Download - Disorders of the Ear, Nose, Throat & Mouth
Disorders of the Ear, Nose, Throat & Mouth
Chapter 10
Medical Considerations
EARS
Otitis Externa- a painful inflammation of the membranous lining of the auditory canal and/or contiguous structures. Refers to acute and chronic inflammatory process It may be diffuse or localized Is largely benign and self-limiting Invasive otitis externa is a potentially life threatneing
situation
EARS
OE continued Epidemiology
10-20% more common in the summer months Patho- inflammation is most commonly
caused by microbial infection. Colonization of the external ear is prevented immune and anatomic mechanisms
EARS
OE patho continued Squamous epithelia of the canal constantly
slough, while hair follicles sweep laterally, cleaning and act as a barrier. The canal maintains an acidic pH and repels moisture and the presence of normal flora inhibit the overgrowth of virulent bacteria. If any of this is broken compromised there may be colonization by bacteria
EARS
OE patho continued Bacteria
Pseudomonas aeruginosa is most common of diffuse infections and most cases of invasive OE
Staphylococcus aureus typically causes a localized infection from a hair follicle
Streptococcus pyogenes associated with local infection presenting as folliculitis
Polymicrobial infection found in up to 1/3 of cases of diffuse disease
EARS
OE patho continued Other causes of OE
Fungal agents Aspergillus niger- usually local infection, but can cause
invasive infection Pityrosporum Candida albicans
Hyperkeratotic processes Eczema, psoriasis, seborrheic, or contact dermatitis
EARS
OE Necrotizing Otis externa is the most severe
infectious form of OEBacterial infection extends from the skin of canal into
soft tissue or boneCranial nerves may be involvedPseudomonas is most common
EAR
OE Presenting complaints
severe ear pain (otalgia) of sudden or acute onset Pain worse at night Worse with pulling on the pinna or earlobe or pushing on tragus Severe cases- pain with chewing May have purulent discharge may be noted Chronic OM
May present with dryness and itching
EAR
Otitis Media (OM) Physical findings
Tenderness with palpation Otoscopic exam- canal appears swollen and red with drainage with
bacterial infections Diffuse cases present with complete involvement Localized cases present with focal lesion Pseudomonas produces a copious green exudate Staphylococcal produces yellow crusting in purulent exudate Fungal infections presents as a fluffy, white or black malodorous growth Except in invasive disease there is no lymphadenopathy TMJ pain indicates invasive disease
EAR
OE Diagnostic testing
Rarely neededCultures may be done of discharge if indicated in
healthy patientsCT or MRI may be needed if suspect invasive disease
EARS
OE Differential DX
OM TMJ Dental disease Trigeminal or glossopharyngeal neuralgia Parotitis Impetigo Herpes zoster Insect bites Mastoiditis Rupture of membrane Excessive cerumen buildup (wax)
EARS
Management and Treatments Pain meds Heat or ice Keep dry- no swimming for 7 days Treatment for basic OE
Irrigation if indicated Pain drops Antibiotic drops
Ciprodex, Floxin Cortisporin May need a wick if very swollen
EARS
Otitis Media- OM- inflammation of the structures in the middle ear.
Otitis media with effusion –OME involves the transudation of plasma from middle ear blood vessels leading to chronic fluid; this can be chronic
Acute Otitis Media-AOM is infection in the middle ear
EARS
OM Epidemiology
Accounts for 2-3% of all family practice office visits. Number of visits increases in the winter. More common in colder weather and in children.
