CAM Exam 1 Study Guide PDF

CAM Exam 1 Study Guide Key: Introduction to Disorder Causes Risk factors Clinical presentation/Signs & symptoms Physical exam Diagnosis/Testing DDx Treatment Prevention/counseling Follow-up Referral Complications ENT 1 Anatomy Review: Auris sinistra (AS) = L ear Auris d...

CAM Exam 1 Study Guide Key: Introduction to Disorder Causes Risk factors Clinical presentation/Signs & symptoms Physical exam Diagnosis/Testing DDx Treatment Prevention/counseling Follow-up Referral Complications ENT 1 Anatomy Review: Auris sinistra (AS) = L ear Auris dextra (AD) = R ear Normal tympanic membrane ◦ Intact ◦ Slightly convex ◦ Translucent ◦ Mobile TM often divided into 4 quadrants ◦ Posterior superior ◦ Posterior inferior ◦ Anterior superior ◦ Anterior inferior Physiology Review: Pinna collects and directs sound waves into ear canal or external auditory meatus Transmission of sound through the TM is optimal when the air pressure is equalized between the outer and middle ear Converted to mechanical energy and transmitted through TM and ossicles to oval window ◦ Ossicular chain amplifies signal by 25 decibels Two tiny muscles, the tensor tympani and stapedius muscles contract to protect the inner ear by reducing the internsity of sound transmission Movement of the oval window creates motion in the cochlear fluid and along the basilar membrane which excites frequency specific areas of the Organ of Corti which in turn stimulates a series of nerve endings Nerve impulses are relayed through the 8th CN, through varies nuclei along the auditory pathway to areas in the brain HAPE Review: Weber test ◦ Normal = sound equal on both sides ◦ Conductive hearing loss (CHL) = sound louder in affected (poorer hearing) ear ◦ Sensorineural hearing loss (SHL) = sound decreased in affected ear ‣ Sound louder on opposite/normal ear Rinne test ◦ Normal = AC > BC ◦ Conductive hearing loss (CHL) = BC > AC in affected ear ◦ Sensorineural hearing loss (SHL) = equally diminished AC and BC in affected ear New Tests: Pneumatic otoscopy ◦ Pneumatic insufflation used to evaluate TM mobility is described as normal, absent, decreased, or increased Digital otoscopy ◦ Small camera used to visualize the TM EAR DISORDERS External Ear Disorders: Cerumen Impaction Intro to cerumen impaction ◦ Accumulation of cerumen (earwax) causing bothersome symptoms and/or preventing needed assessment of ear canal ◦ Common condition & common cause of hearing impairment ◦ ~ 6% of population affected (1 in 10 children, 1 in 20 adults, 1 in 3 older adults) ◦ 12 million visits & 8 million removal procedures annually ◦ Cerumen: naturally occurring from epithelial cells in the external auditory canal (EAC) Impaction caused by disrupted/dysfunctional migratory pattern of epithelium due to: ◦ Canal disease ◦ Canal narrowing ◦ Aging ◦ Foreign objects ◦ Inappropriate removal attempts  ◦ Overproduction Clinical presentation ◦ Accumulation usually asymptomatic ◦ Impaction may cause hearing loss, ear fullness, earache, itchiness, reflex cough, dizziness, and/or tinnitus Diagnosis: otoscopic exam (otoscopy) Treatment: ◦ Indications for removal: ‣ Symptomatic patients ‣ Patients who are unable to express symptoms ◦ Routine removal NOT recommended for asymptomatic patients ◦ Removal is the most common ENT procedure ◦ Removal methods ‣ Cerumenolytic agents Patients w/o h/o ear infections, TM perforation, or otologic surgery In clinic or at home (no more than 3-5 days) Water, saline, mineral oil, hydrogen peroxide, docusate sodium, carbamide peroxide (Debrox) May need follow-up with irrigation ‣ Irrigation MOST COMMON Alone or with pre-treatment Large catheter-tipped syringe or mechanical jet irrigator Warm (body temp) irrigant: tap water, saline, or water + hydrogen peroxide Immunocompromised patients: post-irrigation acidification recommended Use alcohol drops post-irrigation to dry up remaining water ‣ Manual Requires adequate visualization Curettes, spoons, forceps, cotton-tipped applicators, suction ‣ Complications of cerumen removal Cerumenolytics: allergic reactions, otitis externa, earache, transient hearing loss, dizziness Irrigation: water retention, TM perforation, hearing loss, tinnitus, pain, vertigo Manual: ear pain, bleeding, laceration, TM perforation Prevention for patients with h/o recurring symptomatic cerumen impaction (>1/year despite removal) and otherwise normal ears: ◦ Cotton ball dipped in mineral oil in EAC x 10-20 minutes once weekly ◦ Routine cleaning q6-12 months by health professional ◦ No chronic use of cotton swabs or cerumenolytics Criteria for referral to otolaryngologist (seldom necessary): ◦ History of chronic cerumen impaction, perforated TM, or ear surgery ◦ Purulence or necrotic tissue in ear canal ◦ Persistence of otologic complaints after cerumen removal Otitis Externa (swimmer's ear) Intro to otitis externa ◦ Inflammation of EAC ◦ ~ 10% lifetime occurrence; childhood predominant; more likely to occur in summer ◦ Induced by infectious, allergic, & dermatologic disease ‣ Acute bacterial infection is most common cause: Pseudomonas aeuruginosa, S. epidermidis, & S. aureus ‣ Fungi: Aspergillus, Candida Risk factors ◦ Water/swimming ◦ Mechanical trauma ◦ Allergic contact dermatitis ◦ Dermatologic