HEENT Notes PDF

HEENT Ear (Hearing): - Conductive Hearing loss: Due to dysfunction of external auditory canal, ossicles, or TM. - Sensory-Neural Hearing loss: Caused by dysfunction of cochlea or neural components - Mixed Hearing loss: Both conductive and sensory - Weber Test: Tuning fork in center...

HEENT Ear (Hearing): - Conductive Hearing loss: Due to dysfunction of external auditory canal, ossicles, or TM. - Sensory-Neural Hearing loss: Caused by dysfunction of cochlea or neural components - Mixed Hearing loss: Both conductive and sensory - Weber Test: Tuning fork in center of forehead - Normal: BIL ears - CHL: Sound to bad ear - SNHL: Sound to good ear - Rinne Test: Mastoid then shoulder - Normal: AC>BC - CHL: AC=BC or BC>AC - SNHL: AC>BC - Middle Ear Effusions and Conductive Hearing Loss: - Nonmobile TM - Treat: Observe for 3 months - Note: Antihistamines and oral steroids are not useful - Otosclerosis: Stapes loses mobility by excessive bony growth at oval window - Increased osteoblastic and osteoclastic activity and vascular proliferation - Most common location: Anterior stapes footplate - Presents as progressive CHL that is BIL - Treat: Refer to ENT - Medications: Sodium fluoride and bisphosphonates - Sudden Sensory-Neural Hearing Loss - Rapid onset within 72 hours, typically involves one ear - Risk factor: Viral infection/environmental allergies - Treat: Refer ASAP, prescribe high dose oral steroids - Acoustic Neuroma: Schwann cell derived tumors- vestibular portion of CN VIII - Risk factors: Neurofibromatosis - Signs: Unilateral SNHL and tinnitus, balance problems - Exam: CN VII asymmetry in large tumors - Treat: Observation, high dose oral steroids, surgical resection - Hereditary SNHL: Unknown origin - Syndromic exam findings: SNHL typically symmetric - Non-syndromic exam findings: Cookie bite, U-shaped - Treatment: Amplification - Autoimmune SNHL: Rheumatoid arthritis, SLE - Often BIL and progressive - Treat: Refer to ENT, corticosteroids  - Presbycusis: Age related SNHL - Loss of hair cells at basal turn of cochlea - Treatment: Amplification - Acoustic Noise Trauma: Second most common cause of SHL - Loss typically begins in high frequencies - Treatment: Noise/hearing protection - Tinnitus: Ringing/buzzing/roaring noises - Hyperacusis: Excessive sound sensitivity - Symptoms worse with stress, anxiety, fatigue, caffeine, ASA/Ibuprofen - Treat: Amplification, antidepressants Ear (External): - Seborrheic dermatitis: Scaling and erythema usually affecting auricular fold - Can predispose cellulitis - Psoriasis: Scaly silver plaques - Atopic dermatitis: Prominent excoriation - Contact Dermatitis: Due to irritant→ Nickel in earrings - Skin cancer: Squamous cell most commonly - Lack subcutaneous tissue→ consider when treating - Cellulitis: Infection of the pinna, staph most common - Perichondritis: Pseudomonas most common - Relapsing polychondritis: Rheumatologic disorder affecting tracheobronchial tree - Treat: Steroids - Epidermoid cyst: Proliferation of epidermal cells, usually benign - External Ear trauma: Common in wrestlers - Drained promptly→ Cauliflower ear - Needle within 6 hours - Incision up to 7 days - Congenital malformations: Treat by referring early! - Antonia: Absent external ear - Microtia: Small external ear - Atresia: Agenesis of the ear canal→ Conductive hearing loss - Ear canal: - Excessive cerumen: Remove with plastic curette or warm water - Foreign bodies: Do not flush organic material: Insects = Lidocaine first - Otitis Externa: Swimmers ear - Ear pain, itching, sometimes drainage - Treat: Clear external ear canal and antibiotic as needed - Exostoses: Abnormal growth of bone within ear canal “surfers ear” - Refer to rule out cholesteatoma Ear (Middle):  - Eustachian tube dysfunction: May result in negative pressure in middle ear - Sense of fullness in the ear “popping” “cracking” - Treat: Consider nasal steroids, decongestants - Rule out sudden hearing loss - Barotrauma: Consequence of poor eustachian tube function - Airplane descent, rapid altitude change, diving - Treatment: Topical decongestants prophylactic - Acute Otitis Media: Infection of