Clin Med 1 - Ear, Nose, Throat, Mouth PDF

Otalgia: acute otitis media, otitis media with effusion, otitis externa Eustachian tube dysfunction Function: Maintain consistent pressure across the TM Clear the middle ear of secretions Provide the middle ear of secretions Etiology: inflammation or blockage of the eustachian tube r...

Otalgia: acute otitis media, otitis media with effusion, otitis externa Eustachian tube dysfunction Function: Maintain consistent pressure across the TM Clear the middle ear of secretions Provide the middle ear of secretions Etiology: inflammation or blockage of the eustachian tube results in negative middle ear pressure Etiology Characteristics CP Complications DX TX Obstructive Inflammation or HX of otitis media Ear pain, fullness, CP Treat the causes: dysfunction blockage of the Recurrent Otitis pressure, hearing FORMAL - Rhinosinusitis eustachian tube media with loss, tinnitus, “ears AUDIOLOGY - Allergic rhinitis -> negative effusion feel plugged,” “hear ENT referral: - Laryngopharyngeal middle ear popping sounds”, nasal endoscopy, reflux pressure PE: consistent trouble tympanometry - Mass - enlarged - retracted TM equalizing pressure adenosis - Perforated TM Imaging (>3 - Surgery - Prominent bony months of landmarks unilateral Unknown causes: - effusion (fluid symptoms and - insufflation w/ modified buildup in ear) persistent valsalva maneuver - conductive effusion to r/o - referral to ENT hearing loss tumor) - surgery - cholesteatoma - myringosclerosis plaque Patulous PE: - Aural fullness - D/c topical steroid or dysfunction - frequent sniffing - Pulsatile tinnitus (a decongestant - retracted TM rare type of tinnitus - treat the cause: AR,  - subjective that causes a laryngeal reflux, TM joint hearing loss rhythmic thumping, disorders, anxiety, whooshing, or significant weight loss throbbing in one or both ears) - Autophony: loud perception of their own voice/breath sounds - “talking into a barrel” - Fluctuate, accompany exercise, long discussion, singing (activities cause mucosal dehydration) OTITIS MEDIA Otitis Media ETD, AOM, Fluid in the - ear fullness Persistence can MILD - ear fullness: monitor with Effusion URIs, allergies, middle ear - hearing loss lead to speech, < 12 weeks (OME) barotrauma, without acute (temporary, language, or “Serous nasopharyngeal infection conductive) learning issues Mild to moderate - include otitis” cancer signs/symptoms - TM - amber, gray, conductive hearing loss blue, cloudy Intermittent - air-fluid level, auto-insufflation bubbles, retracted Manage seasonal - decreased/ absent allergic rhinitis and mobility of TM URI ENT: - Symptomatic > 12 weeks or needed air travel  - persistent fluid or hearing loss Acute otitis - Streptococcus Acute infection Recent URI or - CSOM Clinical Pediatric recurrent AOM media (AOM) pneumonia involving the increased - Conductive Presentation: prophylaxis (50%) middle ear symptoms of hearing loss - bulging TM - > 3 documented - haemophilus mucosa and seasonal AR from persistent (hallmark) and episodes in 6 months or influenzae middle ear fluid Kid: middle ear decreased/absen - > 4 episodes/ year - moraxella - otalgia (ear pain) effusion t TM mobility OR Daily abx during catarrhalis - fever - TM perforation - Perforated TM winter - irritability - bullous (rupture) with Myringotomy and Risk factors: - anorexia myringitis acute purulent tympanostomy tubes 6-18 months - vomiting/diarrhea - otorrhea (ear if prophylactic abx then 5-6 y/o, - hearing loss/ tympanosclerosi drainage w/ pus NOT effective FMH, daycare, fullness s + fluid) limited Adult: - cholesteatoma breastfeeding, - unilateral pain and - mastoiditis pacifier, decreased/muffled - labyrinthitis secondhand hearing smoke - disequilibrium exposure, ETD - conductive hearing loss Recurrent Signs and < 15 days since completed abx AOM symptoms within - persistent pathogen 30 days of abx tx - if originally treated w/ amoxicillin, start amoxicillin-clavulanate - ceftriaxone > 15 days since completed abx - Different pathogen - amoxicillin-clavulanate Chronic - Pseudomonas, Chronic middle - Purulent middle ear - aural toilet suppurative s.aureus. ear infection > 6 drainage - ear topical abx x 2 weeks otitis media Proteus, WEEKS - otorrhea Ofloxacin otic (CSOM) polymicrobial perforated TM - TM perforation solution and otorrhea (ear - conductive hearing Ciprofloxacin otic (AOM -Risk factors: drainage) loss solution complication early first - tinnitus - ENT s) episode or recurrent AOM, living in crowded conditions, daycare, low parental education, HX of T-tube Conductive Hearing loss secondary to issues in the outer or middle ear leading to Tympanogram Treat underlying cause hearing loss disruption of sound waves reaching the inner ear (AOM - Defects in ear structure complication - OME or AOM s) - Increased middle ear fluid - TM perforation TM +/ pain, otorrhea Most heal