HEENT Disorders of Nose, Sinus, Larynx, Pharynx Student Copy PDF

Clinical Medicine II: Disorders of the Nose, Sinus, Pharynx and Larynx MARAH CZAJA, MPAS, PA-C CLINICAL MEDICINE: SPRING 2025  Objectives 1) Summarize the etiology, pathophysiology, clinical features, how diagnosis is esta...

Clinical Medicine II: Disorders of the Nose, Sinus, Pharynx and Larynx MARAH CZAJA, MPAS, PA-C CLINICAL MEDICINE: SPRING 2025  Objectives 1) Summarize the etiology, pathophysiology, clinical features, how diagnosis is established, potential complications and treatment for the conditions listed below: Acute rhinosinusitis (viral & bacterial) Chronic sinusitis Allergic rhinitis Vasomotor rhinitis Olfactory Dysfunction Nasal polyps  Objectives 2) Determine the indications and management of allergy testing. 3) Summarize the etiology, pathophysiology, clinical features, how diagnosis is established, potential complications and treatment for the conditions listed below: Viral pharyngitis Streptococcal infection Laryngitis Laryngopharyngeal reflux Acute and chronic hoarseness Rheumatic fever Mononucleosis  Acute viral rhinosinusitis = common cold Etiology: numerous viruses (rhinoviruses, adenoviruses, etc) One is susceptible their entire life Benign & self-limited but lead to or exacerbate chronic conditions such as _________  Acute viral rhinosinusitis What are 3 forms of transmission? _________  Acute viral rhinosinusitis: diagnosis Sxs: sore throat, nasal congestion, rhinorrhea, hyposmia Associated malaise, HA, cough, conjunctivitis 10d sxs, severe sx or complicated 1st line: amoxicillin-clavulanate PCN allergic pts: doxycycline or clindamycin + cephalosporin Refer to ENT if doesn’t resolve w/ abx or there is any concern for complications.  Chronic sinusitis > 12 wks CT scan ENT referral Reasons to admit: __________  Allergic rhinitis = “hay fever” 20-30% adults, up to 40% children often family history of atopic disease. What is the atopic triad? ______ Risk factors for allergic rhinitis: ______ Etiology: seasonal pollens/spores Year round sxs: dust, household mites, air pollution, pet dander etiologies  Allergic rhinitis: diagnosis Sxs: clear rhinorrhea, sneezing, tearing, eye irritation & pruritus Associated postnasal drip, cough, bronchospasm, eczematous dermatitis Similar to viral rhinitis but persistent & may be seasonal Allergic rhinitis: diagnosis Physical findings: The nasal mucosa frequently has a pale bluish hue or pallor along with turbinate edema Clear rhinorrhea may be visible anteriorly, or if the nasal passages are obstructed, rhinorrhea may be visible dripping down the posterior pharynx Allergic rhinitis: diagnosis Hyperplastic lymphoid tissue lining the posterior pharynx, referred to as ______ Nasal polyps may be present d/t hypertrophic mucosa from long-standing dx Allergic rhinitis: diagnosis Physical findings Infraorbital edema and darkening , referred to as ______ Accentuated lines or folds below the lower lids, referred to as ______ A transverse nasal crease, referred to as ______  Allergic rhinitis: treatment Intranasal corticosteroids: mainstay of tx May take 2 wks for sx improvement Shrink hypertrophic nasal mucosa/polyps Antihistamines: Non-sedating More immediate relief but temporary Adjuncts: antileukotriene (montelukast), intranasal anticholinergics  Allergic rhinitis: treatment Avoid allergens Plastic covering to mattress/pillows Synthetic materials for animal products (i.e. down, wool) Remove dust collecting surfaces (i.e. carpet, rugs, drapes) Room air cleaner and vacuums with a high-efficiency particular air (HEPA) filter Regulation of humidity Control potential sources of allergen (eg. rodents, cockroaches, pets)  Allergenic testing Allergist referral w/ severe or non-resolving sxs Testing Types Immunoassays for immunoglobulin E (IgE) Blood test Bioassay Skin testing When should skin testing not be performed? ______ Allergy Immunotherapy-Treatment Allergen Immunotherapy (AIT) is the only disease-modifying treatment available for common allergic diseases Repeated subcutaneous injections of increasing amounts of allergen  Vasomotor rhinitis Aka non-allergic rhinitis (NAR) Increased sensitivity to the vidian nerve Common cause of clear rhinorrhea in elderly pts Sxs: rhinorrhea in response to stimuli such as ______ PE: normal or erythematous mucosa; Similar tx to allergic rhinitis  Olfactory Dysfunction = hyposmia or anosmia Etiology: MC anatomical blockage of nasal cavity à airflow obstruction Polyps, septal abnormalities, nasal tumors Can have transient blockage w/ illness or allergies  Olfactory Dysfunction: diagnosis Sxs: ↓ sense of smell or taste PE: look for visible nasal obstruction (polyp, foreign body, trauma, mass) Olfactory testing by ENT but can do gross scent evaluation  Olfactory Dysfunction: Treatment No specific tx Some may spontaneously resolve Degree of hyposmia correlates w/ likeliness of