Adult & Ped Nose and Throat Disorders 2021 PDF

Nose and Throat Disorders Dr. Kim Ballone, APRN-CNP  Red flags that suggest Nose, Mouth and Throat problems Nose Posterior epistaxis: serious nose bleed when artery branches that supply blood to nose is damaged, which created heavier bleeds than an anterior,...

Nose and Throat Disorders Dr. Kim Ballone, APRN-CNP  Red flags that suggest Nose, Mouth and Throat problems Nose Posterior epistaxis: serious nose bleed when artery branches that supply blood to nose is damaged, which created heavier bleeds than an anterior, and often flows out the nose and down throat. If bleeding occurs for more than 20 min, or injury to head and face, it is more likely posterior. Typically occur in hypertension and older adults Mouth Burning in the mouth, oral cavity: consider vitamin B12 deficiency; stomatitis; ill-fitting dentures and bridges Xerostomia: From dehydration; drugs with anticholinergic activity (antidepressants, diuretics and antipsychotics); salivary gland dysfunction following radiation therapy Loss of taste: From drugs (antihistamines; antidepressants); oral infection (candidiasis) Throat Swallowing disorders: esophageal stricture, malignancy, foreign body, stroke  Epistaxis 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  Subjective & Objective Findings 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  Labs & Diagnostic Findings 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 for suspected underlying disease (e.g. allergy testing)  Management Position the pt. with head erect and Apply gentle pressure by elevated (sitting straight up) compressing the nasal alae together Provide reassurance, examine the just below the bridge for 10-15 minutes nostril Apply topical lidocaine anesthetic Clear blood from nostril (4% sol 1-5mg; max. 4.5 mg/kg; then Remove clots with gentle suctioning, touch the site with a silver nitrate visualize point of bleed stick until the vessel ends are Observe closely for foreign object completely cauterized. If unable to cauterize, insert nasal Saturate a cotton ball with Afrin packing and gently insert it into the site of If uncontrollable from a posterior bleeding site, immediate referral to EENT  The Sinuses 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  Sinusitis 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 Common causative organisms Haemophilus influenzae Streptococcus pneumoniae Moraxella catarrhalis Various anerobes  Subjective & Objective Findings Recent Upper Respiratory Generalized malaise Infections Orbital pain or visual disturbances Pain/pressure over face, nose, indicate a serious problem- Refer cheeks, and teeth EENT Often confused with a toothache Fever may not be present in Purulent/blood-tinged nasal elderly drainage Localized tenderness over the Headache, increased pain in supine sinuses position, or sense of fullness in Facial edema head Swollen, red turbinates Nasal congestion Foul smelling nasal or postnasal drainage  Labs/ Diagnostic Findings 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 CT Scan of Sinusitis  Management Antibiotics if not resolved within 2 weeks 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 if allergic to Penicillin 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 (Erythromycin, azithromycin, and clarithromycin), not recommended due to high rate of resistance to S. Pneumoniae  Pharyngitis Pharyngitis is an inflammation of the pharynx that is usually associated with tonsillitis caused by strep A. Pharyngitis can be acute or chronic. Look for inflamed, red spots (petechiae) on palate, inflamed tonsils, exudate (white spots) Most common pathogen is usually viral Abrupt onset of fever, sore throat, painful swallowing, mildly enlarged submandibular nodes, purulent, patchy tonsillar or pharyngeal exudate (yellow-green color), anterior nodes also mildly enlarged  Subjective & Objective Findings of Pharyngitis Sore or painful throat Dysphagia Fever/ chills Malaise/myalgia Causative factors of Pharyngitis 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  Pharyngitis Viral Bacterial Edema of lymphoid tissue in the Streptococcal (GABHS) posterior oropharyngeal wall Bright, red edematous Pale, boggy mucosa, palatial pharyngeal mucosa petechiae White or yellow exudate Painful ulcers/blistering in oral cavity Fever greater than 101 F Posterior cervical lymphadenopathy Anterior cervical (enlarged lymph nodes) lymphadenopathy  Labs & Diagnostic Findings of Pharyngitis 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 (they go together)  Symptomatic Treatment of Pharyngitis Pain Relief Lozenges OTC , use PRN Throat sprays, OTC Warm salt water gargle Systemic analgesics: acetaminophen and NSAIDS Glucocorticoids are not recommended  Pharmacologic Treatment of Pharyngitis Penicillin is first line treatment!! Bicillin L-A 1.2 million units IM Consider antiulcer agents for gastric single dose or Penicillin V 500mg reflux (Pen-Vee K) PO 2x/day for 10 days Omeprazole (Prilosec) 20mg PO daily Cephalexin 500mg PO BID for 10 days Lansoprazole (Prevacid) 15-30mg PO daily Cefadroxil 1000mg PO daily f or 10 Pantoprazole (Protonix) 40 mg PO daily days Analgesics Clindamycin 300mg PO 3x/day for 10 Acetaminophen 650mg PO q4hrs PRN days Azithromycin 500mg PO daily for 