ENT 3 - Nose & Sinus Disorders, Oropharyngeal Disorders, PDF

ENT 3 Professor Boucher South College Where Dreams Find Direction  TOPICS Nose & sinus disorders: chronic rhinosinusitis, invasive fungal rhinosinusitis, foreign bodies, trauma Nasopharyngeal & paranasal sinus neoplasms: pol...

ENT 3 Professor Boucher South College Where Dreams Find Direction  TOPICS Nose & sinus disorders: chronic rhinosinusitis, invasive fungal rhinosinusitis, foreign bodies, trauma Nasopharyngeal & paranasal sinus neoplasms: polyps, inverted papillomas Oropharyngeal disorders Oral cancer  INSTRUCTIONAL OBJECTIVES Describe the epidemiology, etiology, clinical manifestations, diagnosis, and management of epistaxis, nasal polyps, rhinitis, rhinosinusitis, and nasal trauma (LO 1-5, 7). Identify and describe etiology, clinical manifestations, diagnosis, and management of foreign bodies of the nose (LO 1-5, 7). Demonstrate the evaluation, diagnosis, and management of some common benign and malignant neoplasms of the nasopharyngeal and paranasal sinuses (LO 1-5, 7).  INSTRUCTIONAL OBJECTIVES Identify and describe the clinical manifestations, diagnosis, and treatment of diseases of the teeth/gums including necrotizing ulcerative gingivitis (LO 1-5, 7). Identify and describe the clinical manifestations, diagnosis, and treatment of infectious/inflammatory oropharyngeal disorders including aphthous stomatitis/ulcers, candidiasis, deep neck infection, epiglottitis, herpes simplex/labialis, laryngitis, peritonsillar abscess, and pharyngitis (LO 1-5, 7). Identify and describe the clinical manifestations, diagnosis, and treatment of salivary disorders including sialadenitis and parotitis (LO 1-5, 7).  INSTRUCTIONAL OBJECTIVES Identify and describe the clinical manifestations, diagnosis, and treatment of oropharyngeal trauma (LO 1-5, 7). Identify and describe the clinical manifestations, diagnosis, and treatment of other oropharyngeal disorders including leukoplakia (LO 1-5, 7). Identify and describe the clinical manifestations, diagnosis, and treatment of oral squamous cell carcinoma (SCC) (LO 1-5, 7). Identify and describe etiology, clinical manifestations, diagnosis, and management of foreign bodies of the larynx and pharynx (LO 1-5, 7).  CHRONIC RHINOSINUSITIS (CRS) Inflammatory condition involving paranasal sinuses & 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  CHRONIC RHINOSINUSITIS Risk factors/associated conditions Allergic rhinitis Defects in mucociliary Asthma clearance (i.e., CF) Aspirin-exacerbated respiratory disease Viral infections (AERD) Systemic illnesses Depression Dental infections Smoking Anatomic abnormalities Irritants & pollutants Indoor dampness & mold Immunodeficiency exposure  CHRONIC RHINOSINUSITIS 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)  CHRONIC RHINOSINUSITIS Danger signs & complications Suggestive of other conditions or complications requiring immediate evaluation: High fever Double (or reduced) vision Proptosis Dramatic periorbital edema Ophthalmoplegia Other focal neurologic signs Severe headache Meningeal signs Significant or recurrent epistaxis  CHRONIC RHINOSINUSITIS 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)  CHRONIC RHINOSINUSITIS 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  CHRONIC RHINOSINUSITIS Subtypes Three (3) distinct clinical syndromes/subtypes: CRS with nasal polyposis (20-33%) Allergic fungal rhinosinusitis (AFRS)(50% (or atypical lymphocytosis) emedicinehealth.com 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 ages 5-15 Signs & symptoms: Acute-onset sore throat, fever, pharyngeal edema, patchy tonsillar exudates, & prominent, tender, anterior cervical lymphadenopathy Supportive features: palatal petechiae, scarlatiniform rash, & strawberry tongue  GABHS PHARYNGITIS Importance of accurate diagnosis: Prevent suppurative complications & acute rheumatic fever (ARF) Prevent transmission Reduce duration & severity of symptoms  GABHS PHARYNGITIS Which adults to test: Patients with clinical features compatible with GABHS pharyngitis who lack symptoms of a respiratory viral syndrome Up-To-Date algorithm: “Evaluation of acute pharyngitis in adults” Clinical features suspicious for GABHS in adults: Sudden onset of sore throat Fever Pharyngotonsillar and/or uvular edema Patchy tonsillar exudates Cervical lymphadenopathy (often tender & anterior) Scarlatiniform skin rash and/or strawberry tongue History of GABHS exposure  GABHS PHARYNGITIS When the need for testing is unclear, use Centor criteria to help guide decision to test: Per Current: 0-1: very low risk for Pharyngotonsillar exudates GABHS-do not need Tender anterior cervical lymphadenopathy rapid testing or Fever culture. Absence of cough 2-3: need rapid testing, treat if Consider patient age (more likely in those 3-14 yrs positive, if negative old) then treat with Interpretation: supportive measures, but send for throat > 3 criteria present: intermediate likelihood (test culture. these patients) 4: high risk for GABHS < 3 criteria present: unlikely (no benefit with so these can receive testing) empiric antibiotics without testing. (However, if rapid testing is available-use it! If negative-send for culture).  GABHS PHARYNGITIS Diagnosis: For most patients with suspected GAS pharyngitis: Test with a sensitive rapid antigen detection test (RADT) Follow-up throat culture not always needed If positive RADT, treat with antibiotics If negative RADT, additional testing not usually needed If RADT negative, when should we get a throat culture? See next slide   GABHS PHARYNGITIS Diagnosis (continued): Reserve throat culture to confirm negative RADT in selected patients: Children High-risk for severe infection or 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)  GABHS PHARYNGITIS Treatment: Analgesic (i.e., NSAIDs, acetaminophen) PO antibiotic preferred 1st line (i.e., penicillin VK, cefuroxime, cefpodoxime) x 10 days Can also use amoxicillin 500mg BID 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)  GABHS PHARYNGITIS Complications of GABHS: Acute rheumatic fever (ARF): 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, edema  GABHS PHARYNGITIS Complications of GABHS: Peritonsillar abscess: Rare,