spontaneously perforation - conductive hearing within 12 weeks (AOM loss No swimming complication - vertigo Avoid excessive moisture s) Bullous Idiopathic Blisters (bullae) - thick and Same as AOM myringitis Thought to be or vesicles on the erythematous TM viral or same TM - Significant pain: cause as AOM improves when bullae rupture 9 Tympanoscle 32% patients w/ - Scarring (white plaques) in TM as a complications of frequent middle ear rosis h/s T-tubes Cholesteato Accumulation of Can lead to conductive hearing loss as it enlarges by: Surgery ma desquamating - Surrounding and destroying the ossicles squamous - Obstructing the eustachian tube epithelium in middle ear and mastoid Mastoiditis Rare infection of - post auricular pain - Admit the mastoid air - edema, redness - IV abx: recommended if cells - fluctuate or mass patient has recent h/o - fever abx or recurrent AOM - deep temporal pain - ENT: - protrusion of pinna - Aspiration, drainage - facial nerve middle ear paralysis - Myringotomy - Mastoidectomy Vestibular Thought to be Acute, bening, - Acute onset: severe - glucocorticoids: neuritis/ viral or post-viral and self-limited vertigo, nausea, prednisone taper labyrinthitis inflammatory vomiting, gait - symptomatic tx: disorder affecting instability Antihistamine  the vestibular - unilateral hearing Antiemetics portion of CN 8 loss benzodiazepines - nystagmus: - vestibular rehab positive head - education: no driving with impulse test, cannot vertigo, greatest sxs for 1-2 maintain visual days then gradual return to fixation when head baseline over few days to turned to affected weeks side - No CNS deficits OTITIS EXTERNA “Swimmer’s Ear” Otitis externa Bacteria: Inflammation of Otalgia Antimicrobial “Swimmer Pseudomonas the external Tragus tenderness management: ear” aeruginosa -> auditory canal Red/ edema of ear - mild: acetic acid 2% and greenish Most common in canal hydrocortisone 1% otic drainage childhood during Discharge, itch, solution summer months hearing loss - mild to moderate: treat infection and inflammation Considerations: a. Abx and severity of infection, glucocorticoids TM findings i. Non-ototoxic: Fungal - ciprodex otomycosis ii. Ototoxicity (do not use with TM perforation): neomycin, polymyxin B, hydrocortisone otic suspension  b. Antifungal: clotrimazole 1% solution Management considerations: - TM intact vs perforated - severity: a. mild- mild pain and itch with minimal EAC swelling b. Intermediate pain and itch, partially occluded EAC, pain with manipulation of pinna c. Severe infection: severe pain and swelling, swelling occludes EAC - Medical conditions: DM, immunocompromised Management: antimicrobial therapy, pain control, clean canal, acidifying solutions, ear wick PRN, education, f/u with ENT, prevention: ear plugs, bathing cap, dry Necrotizing Pseudomonas Nocturnal pain When to see Suspected Oral or IV ciprofloxacin + external otitis aeruginosa Pain with ENT: clinically in antipseudomonal (NEO) chewing - not improve anyone with EO beta-lactam  Risk factors: with tx and otorrhea not “Malignant adult diabetics, PE: -recurrent responding to Early NEO (short duration, otitis acute OE, EAC severely infection topical abx no spread beyond ear) and externa” aggressive erythematous - EAC mass therapy immunocompromised irrigation of the Purulent - necrotizing - oral ciprofloxacin EAC w/ tap discharge external otitis water, AIDS, Red granulation - concern with CT: best initial Admit if: cancer, recent tissue in the EAC hearing loss, test for diagnosis - uncontrolled diabetes ear surgery, Preauricular delayed speech, of advanced (HA1C not at goal) hearing aid lymph node and or learning NEO -> bone - immunocompromised irritation edema issues erosion - imaging showing bony Trismus, facial involvement nerve palsy - MRI - if CT - infection extend beyond indicates nondiagnostic or external ear soft tissue or progressive contraindicated: affecting cranial nerves osteomyelitis evaluate extent - failing oral cipro of disease, - pseudomonas resistance Presence of dark monitors tx covering or black response spots -> fungal infection Blood cultures White coating -> ESR, CRP candida Cultures & gram stain of drainage of granulation tissue EAR DISORDERS Barotrauma/Flying in PE: If pressure continues - Resolves within minutes to barotitis airplanes - Conductive hearing to change: hours of flying media Dysfunction of the loss due to immobile Ear pain - Prevention eustachian “Airplane Eustachian tube TM Hearing loss tube dysfunction prior to ear” (pressure - possible effusion +/- tinnitus flying: oral, nasal differences b/w - if severe: TM decongestants, oral Conductive middle ear and perforation, blood antihistamine hearing outside behind TM - Swallowing, chewing gum, loss environment) (hemotympanum) hard candies, gentle distorts and valsalva maneuver, immobilize bottle-feeding tympanic - Urgent ENT: membrane - >25% TM