NOSE AND THROATSIOM Western Clinical Science

Fall 2012, Dr. Gonzales ND, LAc

NOSE

Epistaxisa nose bleed

may be primary or secondary, in

children tends to be mild and in adults

often requires nasal packing

Epistaxis

usually following an internal or external trauma eg. punch, pick, insertion of foreign body, low humidity, cold, allergies, sinusitis

Sometimes due to polyps, acute or chronic sinusitis or rhinitis, chemical inhalation

People on anticoagulants, with hypertension, long-term aspirin use, in dry climates or high altitudes, scurvy, vitamin-K deficiency and blood dyscrasias can be predisposed to epistaxis

complications include shock and aspiration

Epistaxis

signs and symptoms: blood from nostrils comes from the anterior nose and the blood is bright red

Blood from the back of the throat comes from the posterior area of the nose can be bright red or dark red

usually unilateral - unless due to dyscrasia or trauma

Severe cases - blood in corners of eyes, middle ear and behind nasal septum

Other symptoms relate to severity - dizziness, light-headedness, respiratory difficulty to hypotension, bounding pulse, dyspnea and palor

Bleeding is severe when it continues more than 10 minutes after pressure is applied. It is unlikely that someone will bleed to death.

Epistaxis labs

Just for your edification/if someone comes to your office with frequent nosebleeds or unremitting nosebleed:

HCT/Hgb

platelets - decreased in dyscrasias

PTT - will be increased in anti-coagulant use and with blood dyscrasias

Treatment of epistaxis

mild nosebleeds treated with gentle squeezing of bridge of nose while patient leans slightly forward

Anterior - cotton ball soaked in epi and pressure

Posterior - packing nasal passage with gauze and antibiotics if it remains in place longer than 24 hours

Elevate patient’s head to 45 degrees, apply ice to the nose add gentle pressure. If it bleeds longer than 10 minutes send out.

Septal Perforation and Deviation

Septal Perforation

a hole in the nasal septum between the two nares in the anterior cartilaginous septum

often caused by trauma (usually nose picking), repeated cauterization, perichondritis, tuberculosis, syphilis, chemical irritants (eg. cocaine), chronic infections, untreated septal hematoma...

can lead to infection and deformity

can be asymptomatic though there can be an inhalation whistle. A large perforation can cause epistaxis, crusting, watery discharge, rhinitis

Perforation diagnosis and Treatment

Diagnosis: based on clinical features and inspection with nasal speculum and pen light

Treatment: symptomatic - vaseline for nasal mucosa, decongestants, antibiotics preventing infection, sometimes surgery to seal hole

Nasal septal deviation

a shift of the nasal septum from the midline common in adults

can obstruct the passage of air through the nostrils

develops through normal growth, a fall or blow to the nose or surgery

Deviated nasal septum

Signs and Symptoms: crooked nose, nasal obstruction, stertor, fullness in the face, SOB, nasal discharge, infection, epistaxis, headache

Diagnosis: symptoms and inspection with nasal speculum and pen light

Treatment: corrective surgery, analgesics, nasal packing, cautery, vasoconstrictors

sinusitis

Sinusitis

inflammation of the paranasal sinuses

there are four classifications - acute, subacute, chronic and allergic.

hyperplastic sinusitis is a combination of acute and allergic sinusitis or rhinitis

Sinusitis

Causes and Incidence:

generally caused by viral or bacterial infection. Pneumococci or streptococci, H. influenzae and M. catarrhalis (acute)

Staphylococci and gram-negative bacteria often cause chronic infections or infect patient’s in intensive care

people who have conditions that interfere with sinus drainage and ventilation are predisposed to infection eg. edema, septal deviation, polyps, DM, CF, chronic steroid use

history of asthma, overuse of nasal decongestants, foreign body, frequent swimming, GERD, air pollution

Sinusitis Complications

Consider anatomy, physiology, blood supply. Sinusitis can be quite dangerous if prolonged, untreated or in a patient with decreased immune function.

meningitis

cavernous and sinus thrombosis

bacteremia, septicemia

brain abscess

osteomyelitis

mucocele

orbital cellulitis

Sinusitis signs and symptoms

ACUTE: nasal congestion with pressure on affected side. Nasal discharge that may become purulent. Associated - fever, malaise, headache, sore throat

pain is associated with involved sinus

if discharge lasts longer than 3 weeks the infection may be subacute and be associated with vague facial pain, fatigue and non-productive cough