middle ear space - Young children most commonly - Viruses: RSV, influenza, adenovirus - Bacteria: S pneumonia - Must be purulence to make the diagnosis - Treat: Amoxicillin high dose - Complications: - Perforation→ Increased pressure in middle ear - Mastoiditis→ Infection spreads from the middle ear to mastoid - Otitis Media Effusion: Fluid in middle ear space - Up to 3 months is normal - Tubes if needed - Treat: - Acute: Tympanocentesis→ Relief of pressure, seldom used - Chronic: Tympanostomy tubes → Spontaneously extrude - Ear drainage= good - Ear pain without drainage= Blockage - Tympanic membrane perforation: Observation, should heal in 3 months - Strict water precautions - Cholesteatoma: Accumulation of squamous cells in middle ear - Painless drainage, hearing loss - Treat: Refer, hearing test Ear (Vestibular): Meclizine is a medication often causing dizziness - Vertigo: Abnormal sensation of movement when none exists - Vestibular neuronitis: Not associated with SNHL - Labyrinthitis: Associated with SNHL - Treat: Benzodiazepines and anticholinergics for two weeks - Meniere's disease: - Vertigo, ear pressure/fullness, tinnitus, fluctuant hearing loss - Treat: Lipoflavonoid, diuretics - Benign Paroxysmal Positional Vertigo: Transient episodic vertigo - Caused by canalithiasis - Posterior semicircular canal most commonly  - Treat: Canalith repositioning maneuvers - Nystagmus: Involuntary rhythmic eye movement - Oscillopsia: Illusion of subtle movement or shimmering - Cupulolithiasis: Otolithic debris adhere to cupula - Vertigo is persistent and episodic - Canalithiasis: Clumping of otolithic debris in endolymph - Vertigo is transient and episodic - Superior semicircular canal dehiscence: Avoid loud noises Eye: - Hordeolum: Stye - Localized infection/inflammation - External: Eyelid/eyelashes - Internal: Meibomian gland - Most common: Staph aureus - Presentation: Eyelid redness, pain, swelling - Treat: Warm compress (>48 hours= I&D) - Chalazion: Noninfectious obstruction of meibomian gland - Painless, small nodule, deep cyst inside li - Treat: Warm compress - Blepharitis: Inflammation of eyelid margins - Associated with rosacea or seborrheic dermatitis - Staph: Red rimmed/dry scales→ Painful - Seborrhea: Greasy scales/pruritic - Treatment: Warm compress - Entropion: Inward turning of lower lid → corneal excoriation - Treat: Lubricant, botox - Ectropion: Outward turning of lower lid - Etiology: Cranial nerve VII palsy, age tissue relaxation - Treat: Symptomatic - Lid tumors: Most benign - Basal cell is most common malignant - Conjunctivitis: Most common eye disease - Viral more common than bacterial - Younger= bacterial - Older= viral - Viral: Adenovirus, bilateral disease, watery discharge - Treat: Symptomatically - Consider HSV: Unilateral with lid vesicles → Antivirals - Bacterial:Staph most commonly, purulent discharge, starts unilateral then bilateral. Eye is stuck shut.  - Treat: Antibiotics if needed, usually self limited - Bacterial Gonococcus: Copious discharge - Usually due to genital secretions - EMERGENCY! - Treat: IM Ceftriaxone - Bacterial Chlamydia: Trachomatis - Most common infectious cause of blindness - Treat: Oral antibiotics - Allergic Conjunctivitis: Itchiness - Vernal→ cobblestone papilla - Treat: Topical antihistamines - Dry eyes (Keratoconjunctivitis Sicca): - Inadequate tear production or accelerated tear evaporation - Symptoms: BIL, dryness, gritty/sandy, eye strain - Schrimer test→ Measure rate of production of aqueous component - Treat: Artificial tears - Pinguecula: Raised yellowish white mass, rarely needs to be removed - Pterygium: Fleshy triangular growth, removal is often indicated - Infectious keratitis: Infection of the cornea - Signs: Eye pain, discharge, eye redness - Treatment: High concentration topical antibiotic drops, ER - Herpes Simplex Keratitis: Corneal ulceration, dendritic branching - Treat: Antivirals - Herpes Zoster Ophthalmicus: Trigeminal nerve - Malaise, fever, Hutchinson's sign. - Treat: Oral antivirals - Fungal Keratitis: Contact with plants - Satellite lesions - Acanthamoeba Keratitis: Fresh water and hot tubs - Perineural