rupture - Ear pain + sensorineural hearing loss + vertigo (dizziness) Tinnitus Risk factors: Perception of sounds Description: unilateral, Goal: identify and treat - prolonged even when no outside bilateral, pulsatile, 1. Non-pulsatile (most underlying cause exposure to source: rining, roaring non-pulsatile, common) noise = most buzzing, cricket-like constant, intermittent - First-line diagnostic - cognitive behavioral common 1. Bilateral testing: audiometric therapy: only tx with high - any condition 1. Acute tinnitus < 6 non-pulsatile testing/ audiometry quality stress reduction causing hearing months continuous - ENT - treat depression, sleep loss or damage to - occur right after a high-pitched tone - patient’s history disturbances auditory system loud event and (non-rhythmic, ringing, - not recommend - exposure to resolve buzzing): most 2. Pulsatile -> vascular -> benzodiazepine ototoxic - can be an acute common vascular surgery medication: manifestation of aminoglycosides another disease 2. Pulsatile (rhythmic  , loop diuretics, 2. Chronic tinnitus > 6 sound beats in time chemotherapeuti months with heartbeat): c agents, - Difficulty with caused by vascular high-dose speech issues like NSAIDS, heavy discrimination* atherosclerotic carotid metals, aromatic (ability to understand disease, HTN solvents speech in quiet and - tinnitus is noisy environment) I. HEENOT, neck, symptoms of: - 18-20% of US neuro (CN 8, TM) presbycusis, - peak 60-69, M>F - imbalance, meniere’s dizziness, visual disease, acoustic changes -> multiple neuroma, sclerosis, tumor, barotrauma, infarction multiple sclerosis, stroke, CNS II. Vascular exam: tumors, vascular atherosclerosis disease vascular disease - Pulsatile tinnitus -> History of: noise vascular origin exposure, hearing - Auscultate for bruits loss or previous in the carotid arteries ear disease, medical conditions, medication, supplements Acoustic Risk factors: - Unilateral Hallmark symptoms: ENT neuroma - Exposure to sensorineural - progressive, First initial screening ionizing hearing loss unilateral hearing test: audiometry Unilateral radiation of - Schwann cell loss - Confirm asymmetric sensorineu head/ neck tumors in CN 8 - unilateral tinnitus sensorineural hearing ral in childhood (vestibular nerve) loss - Neurofibrom - unilateral atosis type - rises with age 50 y/o Other symptoms vary Brain MRI w/ gadolinium 2: present depending on (most accurate diagnostic earlier 20s “Vestibular size/location of tumor modality): bilateral with bilateral schwannoma” within nerve vestibular schwannoma tumors “Acoustic - unsteadiness with tumors - Pathognomonic schwannoma” walking for NF T2 - facial paresthesia, pain, paresis Urticaria Urticaria Exposure Allergic rxn has a 1. Urticaria 1. Antihistamine “Hives, history to known spectrum of acuity (dermis/skin): 1. Persistent urticaria H1: Cetirizine (Zyrtec) welts, or potential from urticaria to well-circumscribed, - lesions resolve within (2nd generation) - 1st wheals” trigger: ask about anaphylaxis itch, blanchable, 24h, but presence overall line acute tx allergies, hx of wheals of variable does not fully resolve for > H2 in combination with urticaria or Anaphylaxis: excess shape/size 6 weeks H1 anaphylactic rxn immune response to - transient, resolve - allergist + dermatologist ○ Cimetidine an allergen -> airway within 24h referral 2. Glucocorticoid for Allergic/ immune compromise, significant angioedema response to circulatory collapse -> 2. Angioedema = 2. Pain + persistence > 6 allergic -> emergency tx swelling of mucosal weeks -> consider other 3. Observation: angioedema increased tissues clinical conditions can worsen over many hours permeability of - face, lips, mouth, -> timeline is key vessels -> fluid throat, larynx -> Epinephrine shifts -> swelling airway compromise self-injection - genitalia, gut -> swelling within swelling, diarrhea dermis -> urticaria submucosal/  subQ tissue in face -> angioedema Many mechanism: - Infection (virus, bacteria, parasite) - IgE-mediated allergies (foods, drugs, latex) - Mast cell activation - Histamine excess NASAL CONDITIONS Rhinitis Rhinitis = inflammation of nasal mucosal tissue; manifest as: Common forms: allergic rhinitis, non-allergic rhinitis, - Nasal congestion, nasal itching, sneezing, rhinorrhea, alcohol-induced rhinitis, rhinitis of pregnancy coughing Allergic Risk factors: Treatment based on severity and timing in rhinitis H/O atopy Hallmark symptoms: following allergen exposure patient aged 2 years and older (asthma, - itching of eyes, nose, upper palate - All patient: avoid allergen, saline nasal eczema, - snoring, irritability, fatigue, poor sleep rinse allergic - rhinorrhea, nasal congestion, coughing, sneezing - First line: intranasal corticosteroid rhinitis) 1. Eyes spray Exposure to “Allergic shiners”: infraorbital darkening, edema due - Add-on based on symptoms not