resolution Patient education: food seasoning, smoke alarms, electric not gas appliances  Nasal polyps Nasal polyps are benign growths in the nose or sinuses nasal polyps are benign growths in the nose or sinuses Pathophysiology likely inflammation + genetic Associated with other conditions: asthma, aspirin allergy, cystic fibrosis, allergic rhinitis, chronic sinusitis Samter’s triad = ______  Nasal polyps: diagnosis Sxs: Nasal congestion, rhinorrhea, anosmia PE: nasal cavity w/ pale, edematous, glistening mass covered in mucosa  Nasal polyps: treatment Sweat chloride test in all children for _______ Glucocorticoids are the mainstay of management Consider short dose oral corticosteroids, surgical excision  Let’s Practice! Vignettes-Give Dx and Tx Case 1: A 35-year-old female presents with nasal congestion, facial pressure, and yellow nasal discharge for the past 8 days. She reports a low-grade fever and worsening symptoms, including increased facial pain and fever over the last two days. She denies recent antibiotic use or a history of chronic sinus issues. Case 2: A 60-year-old male complains of progressive loss of smell over the last year, significantly impacting his ability to taste food. He denies nasal congestion or recent upper respiratory infections but has a history of smoking and Parkinson’s disease. Case 3: A 28-year-old woman presents with sneezing, itchy eyes, clear nasal discharge, and nasal congestion for the past two months, particularly worse in the spring. She denies fever or facial pain but has a history of eczema and asthma.  Let’s Practice! Vignettes-Give Dx and Tx Case 4: A 45-year-old male complains of nasal congestion, facial discomfort, and a postnasal drip that has persisted for over 12 weeks. He denies fever but reports fatigue and a diminished sense of smell. A CT scan of the sinuses reveals mucosal thickening and sinus opacification. Case 5 : A 40-year-old male with a history of asthma and aspirin sensitivity presents with bilateral nasal obstruction, anosmia, and a sensation of fullness in his nose. Examination reveals pale, edematous masses in the nasal passages. Case 6: A 40-year-old woman complains of persistent nasal congestion, yellow-green nasal discharge, and severe facial pain localized over her left maxillary sinus for 14 days. She reports a fever of 102°F for the past 3 days and describes worsening symptoms after initially feeling better. Case 7: Case: A 50-year-old man reports year-round nasal congestion and rhinorrhea that worsens with strong smells, temperature changes, and spicy foods. He denies sneezing, pruritus, or seasonal variation. Antihistamines have provided minimal relief. Break!  Pharyngitis Key to differentiate viral etiology from bacterial (group A beta hemolytic Streptococcal) infection Group A? ________ Beta hemolytic? _______ Other pathogens: Gonorrhea, Mycoplasma, Chlamydia Avoid unnecessary abx & associated resistance Important to diagnose given complications of _______. Viral Pharyngitis Acute viral pharyngitis is the most common cause of sore throat, accounting for up to 70-90% of cases. It is caused by various viruses that affect the upper respiratory tract. Common Viral Pathogens: Rhinovirus (most common cause) Coronavirus (non-SARS-CoV-2 strains in most cases) Adenovirus Influenza and parainfluenza viruses Epstein-Barr virus (EBV) (infectious mononucleosis) Coxsackievirus (herpangina or hand-foot-and-mouth disease) Respiratory syncytial virus (RSV) Herpes simplex virus (HSV)  Viral Pharyngitis Clinical Manifestations: Symptoms of viral pharyngitis are typically mild to moderate and self-limiting. General Symptoms: Gradual onset, Sore throat (may be mild to severe), Fever (low-grade, 1 year old). Rest: Adequate sleep and reduced physical activity.  GAS Pharyngitis: diagnosis What are the purple words on this slide called? Sxs: sore throat, F > 38ºC, absence of cough Rhinorrhea & lack of exudate suggest viral etiology HA, N/V/abd pain more common in kids PE: Tender cervical LAD, pharyngotonsillar exudate Tonsillar erythema & edema, soft palate petechiae Scarlatiniform rash, odynophagia GAS Pharyngitis: Diagnosis  Pharyngitis: diagnosis MDCalc Modified Criteria: ________ criteria: Presence of 5: strongly suggest GABHS 2-4: intermediate likelihood GABHS 1: unlikely GABHS MDCalc Criteria  Pharyngitis: diagnosis MDCalc Modified Rapid Ag testing (takes 15 m) Criteria: Throat culture if RADT negative 0-1 criteria: No testing or abx 2-3 criteria: Cxs or rapid testing 4 criteria: Empiric therapy  Streptococcal pharyngitis: treatment IM penicillin one time if compliance concerns PO Penicillin V potassium or cefuroxime (amoxicillin for kids as taste profile better) Macrolide for PCN allergic Supportive care: analgesics, anti-inflammatories, corticosteroids, salt water gargles, lozenges  Laryngitis Most common cause of hoarseness Larynx = ___________ Can persist 1 week + after other sxs resolved Etiology: viral, can be M. catarrhalis , H. influenzae, or S. pneumo  Laryngitis: diagnosis Sxs: vocal hoarseness, breathiness, vocal fatigue often in setting of other URI sxs PE: Voice quality complete HEENT exam Also consider cranial nerve function, respiration.  