5 days For Candida Nystatin (Mycostatin) 100,000 U/ml 4-6ml Clarithromycin 250 mg PO BID for 10 days Fluconazole (Diflucan) 100mg for 2 weeks  Throat Cancer Red flags for throat cancer: hoarseness that’s persistent (> 1 month), dysphagia with solids, odynophagia (pain with swallowing), nonhealing sore or lump in neck (area in mouth that doesn’t heal, persistently enlarged and painless lymph node for 6 weeks), hemoptysis, dyspnea (later stage), otalgia (ear pain on normal ear exam) Risk factors: smoking/chewing tobacco, alcohol use, HPV, GERD Lower risk: fruit and vegetables, soy, avoid tobacco and alcohol Patient Evaluation: detailed medical history, head and neck exam, office endoscopy, biopsy if there is suspicion on endoscopy Treatment: Surgery, radiation, chemo Key points: don’t use tobacco/alcohol, if you develop red flags, see otolaryngologist 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. Which of the following antibiotics is the best choice? A. Azithromycin (Zithromax) B. Cephalexin (Keflex) C. Cefuroxime (Ceftin) D. Levofloxacin (Levaquin)  The correct answer is: 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. Which condition is caused by trauma to the blood vessels located in Kiesselbach’s triangle? A. Posterior epistaxis B. Subdural hematoma C. Anterior epistaxis D. Stroke  The correct answer is: C. 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.  Where is Kiesselbach’s plexus located? A. Posterior area of the pharynx B. Superior lateral area of the maxillary sinus C. Anterior inferior area of the nasal septum D. Submandibular area of the mouth  The correct answer is: C. Anterior inferior area of the nasal septum When there is trauma to this area (picking nose), it can rupture tiny blood vessels, causing an anterior epistaxis or a nosebleed  A patient presents with a severe sore throat, fever, and a “hot potato” or muffled voice. The patient is drooling due to difficulty opening the mouth. Unilateral swelling and a bulging red mass are noted on physical exam. These findings are suggestive of which diagnosis? A. Epiglottis B. Acute pharyngitis C. Infectious mononucleosis D. Peritonsillar abscess  The correct answer is: D. Peritonsillar abscess Findings are consistent with peritonsillar abscess, a collection of pus between the palatine tonsil and pharyngeal muscles. Epiglottis has drooling and fever, but stridor and respiratory distress are more common. Acute pharyngitis causes nonspecific symptoms like a sore throat and cervical lymphadenopathy. Infectious mono presents with fever, pharyngitis, adenopathy, fatigue, and atypical lymphocytosis  A patient presents with fever, pharyngitis, adenopathy, and atypical lymphocytosis. Physical assessment is notable for splenomegaly and a generalized maculopapular rash. Based on these findings, treatment includes which of the following? A. Acetaminophen and NSAIDS for symptom management B. Initiation of antiviral therapy (Acyclovir) C. Administration of corticosteroids D. Hospitalization for monitoring of possible splenic rupture  The correct answer is: A. Acetaminophen an NSAIDS for symptoms management Presenting with infectious mono. Initial treatment includes supportive therapy and symptomatic management with fluids and proper nutrition, along with acetaminophen and NSAIDs for pain. If signs of impending throat obstruction, corticosteroids are indicated. Antiviral treatment has no effect on latent infection or ability to cure it. Classic triad is fever, pharyngitis, and lymphadenopathy  A patient has bilateral bleeding from the nose with bleeding into the pharynx. What is the initial intervention for this patient? A. Apply firm, continuous pressure to the nostrils. b. Assess airway safety and vital signs. c. Clear the blood with suction to identify site of bleeding. d. Have the patient sit up straight and tilt the head forward  The correct answer is: ANS: B Bilateral epistaxis into the pharynx is more indicative of a posterior bleed which is more likely to be severe. The most important intervention is to ensure airway safety and determine stability of vital signs. Other measures are taken as needed A patient is in the emergency department with unilateral epistaxis that continues to bleed after 15 minutes of pressure on the anterior septum and application of a topical nasal decongestant. The provider is unable to visualize the site of the bleeding. What is the next measure for this patient? a. Chemical cautery b. Electrocautery c. Nasal packing d. Petrolatum ointment  The correct answer is: ANS C. Nasal packing is used if bleeding continues after initial measures. Chemical cautery and electrocautery are used only if the site of bleeding is visualized. Petrolatum ointment is applied once the bleeding is stopped A patient has recurrent epistaxis without localized signs of irritation. Which laboratory tests may be performed to evaluate this condition? (Select all that apply.) A. BUN and creatinine b. CBC with type and crossmatch c. Liver function tests d. PT and PTT e. PT/INR  The correct answer is: ANS: B, D, E A CBC with type and crossmatch is part of the diagnostic workup along with coagulation studies. LFTs and renal function tests are not used to evaluate recurrent epistaxis  A patient presenting with nasal congestion, fever, purulent