allergen/ to vascular congestion well-controlled by 1st line: potential Dennie-morgan lines: accentuated folds below the - Ocular itching, allergic conjunctivitis: triggers lower lids due to swelling add oral antihistamine Timing is variable: - Sneezing + congestion -> add 2nd gen seasonal, antihistamine + decongestant perennial/ year-round, 1. Behavioral: Allergic conjunctivitis: bilateral conjunctival intermittent/ after Minimize allergen exposure injection (redness) with chemosis (conjunctival exposure Pet removal is the most effective method edema), clear, watery discharge IgE-mediated 2. Pharmacotherapy: (immune) a. Nasal saline/ irrigation: rinse allergens response against 2. Ear: from nasal mucosa, relieve mild symptoms inhaled allergens Serous effusion, +/- retracted ™, eustachian tube b. Antihistamine: - Repeated dysfunction ○ Nasal antihistamine = rapid onset “on exposure, demand” pollens Azelastine spray (grass, Effective for nasal ragweed, congestion; bitter taste trees), dust 3. Throat ○ Ocular antihistamine drops for allergic mite feces, Clear post-nasal drainage in posterior pharynx conjunctivitis animal “Cobblestoning” -> hyperplastic lymphoid ○ Oral antihistamine reduce itching, dander, tissue in posterior pharynx sneezing, rhinorrhea: less effective cockroaches for ocular and nasal symptoms -> immune system  release histamine Peak: childhood/ adolescence -> 4. Nose significant risk Transverse crease across nose due to “allergic factor of asthma salute” c. Nasal corticosteroid: most effective development in Rhinoscopy: pale, boggy, blue-tinged nasal single therapy for allergic rhinitis children mucosa, clear nasal discharge ○ First-line treatment: fluticasone (flonase), triamcinolone (nasacort) ALLERGY ○ Morse effective than oral antihistamine TESTING for nasal symptoms 1. Skin - prick ○ Help w/ eye symptoms “Scratch” test ○ Take several days to have maximum (most common) effect Positive result: d. Decongestants “wheal and i. Nasal decongestant sprays are flare” effective for nasal congestion Small risk of Oxymetazoline anaphylactic Should combine with nasal steroid rxn (not monotherapy) Rhinitis medicamentosa: severe rebound nasal congestion following cessation of nasal decongestant spray as monotherapy Congestion -> oxymetazoline -> cessation -> worsening congestion -> … 2. Serum testing - Treatment: start nasal IgE glucocorticoid and withdraw No risk for nasal decongestant ii. Oral decongestant: supplement for anaphylaxis, nasal congestion; can be combined expensive with 2nd gen antihistamine in a single pill (Claritin D) Pseudoephedrine: OTC Multiple adverse effect e. Montelukast useful if patient has asthma f. Cromolyn sodium intranasal spray: +4 daily throughout allergy season g. Ipratropium bromide: excellent for managing profuse rhinorrhea 3. Immunotherapy = allergist/ immunologist - SubQ and sublingual immunotherapy: prevent progression to asthma in children - Weekly administration of minute amounts of allergens x 2-3 + years. Customized based on allergy testing result -> small risk of anaphylaxis. Dosing is stepped up slowly over 2-3 years to “desensitize” immune system Non allergic Adulthood PE: Trigger avoidance rhinitis b. Nasal congestion - absence of allergic - 1st line tx: intranasal and post-nasal drip findings glucocorticoids + intranasal “Vasomotor Perennial - typical normal antihistamine (oral rhinitis” (year-round) antihistamine unhelpful) symptoms: may be - nasal ipratropium bromide worse in winter targets rhinorrhea Nasal polyp Formed from Bening, pedunculated - often sxs of Manage underlying cause of chronically-infla tumors of nasal underlying nasal nasal mucosal inflammation med nasal mucosa mucosal inflammation mucosa - adult: - partial or total Oral steroid (short course) if samter’s triad: anosmia (smell total nasal obstruction due to nasal polyps, blindness) polyp aspirin - nasal passage sensitivity, obstruction: ENT referral for surgical asthma hypo-nasal speech, removal chronic nasal mouth breathing  inflammation - anterior rhinoscopy: - children: associated inflamed nasal with cystic fibrosis mucosa Polyp = “peeled grape” appearance Kawasaki Immune-mediate Rare but significant Fever >101.3: 5+ Cardiac imaging: 1. Intravenous disease d vasculitis of differential for days, no echocardiogram, immunoglobulin (IV “Mucocutan small to medium pediatric patient w/ response to angiography -> IG) eous lymph vessels with fever, conjunctivitis, anti-pyretics hospital PLUS node predilection for adenopathy, rash, and (acetaminophen) admission 2. High-dose aspirin syndrome” coronary skin changes Conjunctivitis (weight-based): not arteries bilateral administered to - all children with Polymorphous children for other unexplained fever > 5 rash Complication: febrile illnesses days Adenopathy: coronary artery unilateral cervical aneurysm CRASH: node Conjunctivitis, rash, Edema / adenopathy, erythema of strawberry tongue, fingers/ toes with hands/feet desquamation Mucosal erythema, cracked/crusted lips, strawberry tongue followed by desquamation Irritable Salivary gland disorder Sialadenitis Stone Pain + swelling Hydration, massage gland, = salivary (sialothiasis) involved gland promote salivary flow - gland within salivary Sxs worse with resolve w/o antibiotics inflammatio system salivation n Salivary stasis (med, radiation, dehydration) predisposes to sialolisthiasis: most common in submandibular gland Suppurative Blocked stensen’s Sudden onset, painful, Purulent intraoral Culture drainage Hospital admission, IV abx -> parotitis duct w/ bacterial unilateral swelling of drainage from potential for deep neck infection of lateral cheek with stensen’s duct with infection parotid gland preauricular erythema manual expression: most common pathogen = S.aureus Viral Viral infection Complication: Parotitis Positive IgM ab Prevention is optimal parotitis Mumps: most epididymo orchitis - Nonspecific sxs: PCR testing for common cause in Testicular pain can be fever, HA, myalgia, mumps virus in Supportive care: analgesics, children < 15 yo severe and require fatigue, anorexia buccal/oral swab antipyretics, warm/cold packs hospital admission - 48 hours after to face Unvaccinated at symptom onset -> Positive result -> highest risk for parotitis report to state infection - Start unilateral -> bilateral Can present in - Obscures angel fully-immunized of mandible older individuals with exposure ->  waning immunity VIRAL UPPER RESPIRATORY ILLNESSES Commo Viral infection of Most frequent Coryza: nasal Clinical dx: Antibiotics of no value URI acute illness in congestion + rhinitis/ negative Supportive care n cold the industrialized rhinorrhea (inflamed COVID-19 - honey: children > 1 y/o Risk factors world nasal mucosa), improve cough w/o side of”catching a - surge in winter conjunctivitis effects cold”: months - Lung sound normal Observe for complications - exposure to - incubation (clear lung sound) children or period: 1-3 days 1. antitussive/ expectorants infected nasal - sneezing, sore throat, (clear mucus): significant secretion Transmitted via: cough, malaise, adverse effects in children - chronic stress - hand contact low-grade fever, HA - 12: analgesics + decongestant only 3. Adults: analgesics (NSAIDS), decongestant PLUS antihistamines COVID-19 Severe acute URI symptoms + HA, Severe infection: PCR/antigen Oral antiviral within 5 respiratory smell/taste pneumonia testing in all days of symptoms onset: syndrome abnormalities, patients Nirmaterlvin/ritonavir coronavirus 2 myalgias, fatigue Increased risk for (paxlovid) -> 1st line tx mortality: unvaccinated, age Supportive care > 50. Medical comorbidities Influenza Influenza A+B - peak in fall + Abrupt symptoms onset 1. Supportive care viruses winter Classic sxs: fever, Multiplex testing: combine with 1. First line neuraminidase - transmission chills, non-productive COVID-19, RSV inhibitors (antiviral med) droplets, fomites deep hacking cough, Oseltamivir - peak shedding widespread myalgias, Diagnostic testing: (tamiflu) 24-48 hrs before HA, severe sore throat, 1. Nucleic acid amplification Shorten course, reduce symptoms -> GI (vomiting, testing (NAAT): preferred method viral shedding, decrease asymptomatic diarrhea) more for influenza testing mortality transmission, common in children Initiate tx oseltamivir prolonged viral - hot/flushed skin 2. Rapid influenza detection test ASAP, regardless of shedding - mild cervical (RIDT): Low sensitivity -> symptoms duration for lymphadenopathy negative test does not eliminate ○ High-risk pts Complications: - normal lung sound influenza ○ Severely-ill patients Pneumonia unless pneumonia (most common present Prevention is key - low risk < 48hrs: tamiflu complication of - fever/ chills (101-104); - low risk > 48h: tamiflu flu, major cause children (>102) Diagnostic testing ->definitely minimal benefit of mortality) -> Caution in pt >65 y/o indicated in high-risk patients: - high risk or severely-ill > lower respiratory and > 65 yo 48 h: tamiflu tract infection immunocompromise < 5 yo d, altered mental Pregnant people  status, anorexia, Underlying conditions malaise, weakness (asthma, diabetes, obesity), immunocompromised Rhinosinu Viral upper Purulent nasal discharge sitis respiratory Nasal obstruction, congestion infection Facial pain + pressure, worsen when leaning forward Majority infections are viral = acute viral rhinosinusitis (AVRS) Viral acute Viral cause Viral sinus Decreased nasal Required for Tx = sxs management rhinosinusi (majority of infection: patency dx: must be Supportive care – Fluids, tis (ARS) cases) Timing: < 10 Purulent rhinorrhea present rest, steamy showers days Sinus tenderness Purulent Intranasal corticosteroid – Sxs intensity: Children: irritability + nasal fluticasone (Flonase), not worsening, vomiting