Nose, Pharynx, Larynx.pdf

Respiratory System Consists of 2 functional parts: ○ Conducting portion Upper respiratory system– nose and pharynx Passageways inside and outside the lung that filter, warm and moisten the air; conduct it to the lungs ○ Re...

Respiratory System Consists of 2 functional parts: ○ Conducting portion Upper respiratory system– nose and pharynx Passageways inside and outside the lung that filter, warm and moisten the air; conduct it to the lungs ○ Respiratory portion Larynx, bronchi and lungs Its where gas exchange occurs Nose External portion: (cartilaginous framework) ○ Septal cartilage ○ Lateral nasal cartilages ○ Alar cartilages (part of the walls of the nostrils) Covered w/ muscle and skin Internal nose ○ Connects w/ the pharynx through two internal nares ○ Nasal cavity (divided by the nasal septum) Right or left ○ Nasal concha Superior, middle, inferior Are bone extensions, covered my mucosa, receive the name as turbinate ○ Lined w/ mucous membrane Nose functions ○ Warms, moistens, and filters the air ○ Detect olfactory stimuli (smell) Anosmia: lack of smell Hyposmia: decrease of smell ○ Contribute to voice resonance Hairs (cilia) in the nostrils help filter out large particles from incoming air Olfactory epithelium  ○ Olfactory receptors on the membrane lining the superior nasal conchae & nasal septum ○ Pseudostratified columnar epithelium secretes mucus to trap particles ○ Blood capillaries warm the incoming air Nasal FB Formed occasionally in young children, the intellectually impaired, and psychiatric patients Common objects: ○ Cotton, paper, pebbles, beads, seeds, beans, nuts, insects, and button batteries Unilateral, foul-smelling, bloody, or purulent rhinorrhea (yellow or greenish secretion) Can be removed in the office w/ a nasal speculum and Hartmann nasal forceps (topical phenylephrine) General anesthesia is necessary if the FB is painful Epistaxis Nose bleeding, move head down; do not tilt head back as they can swallow blood and blood is irritate to tummy and will vomit Range from a trickle to a strong flow Swallowed blood is a gastric irritant (patients also may describe vomiting blood) Common causes: ○ Local trauma (eg, nose blowing and picking) ○ Drying of the nasal mucosa (allergies, anterior part of the nose) ○ Hypertension (severe HTN, more posterior) Posterior ethmoid arteries can break and cause severe hemorrhage ○ Blood dyscrasias (hx) Most nose bleeds are anterior & stop w/ direct pressure and vasoconstrictors  Posterior epistaxis goes back to the throat, treated w/ gauze compression or ballon posterior pressure Screening for bleeding disorders is important Patients should always be asked about aspirin or ibuprofen use Rhinitis Inflammation of the nasal mucous membrane Viral is the most common reason to have rhinitis and allergic (Common in PR) Symptoms: ○ Nasal congestion ○ Rhinorrhea (watery*) ○ Variable associated symptoms (eg, itching in the nose, sneezing, watery eyes, watery purulent rhinorrhea, anosmia- due to chronic and atrophic rhinitis) Cause: ○ Usually viral (common cold) ○ Irritants Diagnosis - Clinical Treatment ○ Humidification ○ Corticosteroid spray Flonase, Rhinocort, Nasacort, Nasonex is recommended. Should be used consistently to treat allergies and can take up to 2 weeks to take effect. Afrin, Sinex severe, NeoSynephrine, Dristan are nasal decongestants that should only be used for severe, acute symptoms and for less than 3 days Not recommended to use chronically ○ Antihistamines, decongestants Loratidine, Cetirizine, Diphenhydramine Pseudoephedrine, phenylephrine [Zyrtec-D, Claritin-D, etc.]