CHRONIC: discharge is more mucopurulent and continuous

ALLERGIC: sneezing, frontal headache, watery discharge, itchy nose

HYPERPLASTIC: bacteria grows on allergic tissue tissue edema and chronic stuffiness and headache.

sinusitis diagnosis

nasal examination shows inflammation and pus

TTP on maxillary or frontal sinuses

transillumination looks dark as compared to normal sinuses which transilluminate

Other measures used: U/S, CT, x-ray can show cloudiness and complications

Sinusitis treatment

decongestants

antibiotics: commonly amoxicillin or amoxicillin/clavulanate, azithromycin

local applications of heat can decrease pain, heat would increase congestion - better hot/cold application.

allergic - remove allergen, antihistamines, steroids

remember to tell patient to drink plenty of fluids - increasing fluidity of discharge

make sure to watch for - chills, fever, vomitting, edema of forehead or eyes, double/blurred vision, change in personality

Sinusitis

remind patients who are on antibiotics to finish the course - preventing antibiotic resistance.

check-in with patient to make sure infection is not spreading/is under control

sinusitis is easily treatable but can be dangerous due to anatomic location, blood supply and the thinness of the bones in the cranium

nasal polyps

Nasal polyps

benign, edematous, multiple, mobile, bilateral growths. May become numerous or enlarged enough to distend nasal passages and deform bony framework causing obstructed airway.

Causes and Incidence: frequently caused by chronic allergy with mucus edema, chronic sinusitis or rhinitis, infection. Often in adults, rarely in children.

Complications: airway obstruction

Signs and Symptoms: obstruction causing anosmia, sensation of fullness, discharge, headache, SOB

Diagnosis: nasal speculum shows dry mucosa with grey growths

Treatment: steroids applied topically. Short course oral, treat underlying cause. Local astringent application to shrink tissue. Usually - polypectomy

Nasal Papillomas

benign tissue overgrowth,, can be associated with squamous cell cancer.

Inverted Papillomas: arise from epithelium and grow into the underlying tissue usually at the junction of maxillary sinus and antrum

Exophytic papillomas arise from the epithelium and are usually on the surface of the nasal septum

Nasal papillomas

may be a benign precursor to neoplasm or response to tissue injury, viral infection. Usually in males.

Complications: nasal drainage, infection, rarely severe respiratory distress

Signs and Symptoms: symptoms are those of unilateral nasal obstruction, epistaxis often occurs with exophytic papillomas

Diagnosis: examination of nasal mucosa. Inverted appear large and edematous while exophytic are raised and attached by a base to the nasal mucosa

Treatment: wide surgical excision, pain relievers and decongestants

Adenoid hyperplasia

common childhood condition AKA adenoid hypertrophy. Enlargement of the lymphoid tissue of the nasopharynx

commonly accompany tonsilitis

Adenoid hyperplasia

Causes and incidence: unknown, hereditary, frequent infection or chronic infection, allergies, inflammation

Complications: OM, conductive hearing loss, sinusitis, cor pulmonale, pulmonary hypertension

Signs and Symptoms: respiratory obstruction eg. mouth breathing, voice changes, facial changes

Adenoid hyperplasia

Diagnosis: nasopharyngoscopy or rhinoscopy confirms.

Treatment: adenoidectomy. Removal eliminates recurrent nasal infections and ear complications and reverses secondary hearing loss.

Velopharyn-geal insufficiencyinherited palate

abnormality, acquired via

tonsillectomy/adenoidectomy.

you won’t see it...great picture though

Throat - pharyngitis

pharyngitis

the most common throat ailment often accompanies the common cold, due to chronic or acute pharyngeal inflammation

pharyngitis

frequently due to a viral infection, sometimes bacteria (b-hemolytic strep, mycoplasma and chlamydia are the most common bacterial infections)

tends to occur in adults who work in dusty or dry environments, excessive voice use, use tobacco and/or alcohol, have allergies or chronic sinusitis

Complications: OM, sinusitis, mastoiditis, rheumatic fever, nephritis

pharyngitis

Signs and Symptoms: a sort throat with some difficulty swallowing. It’s more painful to swallow saliva than food. There may be a sensation of a lump in the throat and a constant urge to swallow. There may be mild fever, headache, myalgia, coryza and rhinorrhea. Usually resolves in 3-10 days

Diagnosis: generalized redness of posterior wall with inflammation, edema and yellow or white follicles of mucous membranes. Exudate is usually only present in lympoid tissue. Culture may be performed to determine bacterial organism.