drainage triamcinolone (Nasacort) no or low-grade Transillumination of Nasal Analgesics – NSAID, fever, not severe frontal or maxillary obstructio acetaminophen sinuses may show n, Saline irrigation opacity congestio Decongestants, n mucolytics may help Facial pressure (pain) Acute Streptococcus Purulent nasal drainage Osteomyelitis Bacterial pneumonia: PLUS nasal obstruction (bone w/ or w/o abx rhinosinusi most common PLUS facial pressure infection) f 1. NO Abx: observe tis (ABRS) sinus/skull 2. ABX: no improvement > 7 days Risk factors: Timing: > 10 days Preseptal Shorter illness, more side effects underlying allergic (virus < 10 days) cellulitis -> evaluate for risk factors for rhinitis, impaired Sxs intensity: Orbital pneumococcal resistance: mucociliary Severe fever cellulitis > 65, 102, clearance, sinus (102) or severe CNS: immunocompromised, hospitalized within 5 drainage, dental pain (3-4+ days) meningitis, days, abx used within past months, daycare infection, URI sxs initially intracranial or attendance immunocompromi improved then epidural sed sinus sxs abscess 1. Low risk worsening Adult: amoxicillin or (double amoxicillin-clavulanate sickening) Children: standard weight-based amoxicillin-clavulanate 2. High risk Adult: high-dose amoxicillin-clavulanate Children: high-dose weight-based amoxicillin-clavulanate Subacut Risk factors: Sxs of acute rhinosinusitis for 4-12 weeks Ent referral e rhinitis, irritant Allergy testing rhinosinusi exposure tis (smoke): systemic Smoking cessation disease, Abx management = controlling inflammation anatomical abnormalities Chronic Similar risk Sign and sxs of Sxs 12+ weeks Primary care management: rhinosinusi factors to acute 1. >2 cardinal sxs > 12 weeks despite tx - ENT tis (CRS) acute/subacute rhinosinusitis for Cardinal sxs: purulent nasal drainage, nasal - Saline irrigation  4-12 weeks obstruction/congestion, facial pain/pressure - Intranasal despite Adult: anosmia corticosteroids symptomatic/anti Children: cough - Observation for microbial tx complications PLUS - Control paranasal inflammation 2. Objective demonstration of mucosal inflammation Direct visualization Mucopurulent drainage Nasal polyps Imaging: mucosal thickening, polyps, opacified sinuses Pharyngiti 1. Virus (most Inflammation of PE: s common) pharynx + - Pharyngeal - respiratory virus surrounding erythema - flu lymph tissue “ - Low-grade fever - sars-cov-2 sore throat” - Mild cervical - ebv lymphadenopathy - hiv, hsv Sore throat, - Tonsillar exudate 2. Bacteria cough, fatigue, Group A malaise, coryza, streptococcal sinus, discomfort infection Viral Infectious 1-2 months Classic triad: Consider pharyngitis mononucleosis incubation Fever covid-10 Most cases Epstein-barr virus Saliva Tonsillar testing of (most common) transmission pharyngitis + pharyngitis tonsillar exudate are due to “worst sore throat of usual my life” respiratory viruses / Lymphadenopathy common Fatigue cold Enlarged spleen Infectious PE: Dx = rapid testing TX: mononucl - low-grade fever + serum testing Viral infection -> supportive eosis -Lymphadenopat 1. Heterophile care hy (posterior) testing Hydration - pharyngeal 2. EBV-specific Topicals, salt-water gargles, inflammation ab = gold rest, NSAIDS, - patchy tonsillar standard acetaminophen exudate (white, 3. CBC: grey, green, lymphocytosis Splenomegaly -> avoid necrotic) contact sports Tx with Abx -> diffuse maculopapular rash Bacteria Group A Highly Fever Centor criterias for Scarlet fever Treatment lessen l streptococcus contagious Tonsillar swelling/ testing contagious phase from 2 pharyngitis pyogenes PE: exudate > 2: perform rapid Peritonsillar weeks to 24 hours (GABHS) - most Low-grade fever Lymphadenopathy strep antigen abscess common cause Tender anterior Patchy tonsillar detection test First line antibiotics of bacterial lymphadenopath exudate, palatal (RADT) Acute 1. Oral abx x 10 days: pharyngitis y (posterior in petechiae 1: no testing, less rheumatic Penicillin V or mono) Malaise, fatigue likely GABHS fever amoxicillin Children: abdominal 2. PCN allergy: pain, anorexia, Centor criteria: macrolide, nausea, vomiting Tonsillar clindamycin, swelling cephalosporin  Tender anterior 3. Injectable abx cervical (1-time dose): lymphadenopat benzathine penicillin hy G Fever NO cough**** 1. Positive RADT: GABHS confirmation 2. Negative RADT: throat culture prior to treatment Scarlet Hypersensitivity Children common Presents with pharyngitis, plus: Testing for fever reaction to GAS Scarlatiniform “sandpaper” rash- rough, streptococcal exotoxin bumpy, texture (trunk-> extremities) pharyngitis Strawberry tongue, facial blushing, - Predispose circumoral pallor d to cardiac Finter-tip desquamation complicatio Pastia’s lines (linear petechiae in ns antecubital fossa) Peritonsill Polymicrobial with Most common SYMPTOMS: Hospitalization: IV abx, IV ar abscess S. pyogenes deep space