and ring infiltrates - Treat: Long term intensive topical biguanide/diamidine - Dacryoadenitis: Inflammation of the lacrimal gland - Usually in children due to viral infection - “S” Shaped lid deformity - Treat: Symptomatic - Dacryostenosis: Nasolacrimal duct obstruction - Common in newborns/infants - Lack signs of infection - Treat: Gently massage downward massage - Dacryocystitis: Inflammation of lacrimal sac  - Commonly due to obstruction - Usually: Strep or staph - Treat: Systemic antibiotics - Adults: Postmenopausal women - Glaucoma: Damage to the optic nerve due to high intraocular pressure - Acute angle closure glaucoma: Physically obstructed anterior chamber - Primary: Preexisting - Secondary: No-preexisting - Symptoms: Rapid onset, extreme pain, halos and lights, nausea, vomiting - Exam: Hard eye, dilated and nonreactive pupil - Treat: Immediate ophthalmology referral→ reduce IOP - IV acetazolamide - Chronic Glaucoma: Irreversible cupping of the optic disc - Risk factors: Black, older, nearsighted, diabetic - Chronic open angle: Most common - Chronic angle closure: Flow of fluid into anterior chamber - Signs: Tunnel vision - Treat: Medication to lower IOP - Prostaglandins are preferred - Strabismus: Misalignment of eyes “cross eyes” - Tropia= constant misalignment - Phoria= intermittent misalignment - Pseudostabismus is NORMAL in kids - Treat: Patching, contact lenses/eyeglasses - Amblyopia: Lazy eye - Preventable if treated - Eye does not match the brain suppresses image from one eye to prevent double vision. - Presbyopia: Loss of accommodation due to aging - Myopia: Nearsightedness, focuses in front of retina - Hyperopia: Farsightedness, focuses behind retina - Astigmatism: Multiple focal points - Iritis (anterior uveitis): Inflammation of the iris - Unilateral eye pain, redness - May have hypopyon from layering of leukocytes/ ciliary flush - Treat: Refer to ophthalmologist - Uveitis Intermediate: Vitreous cavity - BIL, bilateral floaters and blurred vision - Snowballs - Treat: Systemic corticosteroids - Uveitis Posterior: Choroid, retina, vitreous - Floaters, cells in vitreous humor - Treat: Systemic corticosteroids - Scleritis: Inflammation of sclera - Symptoms: deep boring pain, worse at night, photophobia - Increased pain with ocular movements - Treatment: Varies - Cataracts: LEADING CAUSE OF WORLD BLINDNESS - Age related most common - Risk factor: Aging, smoking - Symptoms: Blurry/ghosting images, image problems with night driving - Congenital: Asymptomatic, leukoria (rule out tumor) - Treatment: Surgery - Corneal Ulcers: Most commonly infection - Risk factor: Extended contact lens wearers - Pain, photophobia, tearing - Treatment: Varies with cause ***EMERGENCY*** - Retinal Detachment: - Symptoms: Unilateral sudden flashes of lights, shower of floaters, shadow or curtain coming down, no pain or redness - Treat: Urgent referral to ophthalmologist - Vitreous Hemorrhage: Leakage of blood into vitreous humor - Symptoms: Sudden vision loss, bleeding within the eye - Eye NOT red/painful, unilateral more common - Red reflex diminished or absent - Treatment: Refer to ophthalmologist - Age-Related Macular Degeneration: Leading cause of permanent vision loss in elderly - Non-reversible, bilateral - Dry: Atrophic/geographic (ALL AMD starts as dry) - Progressive, BIL atrophy - Drusen - Treat: Oral antioxidants - Wet: Neovascular/exudative - New leaky vessel growth - Visual distortion straight lines appear crooked - Gray/green discoloration - Treat: Laser photocoagulation - Central and branch retinal vein occlusions: - Painless vision loss, first noticed upon waking, unilateral  - Blood and thunder, cotton wool spots, optic disc swelling - Treat: Refer - Complication: Neovascularization - Central and branch retinal arterial occlusion: MEDICAL EMERGENCY - Sudden painless, profound monocular vision loss - Red fovea (Cherry red spot), box-car segmentation, RAPD - Doppler ultrasonography - Treat: Refer to assess for a stroke - Amaurosis fugax: Transient ischemic attack - Sudden onset, monocular loss of vision usually lasting a few minutes with complete recovery. - Curtain passing