Week 5: ENT 2 (common conditions of the nose, mouth and throat) Flashcards
Nasal polyps Background
- Fleshy, benign swelling of the nasal mucosa
- Usually bilateral: common (>40 years)
causes of nasal polyps
- They result from chronic inflammation and are associated with:
- Asthma
- recurring infection,
- allergies
- drug sensitivity
presentation of nasal polyps
- Polyps look slightly lighter
- In this pic: Emerge out of the middle meatus (between middle and inferior turbinate’s)
- Pale or yellow in appearance/ fleshy and reddened
- Symptoms
- Blocked nose and water rhinorrhoea
- Post-nasal drip
- Drip goes into the pharynx and larynx- irritation and cough
- Decrease smell and reduced taste
- Sinusitis- blockage of the sinus air cavities
Unilateral poly +/- blood tinged secretion may
suggest tumour – cancer
management of nasal polyps
Medical management with topical (nasal drops) and possibly systemic corticosteroids is usually considered the initial treatment of choice, with endoscopic sinus surgery reserved for those patients who fail to improve
rhinitis
- Inflammation of the nasal mucosa lining
- Entire nasal cavity affected- bilateral
causes of rhinitis
- Simple acute infective rhinitis (viral- common cold)
- Allergic rhinitis- similar symptoms to infective rhinitis
presentation of rhinitis
- Nasal congestion
- Rhinorrhoea – runny nose
- Sneezing
- Nasal irritation
- Postnasal drip
management of rhinitis
- Topical/ oral nasal antihistamines
- Topical intranasal steroids
- Nasal saline wash
septal haematoma
- Potential complication from nasal injury
septal haematoma causes
- Buckling(bending) of cartilage due to trauma
- Tears/shears blood vessel
- Accumulation of blood
- Strips perichondrium away from cartilage (nasal septum)
- Starving cartilage of blood supply
- Cartilage dies fibrosis and affects shape
- Infection can be an issue
diagnosis of septal haematoma
must look up the nostrils for swelling
management of septal haematoma
must be incised and drain and a tamponade placed to stick perichondrium back onto cartilage
But if you don’t treat septal haematoma- Saddle nose deformity
acute sinusitis
<3 weeks
background to acute sinusitis
- Inflammation of the mucous membrane of the paranasal sinuses
- Paranasal sinuses are air filled spaces lined with resp mucosa and therefor have cilia and goblets cells – extensions of the nasal cavity
Sinuses drain into nasal cavities via ostia’s into a meatus most commonly the middle meatus
pathophysiology of acute sinusitis
- Infection leads to reduced ciliary function, oedema of nasal mucosa and sinus ostia and increased nasal secretions → that cant drain
- Maxillary most commonly affected due to gravity
- Stagnant secretions- breeding ground for bacterial infection
causes of acute sinusitis
-
Causes
- Usually viral infection
- Rhinovirus
- Parainfluenza virus
- Only 3% require antibiotics
- Streptococcus pneumonia
- Haemophilus influenzae
- Usually viral infection
presentation of acute sinusitis
- Facial pain- esp when looking down
- Headache
- Nasal discharge
- Loss of smell
- Nasal obstruction
- Coryzal symptoms- yellow sputum
- Vertigo if mucus builds up in eustachian tube
- Ear pain, tiredsness
management of acute sinusitis
- Analgesia
- Intranasal decongestants and nasal saline
- Don’t give abx if symptoms have been present for 10 days or less
- Intranasal corticosteroids for 14 days if symptoms present for more than 10 days
- Oral abx e.g. phenoxymethylpenicillin if severe presentation
chronic sinusitis
>3 months
causes of chronic sinusitis
- Allergies esp hay fever and environment allergies
- Nasal polyps/ Deviated septum
- Resp tract infection
management of chronic sinusitis
- Avoid triggers, stop smoking
- Nasal irrigation with saline solution to relieve congestion and nasal discharge
- Intranasal corticosteroids for up to 3 months
- Specialist referral if unilateral symptoms
- Recurrent otitis media/pneumonia in child
deviated nasal septum
- A deviated septum occurs when the thin wall (nasal septum) between your nasal passages is displaced to one side. In many people, the nasal septum is off-center — or deviated — making one nasal passage smaller
causes of deviated nasal septum
- Present at birth
- Injury to the nose
presentation of deviated nasal septum
difficulty breathing, crusting + bleeding, recurrent sinus infections, may also have no symptoms
investigations for deviated nasal septum
CT scan and nasal endoscopy
management of deviated nasal septum
- Nasal sprays including decongestants, antihistamine and corticosteroids
- Surgery: may need a septoplasty operation to correct the septum deviation if causing significant problems
nasal fracture causes
- Trauma to the nose
presentation of nasal fracture
deformity to the nose, swelling, skin laceration, ecchymosis, epistaxis and CSF rhinorrhea
investigations for nasal fracture