Contributing factors include; allergies, rhinitis, pharyngitis due to swelling of upper airway membranes. Most common factor is upper airway infections (colds), caused by many different viruses. Influenza, RSV, pneumovirus, adenovirus
EARS
OM Patho-bacterial infection (or viral) by
nasopharyngeal microorganisms follows eustachian tube dysfunction in which the isthmus becomes obstructed. Inflammation results in response to the bacterial products such as endotoxins, creating infection behind the tympanic membrane in the middle ear
EARS
OME Patho- caused by collection of plasma fluid from
engorged blood vessels resulting from the loss of Eustachian tube patency, either from swelling of the lining or direct blockage
Pathogens Streptococcus pneumoniae, haemophilus influenzae, Moraxella
catarrhalis are most common. Less common are streptococcus pyogenes and aureus
Up to ½ are viral
EARS
OME symptoms Stuffiness, fullness, decreased hearing, pain is
rare, may have popping. Rarely vertigo Usually a history of recent URI, allergies
EARS
AOM- symptoms Deep pain, fever, sometimes decreased hearing,
discharge with a perf, sometimes dizziness or ringing in the ear
Recurrent AOM means there is clearing of the infection between episodes
Chronic OM- presents with history of repeated bouts of AOM followed by effusion with hearing loss being the biggest concern
EARS
Diagnostic Tests Tests are rarely needed. Should use pneumatic
otoscopy. Tympanogram may be helpful otitis with effusion. Cultures are rarely done, but are helpful. X-ray or CT of sinuses or of mastoid area maybe indicated. CBC with severe illness maybe indicated. Hearing tests are needed in some cases or at follow-up
EARS
Otitis Management/Follow-up OM
If over 2 years, watchful waiting for three days If present longer than three days treat for most common organism Recheck children in 2-3 weeks, adults if pain or other symptoms
return OME
Watchful waiting is indicated, recheck every 4-6 weeks for 3-4 months
Steroids are sometimes used for 7 days Nasal steroids used more often for 3 months Rarely an antibiotic is tried
Rhinitis
Rhinitis or coryza –inflammation of the nasal mucosa with congestion, rhinorrhea, sneezing, pruritus, post nasal drip Allergic
Seasonal or perennial Nonallergic
Infectious, irritant related, vasomotor, hormone-related, associated with medication, or atrophic May be chronic or acute
Most common types Viral Perennial (hay fever)
Rhinitis
Epidemiology/Causes Actual prevalence is undocumented, but is very common Occurs at least as much as the common cold Estimated 40-50 million American adults suffer Seasonal allergic rhinitis parallels pollen production
fall/spring Allergy occurs in all age groups
Most common in adults 30-40 years Non allergic rhinitis may be acute or chronic
Chronic maybe associated with bacterial sinusitis
Rhinitis
Epidemiology/Causes Atrophic rhinitis affects older adults, but symptoms may
begin in the teens VIRAL URI’s are more frequent in families with young
children Exposure to offending allergens is the main risk factor of
allergic rhinitis Vasomotor rhinitis is aggravated by low humidity, sudden
temperature or pressure change, cold air, strong odors, stress, smoke
Certain drugs may precipitate rhinitis- ACE, beta-adrenergic antagonists, some anti-inflammatory agents, even asa
Rhinitis
Rhinitis Patho Viral
Viral replication in the nasopharynx with varying degrees of nasotracheal inflammation. Associated with viral upper respiratory tract infection (COLD)
Etiologic agents Rhinovirus, influenza, parainfluenza, respiratory syncytial,
coronavirus, adenovirus, echovirus, coxsackievirus Most rhinosinusitis is viral
Bacterial super-infection rarely occurs
Rhinitis
Rhinitis Patho continued Allergic rhinitis
Type I hypersensitivity to airborne irritants affecting the eyes, nose, sinuses, throat, and bronchi
Antibodies bind to eosinophils and basophils in the bloodstream and the mucosal mast cells. These leukocytes degranulate, releasing chemo inflammatory substances including histamine, leukotrienes, prostaglandin's, slow-reacting substance of anaphylaxis, and erythrocyte chemotactic factor, resulting in increased vasodilatation, capillary permeability, mucus production, smooth muscle contraction and eosinophilia May also be caused by food allergies
Rhinitis
Rhinitis Patho continued Vasomotor rhinitis is chronic, noninfectious process of
unknown etiology, characterized by periods of abnormal autonomic responsiveness and vascular engorgement unrelated so specific allergens
Causes include- hormonal changes, medication overuse, bacterial infection-which can cause atrophic rhinitis
Rhinitis
Rhinitis – symptoms Viral-malaise, HA, substernal tightness, rare
fever, sneezing and coughing Allergic-itching of all upper air way mucosa,
watery eyes, sore throat, sneezing, coughing Vasomotor-watery nasal discharge, nasal speech,
mouth breathing, nasal obstruction that switches sides
Rhinitis
Rhinitis –objective findings Viral- nasal mucosa appears erythematous, throat will
appear erythematous and edematous, external nose may appear erythematous, with a crease across the nose (allergic salute). May have swollen turbinates and tonsils. On palpation, the nasal mucosa appear friable. With a secondary bacterial infection the discharge may be
green/yellow – in adults only. Color is children does not matter
Rhinitis
Allergic – mucosa are pale, boggy (swollen) and may look bluish. Yellowish, gray or red mucosa may also be seen. Polyps of various colors may be seen with chronic perennial rhinitis. Conjunctivae are inflamed with palpebral conjunctiva and cobble-stoned in appearance. Dark circles under the eyes (allergic shiners) may be seen. Wrinkles across the bridge of the nose may be seen.