vertically - Treatment: Aspirin→ look for cardiac returns - Refer for all - Diabetic Retinopathy: Noninflammatory retinal disorder retinal capillary closure and microaneurysms - Type 1 is most common - Pregnancy can impair blood glucose and worsen retinopathy - Nonproliferative: Develops first - Signs: Vision loss, blurriness - Treat: Optimize control of disease - Proliferative: More severe vision loss, neovascularization - Signs: Black spots/floaters, dot and blot, cotton wool spots - Treat: Optimize control of disease - Hypertensive retinopathy/choroidopathy: - Arteriovenous nicking (Copper/silver wiring), blurry vision, visual field defects, superficial flame shaped hemorrhages, yellow hard exudates, optic disc edema. - Risk factors: Smoking, DM - Treat: Aggressive BP control - Optic Neuritis: Inflammation of optic nerve - Strongly associated with demyleniating disease (MS) - Signs: Abrupt vision loss, periorbital pain, brow ache - Papillitis, flame shaped hemorrhage, temporal disc pallor - Treat: Corticosteroids - Optic Disc Swelling: Drusen associated with farsightedness - Papilledema: Swelling due to raised IOP, usually BIL - Oculomotor Palsies: Cranial nerves III, IV, VI innervate extraocular muscles - Symptoms: Double vision, pain on eye movement - Exam: Ptosis, pupil abnormalities - 3rd: Eye down and out  - 4th: Vertical hypertropia - 6th: Lateral movement - Nystagmus: Dancing eyes, limited vision - Congenital: Presents between 6 weeks and 6 months - Acquired: Medical conditions - Symptoms: rapid eye movements, sensitivity to light. - Treatment: Glasses, surgery, treat underlying disorder - Thyroid Eye Disease: Hyperthyroidism - Mucopolysaccharides in extraocular muscles - Symptoms: Exophthalmos, lid retraction and lag - Treatment: protection, corticosteroids - Orbital Cellulitis: Infection of orbital tissues - Organism: Strep - Symptoms: Tender, swelling, warm - Treat: High dose broad spectrum IV antibiotics - Preseptal Cellulitis: Infection of the eyelid surrounding skin - Organism: Staph - Symptoms: Swelling, decreased ocular motility, pain with eye movements, proptosis - Treat: Antibiotics - Conjunctival & Corneal foreign bodies: Something in my eye - Exam: Visual acuity test - Metabolic→ Iron → Rust ring→ Ophthalmology - Treat: Removal with damp, cotton tipped swab, or needle - Intraocular foreign body: Requires emergency treatment - Grinding equipment - Corneal Abrasion: History of trauma to the eye - Symptoms: Severe pain, tearing, foreign body sensation, blurry vision - Look for foreign body→ Evert upper lid - Contusions: Closed globe injury - Eyelid ecchymosis→ Black eye - Treat: Ice Packs, hot packs - Globe Trauma: Massive lid edema or laceration - Usually need immediate eye surgery - Hyphema: Anterior chamber hemorrhage - May cause glaucoma with permanent vision loss - Treat: bed rest and eye shield - Subconjunctival Hemorrhage: Bleeding under conjunctiva - Etiology: Surgery, straining, vomiting - Treatment: None required  - Lens Dislocation: Trauma, some hereditary conditions - Symptoms: Iris may quiver, lens appears off center on eye exam - Treatment: Permanent, glasses - Orbital fracture: Blunt trauma forces contents through orbital floor - Symptoms: Diplopia, posterior displacement of the eye, inferiorly displaced globe - Treat: Referral Teeth/Mouth: - Dental caries are the most common chronic disease of childhood - Most commonly in adolescents ages 12-19 - Bacterial metabolize sugars into acid which remineralize tooth enamel - Remineralization occurs when acid is buffered by saliva - The more frequent the consumption the decreased time for remineralization - Higher cavity risk areas: Newly erupted teeth - White lines/spots = first sign of demineralized enamel - Usually affecting upper front teeth - Dentin is in later stages and may be dark - Prevention: Brushin 2x/day and floss 1x/day - Fluoride guidelines: Main effect is topical mechanism - Less than 3= grain of rice - Older than 3= pea sized - Peridontitis is most common in adults - Associated with diabetes - HIV 16 DNA is involved in oral cancers - Xerostomia: Dry mouth due to decreased salivary