythroplakia
Refer for biopsy
Surgical excision with clear margins
Eliminate contributory factors such as tobacco and alcohol
Hairy leukoplakia
Raised, “hairy” surface occuring on the lateral portion of the tongue - usually in the immunocompromised
Usually no treatment is needed
HAART and antivirals can be used
Oral lichen planus
Chronic inflammatory autoimmune disease of unknow etiology - reticular or lacy pattern on the tongue
Biopsy for definitive diagnosis and to differentiate from carcinoma
Treatment for oral lichen planus
high potency topical corticosteroids
educate on oral hygiene and smoking cessation
Geographic tongue
Looks like a map
Rapidly changing well demarcated red lesions with raised borders
May have discomfort or burning
Comes and goes
No treatment needed
Black tongue
hyperpigmentation of the tongue and oral mucosa commonly seen in dark skinned individuals
5 drugs that can cause black tongue
Tetracycline, Linezolid, Pepto-Bismol, Antidepressants, PPIs
Hairy tongue
NOT the same as hairy leukoplakia
On dorsal midline of tongue, retention of keratin on tips of filliform papillae
Due to coffee, smoking, tea, or poor oral hygeine
Wharton’s duct
Submandibular gland opening - flow against gravity
Stensen’s duct
Drains the parotid gland
Clinical presentation of sialolithiasis
Postprandial pain
Swelling
Spasm upon eating
4 treatments for sialolithiasis
Local heat, Massage, Hydration, Sour candy or salagen/evoxac
Tretment for sialolithiasis that is not improving
Inscise duct and remove stone
Suppurative parotitis
MCC = Staph aureus
Can be anearobic bacteria
Non-suppurative parotitis
Viral (mumps, flu, EBV, etc.) or non-infectious (CF, DM, Alcohol, gout)
5 things that can lead to suppurative parotitis
Intubation, Intensive teeth cleaning, Anticholinergics, Malnutrition, Ductal onstruction
Clinical presentation of suppurative parotitis
Glandular swelling
Fever
Dysphagia
Unilateral
Pus from duct when massaged
3 DIfferentials for parotitis
Stone, Abcess, Tumor
US or CT to look at it
Clinical diagnosis
Treatment for suppurative parotitis
IV antibiotics b/c can spread to neck tissue
Nafcillin or 1st gen cephalosporin PLUS Metronidazole or Clindamycin
Switch to oral clinda plus cipro
Vanc or Linezolid for MRA
Surgical I&D if no response within 48 hours of intiation
Complications of suppurative parotitis
Progression of infection to bone marrow, neck, resp. tractr, blood
Fistula
MCC of non-suppurative parotitis
Parainfluenza and Epstein Barr (was Mumps) resolves in 5-10 days
Sialadentitis
Submandibular gland inflammation
Tenderness and erythema often caused by S. aureus
May need culture and CT
Treatment for sialadenitis
Hydration
Warm compress
Same abx as parotitis
I&D if unresponsive
MCC of bacterial dental decay
Strep Mutans - communicable plaques calcify if not removed
Childhood risk factors for dental caries
Use of a sippy cup containing sugars
Sleeping with a bottle
Non fluoridated water
Dryness
Clinical presentation of dental caries
Demineralized areas
Painless, opaque brown spots
Management of dental caries
Refer to a dentist
Fluoride
4 risk factors for adult dental caries
Sjogren’s syndrome
Medications that decrease saliva flow
Radiation of the head and neck
Existing restorations or appliances
Clinical features of adult dental caries
Brownish discoloration, Diffuse pain with heat or cold exposure
Pain gets more severe with spread to pulp
Treatment for adult dental caries
Refer to dentist
Fluoride mouth rinse
Treat xerostomia
Dental abcess presentation
Toothache with blister at tooth base
Dicharge and thermal hypersensitivity
Dental abcess treatment
SMALL:
PCN +/- metromidazole
Cinda if allergic
LARGE:
I&D
IV antibiotics
Dental referral
Gingivitis
Inflammation of the gums - results from prolonged exposure to plaque, may result from steroid hormones
Clinical diagnosis
3 medications that cause gingival hyperplasia
Calcium channel blockers. Phenytoin, Cyclosporine
Acute necrotizing ulcerative gingivitis
Trench mouth
Poor oral hygeine, alcohol, and tobacco causing painful, friable gingiva
Halitosis
Fever
Lymphadenopathy
Treatment for acute necrotizing ulcerative gingivitis
Debridement and Metro, Clinda, or Augmentin
Peroxide or chlorahexidine as adjunct
Periodontitis
Chronic inflammatory disease which complicates from gingivitis
Damages alveolar bone and periodontal ligaments
Major cause of tooth loss
Management and Risk factors of periodontitis
Poor oral hygeine, smoking, poverty
Educate and refer to a dentist
Dry socket
2-3 days after tooth extraction displacement of a clot leads to exposure of the alveolar bone
Management of Dry socket
Often from impacted 3rd molar extractions
PCN or Clinda
MCC of acute pharyngitis
Usually viral
Symptom that sets apart adenovirus pharyngitis
Conjunctivitis - use to differentiate from strep
Etiologies of a sore throat with ulcers
Ulcers
Mono rash
Happens when PCN given to pt with mono
Macular papular
Classic lab finding for mono`
Atypical lymphocytosis
When does tamiflu need to be started for influenza
within 24-48 hours
Patient education for mono
Avoid contact sports -risk of splenic rupture