conditions ◦ Devices (hearing aids, ear buds, diving caps) ◦ Prior radiation therapy Symptoms ◦ Otalgia (ear pain), pruritis (itching), otorrhea (drainage), hearing loss ◦ History of: ‣ Known TM perforations ‣ Previous ear infections ‣ Prior ear surgery or radiation ‣ Recent ear instrumentation ‣ Use of devices in ear canal ‣ Water exposure Physical exam ◦ Erythema or signs of trauma to auricle or tragus ◦ Tenderness with tragal pressure or auricle manipulation ◦ Canal edema, canal erythema ◦ May have purulent exudate (discharge), periauricular cellulitis, or TM erythema ◦ Mobile TM with pneumatic insufflation ◦ If air-fluid level in TM, suspect middle ear effusion from underlying otitis media ◦ If TM perforated, suspect middle ear condition Severity based on H&P ◦ Mild: minor discomfort, pruritis, minimal canal edema  ◦ Moderate: intermediate pain, pruritis, +/- partial canal occlusion ◦ Severe: intense pain, complete canal occlusion, +/- fever, preauricular erythema, regional lymphadenopathy Diagnosis Mild ◦ Clinical (based on H&P) ◦ Rapid onset (~within 48 hours in previous 3 weeks) ◦ Cultures (severe, recurrent, chronic, immunosuppressed, infections after ear surgery, no response to initial therapy) DDx: otomycosis, contact dermatitis, CSOM, carcinoma of EAC, psoriasis Treatment ◦ Main components of treatment: ‣ Cleaning EAC (aural toilet) Moderate ‣ Treating inflammation & infection ‣ Pain control (NSAIDs or acetaminophen) ◦ Topical therapy is mainstay ◦ Mild: Topical acidifying agent + glucocorticoid (i.e., acetic acid + hydrocortisone TID-QID) x 7 days ◦ Moderate: Topical antibiotic + glucocorticoid (i.e., Cipro HC BID, Cortisporin TID-QID) x 7 days ◦ Severe: Topical antibiotic + glucocorticoid (i.e., Cipro HC, Cortisporin) ‣ Some patients: add wick placement & systemic antibiotics (if evidence of deep tissue infection) Less severe: PO levofloxacin 500 mg daily x 7 days More severe: IV vancomycin + IV cefepime ‣ Obtain cultures of ear drainage severe ◦ Immunocompromised: Same preferred antibiotics as with severe disease Follow-up: depends on severity & resolution; consider culture & ENT referral if no response General counseling: ◦ Protect ear while recovering: ‣ Cotton ball while bathing ‣ Refrain from water sports x 7-10 days ‣ No hearing aids or earbuds until pain & discharge subside ◦ Ear hygiene: ‣ EAC is self-cleaning ‣ Don't insert fingers, towels, cotton swabs, or other foreign objections ‣ Drying EAC: hair dryer, fan, isopropyl alcohol/white vinegar Complications: periauricular cellulitis & malignant external otitis (next disorder) Malignant Otitis Externa Invasive infection of EAC & skull base (osteomyelitis) Diabetics over age 60, HIV, immunocompromised Pseudomonas aeruginosa is #1 cause Symptoms: deep otalgia (nocturnal), persistent & foul otorrhea, EAC granulation Diagnosis: ◦ Cultures of drainage & biopsy of granulation tissue ◦ CT and/or MRI; bone scan Treatment based on severity (4 weeks - 6 months of PO or IV antibiotics) Foreign bodies Most common in children aged 6 & younger More common in right ear (predominant handedness) More common in children with: ◦ Irritating conditions of the ear (i.e., cerumen impaction, otitis externa, otitis media) ◦ Pica ◦ ADHD Common FBs: beads, pebbles, tissue paper, small toys, popcorn kernels, & insects Common presentations: ◦ Caregiver concern (witnessed placement or seeing FB in EAC) ◦ Incidental finding during routine otoscopy ◦ Decreased hearing or pain ◦ Purulent or bloody ear drainage (rare) ◦ Chronic cough or hiccups (rare) Physical exam: otoscopy (also evaluate other ear and nostrils) Diagnosis: visualization on otoscopy DDx: cholesteatoma, AOM with spontaneous perforation Removal ◦ Referral to otalaryngologist: ‣ Urgent removal: button batteries, live insects, penetrating FBs ‣ Removal within a few days: glass or other sharp FB, spherical or other FB wedged in medial EAC, & FB against TM ◦ Non-specialists: ‣ Emergency department or primary care office ‣ Ensure adequate restraint ‣ Commonly available instruments: Irrigation setup Headlight Otoscope Alligator or Bayonet forceps Plastic or metal cerumen curette ◦ Techniques ‣ Irrigation Contraindicated with T-tubes, perforated TM, vegetable matter, button batteries 20-50 mL syringe Irrigation solution at body temp (tap water, sterile water or NS) Plastic butterfly needle tubing or 14-16 g plastic IV catheter Mineral oil or 1% lidocaine  ‣ Instrumentation under direct visualization Middle Ear Disorders: Terminology ◦ Middle ear effusion: fluid in middle ear cavity (occurs with acute otitis media & otitis media with effusion) ◦ Acute otitis media (AOM): acute bacterial infection of middle ear (suppurative otitis media) ◦ Otitis media with effusion (OME): middle ear fluid that is not infected (aka serous, secretory, or nonsuppurative otitis media) Acute Otitis Media (AOM) Acute bacterial infection of middle ear fluid (suppurative otitis media) Often due to obstruction of the eustachian tube usually precipitated by viral URI or seasonal allergic rhinitis (adults) Most common in infants & children (ages 6-24 months) Causes: bacteria > viruses ◦ Most common bacteria: Streptococcus pneumonia, Haemophilus influenzae, & Moraxella catarrhalis ◦ Viruses: rhinovirus, RSV, parainfluenza, coronarvirus, adenovirus, COVID-19 Signs & symptoms ◦ Young children/infants: fever, fussiness, disturbed or restless sleep, poor feeding/anorexia, vomiting, diarrhea ◦ Children: otalgia, ear rubbing, hearing loss, ear drainage +/- fever ◦ Adults: otalgia, decreased/muffled hearing, purulent otorrhea (TM rupture) DDx: OME, chronic otitis media, otitis externa, herpes zoster infection, other deep space head & neck infections PE & diagnosis: ◦ Accurate diagnosis is vital & otoscopy is necessary ◦ Cerumen removal may be necessary ◦ Classic exam findings: ‣ Middle ear effusion ‣ TM that is bulging, opaque, yellow, or white ‣ TM with decreased or absent mobility ‣ Pneumatic otoscopy: painful in children with AOM & not necessary with bulging TM ◦ Diagnosis is made clinically with either: ‣ Bulging of the TM or ‣ Perforation of TM with acute purulent otorrhea if acute otitis externa has been excluded ◦ Assess for position, mobility, color, & translucency ◦ Also assess for bulging, air-fluid levels, perforation, retraction pockets, & cholesteatoma Treatment for Children ◦ 2 strategies ‣ Immediate treatment with antibiotics: If NO antibiotics in prior month: amoxicillin 80-90 mg/kg/day divided q8h or q12h If received antibiotics in prior month: amoxicillin-clavulanate (Augmentin) 90/6.4 mg/kg/day PO divided BID Duration of therapy: 10 days for < 2 y/o & 5-7 days for > 2 y/o OR ‣ Observation with initiation of antibiotic therapy if signs & symptoms worsen or fail to improve after 48-72 hours (different criteria depending on reference used) NOTE: In most cases, you should treat children ages < 2 y/o with antibiotics. ◦ Pain control for both: PO ibuprofen or acetaminophen (alternate topical anesthetics), tympanocentesis, or myringotomy ◦ Children at risk for severe infection, complications, and/or recurrent AOM: ‣ Infants < 6 months ‣ Immunocompromised ‣ Toxic-appearing ‣ Craniofacial abnormalities (i.e., cleft palate) ◦ At-risk children get immediate antibiotic therapy ◦ Not at-risk children can get immediate antibiotic therapy or observation ◦ PCN/beta-lactam allergy: ‣ If no severe reaction (i.e., rash) or no known allergy to cephalosporin, use oral cephalosporin (i.e., cefdinir) ‣ If known severe PCN/beta-lactam allergy or known severe allergy to cephalosporins, (i.e., anaphylaxis, urticaria, angioedema, Stevens-Johnson syndrome), avoid cephalosporins & use a macrolide (i.e., clindamycin) Treatment for Adults ◦ Treat all adults with antibiotics! (& acetaminophen or ibuprofen for pain): ◦ Patients with no PCN allergy: ‣ Low-risk (most adults): Amoxicillin-clavulanate 875/125 mg 1 tab PO BID Amoxicillin-clavulanate 1000/62.5 mg 2 tabs PO BID ‣ High-risk: Amoxicillin-clavulanate 1000/62.5 mg ER 1 tab PO BID (lower weight or milder infection) ‣ Alternate: cephalosporin (i.e., cefpodoxime, cefdinir) ◦ Patients with PCN allergy: ‣ If no severe reaction (i.e., rash) or no known allergy to cephalosporin, use oral cephalosporin (i.e., cefdinir, cefpodoxime, cefuroxime) ‣ If known severe allergy to PCN or known severe allergy to cephalosporins (i.e., anaphylaxis, urticaria, angioedema, Stevens-Johnson syndrome), avoid cephalosporins & use doxycycline or a macrolide (i.e., azithromycin, clarithromycin) Middle ear effusion often proceeds AOM Persistence of middle ear effusion after the resolution of acute symptoms is common. Complications of untreated AOM: mastoiditis, labrynthitis, cholesteatoma, meningitis, brain abscess, epidural or subdural abscess, lateral or cavernous sinus thrombosis Referral criteria: ◦ Recurrent otitis media (> 2 episodes in 6-month period) ◦ Persistent hearing loss following AOM (> 1-2 weeks) ◦ Chronic TM perforation (> 6 weeks) Acute Otitis Media with TM Perforation (children & adults) Most heal spontaneously Treatment  ◦ No data showing benefit of combination topical & PO antibiotics vs PO antibiotics alone (children & adults) ◦ Children: PO antibiotics only ◦ Adults: If topical antibiotics added, avoid topicals with ototoxicity (aminoglycosides) & treat for 7-10 days ◦ Appropriate water precautions until healed Chronic Otitis Media (COM) Recurrent infection of middle ear and/or mastoid in presence of TM perforation Usually a consequence of recurrent AOM P. aeruginosa, Proteus species, S. aureus Hallmark: purulent aural discharge Symptoms: Hearing loss, aural fullness, otalgia, & occasionally vertigo ◦ Frequently associated with cholesteatoma (build-up of fatty tissue in ear) Diagnosis: persistent (6-12 weeks) purulent otorrhea with perforated TM despite treatment Treatment: ◦ Removal of infected debris ◦ Earplugs ◦ Topical antibiotic drops (ciproflaxin or ofloxacin) x 2-4 weeks ◦ Avoid aminoglycosides (ototoxicity) ◦ Consider PO ciprofloxacin ◦ Possible surgical reconstruction of TM Otitis Media with Effusion (OME) Also called serous otitis media Presence of middle ear effusion without signs of acute infection Often occurs after AOM, but may occur with ETD (in absence of AOM) More common in children (pre-school) than adults Rare obstruction of eustachian tube by mass (NP carcinoma) or radiation treatment (nasopharyngoscopy +/- CT for recurrent unilateral OME) Chronic OME: >(or = to) 3 months Risk factors: ◦ FHx of otitis media (otitis-prone