Rhinitis
Vasomotor rhinitis- nasal mucosa will be anywhere from bright red to bluish with swollen turbinates Atrophic rhinitis appear crusted with dried
mucus or blood from repeated bouts of epistasis.
Rhinitis
Treatments Allergic rhinitis
Avoid the triggers Antihistamines
Allegra, Claritin, Clarinex, Zyrtec, Astelin Nasal steroids
Flonase, Nasonex, Nasacort Leukotriene receptor antagonists
Singular Desensitizing immunotherapy
Atrophic- bacitracin to nares, saline, irrigation
Rhinitis
Rhinitis follow up Recheck as needed Advise patient of possible complications and
their symptoms to indicate need for follow upOM, sinusitis, high fevers, restless sleeping, asthma,
allergic attacks Referral as needed to allergist for skin testing Referral to an ENT as needed
Rhinitis
Rhinitis –patient education Avoid exposures
People with URI, environmental irritants Windows doors kept closed, use a HEPA filter air clearer,
consider pets outside, clean for mold and dust mites, cover bedding for dust mites…dusting
Sinusitis
Sinusitis is an inflammation of the mucous membranes of one or more of the paranasal sinuses; frontal, sphenoid, posterior ethmoid, anterior ethmoid, and maxillary Acute-abrupt onset of infection and post-therapeutic
resolution lasting no more than four weeks Subacute with a purulent nasal discharge persist despite
therapy, lasting 4-12 weeks Chronic, with episodes of prolonged inflammation with
repeated or inadequately treated acute infection lasting greater than 12 consecutive weeks
Sinusitis
Epidemiology and causes Frequency of colds accounts for the frequent
occurrence of sinusitis. About 0.5 % of all colds are complicated by bacterial infection of one or more of the paranasal sinuses
Acute bacterial sinusitis accounts for 16 million visits a year
Chronic sinusitis is the most common chronic disease in the US
Sinusitis
Sinusitis – Patho Vast majority of acute sinusitis are caused by the same
viruses found in URI’s Viral rhinosinusitis is most common
Which is the most common cause for acute bacterial sinusitis, from complications in about 2%
Sneezing sends fluid from the nares and nasal cavity into the sinuses which is a great place for microbial replication
The only reliable way of identifying causative organisms in acute sinusitis is direct sinus aspiration
Sinusitis
Sinusitis Patho continued Pathogens
Streptococcus pneumoniae, haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes, staph aureus
Sinusitis
Clinical presentation Gradual onset of symptoms
Pain over the affected sinus, with increasing painPain is worse with coughingArea of pain corresponds the sinus affectedDevelop over at least 2 weeks of URI symptomsNasal congestion, runny nose, pressure, cough, sore
throat, eye pain, malaise, and fatigue, headache, cough, fever
Sinusitis
Sinusitis objective findings Purulent secretions, red swollen nasal mucosa, purulent
secretions from middle meatus On palpation there is tenderness
Sinusitis testing None is usually indicated X-rays or CT’s may be very helpful
Shows air-fluid levels and more than 4mm of mucosal thickening Stains or cultures of mucus may be indicated Allergy testing
Sinusitis
Sinusitis Management Usually viral Supportive care is most helpful
Sinus rinse Few meds are helpful
Sudafed, nasal spray, expectorants, Rarely use steroids or antihistamines
Localized sinus infections are self limited
Sinusitis
Sinusitis- management Amoxil Biaxin Vantin Omnicef Levaquin Augmentin Ceftin Cleocin
Review the therapeutic handouts
Sinusitis
Sinusitis follow up Varies per provider
With increase symptoms recheck If no better in 5-7 days recheck With reoccurrence of symptoms shortly after completing
medication Complications to watch for
Visual changes, cellulites, severe fever, aphasia, palsy, seizures, altered mental status, osteomyelitis, swelling, meningitis, empyema, abscess
Sinusitis
Sinusitis patient education Should focus on the worsening of symptoms Avoid all contributing factors
Smoke, allergens, antihistamine Increase fluids
Pharyngitis
Pharyngitis and tonsillitis are generalized inflammatory process of both infectious and non infectious etiology Most cases are viral and self-limiting Most cases of pharyngitis are contagious All cases of tonsillitis are contagious
Pharyngitis
Epidemiology 8% of all office visits Viral more common in cold weather Increases from 10% in fall to 40% in winter
Causes Herpangina, EBV, URI, postnasal drip, sinusitis, chronic