Associated symptoms of strep pharyngitis
Scarlatinaform rash that fades in 2-5 days
Palatal petichiae
Strawberry tongue
Thorough throat swab
Should cause a gag reflex, avoid gums/teeth
4 centor criteria
Tonsilar exudate
Lymphadenopathy
No cough
Fever
Treatment for strep throat
PCN
Keflex
Z-max
First line
CHange toothbrush
Peritonsilar abcess
Infection penetrates tonsillar capsule
Strep pyogenes or Staph aureus
Unilateral
SIgns of pertonsilar abcess
Hot potato voice
Didn’t finish strep treatment
Drooling
Very painful swallowing
Imaging for peritonsilar abcess
CT with IV contrast
Treatment of peritonsilar abcess
Maintain airway
I&D
Unasyn or CLinda - IV
May need vanc IV
Retropharyngeal abcess
Abcess of deep neck structure that can be the result of a URI or forign body ingestion
Clinical presentation of retropharyngeal abcess
BIG lump in back of throat - must be intubated very carefully
Odynophagia and irritability
Diagnostic of retropharyngeal abcess
CT of neck with IV contrast
Labs not essential as with peritonsilar abcess
May want to culture any pus
Management of retropharyngeal abcess
Maintain airway
Unisyn, Ceftriaxone and Metronidazole or Clinda and Levofloxacin
Drain with US
Surgery if not getting better
Switch to oral once they get better
Tripod position
hands in front leaning forward - indicates difficulty breathing
Laryngitis
Inflammation of the larynx causing hoarseness
Can be reflux, vocal strain, infectious
Clinical presentation of laryngitis
Hoarseness
URI hx
Pharyngitis w/ fever points to infection
Strep, rhinovirus, candidiasis
Treatment of laryngitis
Supportive care if viral
Oral steroids for actors/singers - main need vocal therapy
Surgery for polyps
PCN or erythromycin for bacterial
Treat GERD w/ PPI
Laryngotracheobronchitis (Croup)
Barky seal cough with respiratory distress
MCC=Parainfluenza
COld air helps
Stridor
Steeple sign on X-ray
Treatment of croup
Minimal handling
Supportive care and cool air
Fluids
Most can be managed at home
Bring in if stridor at rest or morethan a week
Dexamethasone shot for severe nebulized epinephrine - observe afterwards
Epiglottitis
Airway emergency MCC=H flu can be vaccinated
Clinical presentation of Epiglottitis
Tripod position
Drooling
Can’t breath
Inflamed epiglottis with laryngoscopy
Sore throat is too severe for what you can see in the back of the throat
Treatment of epiglottitis
Intubate Emperic IV Ceftriaxone possible steroid use
CLassic neck X-ray sign for epiglottitis
THumbprint sign
2 nearves that cause hoarseness when damaged
Recurrent laryngeal nerve and CN X
Ludwig’s angina
Bilateral neck space infection caused by a tooth
MCC=Strep viridans
Aggressive and fast spreading
4 clinical signs of ludwigs angina
Woody cellulitis
Rapidly spreading w/o lymph node involvement
Sublingual and submaxillary spaces involves
Bilateral
Complications of Ludwigs angina
airway obstruction
Bull neck
Drooling
Treatment of ludwig’s angina
Empiric IV abx
Unasyn
Ceftriaxone metronidazole
Clinda and Levo for PCN allergy
I&D may be needed
Vocal chord nodules
Usually benign - often from vocal abuse ie. performers
Vocal chord polyps
Smoking or chemicals
Squamous cell carcinoma of the larynx
Most common malignancy
Hoarseness
Trouble swallowing
Surgery (invasive) and chemo
Vocal cord paralysis
VOcl cords naturally open -get paralyzed on one side - asymmetry on larygoscopy
Cause of vocal cord paralysis
Damage to Recurrent Laryngeal nerve in surgery (thyroidectomy)
Clinical presentation of VCP
Dyspnea, stridor is bilateral
Hoarsness if unilateral
Grade 0 tonsils
TOnsils removed
Grade 4 tonsils
Kissing at midline
One thing to ask about when you see hypertrophic tonsils
Sleep apnea
When to remove tonsils
Causing apnea/snoring
Recurrent throat infection (more than 3 episodes in 3 each in years, 5 each in in two, 7 each in in one)
Treatment for tonsil stones
Irrigation -tonsilectomy if SEVERE
Pain on dynamic loading
Hurts when biting a tongue depressor
3 types of TMJ issues
Myofacial - Most common
Dislocation
Osteoarthritis - Degenration
More in females
Cause of TMJ issues
and clinical presentation
Psych exacerbation or trauma
Teeth grinding
Clicks and crepitus
Tenderness
Jaw can lock
Headache
Ear fullness/pain
Treatment for TMJ issues
Reduce stress
Rest Botos for muscles
Soft diet
When to refer TMJ
Recurrent problems
COmmon emerging cause of head and neck cancer
HPV in young populations
Clinical red flags for neck cancer
Chronic sore throat
Change in speach
Lesions that don’t heal
Tobacco use
Change in tongue mobility
3 neck mass categories
Infectous
Malignant
Non-malignant
Size cutoff for cancer determination
1.5 cm or greater = cancer
Lymph node
Tender and mobile
Tumor
Firm and non painful
Bump that becomes a lesion
Diagnostic study for suspected neck malignancy
FNA
Take whole mass if doing biopsy
Where does HPV show up in the mouth
Base of tongue or tonsils
Can be asymptomatic
Can be spread by aerosol to healthcare workers!!
Where does squamous cells cancer show up in the mouth
Oropharynx
Treatment for SC carcinoma
Surgery if local
Radiation or chemo is lymph involved
Palliative if Mets