parents) ◦ Bottle feeding ◦ Male ◦ Daycare (or in-person school) attendance ◦ Adenoidal hypertrophy ◦ Exposure to tobacco smoke ◦ Low socioeconomic status Signs & symptoms ◦ Conductive hearing loss (predominant) ◦ Other: feeling of ear fullness, tinnitus, balance problems Examination: ◦ Impaired mobility of TM ◦ Type B tympanometry ◦ Air-fluid levels +/- bubbles ◦ Amber (or gray) middle ear fluid ◦ Neutral or retracted TM Diagnosis: ◦ Standard otoscopy ◦ Pneumatic otoscopy (w/ bulb) ◦ Adjunctive testing: ‣ Audiology (CHL + flat tympanogram suggests OME) ‣ Tympanometry ‣ Acoustic reflectometry Treatment for children: ◦ Primary management options: ‣ Watchful waiting (most common) Not at option for children at risk for speech, language, or learning problems or abnormal hearing Also an option for children with mild CHL F/u: clinical evaluation & hearing tests q3-6 months ‣ Myringotomy with T-tube placement (w/wo adenoidectomy) ◦ Unproven/ineffective: antibiotics, PO & intranasal steroids, nasal balloon auto-inflation, antihistamines, decongestants, complementary & alternative therapies myringotomy alone ◦ Most cases spontaneously resolve in 3-6 months ◦ Potential indications for T-tubes: ‣ At risk for speech, language, or learning problems ‣ TM changes (retraction pockets) ‣ Persistent OME-associated hearing loss (threshold > or = to 40 dB) ‣ Bilateral OME > or = 3 months, unilateral > or = 6 months, or recurrent episodes Treatment for adults: ◦ Mild symptoms: no treatment/reassurance ◦ More symptoms: intermittent auto-insufflation ◦ Moderate symptoms due to seasonal allergic rhinitis: short-term ( age 80 Classifications: ◦ Normal: soft whisper (0-20 dB) ◦ Mild: soft spoken voice (20-40 dB) ◦ Moderate: normal spoken voice (40-60 dB) ◦ Severe: loud spoken voice (60-80 dB) ◦ Profound: shout (>80 dB) Types: ◦ Conductive ‣ Results from external or middle ear dysfunction ‣ Mechanisms: Obstruction (cerumen impaction, otitis externa) Mass loading (middle ear effusion, cholesteatoma) Stiffness (otosclerosis) Discontinuity (ossicular disruption) Other (congenital atresia, stenosis, foreign body, neoplasm) ‣ Most commonly due to cerumen impact & transient ETD ‣ Treatment: Usually correctable with medical or surgical therapy ◦ Sensorineural ‣ Results from deterioration of cochlea ‣ AKA age-related hearing loss (ARHL) ‣ Most common form is presbycusis ‣ Gradually progressive, predominantly high-frequency, & symmetrical ‣ Multifactorial causes: genetics, CV health, history of noise exposure, ototoxic drugs, smoking, DM, hypercholesteremia ‣ Other causes: excessive noise exposure, head trauma, & systemic diseases ‣ Auditory loss leads to social isolation, which increases cognitive decline ‣ Usually not correctable ‣ Traditional management: hearing aids ◦ Mixed (combination of conductive & SN) Evaluation ◦ Directed H&P (office test of hearing, Weber & Rinne) for all patients ◦ Exam of auricle & EAC for patients with CHL ◦ Formal audiologic testing for patients without obvious cause ◦ MRI or CT for patients with progressive asymmetric SNHL (r/o acoustic neuroma) ◦ Glucose, CBC w/diff, TSH & serologic test for syphilis for patients with unexplained SNHL ◦ Evaluation by otolaryngologist for patients with unclear cause (urgent referral for sudden HL) Hearing amplification ◦ Indicated for patients with HL not correctable by medical therapy ◦ Contemporary hearing aids contained in EAC or behind ear ◦ Bone-conducting hearing aids for CHL or unilateral profound SNHL ◦ Cochlear implants provide auditory rehabilitation for adults with severe to profound sensory HL External Ear Neoplasms Malignant: ◦ Squamous cell carcinoma (SCC): most common neoplasm of EAC ‣ Suspect if apparent otitis externa fails medical therapy ‣ Get biopsy Benign: ◦ Adenomatous tumors from ceruminous glands Middle Ear Neoplasms Primary middle ear tumors are rare (possible glomus tumor) Pulsatile tinnitus & hearing loss Vascular mass may be visualized behind intact TM May present with cranial neuropathies (CN VII, IX, X, XI, XII) May warrant MRA & MRV to rule out vascular mass) Inner Ear Neoplasms Acoustic neuroma (vestibular schwannoma) Diagnosed with MRI Treatments: observation, surgical excision and/or radiation therapy NOSE & SINUSES Anatomy Review: Epistaxis Epidemiology: ◦ Single episode in 60% of adults; common reason for hospitalization ◦ 40 y/o Anterior nosebleeds often result from mucosal trauma or irritation: ◦ Trauma (nose picking, forceful nose blowing) ◦ Rhinitis  ◦ Nasal mucosal drying (low humidity, nasal oxygen) ◦ Foreign body (purulent discharge) ◦ Chronic intranasal drug (i.e., cocaine) ◦ Facial trauma ◦ Septal deviation ◦ Atherosclerotic disease ◦ Hereditary hemorrhagic telangiectasia ◦ Alcohol abuse ◦ Neoplasm Associations: ◦ Poorly controlled HTN ◦ Anticoagulation or antiplatelet medication (higher incidence, more frequent recurrence, more difficult to control, but not a cause of epistaxis) Symptoms: ◦ Bleeding from nares or mouth ◦ Most common in anterior septum (Kiesselbach's plexus) ◦ Hematemesis common; fresh or clotted blood History: ◦ Conditions that predispose to bleeding (tumors, coagulation disorders, recent trauma or surgery, medications, & other conditions (cirrhosis, HIV, cocaine use) ◦ Assess