illnesses, leukemia, stress, alcohol, gonorrhea, syphilis, herpes, diphtheria, candida, tobacco, marijuana
Pharyngitis
Patho 40% of cases have no know cause URI is 30-50%
Influenza, coxsackievirus, enterovirus, RSV, Rhinoviruses, CMV, EBV, HIV
Bacterial typically cause exudates Which is 20% of sore throats 10-20% of adult cases and could lead to the most serious complications
like heart disease, and rheumatic 80 serotypes of streptococcus
Most significant stain based on the M protein which is antiphagocytic, and if a patient becomes immune to this bacteria, it provides protection for future infections of this type
Pharyngitis
Patho continued Streptococcus pyogenes strains are more virulent with more
renal disease side effects Streptococcus exotoxins can cause bacteremia, deep tissue
cellulitis, toxic shock Other bacteria
N gonorrhea, H flu, streptococcus pneumoniae Corynebacterium diphtheria and hemolyticum are associated with
epiglottitis Atypical bacteria
Chlamydia pneumoniae, chlamydia trachomatis, and Mycoplasma pneumonia are also know to cause bronchitis
Pharyngitis
Patho continued Non-infectious causes of pharyngitis
Trauma, allergies, collagen vascular disease, autoimmune blistering disease, chemical/drug damage, severe dehydration.
Patho of Tonsillitis is usually an infectious disorder, with swelling and exudates with the same causes
Pharyngitis
Subjective findings Mild to severe throat pain, tickle or itching With Strep, Mono, Adenovirus the pain is more
severe. May have the feeling of a lump Dysphagia is seen with H flu Hoarseness is seen with Chlamydia pneumoniae Laryngitis and cough are usually viral Chills and fever more common with bacterial
Pharyngitis
Subjective continued Cough and congestion are rarely present Allergic pharyngitis does not present with fever Mono has a gradual onset of low grade fever and
fatigue Influenza will have abrupt onset with headache
and body pain also, then followed by a cough
Pharyngitis
Objective for pharyngitis Inflamed throat, erythematous Conjunctivitis is associated with adenovirus Exudates and large tonsils occur rarely with viral illness Exudate and petechiae on the palate and swollen PCN and
increase spleen and liver size Strep produces a white exudate, they may also have a
sandpaper rash on their body C diphtheria has a grayish pseudomembrane over the mucosa
of the pharynx Tonsillitis has swollen posterior lymph glands on either side of
the jaw
Pharyngitis
Testing Viral throat swab cultures are used to detect herpes virus as well
other viral infections… Tzanck smear of a exudate is used to detect HSV, and herpes
zoster Blood test may be used for viruses
HSV, EBV, CMV Candida – KOH potassium hydroxide- looking for hyphal yeast Mono spot for mono CBC for infectious pharyngitis X-ray may be needed to assess for abscess
Pharyngitis
Management depends on the cause Home care with symptom management
Voice rest, humidification, saline, viscous Xylocaine, gargles, cool mist, lozenges, sprays, Acetaminophen, codeine, warm compresses for lymph nodes
Antibiotics for bacterial causes See therapeutics handout
Antifungal for candida Diflucan, nystatin Be sure and assess immune status if no known cause is found
Viral illnesses May use antivirals in some cases- IE; Flu- use Tamiflu
Abscess- hospital IV antibiotics and maybe surgery
Pharyngitis Follow and referral
Usually self limiting and improves in few days If pt fails to improve- recheck in 2-3 days May repeat cultures as needed Assess for scarlet or rheumatic fever as needed Hematuria may occur 1-2 weeks post strep
Monitor kidney function and blood pressure Mono follow up to assess liver and spleen size
May need to do liver function tests with prolong symptoms or jaundice occurs
Prolonged throat or node pain must be reassessed for abscess or cellulitis Enlarged tonsils or recurrent infections may indicate a need for
tonsillectomy
Pharyngitis
Education for pharyngitis
prevention, replace toothbrushes
do not share food or drinks, avoid irritants, avoid allergens, avoid heavy lifting or contact sports with mono, always complete all medications
Temporomandibular Joint (TMJ) Disease
TMJ is a collective term that refers to disorders affecting the masticatory musculature and associated structures. Sometimes know as temporomandibular disorder. TMD is a cluster or related disorder that have many features in common. The most common is pain in the muscles of mastication,
the preauricular and the TMJ Is a sub classification of musculoskeletal disorder
