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Clinical Medicine 2 > Lecture 11 (HEENT)-Exam 4 > Flashcards

Lecture 11 (HEENT)-Exam 4 Flashcards

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1
Q

Where are all the sinuses?

A

The framework of thenoseconsists ofboneandcartilage. Two smallnasalbones and extensions of themaxillaeform the bridge of the nose, which is the bony portion. The remainder of the framework is cartilage and is the flexible portion.Connective tissueand skin cover the framework.

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2
Q
A
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3
Q

Examination of the Nasal Cavity- Basics

A
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4
Q

What is an nasal speculum and flexible rhinolaryngoscope?

A
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5
Q

Nasal Polyps
* What are they?
* What do you they look like?
* How many adults have them? What is the peak age?

A
  • Benign lesions arising from mucosa
  • Usually semitransparent
  • 1-4% of adults
  • Peak age 20-40 years
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6
Q

Nasal Polyps
* Associated with that?
* May be what?
* What is the mainstay treatment? What about if infection present?

A
  • Associated with asthma, allergic rhinitis, sinusitis, CF, alcohol intolerance
  • May be surgically removed
  • Mainstay treatment: intranasal steroids
  • Consider decongestants, doxycycline or amox/clavulanic acid if infection suspected
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7
Q

Allergic Rhinitis
* What is it?
* What are the sx?

A
  • Immunoglobulin E mediated chronic and recurrent u inflammatory response often accompanied by
    conjunctivitis
  • Sneezing, itching, boggy mucosa

  • Affects 10-30% of adults and children in US
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8
Q

What is the txt for allergic rhinitis?

A

Treatment includes intranasal steroids, antihistamines
* Most effective single therapy is glucocorticoid nasal spray (2nd gen less systemic side effects)
* 2nd generation: fluticasone (Flonase), mometasone (Nasonex), ciclesonide (Omnaris)
* Antihistamines-po (loratadine, cetirizine, etc)
* Antihistamine sprays- Azelastine, Olopatadine
* Nasal irrigation 1-2 times daily (nonspecific improvement)

  • 1st generation: beclomethasone (Qnasal), flunisolide (Nasalide), triamcinolone (Nasocort), budesonide (Rhinocort)
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9
Q

Irrigation
* What do you need to tell your patient?

A

If instructing patients to perform this-
* Recommend saline solution, room temperature or warmed
* Only use distilled, sterilized, or previously boiled water to avoid risk of amebic meningoencephalitis (Naegleria fowleri contamination)
* Clean irrigation devices regularly

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10
Q

Rhinosinusitis
* What is it?
* What is this NOT?
* What does it increase the risk of?

A
  • Symptomatic inflammation of the paranasal sinuses, nasal cavity and epithelial lining
  • Term could be used interchangeably with sinusitis but does not mean the same thing
  • Mucosal edema blocks drainage increasing risk of viral or bacterial infection

  • Very common- 12% of adults
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11
Q

Rhinosinusitis
* Classified into what?
* How much is bacterial?
* What sx do you need to dx bacterial?
* What is the clincal dx?

A
  • Classified as acute (<4weeks) or chronic (>12 weeks)
  • Only 10% are bacterial
  • Need 10-14 days of symptoms to diagnose bacterial or severe worsening, systemic symptoms (fever, etc)
  • Clinical diagnosis- no imaging needed unless complication suspected
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12
Q

What organisms are for community-acquired bacterial rhinosinusitis ? What about virus?

A
  • Strep- tococcus pneumoniae, Haemophilus influenzae, and Moraxella (Branhamella) catarrhalis
  • The most common viruses in acute viral rhinosinusitis are rhinovirus, adenovirus, influenza virus, and parainfluenza virus
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13
Q

What does this show?

A

Sinusitis-

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14
Q

What does this show?

A
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15
Q

Rhinosinusitis- Treatment (suspected viral)

A
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16
Q

list out the names so that way you are familiar?

A
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17
Q

Rhinosinusitis- Treatment (bacterial)?

A
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18
Q

Rhinosinusitis
* What are warning signs? 6
* What are complications?
* What may immunocompromised people develope?
* What type of tumor?

A
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19
Q

Epistaxis
* What are the two types and their blood supply?
* Which is more common?
* Estimated 60 percent of adults experience?

A
  • Can be anterior (Kiesselbach’s plexus) or posterior (posterolateral branches of sphenopalatine artery)
  • Anterior most common by far (90%)
  • Estimated 60 percent of adults experience an epistaxis episode, only 10 percent or fewer seek medical attention
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20
Q

What are tips to prevent epistaxis?