timing, frequency, & severity ◦ Comorbidities possibly exacerbated by blood loss (CAD, COPD) ◦ Related symptoms (chest pain, dyspnea, lightheaded) Physical exam (stable patient): ◦ Pre-treat/anesthesize nasal cavity: cotton swabs soaked in anesthetic & vasoconstrictive agents (i.e., lidocaine with epinephrine) ◦ Localize source: visualization with nasal speculum, headlamp, & suction (use eye protection) ◦ Head & neck exam Approach to management: ◦ First correct severe active bleeding & hemodynamic instability (airway intervention, fluid resuscitation, & otolaryngologic consultation may be necessary ◦ May safely address patients with normal appearance, vital signs, & respiratory function ◦ Labs/tests: ‣ PT/INR for anticoagulated patient ‣ Hct+ type & crossmatch for massive or prolonged hemorrhage ◦ Referral: ‣ Local ED for ongoing bleeding > 15 minutes (if not prepared/able to manage) ‣ Otolaryngologist: Recurrent Large-volume Episodic associated with nasal obstruction Initial treatment (anterior) ◦ Initial tamponade (anterior): ‣ Patient blows nose to remove blood & clots ‣ Clinician sprays nares with oxymetazoline (Afrin) ‣ Patient pinches mid-nose tightly for 10-15 minutes ◦ Cauterization (if source visualized): silver nitrate, diathermy, or electrocautery ◦ Packing: ‣ Anesthetic-vasoconstrictory solution pleglets - 4% lidocaine & topical epinephrine (1:10,000) ‣ Petrolatum gauze packing (not well tolerated) ‣ Compressed sponge (Merocel) ‣ Tampons ‣ Balloons (Rapid Rhino) ‣ Absorbable Materials (Surgicel, Gelfoam) Treatment (posterior) ◦ Insert posterior nasal packing: posterior (+/- anterior) balloon or Foley catheter (usually performed by otolaryngologist) ◦ Urgent ENT consultation & hospitalization (may require surgical cauterization) ◦ Hematology consultation for bleeding disorders & coagulopathies Sinus Anatomy Rhinitis Presence of one or more of the following nasal symptoms: ◦ Sneezing ◦ Rhinorrhea (anterior and/or posterior) ◦ Nasal congestion (stuffiness) ◦ Nasal itching  ◦ Cough Most common forms: ◦ Allergic ◦ Non-allergic (various forms) ◦ Atrophic ◦ Rhinitis of pregnancy ◦ Occupational Other forms: ◦ Rhinitis medicamentosa ◦ Chronic atrophic rhinitis ◦ Infectious Allergic Rhinitis AKA "Hay fever: Epidemiology: ◦ 5th most common chronic disease in the US ‣ Adults 20-30% ‣ Children ~40% Etiology: ◦ Pollens & spores (most common cause of seasonal AR) ◦ Flowering shrubs & tree pollen (spring) ◦ Flowering plants & grasses (summer) ◦ Ragweed & molds (fall) ◦ Dust, household mites, air pollution, & pet dander ("year-round" symptoms-perennial) Symptoms: ◦ Symptoms same as viral rhinitis (occur within minutes following exposure): nasal congestion, rhinorrhea (clear), nasal pruiritis, & sneezing ◦ Often accompanied by eye irritation, eye pruritis, conjunctival erythema, & excessive tearing ◦ Symptoms persistent & show seasonal variation ◦ Allergic triad: allergic rhinitis, asthma, atopic dermatitis ◦ May have strong family history of atopy (allergies) ◦ Must distinguish from non-allergic rhinitis Clinical features: ◦ Temporal pattern: ‣ Intermittent: < 4 days/week or < 4 weeks ‣ Persistent: > 4 days/week & > 4 weeks ◦ Severity: ‣ Mild: absence of the "moderate-severe" items ‣ Moderate-severe: > 1 of the following symptoms Sleep disturbance Impairment of school or work performance Impairment of daily actives, leisure, and/or sports Troublesome symptoms ‣ Other: Seasonal: symptoms at particular times of year Perennial: year-round symptoms Physical exam: ◦ Include nose, oropharynx, TMs, & eyes ◦ Nasal exam: ‣ Pale or violaceous/bluish turbinate mucosa (contrast with erythema of viral rhinitis) ‣ Turbinate edema ‣ Clear rhinorrhea ‣ Nasal polyps (yellowish, boggy masses) associated with long-standing AR ‣ Posterior pharyngeal rhinorrhea ‣ "Cobblestoning" of posterior pharynx ‣ TM retraction or middle ear effusion ‣ Infraorbital edema or darkening ("allergic shiners") Diagnosis: ◦ Clinical based on H&P (can use allergen-specific skin & serum diagnostic testing to improve outcomes) Management: ◦ Environmental control measures & allergen avoidance: ‣ Pollens and outdoor molds Daily pollen counts - higher on dry, sunny, windy days Keep windows closed Shower after exposure ‣ Indoor allergens (dust mites) Impermeable covers Wash in hot water every 2 weeks Remove carpets when possible (or treat) Keep indoor humidity low ‣ Animals Keep pets out of bedroom HEPA filters Bathe animals weekly Cockroach extermination ‣ Nonspecific triggers Smoke, strong perfumes, fumes, changes in temperature, outdoor pollution ◦ Nasal saline sprays & irrigations ◦ Pharmacotherapy: ‣ Intranasal corticosteroids (mainstay of therapy) (i.e., fluticasone)  ‣ Oral & intranasal antihistamines (i.e., fexofenadine, azelastine) ‣ Oral antihistamine/decongestant (i.e., fexofenadine/pseudophedrine) ‣ Intranasal cromolyn ‣ Intranasal anticholinergics (i.e., ipratropium bromide) ‣ Leukotriene receptor antagonists (i.e., montelukast) ◦ Pregnancy ‣ Intranasal cromolyn sodium: 1st line for mild disease (excellent safety profile) ‣ 2nd generation antihistamines preferred (loratidine & cetirizine) ‣ 1st generation antihistamines (chlorpheniramine) ‣ Intranasal glucocorticoids: TOC for moderate-to-severe disease ‣ Leukotriene inhibitor (montelukast): only if benefit before pregnancy (caution advised) ‣ Nasal saline rinse/lavage ‣ Avoid antihistamine nasal sprays, oral and nasal decongestants, initiating immunotherapy Non-Allergic Rhinitis Chronic presence of one or more of the four following cardinal symptoms of rhinitis, in the absence of a specific etiology (such as an immunologic, infectious, pharmacologic, structural, hormonal, vasculitic, metabolic, or atrophic cause): ◦ Nasal congestion ◦ Post-nasal drainage ◦ Sneezing ◦ Rhinorrhea F>M How to differentiate from allergic rhinitis: ◦ Later age of onset (usually > 20 y/o) ◦ More prominent nasal congestion & post-nasal drainage ◦ Weather conditions or respiratory irritants as triggers ◦ Symptoms of allergic conjuctivitis are absent Nonspecific stimuli ◦ Changes in temperature, humidity, barometric pressure ◦ Airborne irritants (odors, fumes, smoke) ◦ Exercise, sexual arousal, emotional factors ◦ Spicy food, alcohol (gustatory NAR) Treatment ◦ Topical intranasal glucocorticoids (i.e., budesonide) ◦ Topical antihistamine (i.e., azelastine) ◦ Combination glucocorticoid & antihistamine more effective (i.e., fluticasone/azelastine) ◦ Nasal saline irrigation Rhinitis Medicamentosa AKA "rebound nasal congestion" Medication-induced rhinitis caused by excessive use of OTC decongestant nasal sprays (i.e., oxymetazoline, phenylephrine) Edematous & erythematous nasal mucous membranes Treatment: withdrawal of offending agent, intranasal glucocorticoid ◦ MAX 3 DAY USE Rhinosinusitis AKA "sinusitis" Symptomatic inflammation of nasal cavity & paranasal sinuses Classification based on symptom duration: ◦ Acute rhinosinusitis: symptoms < 4 weeks ◦ Subacute rhinosinusitis: symptoms 4-12 weeks ◦ Chronic rhinosinusitis: symptoms persist > 12 weeks ◦ Recurrent acute rhinosinusitis: >/= 4 episodes ARS per year, with interim symptom resolution Acute Rhinosinusitis Acute rhinosinusitis (ARS) further classified based on etiology & clinical manifestations: ◦ Acute viral rhinosinusitis (common cold): ARS with viral etiology (majority of cases) ◦ Uncomplicated acute bacterial rhinosinusitis (ABRS): ARS with bacterial etiology without clinical evidence of extension outside the paranasal sinuses & nasal cavity (no neuro, eye, or soft tissue involvement)  ◦ Complicated ABRS: ARS with bacteral etiology with clinical evidence of extension outside the paranasal sinuses & nasal cavity Occurs in 1 of 7 or 8 persons each year in Western countries Incidence: F > M, highest in age 45-64 Viral ARS typically resolves in 7-10 days (complicated by acute bacterial infection in only 0.5-2.0% of cases) Most common bacteria associated with ABRS: ◦ Streptococcus penumoniae ◦ Haemophilus influenzae ◦ Moraxella catarrhalis Risk factors: older age, smoking, air travel, exposure to changes in atmospheric pressure, swimming, asthma & allergies, dental disease & immunodeficiency Symptoms: ◦ Nasal congestion & obstruction ◦ Purulent nasal discharge ◦ Maxillary tooth discomfort ◦ Facial pain or pressure that is worse when bending forward ◦ Other symptoms: fever, fatigue, cough, hyposmia or anosmia, ear pressure or fullness, headache, & halitosis Distinguishing between bacterial & viral infection: ◦ More common features of a true bacterial sinusitis (ABRS) ‣ Fever & symptom duration > 10 days ‣ Maxillary toothache ‣ Initial symptom improvement, then worsening of symptoms ("double worsening") ‣ Cacosmia (sense of bad odor in the nose) ‣ Unilateral facial pain **CT imaging is NOT helpful in differentiating viral & bacterial etiology! Physical exam: ◦ Vital signs, HEENT, sinus tendernes, lymph nodes, lung & heart examination ◦ Ask patient to bend forward to evaluate if pain is localized to the sinuses ◦ Evaluate for pain provoked by direct percussion of sinuses Diagnosis: ◦ Based on clinical signs & symptoms ◦ Diagnostic imaging is NOT required unless signs are present indicating complicated disease (such as diminished visual acuity, diplopia, periorbital edema, severe headache, altered mental status), or in cases of treatment-resistant sinusitis ◦ CT scan is the imaging procedure of choice if indicated (rare) Imaging ◦ Not indicated in patients with uncomplicated ARS ◦ If obtained, findings consistent with acute rhinosinusitis on CT include air-fluid levels, mucosal edema, & air bubbles within the sinuses ◦ However, these findings are nonspecific. Mucosal abnormalities are common among asymptomatic adults; same findings have also been observed in patients with the common cold ◦ Plain films are also NOT helpful due to poor sensitivity and specificity Treatment ◦ Acute viral rhinosinusitis: ‣ Supportive care (antibiotics NOT indicated): OTC analgesics & antipyretics: NSAIDs & acetaminophen Saline irrigation: buffered, physiologic, or hypertonic saline Intranasal glucocorticoids: short-term Others: intranasal saline spray, intranasal ipratropium bromide, oral decongestants, intranasal decongestants, antihistamines, mucolytics, & steam inhalation (tenting) ◦ Uncomplicated ABRS: ‣ Supportive care (same as AVRS) ‣ Observation or antibiotics (depending on patient follow-up) No penicillin allergy: Augmentin OR Penicillin allergy: ◦ Able to tolerate cephalosporins = Doxycycline or Cefixime or