nose/throat/sinus Flashcards
I came in to see my physician assistant because of…
I’ve had a cold for about a week and it is getting worse
Headache
Runny nose
Sinus pain, tooth pain
Fever
General malaise
sinusitis
Labs, Studies and Physical Exam Findings
Transillumination – putting a light up to the ___
Tender over __
Nasal endoscopy may be helpful with chronic ___ lasting longer than 12 weeks
CT may be helpful with chronic __ lasting longer than 12 weeks
_**what is dx and tx?_
sinusitis and treatment
Nasal irrigation with saline
Steam
Hot packs
Lots of fluids
Humidifier
Acetaminophen or ibuprofen
Decongestant
Antibiotics after 10 days
Amoxicillin
Surgical correction by
I came in to see my physician assistant because of…
Runny nose – typically clear mucus
Itchy watery eyes – bilateral
Sneezing
what is dx and tx?
allergies, tx:
Prevention! Avoid triggers
Best choice – Intranasal corticosteroids
Require several days of treatment to achieve desired effect
Beclomethasone BID or Flunisolide BID
Antihistamines
Decongestants
Desensitisation
No true known cause
Increased incidence with allergic rhinitis
Increased incidence with asthma
Nasal polyps
Inflamed sacs of tissue along the nasal mucosa
bluish discoloration below eyes, bluish/pale/boggy nasal mucosa, horizontal nasal crease, clear and watery discharge
allergic rhinitis
kiesselbach vs woodruff plexus
anterior is kiesselbach
posterior(woodruff) is an emergency! cause it can bleed into the posterior pharynx
organisms of sinusitis
usually viral. or same organisms as OM:
Most common pathogens are
Strep pneumoniae
Haemophilus Influenzae
Moraxella catarrhalis(less often)
Staph aureus(less often)
risk factors for sinusitis
recent URI, chronic rhinitis, smoking, trauma/FB, obstructing draining, infection risk
osteomyelitis, cavernous sinus thrombosis, orbital cellultis complications of what
sinusitis
xray tests for sinusitis
CT, water view radigraph, MRI(malignancy)
Causes and predisposing factors
Typically secondary to an upper respiratory infection
Allergies
Anything which obstructs drainage from the sinuses
Smoking – decreases movement of cilia
Deviated septum
Cystic fibrosis
Large adenoids
sinusitits
get a CT
I came in to see my physician assistant because of…
I’ve had a cold for about a week and it is getting worse
purulent nasal discharge, Headache, Runny nose, Sinus pain, tooth pain, Fever, General malaise
Labs, Studies and Physical Exam Findings
decreased Transillumination – putting a light up to the ___
Tender over ___
Nasal endoscopy may be helpful with ___ lasting longer than 12 weeks
CT may be helpful with ___ lasting longer than 12 weeks
sinusitis
sinusitis tx
Treatment
Nasal irrigation with saline
Steam, Hot packs, Lots of fluids, Humidifier
Acetaminophen or ibuprofen
Decongestant
Antibiotics after 10 days (Amoxicillin first line)
PCN allergic: bactrim, FQ, macrolide, doxy
Surgical correction
CT vs MRI for sinusitis
CT sensitive but lacks specificity
MRI indicated w/ possible malignancy or intracranial spread of infection
3 types of rhinitis
allergic rhinitis, vasomotor rhinitis, rhinitis medicamentosa
what causes vasomotor rhinitis
caused by increased secretion of mucus from the nasal mucosa
it may be precipitated by changes in temperature or humidity, odors, alcohol, or result from a neurovascular imbalance
rhinitis tx
Treatment
Prevention! Avoid triggers
Best choice – Intranasal corticosteroids
Require several days of treatment to achieve desired effect
Beclomethasone BID
Flunisolide BID
Antihistamines, Decongestants, Desensitisation
Anterior nosebleed vs Posterior nosebleed
Anterior nosebleed is the most common and originates from Kiesselbach’s plexus.