- decongestants ○ Bacterial superinfection requires appropriate antibiotic treatment (rhinorrhea is yellowish/greenish secretion, watery anymore) Augmentin (Amoxicillin/Clavulanic acid) 250 for children or 500 mg for adults / 125 mg TID x 7 days, QID in severe but most of the time TID Suspension is available for children if they cannot swallow pills Zithromax 500 mg qd x 3 days Allergic to PCN Acute rhinitis (No more than 2 weeks, still have sense of smell, exposure to pollen) ○ Cough, low-grade fever, nasal congestion, rhinorrhea & sneezing Chronic rhinitis ○ Manifestation are similar to those of acute rhinitis, but in prolonged or severe cases ○ Also have thick, foul-smelling, mucopurulent drainage  ○ Mucosal crusting and/or bleeding Atrophic rhinitis ○ Crust formation, gives anosmia, and epistaxis that may be recurrent and severe Anosmia Complete loss of smell Can be from trauma (ethmoid bone fracture and the nerves that go to olfactory are affected) Hyposmia is the partial loss of smell (can be from inflammatory, URTI, common flu) ○ Part of normal aging Common causes include ○ URI, sinusitis, and head trauma Cranial imaging is typically required unless the cause is obvious Other causes ○ olfactory neuroepithelium destroyed Treatment ○ Specific causes are treated; however, smell does not always recover even after successful treatment of sinusitis Pharynx Funnel-shaped tube ○ From the internal nares to the cricoid cartilage (larynx) Functions: ○ Passageway for air and food ○ Voice resonance ○ Houses the tonsils (immunity) Uvula ○ Hangs in the midline at the far end of the soft palate ○ Varies greatly in length Divided in: ○ Nasopharynx Entrance of air ○ Oropharynx  2 fauces (pass food, drinks and air) ○ Laryngopharynx Opens into the esophagus (food passage) and larynx (passage of air) Tonsils and adenoids are patches of lymphoid tissue surrounding the posterior pharynx ○ Combat infection Can be affected by inflammation, infection, trauma, tumors, etc. Pharyngitis Sore throat that results from infection (pain in the posterior pharynx with or w/out swallowing) Sore throat results from infection The most common cause: tonsillopharyngitis Rarely: abscess or epiglottis Treatment ○ Broad-spectrum antibiotic Augmentin (Amoxiclav) 250 or 500 mg / 125 mg TID x 7 days Zithromax 500 mg qd x 3 days Symptomatic treatments Warm saltwater gargles Topical anesthetic (Benzocaine) Analgesics and antipyretics Tonsillopharyngitis Predominantly a viral infection Lesser number of cases are caused by bacteria The respiratory viruses (rhinovirus, adenovirus, influenza, respiratory syncytial virus) are the most common viral causes Most common cause of bacterial infection is group A β-hemolytic streptococci (GABHS) Uncommon bacterial causes include gonorrhea, diphtheria, mycoplasma (give Azithromycin), and chlamydia Accompanied by URI symptoms (runny nose, cough) GABHS infection overlap significantly a viral infection ○ Tonsillar exudate ○ Tender lymphadenopathy  ○ Fever ○ Absence of cough Treatment ○ Penicillin 1.2-2.4 million IM inj one dose ○ Amoxicillin 500 mg TID x 10-14 d ○ Allergy to penicillin: Erythromycin 400 mg QID x 10-14 d Clarithromycin 500 mg q 12 hr for 7-14 d Azithromycin 500 mg daily x 3 d ○ Pharyngeal abscess An abscess in the pharyngeal area ○ Peritonsillar ○ Parapharyngeal ○ Retropharyngeal (children) Uncommon but causes significant throat pain, severe fever The usual causative organism is GABHS Tx as in tonsillopharyngitis  Epiglotitis The epiglottis is flap of cartilage located in the throat behind the tongue and in front of the larynx Is usually upright at rest allowing air to pass into the larynx and lungs When a person swallows the epiglottis folds backward to cover the entrance of the larynx so food and liquid do not enter the lungs After swallowing the epiglottis returns to its original upright position Signs and symptoms: ○ Fever ○ Signs of respiratory distress (tachypnea, dyspnea, stridor) complaining of troubled breathing ○ Abrupt onset of severe throat pain and dysphagia ○ Usually with no preceding URI symptoms ○ Drooling ○ Muffled, “hot potato” voice Occur primarily in children