Cefpodoxime ◦ Unable to tolerate cephalosporins = Doxycycline Complications ◦ Pre-septal (periorbital cellulitis) ◦ Orbital cellulitis ◦ Subperiosteal abscess ◦ Osteomyelitis of sinus bones ◦ Meningitis ◦ Intracranial abscess ◦ Septic cavernous sinus thrombosis Complicated ABRS ◦ Indications for urgent referral: ‣ High, persistent fevers (> 102 degrees F) ‣ Evidence of complications on imaging ‣ Periorbital edema, inflammation, or erythema ‣ Cranial nerve palsies ‣ Abnormal extraocular movements ‣ Proptosis ‣ Vision changes (double vision or impaired vision) ‣ Severe & persistent headache ‣ Altered mental status ‣ Neck stiffness or other meningeal signs ‣ Pain with eye movement ‣ Papilledema or other sign of increased intracranial pressure ENT 3 Chronic Rhinosinusitis (CRS) Inflammatory condition involving paranasal sinsues & linings of the nasal passages lasting >/= 12 weeks Affects 5-12% of general population (children & adults); mean age at diagnosis 39 Abrupt onset or slow/insidious onset (months-years) Diagnosis requires objective evidence of mucosal inflammation Risk factors/associated conditions ◦ Allergic rhinitis ◦ Asthma ◦ Aspirin-exacerbated respiratory disease (AERD) ◦ Depression ◦ Smoking ◦ Irritants & pollutants ◦ Immunodeficiency ◦ Defects in mucociliary clearance (i.e., CF) ◦ Viral infections ◦ Systemic illnesses ◦ Dental infections ◦ Anatomic abnormalities ◦ Indoor dampness & mold exposure Clinical features ◦ Four (4) cardinal signs & symptoms in adults: ‣ 1. Anterior and/or posterior nasal mucopurulent drainage (opaque white or light yellow) ‣ 2. Nasal obstruction/nasal blockage/congestion (bilateral) ‣ 3. Facial pain, pressure, and/or fullness (headache) ‣ 4. Reduction or loss of sense of smell ** **In children, the 4th cardinal symptom is cough (instead of loss of smell) Suggestive of other conditions or complications requiring immediate evaluation: ◦ High fever ◦ Double (or reduced) vision ◦ Proptosis ◦ Dramatic periorbital edema ◦ Ophthalmoplegia (severe eye pain) ◦ Other focal neurologic signs ◦ Severe headaches ◦ Meningeal signs ◦ Significant or recurrent epistaxis Evaluation: ◦ Clinical history (4 cardinal symptoms, duration, risk/causative factors, previous Tx & imaging, previous surgeries, exposures) ◦ Objective documentation of mucosal disease using anterior rhinoscopy, nasal endoscopy, and/or CT w/o contrast (purulent mucus or edema, polyps, imaging showing mucosal thickening or partial or complete opacification of the paranasal sinuses) ◦ Allergy evaluation (optional testing; mainly perennial allergens) ◦ Consideration of immunologic defects & infectious complications (pts with recurrent episodes of acute purulent sinusitis; consider if h/o pulmonary infections or recurrent otitis media; labs and/or imaging for systemic diseases) DDx: ◦ Pain syndromes (various headaches) ◦ Rhinitis without sinusitis ◦ Laryngopharyngeal reflux ◦ Disorders of olfaction (head trauma, URIs, age) Diagnosis: ◦ Based on presence of suggestive symptoms + objective evidence of mucosal inflammation: ‣ Must have at least 2 of the 4 cardinal signs & symptoms ‣ Must be present for >/= 12 weeks ‣ Must have 1 or more findings on nasal endoscopy or CT: Purulent (not clear) mucus or edema in the middle meatus or ethmoid regions Polyps in the nasal cavity or the middle meatus Radiographic imaging demonstrating mucosal thickening or partial or complete opacification of the paranasal sinuses ◦ Subtypes: ‣ Three (3) distinct clinical syndromes/subtypes: CRS with nasal polyposis (20-33%)(Triad asthma/Samter's syndrome) Allergic fungal rhinosinusitis (AFRS)( 4500/microL) ◦ Peripheral smear: differential count > 50% (or atypical lymphocytosis) Treatment: ◦ Supportive (fluids, rest, acetaminophen or NSAIDs, no contact sports for minimum 3-4 weeks) ◦ NO antibiotics GABHS Pharyngitis Group A beta-hemolytic streptococcus (GABHS) Highest in children 5-15 Signs & symptoms: ◦ Acute-onset sore throat ◦ Fever ◦ Pharyngeal edema ◦ Patchy tonsillar exudates ◦ Prominent, tender, anterior cervical lymphadenopathy Supportive features (scarlet fever): ◦ Palatal petechiae ◦ Scarlatiniform rash ◦ Strawberry tongue Importance in accurate diagnosis: ◦ Prevent suppurative complications & ARF ◦ Prevent transmission ◦ Reduce duration & severity of symptoms Which adults to test: Patients with clinical features compatible with GABHS pharyngitis who lack symptoms of a respiratory viral syndrome Clinical features suspicious of GABHS in adults: ◦ Sudden onset of sore throat ◦ Fever ◦ Pharyngotonsillar and/or uvular edema ◦ Patchy tonsillar exudates ◦ Cervical lymphadenopathy (often tender & anterior) ◦ Scarlatiniform rash and/or strawberry tongue ◦ History of GABHS exposure When the need for testing is unclear, use Centor criteria to help guide decision to test: ◦ Pharyngotonsillar exudates ◦ Tender anterior cervical lymphadenopathy ◦ Fever ◦ Absence of cough Interpretation: ◦ >/= 3 criteria present: intermediate likelihood (test these patients) ◦ < 3 criteria present: unlikely (no benefit with testing) Diagnosis: ◦ For most patients with suspected GAS pharyngitis: ‣ Test with a sensitive rapid antigen detection (RADT) ‣ Follow-up throat culture not needed If positive RADT, treat with antibiotics If negative