A
  • Don’t pick your nose
  • Keep the air moist
  • No foreign bodies
  • Don’t use cocaine
  • Don’t get punched
  • Don’t get in a car accident
  • Don’t take anticoagulants
  • And if you do any of the above, Don’t blow your nose
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21
Q

What do you need to consider with epistaxis?

A
  • Bleeding disorders (labs like INR)
  • Aneurysm of carotid artery (think head/neck surgery or trauma)-> pulsing bleeding
  • Neoplasm
  • Hypertension-> does not cause but harder to control
  • Rhinitis/Rhinosinusitis
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22
Q

How do you stop a nose bleed?6

A
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23
Q

how do you pitch your nose for a bleed?

A
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24
Q

What can you use for cautery for anterior epistaxis?

A
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25
Septal Hematoma * What is it? * Can be what? * History of what? * What does it look like?
* Midline swelling of the septum * Unilateral or bilateral * History of nasal trauma, +/- fracture * Soft, fluctuant septal collection of blood, usually compressible
26
Septal Hematoma- * What is the Treatment * Who do you need to follow up with? * If bilateral, then what? * What happens if not treated?
27
Nasal Fractures * Evaluate for what? * Imaging not needed if the following criteria met (4)? * How do you dx?
Evaluate for other facial trauma when present Imaging not needed if the following criteria met: * Tenderness isolated to nasal bony bridge * Can breathe through both nares * No deviation of septum * No septal hematoma (look for this, will need I&D) CT preferred if extensive injury suspected (diffuse tenderness)
28
Nasal Fractures * How do you txt? * What do you for displaced fractures? * Who do you need to refer to?
* Treat with ice, decongestant * Displaced fractures- some reduce immediately but can wait 3-7 days for edema to resolve * ENT outpatient follow up unless complications
29
What do you order nasal fractures?
30
What are these/
31
Patient presents to the urgent care with a nosebleed. Which of the following should be done first? A. Silver nitrate application B. Apply pressure to the ala bilaterally C. Lean backwards until bleeding stops D. Insert rhino rocket
B. Apply pressure to the ala bilaterally
32
30-year-old male with PCN allergy presents complaining of sinus pressure, facial pain, and green thick nasal discharge x 5 days. What is an appropriate medication for this patient.? a. Amoxicillin b. Doxycycline c. Hydroxyzine d. Ibuprofen e. Prednisone
d. Ibuprofen * No antibiotics until after 10 days
33
How many teeth do we have?
34
Tooth & Gum Disease * What are the risk factors? * What is the treatment?
Risk factors * Age, smoking, methamphetamine use (“meth mouth”), sugar rich diet, acid reflux, salivary gland damage (radiation or ketaroconjunctivitis sicca) Treatment with regular dental care, fluoride mouth rinses
35
Gingivitis * What is this? * May be due to what? * What are risk factors? * Exam shows what? * Treatment?
* Inflammation of the gums * May be due to certain medications- older psychotropics * Risk factors include drug use, tobacco smoking * Exam shows erythematous inflammation of the gums, often with retraction * Treatment- **dental referral**, stop smoking/ETOH/drug use, brushing/flossing
36
Acute Necrotizing Ulcerative Gingivitis * What is this? * Acute onset of what?
* “Trench mouth” * Acute onset foul breath, severe oral pain, +/-fever, lymphadenopathy
37
Acute Necrotizing Ulcerative Gingivitis * How do you treat? * May perform what? * What type of rinses?
38
* What is this? * What is it seen in? * What are the sx? * How do you txt?
## Footnote Blunting of the interdental papilla, and an ulcerative necrotic slough of the gingiva. The sloughed material, or film, consists of fibrin, necrotic tissue, leukocytes, erythrocytes, and bacteria. Removal of this film causes bleeding and exposure of ulcerated and erythematous tissue.
39
Dental Abscess * How do you clinical diagnois?
If large enough or concerning symptoms (regional LAD, trismus, secretion intolerance) ->obtain CT face or neck with contrast depending is upper or lower
40
Dental abscess: * What is the txt?
## Footnote Inferior alveolar block
41
What is this?
Dental/Periapical Abscess
42
Dental Fractures * What is the classification? * What type of paste can be used for fix? * What can you use to preserve?
43
What are 1, 2, 3 ellis classification?