nasal discharge, headache, and facial pain begins treatment with amoxicillin-clavulanate. At a follow- up visit 10 days after initiation of treatment, the patient continues to have purulent discharge, congestion, and facial pain without fever. What is the next course of action for this patient? a. A CT scan of the paranasal sinuses b. A referral to an otolaryngologist c. An antibiotic based on likely resistant organism d. A trial of azithromycin  The correct answer is: ANS C Treatment failure is seen in patients who do not have symptom improvement and the provider has re-confirmed the diagnosis of ABRS and assessed for complications. In these patients, the choice of antibiotic treatment is based on likely resistant organisms. The lack of fever shows improvement, so this antibiotic may be used. CT scan is usually not performed in adults unless other complications are present or suspected. Referral to an otolaryngologist is necessary if no improvement after the second course of antibiotics. Azithromycin is not used in adults unless pregnant, due to resistance patterns  A patient with allergic rhinitis develops acute sinusitis and begins treatment with an antibiotic. Which measure may help with symptomatic relief for patients with underlying allergic rhinitis? a. Intranasal steroids b. Oral mucolytics c. Saline solution rinses d. Topical decongestants  The correct answer is: ANS: A Intranasal steroids should be considered for symptomatic relief for patients with sinusitis, especially those with allergic rhinitis. Oral mucolytics have little support in efficacy. Saline solution rinses may provide some relief, but there is no evidence to support their usefulness. Topical decongestants do decrease nasal congestion and edema, but thepotential harm of rebound congestion requires recommendation with caution  Which are potential complications of chronic or recurrent sinusitis? (Select all that apply.) a. Allergic rhinitis b. Asthma c. Meningitis d. Orbital infection e. Osteomyelitis  The correct answer is: ANS: C, D, E Complications of chronic or recurrent sinusitis include spread of infection to other tissues and may cause meningitis, orbital cellulitis, and osteomyelitis. Allergic rhinitis and asthma are associated with chronic sinusitis, but not complications of this condition  An adolescent presents with fever, chills, and a severe sore throat. On exam, the provider notes foul-smelling breath and a muffled voice with marked edema and erythema of the peritonsillar tissue. What will the primary care provider do? a. Evaluate for possible epiglottitis. b. Perform a rapid strep and throat culture. c. Prescribe empirical oral antibiotics. d. Refer the patient to an otolaryngologist  The correct answer is: ANS: D This patient has clinical signs of peritonsillar abscess, which may be diagnosed on clinical signs alone. Patients with peritonsillar abscess should be referred to an otolaryngologist for possible I&D of the abscess and hospitalization for IV antibiotics. A rapid strep and culture are not indicated. Oral antibiotics generally do not work  A patient reports a sudden onset of sore throat, fever, malaise, and cough. The provider notes mild erythema of the pharynx and clear rhinorrhea without cervical lymphadenopathy. What is the most likely cause of these symptoms? a. Allergic pharyngitis b. Group A streptococcus c. Infectious mononucleosis d. Viral pharyngitis  The correct answer is: ANS: D Viral pharyngitis will cause sore throat, fever, and malaise and is often accompanied by URI symptoms of cough and runny nose. Allergic pharyngitis usually also causes dryness. GAS causes high fever, cervical adenopathy, and marked erythema with exudate. Infectious mononucleosis will cause an exudate along with cervical adenopathy  A patient presents with sore throat, a temperature of 38.5°C, tonsillar exudates, and cervical lymphadenopathy. What will the provider do next to manage this patient’s symptoms? a. Order an anti-streptolysin O (ASO) titer. b. Perform a rapid antigen detection test (RADT). c. Prescribe empirical penicillin. d. Refer to an otolaryngologist  The correct answer is: ANS: B The RADT is performed initially to determine whether Group A -hemolytic Streptococcus (GAS) is present. The ASO titer is not used during initial diagnostic screening. Penicillin should not be given empirically. A referral to a specialist is not required for GAS infection  A school-age child has had 5 episodes of tonsillitis in the past year and 2 episodes the previous year. The child’s parent asks the provider if the child needs a tonsillectomy. What will the provider tell this parent? a. Current recommendations do not support tonsillectomy for this child. b. If there is one more episode in the next 6 months, a tonsillectomy is necessary. c. The child should have radiographic studies to evaluate the need for tonsillectomy. d. Tonsillectomy is recommended based on this child’s history.  The correct answer is: ANS: A Management of chronic pharyngitis or tonsillitis with GAS infection may require tonsillectomy. Tonsillectomy is not performed as often as in the past due to retrospective studies that suggest there is little benefit and a chance of significant postsurgical complications. Radiographic studies are not indicated.