Laryngitis: treatment Vocal rest Supportive treatment (fluids, humidified air) mucolytics, anti-reflux medication, and NSAIDs can be considered Antibiotics despite etiology not generally recommended PO/IM corticosteroids in professional vocalists à requires vocal cord visualization by ENT prior since inflamed vocal cords are at higher risk of hemorrhage https://www.youtube.com/watch?v=GMS8dEtfis4  Laryngitis: treatment ENT referral if > 2 wks or other warning signs Duration > 2 weeks in absence of acute upper respiratory sxs, especially in smokers or alcoholics No obvious cause Pain (not due to known reason) Hemoptysis Dysphagia Neck mass Unilateral otalgia Weight loss Stridor, shortness of breath  Laryngopharyngeal reflux = gastroesophageal reflux into the larynx Recall the GERD Alarm Sxs: Diagnosis after exclusion of other hoarseness 1. etiologies via laryngoscopy (ie tumor) 2. 3. Only 1/2 pts have typical GERD sxs 4.  Laryngopharyngeal reflux: diagnosis Sxs: hoarseness, throat irritation, chronic cough Associated post-nasal drip, throat clearing, esophageal spasm and asthma Sxs typically when upright Laryngoscope evaluation by ENT to exclude other diagnoses  Laryngopharyngeal reflux: treatment Empiric trial of PPI since no gold standard for tx Diagnose made from + response to PPI Sxs in larynx take 3-6 mos to demonstrate improvement PPI tx failure à suggests other etiology Non-responders need pH testing, manometry  Rheumatic fever = systemic autoimmune process that can occur 2-4 weeks following group A streptococcal pharyngitis More common in developing countries Peak age 5-15 years Mortality 1-2%...but w/ persistent carditis up to 30% kids die w/in 10 yrs Can involve _____ valve  Rheumatic fever: diagnosis Acute RF: 2-3 weeks s/p infection Progressive valvular deformity, new murmur, CHF, CP, SOB, cough Carditis, arthritis, chorea, subcutaneous nodules & erythema marginatum Chronic RF: valvular stenosis or regurgitation secondary to RF attack  Rheumatic fever: Jones criteria Two major or 1 major + 2 minor = dx Major Minor Carditis (clinical/subclinical) Polyarthralgia Polyarthritis Chorea Erythema marginatum Subcutaneous nodules Rheumatic fever: Major jones criteria Carditis: Pericarditis Cardiomegaly Heart failure Mitral regurgitation ALL suspected cases of RF need an echo  Rheumatic fever: Major jones criteria Erythema marginatum: rapidly increasing macules, rings, or crescents with clear centers, usually on trunk or proximal extremities. Subcutaneous nodules: uncommon except in kids, small, firm, nontender  Rheumatic fever: Major jones criteria Chorea: involuntary movements of face, tongue, upper extremities Polyarthritis: migratory, involves large joints, sequentially  Rheumatic fever: Minor Jones criteria Fever –usually ≥38.5°C orally (101.3°F). Arthralgia – Arthralgia usually involves several joints (polyarthralgia) when it occurs in patients with ARF. Elevated acute phase reactants –ESR ≥60 mm/hour and CRP ≥3 mg/dL (≥30 mg/L). Prolonged PR interval on electrocardiogram  Rheumatic fever: treatment Strict bed rest until afebrile, normal ESR/EKG NSAIDS ↓ fever & joint pain Penicillin IM to eradicate infection Prevent w/ detection & tx of strep! PCN x at least 5 years to prevent recurrence  Mononucleosis Etiology: __________ Young adults 12-19 y/o primarily impacted Effects 95% adult population Pharyngitis but also salivary glands involvement, lymphocytes in the tonsils Transmission via saliva, also genital secretions Incubation period of several wks & saliva transmissible up to 6 mos after onset 1/3 pts have secondary streptococcal pharyngitis  Mononucleosis: diagnosis Sxs: fever, malaise, sore throat, anorexia, myalgia early on PE: Marked discrete posterior chain LAD, splenomegaly (50% pts), fatigue, upper lid edema (Hoagland sign) ,tonsillar exudate, palatal petechiae, maculopapular rash  Mononucleosis: diagnosis Lymphocytic leukocytosis + heterophile agglutination test (Monospot) Elevated anti-EBV titer (performed if rapid testing not + & high clinical suspicion) Consider strep test  Mononucleosis: treatment Supportive care: NSAIDs/acetaminophen, throat gargles, hydration, rest Avoid ______ as leads to rash & may be interpreted as PCN allergy Pt education: ________ Complications: hepatitis, myocarditis, neuropathy, encephalitis, airway obstruction d/t adenitis, hemolytic anemia, thrombocytopenia  Review How would you differentiate bacterial vs. viral rhinosinusitis? How would you differentiate viral vs. streptococcal pharyngitis? Recall the Jones major/minor criteria. Evaluate the labs for mononucleosis diagnosis. Questions?