Pharyngitis

Treatment: acute viral - warm salt water gargles, and symptomatic relief. Bacterial requires antibiotic treatment to avoid sequelae of untreated infection - namely rheumatic fever and mitral valve prolapse. Chronic pharyngitis requires symptomatic relief and removal of underlying cause eg. smoke/allergen. *Remember that bacterial infections tend to have profuse exudate.

Tonsillitisplease do not start tongue diagnosis!

Tonsillitis

acute or chronic inflammation of the tonsils. If uncomplicated then it should self resolve within 4-6 days. Tonsils tend to hypertrophy in childhood and atrophy at puberty.

usually due to group A beta-hemolytic streptococci but can be due to infection with other bacteria or viruses.

Complications: chronic upper airway obstruction, sleep apnea, cor pulmonale, failure to thrive, eating/swallowing disorders, febrile seizures, OM, cardiac valvular disease, peritonsillar abscess, bacterial endocarditis, cervical lymph nose abscess

tonsillitis

considering the complications it might be best to treat quickly and effectively!

Signs and Symptoms: begins with mild to severe sore throat and there may be dysphagia, fever, swelling of lymph nodes and glands in the submandibular area, myalgias, chills, malaise, pain that can refer to the ears.

Diagnosis: examination of the throat, visibly swollen tonsils that show white or yellow exudate. Need to do a culture to rule out mononucleosis and diphtheria.

tonsillitis

Treatment: rest, fluids, NSAIDS, antibiotics. Chronic cases may result in tonsillectomy after the infection has resolved for 3 to 4 weeks.

offer cold drinks/ice/popsicles to help increase fluid intake.

throat abscess

throat abscess

the previous picture was of a peritonsillar abscess which can be quite dangerous as you can see. An abscess can also be present retropharyngeally. This is when an abscess forms in areas of connective tissue around the pharynx.

if treated the prognosis is good

Causes and Incidence: peritonsillar abscess arises from acute tonisillitis. Acute Retropharyngeal abscess comes from infections in the retropharyngeal lymph glands often post-URI bacterial infection. This happens in young children as the lymph glands start to atrophy after 2 years of age. Chronic retropharyngeal abscess can occur at any age but is related to tuberculosis of the cervical spine.

throat abscess

Complications: airway obstruction, cellulitis, endocarditis, pericarditis, pleural effusion and pneumonia

Signs and Symptoms: severe throat pain, ear pain on the same side as the abscess. Patient’s can experience difficulty opening their mouths, malaise, dysphagia and drooling, fever, chils, rancid breath*, muffled speech, localized or systemic sepsis.

Diagnosis: begins with bacterial pharyngitis, there will be swelling of the soft palate on the affected side. The uvula will be displaced to the opposite side affected.

Treatment: broad spectrum antibiotics early in infection. In late stages excision and drainage and treatment with antibiotics is necessary.

Vocal cord paralysis

Vocal cord paralysis

results from disease or injury to the superior or common laryngeal nerve. Can be congenital. This happens frequently during thyroidectomy, from a thoracic aortic aneurysm or from an enlarged atrium due to mitral valve stenosis.

Complications: airway obstruction, respiratory failure

Signs and Symptoms: most commonly unilateral which results in vocal weakness and hoarseness. If bilateral it can cause incapacitating airway obstruction.

Diagnosis: history and vocal features.

Vocal Cord Paralysis

Treatment: unilateral paralysis is treated with teflon injection into the paralyzed side to bring it closer to the opposite side - strengthening the vocal cord and preventing aspiration. Other interesting operations are used such as thyroplasty and arytenoidectomy.

Vocal cord nodules and polyps

more likely something you could :see”

vocal cord nodules and polyps

Nodules are the result of hypertrophy of fibrous tissue at the point where the cords forcibly come together. Polyps are subepithelia edematous masses. If continued voice abuse occurs they recur.

vocal cord polyps and nodules

Causes and Incidence: usually the result of voice abuse - most common in teachers, musicians, sports fans and energetic children who continually shout while playing.

Complications: permanent hoarseness

Signs and Symptoms: produce painless hoarseness or “huskyness”.

Diagnois: persistent hoarseness, visualization

Treatment: conservative for small nodules/polyps includes voice rest and training to decrease use. Surgical removal occurs if conservative therapy fails. If bilateral lesions are present surgery is done in two stages to prevent laryngeal web formation.

Laryngeal Web Post surgery

best picture i could find - you can just make out the true vocal cords

Laryngitis

Laryngitis

a common disorder of inflammation of the vocal cords either acutely or chronically. Acute laryngitis may happen in isolation of infection or as a result of an upper respiratory infection. Repeated acute laryngitis causes inflammatory changes that lead to chronic laryngitis.