● Class I fractures involve only the enamel of the tooth, are not painful, and can be evaluated on an outpatient basis. ● Class II fractures expose the yellow dentin and may be painful. These injuries are suitable for outpatient care. They may be dressed. This is done by covering the exposed area with calcium hydroxide (taking care that the tooth is dry to ensure adherence) and then wrapping dental foil around the tooth to create a protective barrier. Advise patients to drink liquids and avoid solids until they are seen by a dentist in follow-up to avoid losing the dressing. ● Class III fractures expose the dental pulp, seen as a red line or dot, and are exquisitely painful. They require evaluation by a dentist or endodontist within 48 hours.
44
Dental Fractures: what do you do when treatment?
* Disturb the socket as little as possible * Handle the tooth by the crown (the root should not be wiped or handled) * Gently rinse the tooth and socket with tap water or saline * Replace the tooth in the socket, where it generally "clicks" into place * If the tooth is only partially avulsed, extruded, or laterally luxated, it should not be removed. Rather, it should be reimplanted or relocated. Intruded teeth should not be manipulated
45
Aphthous Ulcers * What does it look like? * May painful with what? * May cause what? * Can be what? * Risk increases what? * Most require what?
* Round, shallow ulcers with red halo * Well defined border * May be painful with eating * May cause slurring of speech * May be viral, stress induced * Risk increases with NSAID use, b-blockers, ACEI, zinc/iron/b12 deficiencies * Most require no treatment but may use magic mouthwash ## Footnote Common- 20% population, may be genetic
46
Pseudomembranous Candidiasis (exudative) * What is it? * Commonly seen in who?
* Candida albicans – normal flora but can overgrow * Commonly seen in babies, immunocompromised individuals, chronic steroid/ABX users, denture wearers * 90% of HIV patients will develop this
47
Pseudomembranous Candidiasis (exudative) * How do you dx? * How do you tx?
Dx: clinical (white plaques) * Can be scrapped off leaving a red friable mucosa * Chronic lesions will require Biopsy (malignant) Tx: topical antifungals in mild (nystatin, miconazole, clotrimazole/ketoconazole) * Moderate to severe: oral antifungals (fluconazole) * 7-14 days * ”swish and swallow” (esophagel component)
48
What are these?
49
Leukoplakia * What is it? * Usually what? * Precursor to what? * Leukoplakia cannot be what?
50
Erythroplakia * What is it? * Higher risk of what? * What do you need to do?
51
What is the difference between the Pre-malignant lesions
52
Herpes Simplex * What is it? * Prodrome of what? * Once or recurrent? * How do you transmit it?
* Ulcerative lip lesions * Prodrome of tingling, pain, +/- flu symptoms * Recurrent (typically stress induced) * Transmission through direct contact with lesions or infected oral secretions
53
Herpes Simplex * How do you dx and txt it?
* Diagnosis confirmed by PCR Treatment with antivirals but will resolve without treatment * Acyclovir, Famciclovir, or Valacyclovir x 7 days
54
Laryngitis * What is it? * Typically what? * What are sxs?
* Inflammatory process of the vocal cords caused by a variety of infectious and non-infectious processes (broad ddx) * Typically viral (~95%) but rarely associated w/strep * Hoarseness associated with decreased vocal pitch, loss of clear verbalization * If concomitant with cough or URI type symptoms, definitely viral
55
Laryngitis * How do you txt? * If no systemic sx, then what do you need to consider?
* Treat underlying condition * Hydration, humidification, voice rest * If no systemic symptoms, consider neoplasm
56
What is this?
Laryngeal cancer
57
Laryngeal Cancer * 90% are what? What are the risk factors? * What is the clinical presentation? (early and late) * How do you dx? * How do you tx?
58
Pharyngitis * What is it? * Common or not? * What is the mc organisms?
59
Pharyngitis- * What does the presentation show? * What does the exam show?
60
Pharyngitis * How do you dx it?
Diagnosis * Viral is clinical dx, consider COVID testing * Rapid Strep Test to confirm Strep (Consider CENTOR criteria) * Throat culture if refractory
61
Pharyngitis * how do you txt it?
Treatment * Viral- symptomatic (analgesics, lozenges, sprays, warm fluids) Group A Strep- Antibiotics * Adults- PCN 500 mg TID x 10 days * Children- amoxicillin or PCN * PCN allergy- cephalosporins, clindamycin, and macrolides
62
Tonsillitis or Tonsillopharyngitis * What is it? * Sam etiology as what? * What is the mc organism and seen in who? * Always consider what?
63
What is the centor criteria?
64
Tonsillitis or Tonsillopharyngitis * how do you tx it?
Tx: based on etiology (see pharyngitis txt) * ABX +- steroids (decreases swelling) * Tonsillectomy if recurrent or non-resolving ## Footnote Pharyngitis tx: * Viral: symptomatic * Ant: adults (PCN), child (Amox or PCN), PCN allergy (3rd gen ceph, clinda or macrolides