Usually was caused by Haemophilus influenzae type B Causal organisms in children and adults include: ○ Streptococcus pneumoniae, Staphylococcus aureus, nontypeable H. influenzae, Haemophilus parainfluenzae, β-hemolytic streptococci, Branhamella catarrhalis, and Klebsiella pneumoniae ○ HiB is still a cause in adults and unvaccinated children HiBis still a cause in adults and unvaccinated children Severe sore throat in a patient with a normal-appearing pharynx should raise suspicion of epiglottitis Tx: corticosteroids and antibiotics ○ Ceftriaxone is the most common  Sialadenitis Bacterial infection of a salivary glands (parotid, submandibular, and sublingual glands) Usually due to an obstructing stone or gland hyposecretion More common: ○ in the parotid gland ○ 50s and 60s ○ Patients with xerostomia (Sjögren syndrome) ○ Received radiation therapy to the oral cavity The most common causative organism is Staphylococcus aureus Symptoms and Signs ○ Fever and chills ○ Unilateral pain and swelling ○ Tenderness of the gland ○ Erythema and edema of the overlying skin ○ Pus can often be expressed from the duct ○ Focal enlargement may indicate an abscess Diagnosis ○ CT, ultrasonography, and MRI ○ Gram stain and culture Treatment ○ Antibiotics ○ Local measures (warm compresses, hydration, massage) ○ Pain relief w/ analgesics (eg NSAIDs, if pt is allergic to NSAIDs, acetaminophen is ok. If really severe, corticosteroids but are not really used in children) ○ Antibiotic therapy Amoxicillin/Clavulanate Clindamycin 7 MG/KG/D children, adult 450 mg QID x 7d  Adenoids Rectangular mass of lymphatic tissue in the posterior nasopharynx Largest in children 2 to 6 yr Enlargement may be secondary to viral or bacterial infection, allergy, irritants, and, possibly, gastroesophageal reflux Severe hypertrophy can obstruct the eustachian tubes (causing otitis media) Hypertrophy or inflammation common among children Symptoms include ○ Nasal obstruction ○ Sleep disturbances ○ Mouth breading ○ Middle ear effusions with hearing loss ○ Hyponasal voice ○ Halitosis ○ Recurrent otitis media Diagnosis ○ Flexible nasopharyngoscopy Treatment ○ Treatment of cause ○ Sometimes adenoidectomy ○ Underlying allergy is treated with intranasal corticosteroids ○ Underlying bacterial infection is treated with antibiotics ○ In children with persistent middle ear effusions or frequent otitis media - adenoidectomy ○ Some require tympanostomy tubes  Larynx Voice box Connects laryngopharynx with trachea Part of the lower respiratory system Cartilaginous walls ○ Thyroid cartilage (Adam’s apple) – anterior ○ Cricoid cartilage – inferior ○ Arytenoid cartilages posterior Epiglottis ○ Elastic cartilage ○ Moves over the larynx during swallowing ○ Roots food and liquids Glottis ○ True vocal cords and the space b/w them Voice production ○ Vestibular folds (false vocal cords) One or two pairs of mucous membrane folds of the larynx ○ Vocal cords (true vocal cords) One pair of deep bands of elastic ligaments  Laryngeal disorders include various benign and malignant tumors, contact ulcers, granulomas, laryngitis, laryngoceles, spasmodic dysphonia, vocal cord paralysis, and vocal cord polyps and nodules or acute laryngotracheobronchitis Most laryngeal disorders cause dysphonia A persistent change in the voice ( > 3 wk) requires visualization of the vocal cords Internal visualization by laryngoscopy with a topical anesthetic Laryngoscopy with the patient under general anesthesia allows for biopsy When relaxed, the vocal cords normally form a V-shaped opening that allows air to pass freely through to the trachea The cords open during inspiration and close during swallowing or speech Laryngitis Inflammation of the larynx Usually the result of a virus or overuse Acute change in the voice, with decreased volume (aphonia) and hoarseness Laryngoscopy is required for symptoms persisting > 3 wk