RADT, additional testing not needed ‣ Reserve throat culture to confirm negative RADT in selected patients: High-risk for severe complications (i.e., h/o ARF or immunocompromised) Close contact with high-risk people (i.e., caring for infants, immunocompromised) Living in areas of high GAS prevalence (i.e., college dorms) Living in areas of ARF endemic or active epidemics High clinical suspicion for GAS despite negative RADT (i.e., exposure to persons with GAS, >/= 3 Centor criteria) Treatment: ◦ Empiric treatment without microbiologic confirmation not recommended ◦ Analgesic (i.e., NSAIDs, acetaminophen) ◦ PO antibiotic preferred 1st line (i.e., penicillin VK, cefuroxime, cefpodoxime) x 10 days ◦ PO antibiotic for PCN allergy (i.e., erythromycin, azithromycin) ◦ Antibiotic for compliance problem or unable to take PO meds (i.e., benzathine PCN or procaine PCN as single IM injection)  Complications of GABHS: ◦ Rheumatic fever ‣ Rare - 1 case per 100,000 ‣ Joint swelling/pain, subcutaneous nodules, erythema marginatum, myocarditis, chorea ‣ Lab: elevated ESR/CRP ◦ Poststreptococcal glomerulonephritis: ‣ Intrinsic renal failure ‣ Hematuria, systemic edema ◦ Peritonsillar abscess: ‣ Rare, < 1% ‣ Toxic appearance ◦ Scarlet fever: ‣ Punctate, erythematous, blanchable, sandpaper-like exanthem ‣ Neck, groin, axillae ‣ Accentuated in body folds and creases (Pastia's lines) ‣ Strawberry tongue Gonococcal pharyngitis Sexually active patients Signs & symptoms: ◦ Fever ◦ Sore throat ◦ Dysuria ◦ Greenish exudate Treatment: ◦ Ceftriaxone 250 mg IM PLUS Azithromyocin 1 gm PO x 1 dose Diphtheria Signs & symptoms: ◦ Sore throat ◦ Low-grade fever PE: ◦ Adherent grayish membrane (at back of throat) ◦ Tender cervical adenopathy Treatment: ◦ Antitoxin + Antibiotic ‣ Erythromycin 500 mg IV QID OR PCN G 50,000 units/kg IV q12h Salivary Disorders Sialadenitis General: ◦ Acute swelling of the parotid or submandibular gland ◦ Can also be seen with dehydration and chronic illness ‣ Sjogren's syndrome, chronic periodonitis Cause: ◦ Often bacterial - S. aureus Signs & symptoms: ◦ Increased pain and swelling with meals Physical examination: ◦ Tenderness and erythema of the duct opening ◦ Pus often massaged from the duct Treatment: ◦ Hydration, warm compresses ◦ Sialagogues - lemon drops ◦ Massage the gland ◦ IV antibiotics (PO for less severe cases) Suppurative Parotitis Acute infection of parotid gland (viruses & bacteria) Typically S. aureus & mixed oral aerobes & anaerobes Most common in debilitation, dehydration, & poor hygiene, particularly among elderly postoperative patients Consider mumps in children & young adults; sarcoidosis ◦ Evaluate testicles (epididymo-orchitis) Signs & symptoms: ◦ Firm, erythematous swelling ◦ Pain and tenderness ◦ Possible trismus & dysphagia ◦ Systemic: fever & chills Exam: ◦ Possible purulence from Stenson's duct Diagnosis: ◦ US (preferred initially), CT, MRI ◦ Elevated Sr amylase in absence of pancreatitis ◦ Gram stain & culture discharge Treatment: ◦ Inpatient hydration & IV antibiotics ◦ Surgical I&D if no response in 48 hours OTHERS Pre-Cancer (Leukoplakia) White adherent patch or plaque Premalignant lesion Risk factors: ◦ Tobacco ◦ Dentures ◦ Lichen planus 2-6% dysplasia or early SCC Diagnosis: biopsy Treatment: ◦ Watchful waiting ◦ +/- excision Oral Hairy Leukoplakia White, corrugated & painless plaques usually on lateral tongue Plaques cannot be scraped off Prevent in HIV, organ transplant, malignancy, steroids (systemic or inhaled) Associated with EBV Not considered premalignant Treatment not usually indicated ◦ Antivirals may provide temporary resolution Oral Cancer - Squamous Cell Carcinoma Risk factors: ◦ Increasing age ◦ Tobacco use ◦ Alcohol use Physical examination: ◦ Raised, firm, white lesions with ulcers at base ◦ Can lead to nodularity or ulceration ◦ Usually involves the lateral surface of the tongue ◦ Quite painful with gentle palpation Diagnosis: biopsy Treatment: surgery/radiation Upper Airway Foreign Body More common in young children One study of 1,068 foreign body aspirations ◦ 3% in larynx ◦ 13% in trachea ◦ 52% in right main bronchus ◦ 6% in right lower lobe bronchus ◦ 18% in left main bronchus ◦ 5% in left lower lobe bronchus Signs & symptoms ◦ Sudden episode of choking or coughing ◦ Subsequent wheezing, coughing, or stridor ◦ 1/3 of parents were unaware of the aspiration or remembered an event that occurred more than a week prior Airway management (children under 3) ◦ 5x back blows ◦ 5x chest thrusts ◦ Alternate Airway management (adults) ◦ Heimlich maneuver Esophageal Foreign Body Usually due to food bolus impaction ◦ Most will pass spontaneously (80%) ◦ Peak incidence between 6 months & 6 years ◦ Small batteries (necrosis/perforation) Complete obstruction: drooling, inability to handle secretions Airway management Treatment: flexible endoscope ◦ Glucagon 1.0 mg IV (relaxes the esophagus) Emergent Airway Management Cricothyroidotomy ◦ Quick, relatively easy stab through cricothyroid membrane ◦ Insert any small round airway such as a biro casing ◦ Anesthetic not essential ◦ Life saving Formal tracheostomy ◦ Not usually an emergency ◦ Needs full anesthetic ◦ Ideal for temporary or permanent intubation ◦ Hole cut in 2nd & 3rd tracheal rings