HEENT: Nose and paranasal sinuses

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179 terms

respiration, conduction, purifying, olfaction

Nose provides for functions of _____, _____ and _____ inspired air and _____

t

t/f: Nasal and sinus related disorders are among the most common reason patients now visit physicians in the United States. These may be sources of discomfort and cause lifestyle interruptions

anatomy of the nose

Nares, Turbinates, Meatus, Septum, Sinuses (frontal, maxillary, ethmoid, sphenoid), Kiesselbach plexus, Eustachian tube

f

t/f: Many disorders can be diagnosed by H & P
but need lab testing for diagnosis

major sx of nasal or paranasal disorder

obstruction (congestion), drainage, facial pain or headache, epistaxis, change in smell or taste

nasal obstruction

Can be caused by deviated nasal septum, turbinate enlargement, polyps, or mass lesions. It is a common symptom. Assess whether unilateral, bilateral, or alternating and if constant or intermittent

nasal obstruction

Constant or fixed could be anatomic problems (septum, polyps, mass). Intermittent or alternating relate to variations in turbinate size. Bilateral; polyps, allergy, complex deviation of septum. Unilateral; fixed lesion, polyp, mass, deviated septum, foreign body

nasal drainage

Rhinorrhea can be unilateral or bilateral, clear or discolored, watery, mucoid, color, tenacious (sticky or clumps). Unilateral means localized; unilateral sinusitis, CSF leak. Bilateral means systemic, sinusitis. Clear; vasomotor, nonallergic or allergic rhinitis. Thick and discolored suggests infection. Post Nasal drainage is more bothersome if the consistency is thicker. There is a sense of mucus in the throat, hoarseness, chronic throat clearing

facial pain and HA

May not be useful in differentiating disorders because many disorders have these symptoms: TMJ, migraines, tension headaches, dental caries

sinusitis

Severe facial pain with swelling over sinuses and purulent drainage usually related to _____

allergic conditions

_____ _____ may cause patient complaints of intermittent facial pressure associated with changes in weather, humidity, or other environmental factors

malignant tumors

Persistent unilateral facial pain without purulent rhinorrhea consider _____ _____

anosmia

complete loss of olfaction

hyposmia

decrease in sense of smell

parosmia/dysosmia

altered sense of smell

cacosmia

sensation of unpleasant smell (sinusitis)

phantosmia

hallucination of smells

presbyosmia

decrease is sense of smell in aging

nasal polyps; chronic sinusitis

Alterations in smell is common with _____ _____ and _____ _____

anosmia

can occur in any condition that affects nasal air flow to the region of the cribiform plate bilaterally

anosmia

without nasal obstruction can be caused by viral URI or severe head trauma. Bilateral causes of constriction consider chronic sinusitis, polyps. _____ and hyposmia can be from formaldehyde, lead poisoning, vitamin A deficiency, tobacco use, radiation therapy. rare cases are caused by are anterior cranial fossa meningioma, diabetes, hypothyroidism, pernicious anemia

anosmia

tx: Directed at cause, counsel with regards to smoke detectors, avoid excess perfume or cologne, control of body odors, attention to expiration dates of food

allergic symptoms

Sneezing, nasal or ocular pruritus, bilateral clear watery or mucoid nasal drainage, nasal congestion, pruritus of upper palate and ears, dry scratchy erythematous conjunctiva

dust; mite

_____ or _____ allergies are usually more symptomatic in morning and with exposure to upholstered furniture, mattresses, pillows, carpeting

mold

_____ allergies vary throughout the year.

dust; mold

_____ and _____ allergies may occur with congestion and nasal drainage without sneezing or pruritus

tree pollen

spring allergies are associated with _____ _____

grass

midsummer allergies are associated with _____

weed pollen

fall allergies are associated with _____ _____

tobacco smoke

_____ _____ causes congestion of turbinates, destruction of cilia, and alteration in mucous secretion cells of the nasal mucosa

smokers

_____ have increased symptoms of nasal congestion and thick Post Nasal Drainage. (May be predisposed to sinusitis)

phenylephrine

_____ can cause rebound affect (rhinitis medicamentosa): Causes swelling of the nasal turbinates

diuretics

_____ cause thickened, more tenacious secretions

hypertrophy

Beta blockers, reserpine, exogenous estrogen cause turbinate _____. can become irreversible if used long-term

cocaine

_____ can cause large septal perforations with bleeding

asbestos

Wood dust and _____ exposure can cause irritant effects

transillumination

_____ of the frontal sinuses occurs with normal or slightly thickened mucosa

2-3

Otoscope will view the anterior nares, the first _____cm

ENT physical exam

Nasal speculum with light; Anterior rhinoscopy: Visualization of the septum, inferior and middle turbinates. Portions of the nasopharynx and limited view into the middle meatus. Posterior rhinoscopy with a tongue blade, nasopharyngeal mirror and headlight can view the posterior choana, nasopharynx, eustachian tubes, posterior edge of the septum and inferior turbinates

f (before and after)

t/f: Perform an ENT exam only after topical decongestants are given

nasal smears

_____ _____ can help differentiate sinusitis from allergic or nonallergic by determining type of white cells present. eosinophils - allergic cause. neutrophils - infection. CBC is sometimes helpful in bacterial (neutrophil) vs viral (lymphocytes). Immunologic studies: Elevated IgE; allergic. Sinus Films - CT most useful for paranasal sinuses. Allergy testing helpful.
Allergen-specific IgE test. Scratch test.