Viral laryngitis is self-limited Coughing-induced laryngitis may also occur in bronchitis, pneumonia, influenza, pertussis, measles, and diphtheria Excessive use of the voice (especially with loud speaking or singing) Other: allergic reactions, gastroesophageal reflux, bulimia, or inhalation of irritating substances (cigarette smoke or certain aerosolized drugs) Drugs can induce laryngeal edema, for example, as a side effect of ACE inhibitors Bacterial laryngitis is extremely rare Diagnosis ○ Clinical evaluation ○ Sometimes direct or indirect laryngoscopy Treatment ○ Symptomatic treatment Cough suppressants Voice rest Steam inhalations  Polyps, Nodules, and Granulomas Acute trauma or chronic irritation causes changes in the vocal cords that can lead to polyps, nodules, or granulomas Judicious surgical removal restores the voice, and removal of the irritating source prevents recurrence Symptoms and Signs ○ All result in slowly developing hoarseness and a breathy voice Diagnosis ○ Laryngoscopy ○ Sometimes biopsy ○ Diagnosis is based on direct or indirect visualization of the larynx with a mirror or laryngoscope ○ Biopsy of discrete lesions to exclude carcinoma is done by microlaryngoscopy Polyps ○ Polyps and nodules result from injury to the lamina propia of the true vocal cords ○ Occur at the mid-third of the membranous cords ○ Often unilateral ○ Several other causes: gastroesophageal reflux, untreated hypothyroid states, chronic laryngeal allergic reactions, or chronic inhalation of irritants, such as industrial fumes or cigarette smoke ○ Larger and more protuberant than nodules ○ Nodules  ○ Usually occur bilaterally at the junction of the anterior and middle third of the cords ○ Cause is chronic voice abuse yelling, shouting, singing loudly, or using an unnaturally low frequency ○ Granulomas ○ Occur in the posterior glottis against the vocal processes ○ Can be bilateral or unilateral ○ Usually result from intubation trauma ○ May be aggravated by reflux disease ○ Carotid pulse palpation and auscultation Bruits (“noises”) ○ Rushing sounds heard over medium and large arteries ○ Caused by vibrations of the blood vessel walls induced by turbulent blood flow ○ Caused by partial vessel lumen occlusion ○ Atherosclerotic plaque Atherosclerotic plaque is more common at the proximal and distal ends of the common carotid artery (bifurcation places) Auscultation helps to screen for atherosclerotic plaque formation  Carotid auscultation ○ Carotid artery integrity assessment– palpation and auscultation Indications for auscultation: ○ Amaurosis fugax ○ Transient ischemic attacks (TIA) ○ Hollenhorst plaques ○ Retinal occlusion ○ Asymmetric diabetic retinopathy ○ Anterior segment ischemic syndromes Carotid auscultation– double-head stethoscope ○ Bell: transmit better low frequency sounds (heart and vascular sounds) ○ Diaphragm: transmit better high frequency sounds (lung) ○ 1 inch above the clavicle Ask stop breathing in mid-expiration for a few seconds Hear Resume breathing Repeat the procedure 2 or 3 times along the length of the carotid Repeat in the other side ○ When a bruits is present– Blowing or “wooshing” type sound will be heard superimposed on the normal sound of the pulse Bruits be louder in the obstructed portion of the artery ○ Carotid bruits are indicative of poetically life-threatening cerebrovascular or cardiovascular disease Palpation of the Carotid Pulse ○ Grades: Grade 0: no pulse Grade 1+: detectable but faint pulse Grade 2 +: stronger pulse but decreased in intensity Grade 3 +: normal pulse Grade 4 +: bounding or forceful pulse  ○ ○ Atherosclerotic plaque will reduce carotid blood flow ○ Evident diminished pulse by palpation Precautions and contraindications ○ Do not apply excess pressure Interrupt blood flow Occlude the vessel with an atherosclerotic plaque Induce a TIA Not do it bilaterally (blood flow interruption)