neck Severe throat pain, dysphagia, odynophagia fluids, pain control, airway (PTA) - Bacterial infection Trismus: cannot move jaw or open mouth monitoring, ENT “quinsy” pharyngitis Excessive drooling Needle aspiration of (GABHS) -> Difficulty speaking or voice change abscess peritonsillar Diagnostic + therapeutic: cellulitis -> SIGNS pus on needle aspiration peritonsillar Toxic patient: fever, chills, sepsis, appear ills confirms diagnosis abscess (PTA) Drooling “Hot potato voice” If patient unable to open  Erythematous fluctuate fullness of soft palate: uvula mouth adequately for is deviated away from affected side visualization / aspiration CT head / neck (not required for diagnosis) + operating room Epiglottis Bacterial Sudden onset of fever (very sick) Clinical DX: Airway management: infection of Toxic appearance, tripod position Progressively severe sore throat maintain oxygen status epiglottis Respiratory distress: refuse to lay flat, over many days Immediate airway Classic (panic, stridor, cyanosis, tachypnea) Abrupt onset of fever, stridor, assistance association with Drooling and voice change - muffled respiratory distress H.influenzae “hot potato” voice Classic association on lateral type B Severely sore throat neck X-ray -> Thumbprint sign Laryngitis Most common: Present as voice Chronic laryngitis > 3 weeks Supportive care (hydration,  upper “hoarseness” or Malignancy of larynx/vocal folds voice rest, humidifier) respiratory change in “vocal must be considered Removal of offending infection quality”: courses, Can be due to GERD, smoke, agents: smoke - Singing, rough, raspy, prolonged viral URI Manage GERD shouting, harsh, strained, screaming inaudible For laryngitis lasting 3 weeks or - head/neck more, especially with absence of surgery URI: - GERD Otolaryngology evaluation for - Smoke direct laryngoscopy and biopsy (directly visualize larynx/ vocal folds, obtain tissue sample) ORAL LESIONS 1. Normal variants of oral mucosa: ◦ Leukoedema, Fordyce granules, physiologic oral pigmentation 2. White and red oral lesion: Oral candidiasis ◦ Leukoplakia ◦ Oral hairy leukoplakia ◦ Erythroplakia ◦ Oral lichen planus ◦ Oral squamous cell carcinoma 3. Pigmented oral lesions: ◦ Melanotic macules, melanoma, amalgam tattoo PRINCIPLE FOR USE OF MEDICATION IN ORAL CAVITY 1. Gel for few localized lesions 2. Rinse for widespread or generalized erythema 3. Educate about the possibility of oral candidiasis with topical and inhaled immunosuppressants 4. Systemic therapy for more severe lesions and symptoms TOBACCO 1. Oxidative stress on tissues 2. Oral cancer 3. Smoking + alcohol = synergistic effects on oral cancer ETOH 1. Produces ROS 2. DNA damage 3. Increase the permeability of the oral mucosa 4. Solvent for tobacco products NORMAL VARIANTS OF ORAL MUCOSA Leukoedema - Common - Bilateral grayish-white condition among semi transparent Black individuals mucosal alteration -> - Bening disappear when - Asymptomatic mucosa stretch Fordyce Extremely White to yellow 1-2 granules common mm discrete papules Symmetry on buccal mucosa and vermilion border or the lips Physiologic Increased Commonly seen in Bilateral brown-gray oral melanocyte patients with band on the attached pigmentation activity and darker skin types gingiva, hard palate, melanin mouth floor, and buccal production mucosa WHITE AND RED ORAL LESIONS  Etiology Characteristics CP Complications DX TX (Oral Candida Can be Lesions can be 1. Pregnancy: KOH Prep 1. Mild disease candidiasis) albicans asymptomatic wiped off with a no oral azoles ◦ Budding yeast, Topical antifungal gauze, exposing an in the first with or without agents: Clotrimazole Pseudomem Risk factors: Mouth pain erythematous base trimester pseudohyphae oropharyngeal lozenges, branous Infancy, denture Sore throat Asymptomatic white nystatin swish and candidiasis wear, “Cottony” patches or plaques 2. Denture swallow (thrush) Most xerostomia, feeling in Buccal mucosa, stomatitis: common antibiotic, mouth” palate, tongue, or soaking in Rinse mouth after form of oral corticosteroid, Painful eating oropharynx chlorhexidine steroid inhalers, clean candidiasis Immunocompro gluconate, dentures frequently, mised: Diabetes, avoid brushing replace toothbrushes, HIV/AIDS, dentures pacifiers, bottle nipples hematologic malignancies, 3. Angular 2. Moderate to severe chemotherapy or cheilitis: disease: Oral antifungal head and neck Topical (fluconazole) irradiation antifungal ointments: Miconazole, (Oral 1. Denture stomatitis: clotrimazole candidiasis) painful, red palate Erythematou s oral candidiasis 2. Angular cheilitis: painful fissuring at the corners of the mouth Leukoplaki Risk factors: White patches that cannot be removed with gauze: typically Biopsy Prevent or decrease a Tobacco, not painful (oral candidiasis: pain, can be removed) Clinical risk of oral squamous alcohol, HPV 1. Homogeneous leukoplakia: Uniformly white plaque with suspicion: white cell carcinoma infection well-defined margins lesion doesn't wipe off, does not Surgery, destructive appear therapies, medical traumatic/frictiona therapies and watchful l and persist > 6 waiting with close clinical weeks and histologic follow-up 2. Nonhomogeneous leukoplakia: Speckled, Avoid risk factors erythroleukoplakia, nodular/verrucous white lesions ENT Precancerous lesion with 1-20% of lesions progressing to oral squamous cell carcinoma Features associated with high risk of oral cancer: - Non Homogeneous subtype - > 4 cm diameter - mouth floor, lateral tongue - dysplasia (abnormal cell growth) - long duration of leukoplakia Oral hairy Epstein-Barr White, corrugated, painless plaques that CANNOT be Biopys for EBV leukoplakia virus-induced scraped from the surface generally on lateral tongue NO treatment is necessary lesion May be presenting sign/symptom of HIV infection NOT A PREMALIGNANT LESION Risk factors: Immunocompro mised (almost exclusively in patients infected with HIV) Erythroplak Risk factors: Fiery red, sharply demarcated patch Biopsy ia Tobacco and Asymptomatic Surgery EtOH Most commonly located on the floor of the mouth, the ventral tongue or soft palate High risk of 4 malignant transformation to oral SCC Oral lichen Idiopathy 1. Reticular: Lace-like, white patches on Physical exam 1. Asymptomatic patients do not planus Immune-mediate the buccal mucosa (“Wickham striae”) ENT require treatment d ◦ Most common presentation * Biopsy 2. Pain relief (NSAIDs, acetaminophen, May increase ◦ Asymptomatic intraoral topical anesthetics) risk of oral scc 3. High potency topical 2. Erythematous: Red patches among corticosteroids x 1-2 months reticular features leading to oral candidiasis ◦ Pain, burning, swelling and irritation 3. Erosive: Erosions and ulcers with reticular and erythematous lesions ◦ Painful Oral Arise from Most common An ulcer with ◦ Biopsy and HPV testing Surgery, chemo and squamous leukoplakia, oral cavity cancer indurated margins or radiation depending on erythroplakia or a mass that does not Risk factors: Tobacco Alcohol extent of disease cell oral lichen More common in heal Areca nut (betel nut) Human carcinoma planus Southeast Asia papillomavirus (HPV), primarily Tongue (particularly HPV-16 Radiation exposure of ventral and lateral the head and neck aspects) Loosening of teeth, dysphagia, weight loss, referred otalgia PIGMENTED ORAL LESION Oral Most common mucosal Small, Biopsy. No treatment melanotic pigmented lesions well-circumscribed macules Benign brown-black macules Adulthood commonly occurring on Darker pigmented skin the vermillion border, gingiva and hard palate Oral cavity Idiopathy Rare Asymptomatic brown to Biopsy. Surgery melanoma Risk factors: Highly black pigmented tobacco aggressive macule or patch that may have characteristics of cutaneous melanoma ABCDE Amalgam Deposition of Blue-black macules seen within the gingiva Biopsy, radiologic visualization Tattoo amalgam into at the gingival margin or in the buccal No treatment the oral soft mucosa next to “silver” amalgam dental tissues. Next to fillings dental filling APHTHOUS ULCERATION Recurrent IDIOPATHIC Most common Recurrent development of discrete, Typically heal in 7-14 days, if not, refer to Aphthous Stress, smoking, cause of mouth painful ulcers on buccal or labial ENT for biopsy Stomatitis local trauma ulcers “canker mucosa ◦ Avoid irritating food/drink sores” Lesions are shallow, round/oval ulcers with an red border and yellowish exudate centrally Multiple lesions lasting up to 14 days Behçet Idiopathic Rare, 1. Oral ulcers are the Pathergy test 1. Refer to Syndrome neutrophilic most common feature A positive result is a papule or Rheumatology inflammatory (up to 100% of pustule > 2mm surrounded by 2. Oral and genital disorder patients) an erythematous halo on the lesions treated - Aphthous ulcers with topical Multisystemic (Painful, shallow steroids disorder with or deep with 3. Oral clinical central yellowish corticosteroids manifestations necrotic base) skin can be used for  including oral - Multiple and ocular disease, ulcerations, extensive arthritis and other urogenital lesions, 2. Urogenital lesions systemic cutaneous lesions, occur in 75% of manifestations ocular disease and patients neurologic disease MISCELLANEOUS ORAL TONGUE LESIONS INFECTIOUS ULCERATIONS AND VESICLE Herpes HSV-1 1. Primary infection PCR assay Oral antiviral therapy Simplex Multiple, painful, ulcerated oral Antibodies to HSV-1 and HSV-2 Labialis/Stom lesions with local lymphadenopathy atitis Systemic symptoms include fever, malaise and headache In children, gingivostomatitis In adults, severe pharyngitis 2. Recurrent infection Prodromal symptoms (pain, burning, tingling, pruritus) 24 hours prior to the appearance of oral-labial lesions  Vermillion border Lesions progress from vesicle to crust