X-ray would only be needed with more serious injuries needing facial and skull x-ray
management of nasal fracture
- non-displaced fractures can be managed conservatively
- if displaced- manipulation under either local or general anaesthetic, , if not it may need surgery 12 months after the operation
- must also exclude complications like septal haematoma which would need draining
- Refer to ENT if required
salivary stones (sialothiaiss)
- Most stones are located in submandibular glands
- Dehydration, reduced salivary flow
- Most stoned less than 1cm
presentation of sialothiasis
- Pain in gland
- Swelling
- Infection
diagnosis of sialothiasis
- History
- X-ray
- Sialogram- contrast dye injected into gland
Peritonsillar abscess ‘quinsy’
*
- Diff to tonsilitis
- Affects tissue around the tonsil
- If its unilateral (quinsy)→ will deviate the uvula towards the swelling
Pharyngeal tonsil (adenoid)- clinical correlates
- Enlarged pharyngeal tonsils
- Block eustachian tube (recurrent/persistent middle ear infection
- Snoring/sleep apnoea
- Sleeping with mouth open
- Chronic sinusitis
- Sore throat
- Nasal tone to voice
dysphagia signs and symptoms
- Coughing and chocking
- Sialorrhea (drooling)
- Recurrent pneumonia
- Change in voice/speech (wet voice)
- Nasal regurgitation
causes of dysphagia
-
Stroke
- 30% of post stroke death are due to pneumonia
- E.g. aspiration pneumonia
- 30% of post stroke death are due to pneumonia
- Progressive neurological disease
- Parkinson’s/MS
- COPD
- Dementia
- MALIGNANCY e.g. oesophageal cancer
interventions of dysphagia
- Fluids are thickened
false diverticulum
Caused by a posteromedial (false diverticulum)→ arises in weakness between the 2 parts of the inferior constrictor (Killians dehiscence)
- Probably due to
- Failure of UOS to relax
- Abnormal timing of swallowing
- Essentially there is a higher pressure in laryngopharynx
- Weakness in inferior constrictor muscle produces outpouching
- Essentially there is a higher pressure in laryngopharynx
presentation of false diverticulum
bad breath
regurg of food
occasional choking on fluids
general difficulty swallowing
Tonsilitis
inflammation of the palatine tonsils
presentation of tonsillitis
- Fever
- Sore throat
- Pain/difficulty swallowing
- Cervical lymph nodes
- Bad breath
- Viral causes (most common)
- Bacterial causes (up to 40% of cases)
- Strep pyogenes
- White spots
- Can be bacterial secondary to viral tonsilitis
injury to either the IX (glossopharyngeal) and X (vagus) can cause
- Obvious things
- Absent gag
- Uvula deviated away from lesion (Lower Motor Neurone lesion)
- More subtle
- Dysphagia
- Taste impairment (posterior tongue IX)
- Loss of sensation oropharynx
Injury to IX/V caused by
Medullary infarct, jugular foramen issues (fracture)
injury to XII- hypoglossal
- Wasted tongue
- Stick tongue out- tongue may deviated
- Damage to nerve itself (LMN)- points to side of the lesion (tongue never lies)
- Muscle wasting
- Fasciculations
thyroid nodules differentials
- Common head and neck presentation with patient presenting with thyroid masses or nodules
- Can be benign or malignant
benign causes of thyroid nodules
- Colloid nodules
- Hyperplastic nodules
- Thyroid adenoma
- Thyroid cyst
- Viral thyroiditis
- Graves disease
malignant causes of thyroid nodules
investigations for thyroid nodules
-
Swallow and stick out tongue
- Any lump related to thyroid will move on swallowing
- If the lump moves when tongue being stuck out- thyroglossal
- TSH and T4 levels
- US
- Fine needle aspiration if malignancy suspected
- Calcitonin levels, calcium and PTH in suspected PT pathology
- Radioactive iodine uptake- graves and multinodular goitre and thyroiditis differentiation
presentation of thyroid nodule
-
Presentation
- Mass effect symptoms of thyroid neck lump
- SOB due to tracheal compression
- Dysphagia
- Hoarseness- irritation of recurrent laryngeal nerve
- Hyperthyroid symptoms
- Systemic malignant features e.g. weight loss, night sweats and lymphadenopathy
- Hypothyroid symptoms
cervical lymphadenopathy
- Enlargement of cervical lymph nodes in the neck region
- Important clinical indicator of underlying condition of infection
causes of cervical lymphadenopathy
- Throat infection
- Dental decay
- Ear infection
- Salivary glands
- Cancer
- HIV, HEP
presentation of cervical lymphadenopathy
- Cervical lymph nodes are usually very small cand cannot be felt upon touch until underlying infection or malignancy has triggered increase in size
- Symptoms
- >6 weeks
- Firm, hard
- Lymph nodes >2cm
- Unintentional weight loss, night sweats, appetite loss
- Exposure to HIV or hep
- Unexplained fever
- Any associated facial swelling
diagnosis of cervical lymphadenopathy
- Physical exam
- US, CT and MRI
- Further test dependent on findings of examination
- Biopsy needed if malignancy is being considered
- Persistent cervical lymphadenopathy- FBC, LFT, CRP
