Nose & Throat

Question 1

Nose red flags

Answer 1

Posterior epistaxis

Posterior nose bleed –damage to nose arteries –heavier bleeding. Bleeding from the nose and down the throat. Lasts longer than 20 min or starts after an injury to head or face -more likely posterior. More likely in older adults and HTN

Question 2

Mouth red flags

Answer 2

Burning in the mouth, oral cavity: vitamin B12 deficiency; stomatitis; ill-fitting dentures and bridges

Xerostomia: dehydration; drugs with anticholinergic activity (antidepressants, diuretics and antipsychotics); salivary gland dysfunction following radiation therapy

Loss of taste: drugs (antihistamines; antidepressants); oral infection (candidiasis)

Question 3

throat red flags

Answer 3

Swallowing disorders: esophageal stricture, malignancy, foreign body, stroke

Question 4

Epistaxis

Answer 4

Spontaneous bleeding from the nose
May be minor or may indicate a serious disease process
Commonly seen from Kiesselbach’s plexus in the anteroinferior septum
Predisposing factors:
Drying or thinning as the result of oxygen use and nasal sprays
Infectious /allergic sinusitis, rhinitis, and systemic infection
Nasopharyngeal fibroma, angioma, and malignant tumors
Hypertension
Coagulopathies
Change in atmospheric pressure

Question 5

Nose bleed sub and obj

Answer 5

History of bleeding from the nose, there may be none
Acute bleeding from nasal fossa or posterior nasopharynx

Site of bleeding
Anterior bleed- Kiesselbach plexus
Posterior bleed – inspect for active bleeding from the posterior oropharynx
Multiple oozing points may be evident

Ulcerations or erosions of tissue/septal wall

Blood pressure may be normal or elevated

Question 6

Nose bleed labs and dx

Answer 6

Sinus series to rule out sinusitis, tumor, and angiofibroma
May consider CBC, PT/PTT or bleeding time studies to rule out coagulopathy
Other laboratory studies as indicated f or suspected underlying disease (e.g. allergy testing

Question 7

Nose bleed mgmt

Answer 7

Position the pt. with head erect and elevated

Provide reassurance, examine the nostril

Clear blood from nostril
Remove clots with gentle suctioning, visualize point of bleed
Observe closely for foreign object

Saturate a cotton ball with Afrin and gently insert it into the site of bleeding

Apply gentle pressure by compressing the nasal alae together just below the bridge for 10-15 minutes

Apply topical lidocaine anesthetic (4% sol 1-5mg; max. 4.5 mg/kg; then touch the site with a silver nitrate stick until the vessel ends are completely cauterized.

If unable to cauterize, insert nasal packing

If uncontrollable from a posterior site, immediate referral to EENT

Question 8

Sinuses

Answer 8

Sinus are air filled cavities in the skull

There are four sinuses
Ethmoid and maxillary sinuses (both present at birth)
Frontal (age 5 years)
Sphenoid (age 12 years)

By AGE 12 years of age, a child’s sinuses are nearly at adult proportions

Question 9

Sinusitis

Answer 9

Infection/ inflammation of the paranasal sinus mucous membrane
May be acute (lasting less than 4 weeks) or chronic (occurring 3 or more times a year)
Viruses cause 1/5 of cases
In all 1-3% of URIs involve sinusitis

Question 10

Sinusitis common cause

Answer 10

Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis
Various anerobes

Question 11

Sinusitis sub and obj

Answer 11

Recent Upper Respiratory Infections
Pain/pressure over face, nose, cheeks, and teeth
Often confused with a toothache
Purulent/blood-tinged nasal drainage
Headache, increased pain in supine position, or sense of fullness in head
Nasal congestion
Generalized malaise
Orbital pain or visual disturbances indicate a serious problem- Refer EENT
Fever may not be present in elderly
Localized tenderness over the sinuses
Facial edema
Swollen, red turbinates
Foul smelling nasal or postnasal drainage

Question 12

Sinusitis labs and dx

Answer 12

Sinus series reveals clouding or thickening of sinus cavity; air-fluid levels may be seen

For chronic sinusitis or for hospitalized patients, CT of the sinuses is indicated

In chronic manifestation, culture the drainage to determine the causative organism

Question 13

Sinusitis mgmt

Answer 13

Antibiotics
Amoxicillin/clavulanate (Augmentin) 500 mg PO 3X/day or 875 mg 2x/day for 7-10 days
Augmentin 2 GM BID for those 65yrs+ for S. Pneumoniae with Sinusitis

Doxycycline
100 mg PO 2x/day and Levofloxacin 500-750 mg PO daily, alternatives for patients allergic to penicillin

Analgesics
Acetaminophen 650 mg PO q4hrs. 3-4X/day (max. 4Gm daily)
NSAIDS and narcotics to be used judiciously with elderly;
Macrolides not recommended due to high rate of resistance to S. Pneumoniae

Question 14

Pharyngitis

Answer 14

Pharyngitis is an inflammation of the pharynx that is usually associated with tonsillitis. Pharyngitis can be acute or chronic.