Posterior nosebleed is less common and much more difficult to treat.
epistaxis tx
anterior: Direct pressure – pinch the bridge of the nose for 15 minutes; placed in sitting position and lean forward slightly to avoid swallowing blood leading to nausea and vomiting
Topical vasoconstrictor ie cocaine or oxymetazoline
If you can visualize the source silver nitrate may be used to cauterize the vessels
Packing for 24 hrs if necessary; Pneumatic tamponade; Surgical correction
Posterior packing is more difficult; need specialist
epistaxis associated with HTN and atherosclerosis
posterior/woodruff
samter triad
nasal polyps, asthma, allergic rhinitus
AVOID ASPIRIN due to possibility of severe brochospasm
nasal polyp tx
Treatment
Topical nasal steroid for 1-3 months(initial course)
Oral steroid may be helpful
Surgical removal
triad for polyps with allergic rhinitis
asthma, nasal polyps, aspirin sensitvity
centor criteria [group A b-hemolytic streptococci]
1)100.4 fever greater 2)tender ant cervical adenopathy, 3)lack of cough, 4)exudates
abdomial pain in kids secondary to adenopathy in the abdomen
strep pharyngitis
complications of strep pharyngitis
rheumatic fever, ludwigs angina, tonsillar abscess
onset of strep vs viral pharyngitis
acute for strept and insidious for viral
etiology is more commonly viral
hoarseness is the hallmark for what
laryngitis
Acute pharyngitis
viral causes
Epstein barr – mononucleosis
Adenovirus
Cold viruses
Herpes
acute pharyngitis bacterial organisms
Strep pneumonia: The most common bacterial cause of acute pharyngitis however this only accounts for between 15 and 30% of sore throats
Neisseria gonorrhoeae
Mycoplasma
Chlamydia
I came in to see my physician assistant because of…
Sudden onset
Fever/chills
Difficulty swallowing
Tender, swollen throat
No cough
Typically younger than 15 years old
acute pharyngitis
Labs, Studies and Physical Exam Findings
Tender anterior cervical adenopathy
Purulent exudate in pharynx
Shaggy white tonsillar exudate think mono
Throat culture – 90-95% sensitive for ____
Rapid antigen test is 90-99% effective for ____
acute pharyngitis
**strep
acute pharyngitis tx
Treatment
Symptomatic treatment
NSAIDS or tylenol
Fluids
Appropriate antibiotic treatment Strep –
Penicillin 500 mg BID or Amoxicillin 500 mg TID
PCN allergic: cefuroxime, emycin, macrolide
I came in to see my physician assistant because of…
Severe, one sided sore throat
Odynophagia – difficulty swallowing
Fever
Tender glands – pain in head and neck
Trismus – difficulty opening the mouth
HOT Potato Voice – muffled voice
deviation of soft palate/uvula
peritonsillar abscess
Labs, Studies and Physical Exam Findings
Erythematous pharynx
Uvula displaced towards unaffected side
Ultra sound
CT with contrast
*what is dx and tx?
peritonsillar abscess and treatment
Needle aspiration
Incision and drainage
Tonsillectomy
Antibiotic therapy
Amoxicillin – though likely resistant to PCN
Clindamycin – probably the better choice here.