65
Uvulitis * What is it? * Associated with that? * usually what? * Consider what?
* Inflammation and/or infection of the uvula * Associated with pharyngitis / other infectious etiologies * Usually benign * Consider angioedema (ACE inhibitors can cause this)
66
how do you tx uvulitis?
Tx: symptomatic * Steroids * Antihistamines * ABX if infection suspected
67
What are the GAS complications?
* Peritonsillar Abscess (approx. 1% of confirmed GAS cases) * Rheumatic Fever (joint pain, murmur, rare) * Poststreptococcal glomerulonephritis (hematuria, rare) * Scarlet fever (sandpaper rash)
68
What is this?
Viral Pharyngitis (most common)
69
What is this?
Tonsillitis
70
What is this? * What are other sxs? * What can you test with?
MONO * Posterior LAD * Hepatosplenomegaly * Do NOT give amoxicillin * Test with Monospot or IgM antibody test
71
What is this? What are other sxs?
Gonorrhea * Signs and symptoms of gonococcal pharyngitis are nonspecific and include sore throat, pharyngeal exudates, and cervical lymphadenopathy. 
72
What is this?
Coxsackie * Low grade fever, rash on soles+palms and mouth
73
Diphtheria * What does it look like? * What causes it? * What is the txt? * What is the prevention?
74
Measles (Rubeola) * Rare or common? * Highly what? * What are the sx?
* Rare, but increasing due vaccine hesitancy * Highly contagious * Pentad of fever and rash + 3 C’s: cough, coryza and conjunctivitis * Koplik Spots are pathognomonic- Tiny grains of white sand with red ring
75
Measles (rubeola) * How is it dx? * How do you tx? * Report to who?
* Dx: Clinical, IgM antibodies test to confirm * Tx: Supportive * Report to health department
76
Post Tonsillectomy Bleed * May be what? * 50% of patients that bleed require what? * Adults twice as likely to what? * What is the txt for minor and major bleeding?
77
What is this?
Tonsillectomy Bleed
78
Peritonsillar Abscess * What are the sxs? * Enlarged what? * Medial deviation of what?
* Severe sore throat, muffled voice, trismus * Enlarged fluctuant tonsil * Medial deviation of the soft palate and sometimes uvula
79
Peritonsillar Abscess * How do you dx? * How do you txt?
80
What is this?
Peritonsillar abscess
81
Ludwig’s Angina * What is it? * Common after what? * What organisms are part of it?
82
Ludwig’s Angina * What is the presentation? * What is the exam? * What is dx?
* Presentation: “Hot potato” voice, dysphagia, drooling, stridor, trismus, tongue elevation, stiff neck, floor of mouth edema, fever/chills, malaise * Exam: Symmetric neck swelling, tenderness, crepitus, elevated floor of oral cavity * Dx: Clinical, + CT with contrast
83
Ludwig’s Angina * What is the txt?
84
What is this?
85
Epiglottitis * What it is? * What is it previously caused by? * More common in who?
86
Epiglottitis- Clinical presentation * What happens on exam * What are the sxs? * What are the two types? * Peaks within what?
87
Epiglottitis- Diagnosis and Treatment * how do you dx? * How do tx?
88
What is the thumb sign?
89
Sialadenitis * What is it? * May be what? * Rapid onset with? * What is the presentation? * Exam?
* Infection/inflammation of salivary glands * May be bacterial, viral, or due to obstructive salivary stone (sialolithiasis) * Rapid onset with drainage supports bacterial etiology- may be due to stone * Presentation: Pain, erythema, tender to palpation, swelling of involved gland * Exam: Inspect posterior to anterior palpation of the floor of the mouth and inspection of the opening of Wharton's duct, look for stone
90
Sialadenitis- Dx and Txt * How do you dx? * How do you tx? * What antibiotics?
91
What is this?
Sialadenitis
92
Parotitis * What it is? * What is the etiology? * May be what? * What are some sx?
* Infection/inflammation of parotid gland * Viral etiology, classic mumps * May be bacterial- staph aureus, MRSA * Localized swelling, difficulty swallowing, anorexia
93
Parotitis * What does the exam? * How do you dx? * What is the txt?
* Exam: Swelling, erythema, tenderness over parotid gland * Dx: clinical, but may investigate with US or CT * Txt: Depends on cause * Viral->supportive * Bacterial suppurative parotitis (uncommon)- antibiotics, sometimes hospitalization
94
Geographic Tongue * What is it? * What may have predispose? * Common in patients with what? * Typically requires what?
* Benign migrator glossitis * Stress, allergies, type I DM may predispose * Common in patients with psoriasis * Typically requires no treatment but may use topical steroid, antihistamine mouthwash
95
Mandibular Dislocation * Typically dislocates where? * What techniques?

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