Question 15

Pharyngitis Subjective & Objective Findings

Answer 15

Sore or painful throat
Dysphagia
Fever/ chills
Malaise/myalgia

Question 16

Pharyngitis cause

Answer 16

Viral
Influenza A and Influenza B
Adenovirus
Enterovirus

Bacterial
Group A B-hemolytic streptococcus (GABHS)
Haemophilus influenzae
Neisseria gonorhoeae
Mycoplasma

Fungal: Candida albicans is commonly seen in immunosuppressed patients

May also be associated with esophageal, allergic rhinitis, sinusitis, carcinoma

Question 17

Viral pharyngitis

Answer 17

Edema of lymphoid tissue in the posterior oropharyngeal wall
Pale, boggy mucosa, palatial petechiae
Painful ulcers/blistering in oral cavity
Posterior cervical lymphadenopathy

Question 18

Bacterial pharyngitis

Answer 18

Streptococcal (GABHS)
Bright, red edematous pharyngeal mucosa
White or yellow exudate
Fever greater than 101 F
Anterior cervical lymphadenopathy

Question 19

Pharyngitis lab and dx

Answer 19

Rapid strep antigen screen
Throat culture to identify pathogen, if rapid strep is negative get CBC with differential
Mono spot rule out Mononucleosis
If indicated, culture for chlamydia and/or gonorrhea

Question 20

Pharyngitis symptoms tx

Answer 20

Pain Relief
Lozenges OTC , use PRN
Throat sprays, OTC
Warm salt water gargle
Systemic analgesics: acetaminophen and NSAIDS
Glucocorticoids are not recommended

Question 21

Pharyngitis pharm tx

Answer 21

Bicillin L-A 1.2 million units IM single dose or Penicillin V 500mg (Pen-Vee K) PO 2x/day for 10 days
Cephalexin 500mg PO BID for 10 days
Cefadroxil 1000mg PO daily f or 10 days
Clindamycin 300mg PO 3x/day for 10 days
Azithromycin 500mg PO daily for 5 days
Clarithromycin 250 mg PO BID for 10 days

Consider antiulcer agents for gastric reflux
Omeprazole (Prilosec) 20mg PO daily
Lansoprazole (Prevacid) 15-30mg PO daily
Pantoprazole (Protonix) 40 mg PO daily
Analgesics

Acetaminophen 650mg PO q4hrs PRN

For Candida
Nystatin (Mycostatin) 100,000 U/ml 4-6ml
Fluconazole (Diflucan) 100mg for 2 weeks

Question 22

A 13 year-old girl has a throat culture that is positive for strep throat. She reports that her younger brother was recently diagnosed with strep throat and treated. The pt. has a severe allergy to penicillin and reports that clarithromycin makes her very nauseated.

Answer 22

A. Azithromycin (Zithromax)

Rationale
If the patient has a severe penicillin allergy, there is a 10% chance of cross-reactivity to cephalosporins (especially first generations). Because the patient is a child, the levofloxacin is contraindicated. Nausea is common adverse reaction (it is not an allergic reaction). The best option is to use azithromycin because of its minimal GI adverse effects. Azithromycin has fewer drug interactions compared with macrolides.

Question 23

Which condition is caused by trauma to the blood vessels located in Kiesselbach’s triangle?

Answer 23

. Anterior epistaxis

Rationale: Trauma to the small blood vessels in Kiesselbach’s triangle located inside the nose anteriorly, causes anterior nosebleeds (anterior epistaxis). This is the most common type of nosebleed and is usually self-limited.
Up to 10% of nosebleed are posterior nosebleeds (hemoptysis, melena, nausea anemia) which can result in hemorrhage. Posterior nosebleeds can cause significant hemorrhage. If suspected refer call 911. Trauma to Kiesselbach’s triangle does not cause stroke or subdural hematoma.