parenteral antibx for severe cases
what symptoms are not suggestive of strep
coryza, hoarseness, cough
rapid strep test sensitivity
90-99% for GABHS
inadequate tx of strep can lead to what
scarlet fever, glomerulonepritis, abscess formation
scarlet fever, glomerulonepritis, abscess formation
inadequate tx of strep can lead to what
I came in to see my physician assistant because of…
Hoarseness, Fever, Swollen glands, Cough, Cold and flu symptoms
Labs, Studies and Physical Exam Findings
Usually clinical diagnosis
Laryngoscopy may be helpful in chronic patients
Treatment of laryngitis
Resting the voice
Humidifying the air
Fluids
Treat for GERD if appropriate
Antibiotics if appropriate
corticosteroids for performers
laryngitis organisms
usually viral: rhinovirus, adenovirus
bacterial: m cat, h flu, group A strep
epiglottis organisms
h flu, staph, group A strep, pneumococci
who is at highest risk for epiglottitis
dm
used to be in kids but has lessened due to the H flu vaccine
I came in to see my physician assistant because of…
High fever
quickly developing sore throat/pain
Difficulty moving air
Difficulty swallowing
Drooling
possible tripod position
describe dx and PE
epiglottitis
Stridor
Cyanosis
Laryngoscopy in OR as it may cause spasms
Throat culture
X-ray – Thumbprint sign on c spine film
CT
epiglottitis tx
Be prepared for intubation (<10%)
Keep patient calm and breathing easily
IV Antibiotics may be necessary or corticosteroids then po
50% of humans have ___ in the oral cavity
Causes
Newborns, Uncontrolled Diabetes
HIV/AIDS, Chemotherpy
Side effect of inhaled steroids
Side effect of antibiotics
Dentures or poor hygiene
thrush
Lesions can be scraped off and may bleed
Culture of scarpings
Microscopic examination of scrapings
thrush tx
Treatment
Address underlying cause
Fluconazole 100mg x 7 days for non-immunocompromised patients
½ hydrogen peroxide mouth rinse
Herpetic Whitlow
Herpes keratitis
Herpes encephalitis
Neonatal infection
Herpetic Whitlow – infection of the fingers
Herpes keratitis – eye infection
Herpes encephalitis – CNS infection
Neonatal infection – Active herpes infection in the mother is an indication for a c-section [FATAL]
aphthous ulcer virus
human herpes virus 6
single or multiple painful, round ulcers with yellow gray centers and red halos
occur where
aphthous ulcers
occur on non keratinized mucosa and usually recurrent
aphthous ulcer tx
No true cure
Typically self limiting
Topical antiviral 5% acyclovir
Oral antiviral, acyclovir, valacyclovir
1 wk prednisone, Tylenol and ibuprofen
cimetidine used as maintenance therapy in recurrent cases
leukoplakia
painless white area on tongue, inside cheek, lower lip, or on the floor of the mouth. cannot be scraped off. 5% malignant
Causes
Often associated with tobacco use
Alcohol and smoking
HPV
I came in to see my physician assistant because of…
painless white plaque on the oral mucosa/ does not scrape off
Often found on routine exam
Treatment for leukoplakia
Remove offending agents
Monitor closely as this is a premalignant condition if associated with erythematous appearance- risk of dysplasia is 90%
what is parotitis?
from what?
2 most common organisms
Parotitis
An inflammation of one or both salivary glands
Viral infection
Historically the number one cause was the mumps
Para influenza and Epstein barr are the most common
HIV
Bacterial infection: Staph Aureus is the most common bacteria
Autoimmune disease, sjogrens, Blockage, stone, Mucus plug
I came in to see my physician assistant because of…
Facial swelling, Facial pain, Difficulty swallowing
Labs, Studies and Physical Exam Findings
Clinical diagnosis
Treatment of parotitis
Supportive care
Appropriate antibiotics
___ usually occurs after hyposecretion or duct obstruction but may develop without an obvious cause.
___ typically occurs in
Patients in their 50s and 60s, xerostomia, Sjögren syndrome
Adolescents and young adults with anorexia
radiation therapy to the oral cavity or radioactive iodine therapy for thyroid cancer.
Sialadenitis is most common in the parotid gland
The most common causative organism is Staphylococcus aureus
Although sometimes described as sialoadenitis, this inflammation is rarely a bacterial infection, particularly in the absence of fever.
The major salivary glands are the ___
parotid, submandibular, and sublingual glands.
Symptoms and Signs of sialadenititis
Diagnosis
Fever, chills, and unilateral pain and swelling develop. The gland is firm and diffusely tender, with erythema and edema of the overlying skin. Pus can often be expressed from the duct by compressing the affected gland and should be cultured. Focal enlargement may indicate an abscess.
CT, ultrasonography, and MRI can confirm sialadenitis or abscess that is not obvious clinically, although MRI may miss an obstructing stone. If pus can be expressed from the duct of the affected gland, it is sent for Gram stain and culture.