flow - Steroids, antihistamines, diuretics, opioids - Signs: Dry mouth, burning sensation, changes in taste, difficulty swallowing - Treat: Encourage drinking water, avoid caffeine/sugary drinks - Oral exams should be performed at each well child visit - Gingivitis: Tenderness, mild gum swelling, redness, bleeding gums - Treat: Effective brushing and flossing - Periodontitis: Destruction of periodontal ligament - Can be halted but not reversed - Treat: Brushing and flossing - Gingival hyperplasia: Gingival enlargement, teeth are hard to clean - Treat: Oral hygiene and regular cleaning - Dental erosion: Teeth are smooth/glassy, pulp exposure caused heat/cold sensitivity - Treat: Rinse with water after reflux/vomiting, don’t immediately brush - Herpes Labialis: Burning, itching, crusting - Treat: Antiviral agents topical or oral - Pyogenic Granuloma: Erythematous, nonpainful, smooth, lobulated mass - Bleeds when touched - Treat: Conservative surgical excision - Oral ulcerations: Most common in aphthous minor - Symptoms: Recurring painful ulcers with erythematous halo - Treat: Magic mouthwash - Herpetic Stomatitis: Burning sensation then vesicle rupture buccal mucosa (inside mouth) - Treat: Antivirals - Necrotizing ulcerative gingivitis: Bleeding, halitosis - Treat: Penicillin x 10 days - Geographic tongue: Normal variant - Spicy foods, waxes and wanes - Treat: None needed - Hairy tongue: Asymptomatic, associated with tobacco use - Glossitis: Smooth tongue - Nutritional deficiencies: Iron, B12, folate - Treat: Underlying problem - Glossodynia: Burning mouth syndrome - Treat: Clonazepam - Fissured tongue: Normal variant, asymptomatic - Bony Tori: Benign arising from cortical plate - Treat: Surgery if needed - Candidiasis: Fungal infection oftenly pseudomembranous candidiasis (thrush) - Burning sensation, white/curd patches over red mucosa that CAN be rubbed off - Treat: Topical antifungal agents - Adult patient: Workup for HIV - Lichen Planus: Reticular white lacy striations - Treat: Corticosteroid gels or mouthrinses - Oral Hairy Leukoplakia: Hairy tongue on lateral sides - Common early HIV sign - Leukoplakia and erythroplakia: Premalignant, subtle white patch that progresses to ulcerate - Cannot be rubbed off - Treat: >14 days should be biopsied as they can be carcinoma or dysplastic - Oral Cancer: Usually squamous cell carcinoma - Risk factor: Tobacco and alcohol usage as well as HPV - Treat: Biopsy >14 days - Reversible pulpitis: Pain with hot/cold/sweet but resolves once removed - Treat: Dental filling - Irreversible pulpitis: Pain is severe and persistent, sensitive to percussion - Treatment: Root canal/tooth extraction - Periapical abscess: Purulent form for periapical periodontitis - Pain is well localized, abscess is draining - May cause cellulitis - Treatment: Urgent dental referral - Pericoronitis: Infection of a gum flap overlying partially erupted molars - Treatment: Irrigation - Periodontal abscess: Deep infection of tooth support structures - Tooth is loose and sensitive to touch - Treat: Analgesics - Alveolar bone fracture: Localized tenderness, step-offs in occlusion of teeth - Treat: Image with CT, dentist - Condylar fracture: Preauricular swelling, limited ability to open mouth - Treat: Refer - Intrusion of primary teeth: Do not remove tooth - Treat: Refer - Luxation: Lateral displacement though still in socket - Treat: Dental referral as needed - Avulsion of primary teeth: Completely knocked out of socket - Treat: Referral as needed - Fractures of primary teeth: - Simple crown fracture: Enamel and dentin - Crown fracture with pulp involvement: Enamel, dentin, and pulp- Urgent - Root fracture: Routing referral- not very detectable - Intrusion of permanent teeth: Do not attempt to remove tooth - Treat: Refer immediately! - Avulsion of permanent teeth: DO NOT touch root of tooth - TRUE DENTAL EMERGENCY - Medication effects: - Gingival hyperplasia: Anticonvulsants, methotrexate, cyclosporine - Dental erosion: Progesterone, nitrates - Osteonecrosis: Bisphosphonates - Dental caries: Sugar preparations - Most patient do not require antibiotic prophylaxis - Oral Pain: First line is NSAIDS - Angioedema: Hypersensitivity reaction: soft, non-itchy swelling of mouth/lips, tongue or cheeks - Rapid onset - Treat: Airway management (epinephrine) Throat: - Tonsillitis: Congestion with bacteria in the tonsils - Tonsillectomy indications: Recurrent infections, sleep apnea, gagging, one tonsil larger than other, bad breath. - 7 episodes/year - Adenoiditis: Junky nose- always feeling stuffed up - Unable to breath through nose, ill feeling/appearing, cervical lymphadenopathy - Long face, gummy smile, dry lower lip, mouth breathing - Adenoidectomy indications: Recurrent adenoiditis, sinusitis, persistent middle ear fluid, sleep apnea. - Pharyngitis: Viral > bacterial, more prevalent in winter, ages 4-7 - Bugs: Streptococcal, herpes/coxsackievirus, oral candida, GABHS - We treat GABHS to prevent sequelae! - Streptococcal further: Types include non-hemolytic and hemolytic - Symptoms: Sore throat, dysphagia, fever, malaise, headache, vomiting (kids!), absence of other upper respiratory infection symptoms. - Screening: Rapid strep antigen test (RST) - Center Criteria: - Fever or temperature - Absence of cough - Tender anterior cervical lymph nodes - Tonsillar swelling or exudates - Age 2mm or does not resolve - Salivary gland tumors: Often benign but need to be evaluated  - Parotid most likely to be benign and most common - Submandibular and sublingual more rare and more likely to be malignant - Signs: Painless swelling, gradual onset - Imaging: MRI - Treat: Refer to ENT Nose: - Allergic Rhinitis: - Typically presents at younger ages - Risk factors: Family history - Perennial allergic rhinitis increases the risk for sleep disorder - IgE mediated type I hypersensitivity - Sensitization→ IgE production → Mast cells → Mediators → Clinical signs - Perennial: Dust, mites, indoor molds, animal dander - Seasonal: Tree, grass, weed pollens - Occupational: Latex, chemicals, farm animals - Symptoms: Nasal congestion, rhinorrhea (clear/watery), pruritus, sneezing - Exam: - Eyes: Conjunctiva, watering, shiner - Nose: Boggy turbinates, wet, swollen nasal mucosa, itching - Increased occurrence in pregnancy - Diagnosis: Skin testing, CBC shows increased eosinophils - Swab for eosinophils - Prevention: Avoid irritants - Treatment: Corticosteroid nasal sprays - Avoid first generation antihistamines (sedating) - Antihistamine second generation is preferred - Mast cell stabilizers must start prior to symptom onset take weeks for effect - Leukotriene antagonist: Add on therapy→ Mental health effects - Saline irrigation: NEVER unboiled tap water - Oral Allergy Syndrome: Raw fruits, vegetables, and tree nuts - Itchy mouth/throat or swollen lips/tongue throat - I can eat blueberry muffins but NOT blueberries raw - Rhinitis medicamentosa: Rebound effect with continued use of topical decongestants - Afrin for too long, >3 days→ body compensates by creating more blood vessels - Can lead to atrophy of nasal mucosa - Treat: Stop nasal spray, use nasal steroids/oral steroids/IM steroids - Vasomotor and gustatory rhinitis= difficult to treat - Olfactory Dysfunction: Altered sense of smell - CN I (through cribriform plate)  - Smell and taste are closely related - Sense of smell decreases with age - Hyposmia: Reduced ability to detect odors - Anosmia: Inability to detect odors - Dysosmia: Change in normal odor perception - Phantosmia: Sensation of odor when none is present - Treat of transport loss: Treat underlying issue - Treat of sensorineural loss: No effective treatment - Safety counseling: Smoke detectors - Hyperosmia: Smell more than usual (pregnancy) - Normosmia: Normal sense of smell - Complications: Increased risk of food poisoning, environmental exposure, diminished satisfaction, social isolation. - Nasal Polyps: Benign lesions from middle meatus - Signs: Anosmia, soft, painless, benign (typically), chronic nasal congestion - Physical exam: Pale, edematous, mucosally covered masses peeled grapes - Arise from chronically inflamed sinonasal mucosa (ethmoid sinuses) - Children: Cystic fibrosis - Treat: Nasal saline irrigations (add budesonide), intranasal corticosteroids, surgery, allergy