Temporomandibular Joint (TMJ) Disease
Epidemiology 75% of people have at least one sign of joint dysfunction
and 33% have at least one symptom, like face pain Only about 5% are in need of treatment Differentiate contributing factors
Predisposing factors- increase the risk Initiating factors- cause the onset Perpetuating factors- interfere with healing
Temporomandibular Joint (TMJ) Disease
Symptoms Pain in the preauricular area/or TMJ Pain, jaw noise, ear symptoms, rarely jaw dislocation Chewing aggravates Pain in face or head Dull pain in temple are Tinnitus Sinus symptoms FB sensation in ear canal Decreased hearing Neck or shoulder pain Visual disturbance Limited jaw opening Jaw popping
Temporomandibular Joint (TMJ) Disease
Questionnaires for screening- Example questions Do your jaws make noise Does using your jaw cause you pain Have you had jaw joint problems before Does you jaw ever get stuck Is opening your mouth difficult or cause pain With ringing in the ear does opening or closing you
mouth change the sound Do you have frequent headaches, neck aches, or tooth
aches
Temporomandibular Joint (TMJ) Disease
Physical finding Complete exam to exclude other problems Observation of gait, balance, unusual habits Palpate the muscles of mastication using
bimanual techniqueStart with the mouth closed then open
Temporomandibular Joint (TMJ) Disease
Management Involves understanding and treating the whole patient Goals for management- reduction of pain, restorations of acceptable
function Initial TX designed to be palliative and promote healing, with self-
help techniques and pharmacotherapy Adjustment of diet Education and alteration of oral habits (gum chewing) ICE/ HEAT Medications such as pain meds, anti-inflammatory meds, injection
of trigger points Most care will be given by the specialist
TMJ
Follow up and referral Refer to a specialist is best idea for real TMJ
disease
TB
TB Testing
Tuberculin skin test remains the standard test for determining infection with Mycobacteria tuberculosis, but does not distinguish between active and latent infection
Who to test Patient with signs and symptoms, known contact, high risk, people
suspected to have, abnormal chest x-ray, medical conditions that increase risk, pt with HIV, immigrant, medically underserved, high-risk minority, resident or employee in a prison or long term care facility, employee on a health care facility
TB
Interpretation of TB skin testing Greater than 5 mm is positive for the following
People with HIV, or risk factors for HIVPeople recently exposed to active TBPersons with organ transplantsPersons with chest film indicating healed TB
TB
Greater than 10 mm Recent arrivals (less than 5 years) Foreign born from Africa, Asia, Latin America Medically underserved low income population and high
risk racial ethnic minority populations IV drug users Residents and employees of high risk congregate setting Mycobacteriology lab personnel Persons with medical conditions known to increase risk
of TB
Gingivitis
Inflammation of the gingiva It may be characterized by edema, erythema,
bleeding, and occasionally pain Gingivitis is usually reversible with
appropriate therapy
Periodontitis
An inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both.
Oral Trauma
What happened Tooth/jaw/lip/tongue hurt What hit you How long ago
Where are the teeth
Oral Trauma
Teeth Avulsed (knocked out, loose) Fractured Chipped Intrusion
Jaw/face: feel for “crunchy” sensation Mucosal/tongue injury
Tooth Anatomy
Avulsed Teeth
Fractured Teeth
Intrusion
Tongue/Mucosal Trauma
Oral Trauma
Teeth Avulsion
Primary teeth Out, leave out Loose, straighten or is very loose remove
Permanent teeth Out, leave out, wash gently, tooth kit Loose, leave alone
Fracture, keep fragment, store as above
Oral Trauma
Tongue Well approximated, nothing Bleeding direct pressure with gauze Gaping need repair
Mucosal Well approximated, nothing Gaping and vermillion border need repair
Oral Trauma
Dental injuries Dentist for most injuries Baby teeth may need nothing
Tongue/Mucosa Most need nothing Doctor if gaping or severe bleeding
Nose Bleeds
Nose Bleeds
How much blood, how long What has been done to stop bleeding Trauma
Blunt Picking
Upper respiratory infection/Allergies History of Bleeding
Nose Bleeds
Nose Fracture (usually at bridge) Active bleeding
Which side? Always the same?Throat
Neurologic Vision
Nose Bleeds
Pinch x 10-20 minutes Ice Nose plugs Don’t blow nose Afrin if available No picking