Causes and Incidence: virus, excessive voice use, inhalation of smoke or fumes, aspiration of caustic chemicals.

Complications: permanent hoarseness, airway obstruction with chronic laryngitis

Laryngitis

Signs and Symptoms: begins with hoarseness and maybe complete loss of voice. Pain on speaking or swallowing, persistent dry cough, fever, malaise. Chronically hoarseness is generally the only symptom.

Diagnosis: viewing vocal cords, culture of exudate may be obtained in severe cases, may need to check for GERD in chronic cases.

Treatment: Resting the voice. Analgesics and throat lozenges. In severe cases hospitalization may be required due to obstruction from edematous vocal cords.

Juvenile angiofibroma

You Don’t need to worry about this

WOAH! Can’t forget croup and epiglotitis

TRACHEITIS (CROUP)

CroupII. Epidemiology

A. Incidence

1. Overall Incidence: 6 cases per 100 children <6 years

2. Hospitalizations: 1-15% of US cases (20,000 per year)

3. Intubation: 1-5% of cases hospitalized

B. Boys affected more than girls by ratio of 1.5 to 1

C. Outbreaks and epidemics occur in autumn to early winter

II. Affects ages under 12 years (peaks at age 1-2 years)

A. Pathophysiology

1. Subglottic infection

1. Etiology

1. Parainfluenza virus type 1 (18% of cases)

2. Parainfluenza virus types 3, 2

B. Adenovirus

II. Respiratory Syncytial Virus (RSV)

1. Influenza A and Influenza B

2. Rhinovirus

3. Enteroviruses

4. Mycoplasma pneumoniae (uncommon)

Croup

V. Symptoms

A. Fever

B. Coryza precedes other symptoms by several days

C. Upper respiratory symptoms rapidly develop

1. Hoarseness

2. Cough: "Barking" OR "seal-like"

V. Inspiratory Stridor

A. Expiratory Wheezing

B. Dyspnea

D. Symptoms worse at night

E. Symptom duration <1 week (peaks at 1-2 days)

1. Signs

1. "Sound worse than they look" (Opposite of Epiglottitis)

V. Mild to Moderate respiratory distress

A. Mild Wheezes

DDx Epiglottitis!

Aka: Epiglottitis

I. Epidemiology

A. Commonly misdiagnosed as croup (20% in some studies)

B. Average age is older than that seen in Croup (Age 2-5)

II. Definition

A. Potentially fatal infection of supraglottic tissue

III. Etiology

Children

A. HaemophilusInfluenzae type B

A. Adults

II. Group A beta hemolytic Streptococcus

A. Streptococcus Pneumoniae

III.HaemophilusInfluenzae

EpiglottitisIV. Symptoms (Acute onset with rapid progression)

A. Initial Symptoms

1. Severe Pharyngitis (82%)

2. Fever

B. Mild or subtle Stridor (77%)

IV. "Look worse then they sound" (opposite of Croup)

1. Shortness of Breath (100%)

2. Irritability or restlessness (46%)

3. Dysphagia (64%)

B. Drooling (41%)

IV. Soft muffled voice or Hoarseness (31%)

1. Diagnosis (Differentiate from Croup)

1. Absence of cough

B. Dysphagia (difficult swallowing with Drooling

C. Toxic appearance

Study...

General anatomy of the sinuses and throat: where are sinuses? Which are which? Nasopharynx? Oropharynx? “Throat”?

Why are infections in this area (EARS, NOSE, THROAT and eventually - EYES) something to watch/be concerned about?

What is the time frame to be aware of when treating epistaxis? What are some conditions or exogenous substances that might cause an increase in bleeding time?

What are the more common causes of nasal septum perforation?

Differences between acute, chronic, allergic and hyperplastic sinusitis.

Complications that can arise from untreated sinusitis.

Physical exam findings (what is transillumination? Where might you find tenderness to palpation - TTP?)

and more...

what’s the difference between a nasal polyp and nasal papilloma?

Where are adenoids located? What are some complications of adenoid hyperplasia?

Causes of acute vs. viral pharyngitis. Signs and symptoms of pharyngitis.

What bacteria is most dangerous in tonsillitis? What are possible complications from untreated tonsillitis?

Location of peritonsillar vs. retropharyngeal abscess

Causes of vocal cord nodules or polyps. Why would one opt for surgical removal? What is larygneal web?

Causes of laryngitis. Treatment? Worst case scenario of no treatment/treatment?

Ddx Croup and Epiglottitis. Why do we care? Which is an emergent referral?