evaluation - ENT referral WITH maxillofacial CT - Polyps frequently come back - Nasal polyps + Asthma = NO ASPRIN - Epistaxis: - Airway assessment and cardiovascular stability - Etiology: - Local (A): Trauma, nose picking/blowing, surgery, dry air/irritants - Nasal pyramid is most frequently fractured bone in body - Systemic (P): Bleeding disorders, hereditary hemorrhagic, drugs, HTN - Anterior: Kiesselback’s plexus or Little’s area - Treat: Observation, anterior pressure, oxymetazoline, packing - Spray anesthetic with decongestant (Afrin) - Cauterization: Start from outside in - Bilateral cauterization may result in septal perforation - Nasal Packing: Absorbable gelfoam, vaseline gauze, surgicel - Usually just pack the side the bleeding is on (not both) - Packing: Form a tight seal to hold pressure→ Lubricate! - Add moisture to expand ONCE placed - Rhino-rocket: Add liquid prior to inserting - Insert horizontally→ inflate with air  - Expectations: Less frequent and less severe nosebleeds - Posterior: Woodruff’s plexus (venous), Sphenopalatine artery (more common) - Often elderly with underlying pathology - Bleeding from both nostrils, coughing up clots, blood in throat - Posterior are more difficult to control→ underlying etiology - EMERGENCY SERVICES!!! - Likely go to operating room very quickly - Control that blood pressure :) - Vitamin K, posterior packing, endoscopic cauterization - Prevention: Humidification measures, control BP, saline mist (especially for itchiness, can’t overuse it), monitor Warfarin/INR, avoid digital/FB trauma - Nasal Septal Hematoma: Uncommon→ secondary to nasal/septal fracture - Treat: Drained within 24 hours, nasal packing if needed - Risks: Infection, sepsis, cartilage death - Nasal Foreign Body: Common in young children/disabled adults - Most are inorganic (paper, duct tape, beads) - Inorganic/Porous/Organic material: Unilateral, purulent, foul smelling drainage - Inflamed nasal vestibule - Treat: Removal of FB - Urgent: Removal of button batteries and paired magnets across septum - ENT consultation for deep, impacted, penetrating FB - Early + Inorganic= Positive pressure, curved hook, balloon extractor - Later= ENT with/without oral antibiotics - Septal Perforation: Consider past drug use (cocaine), consider rhinitis medicamentosa - Systemic disease may be a consideration→ in kids - “Have you ever taken drugs through your nose” - Symptoms: Increased nasal sound, nasal dryness, epistaxis - Treatment: Increase nasal moisture, nasal button, reconstruction limited - Inverted Papilloma (Schneiderian Papilloma): - Signs: Unilateral and flesh colored, typically located on lateral nasal wall and middle meatus - Very uncommon→ HPV virus? - Findings: Unilateral nasal obstruction, facial pressure, headache, similar to nasal polyp - Mostly benign: 5-15% are squamous cell carcinoma - Treat: Surgical excision (medial maxillectomy) - Recurrence rates are high - Juvenile Angiofibroma: Slow growing tumor in young boys (Uncommon!) - Posterior nasal cavity growing into nasopharynx  - Girls= Gonadal dysgenesis - Treatment: Removal - Malignant Tumors: VERY RARE - Symptoms: Chronic rhinitis/sinusitis, unilateral ear pain, hearing loss - Nasopharyngeal malignant tumors - Nasopharyngeal carcinoma (squamous cell) - Most common cancer of nasopharyngeal cancer - Risk factors: Adult, race (Asians), EBV exposure - Adenocarcinoma/Adenoid cystic carcinoma (less common) - Sinonasal tumors - Risk factors: Wood dust, leather dust, asbestos - Most commonly from ethmoid sinuses - Lymphoma “Lethal midline granuloma” - Most commonly T-cell lymphoma - Bleeds quite a bit associated with Epstein-Barr Virus - Overall high cure rates - Paranasal sinuses and nasal malignancies - Squamous cell carcinoma- Maxillary Antrum (epicenter) - Lymphoma - Symptoms: Advanced: Proptosis, expansion of cheek, ill fitting maxillary dentures, severe pain, malar hypesthesia (infraorbital nerve is involved). - Risk Factor: Smoking - Treatment is higher if base of skull is NOT involved - Lower cure rates - Diagnostics: CT and MRI - Treatment: Depends on tumor type and extent (chemotherapy/radiation)