common disorders

Epistaxis, Common cold
Trauma, Acute and Chronic sinusitis, Deviated septum, Turbinate hypertrophy, Nasal vestibulitis, Nasal polyposis, Allergic, nonallergic, vasomotor rhinitis

epistaxis

May accompany almost any pathology of nose, nasopharynx, or paranasal sinuses. Most common cause is break in prominent capillary vessels along the anterior septum (Kiesselbach's Plexus or Little's Area). Most common site of bleeding is Kiesselbach Plexus. Usually with local trauma (Digital Extraction, nose blowing, sneezing, Foreign Body, infection, allergic rhinitis). If the scab dislodges, bleeding may recur. Systemic causes (anticoagulation, coagulopathies)

epistaxis

tx: Inspect and evacuate clots by suction. Patient seated upright apply firm pressure to the nares for 10-15 mins. Identify the site of bleeding and anesthetize with lidocaine. Cauterize w/ a silver nitrate stick. Place packing and leave in for 24 hours. Topical vasoconstrictive agents oxymetazoline - 2 sprays every 12 hours for 3 days can be helpful if persistent. Improve humidity. Petroleum jelly. Nasal saline sprays and water based lotion can prevent recurrences. education important

posterior epistaxis

Woodruff's plexus. Uncommon and significant. The bleed cannot be visualized by anterior rhinoscopy. More common in adults. Cause: Acute trauma and bleeding. Generally arterial. Presentation: Blood may be seen in the posterior pharynx. May cause airway compromise

posterior epistaxis

tx: Often requires ENT consult. Posterior packing placed. Monitor for Toxic Shock Syndrome from retained packing. Often admitted, placed on supplemental oxygen and monitored for hypoxemia. Antibiotic often used. Last resort is ligation of the internal maxillary and ethmoidal arteries

recurrent

_____ epistaxis: humidify air, saline spray, vaseline petroleum jelly, antibiotic ointment

deviated septum

_____ _____ may cause bleeding along the defected portion of the septum

sinusitis

Blood with purulent drainage suggests acute _____

t

t/f: Tumors are a rare cause of nasal bleeding

juvenile nasopharyngeal angiofibroma

Adolescent male with profuse bleeding consider _____ _____ _____

acute viral rhinosinusitis

aka the common cold. inflammation of all mucosa of nose and paranasal sinuses. Cause: Rhinovirus, coronavirus, respiratory syncytial virus (RSV), additional viral causes. Rhinoviruses cause at least ½ of all common cold illnesses

acute viral rhinosinusitis (the common cold)

Sx: Malaise, fatigue, occasionally a low grade fever possible (>38C suggests influenza or bacterial infection), chills, cough, sore throat. Nasal sx: obstruction, clear rhinorrhea, pressure over sinuses, blocked ears, stuffy nose. In children a fever for the first 2-3 days is not unusual. Anterior cervical lymph node enlargement can occur. Cold may last 10-14 days in infants and children

acute viral rhinosinusitis (the common cold)

Labs: WBC predominance of lymphocytes Tx: Management is supportive. Antipyretics, analgesics, oral decongestants/adrenergic agents (pseudoephedrine), antihistamine 1st generation, rehydration, symptoms resolve 5-8 days. Nasal saline spray or short term use of nasal decongestant. Ipatropium bromide nasal spray (Atrovent) anticholinergic

f

t/f: abx are effective in the treatment of the common cold

5-8

common cold: tx of sx. sx generally clear in _____ days

influenza

Viral infection involving the respiratory system. sx: Fever, Headache, Severe achiness, exhaustion, fatigue, weakness, chest discomfort and cough. Less common: stuffy nose, sneezing, sore throat. in 2011-12, 42,000 US residents hospitalized and 2,125 died. Prevention is key through vaccination

influenza

three types: A, B, C. is a respiratory illness but GI sx are often present in children or cases of H1N1. Testing can determine the presence of virus

48

Antiviral medications can help decrease duration of symptoms if started within _____ hours of symptom onset

trauma

Nasal bone most frequently fx facial bone. Presentation: Often with epistaxis from intranasal mucosal tears. Bruising is common. Tenderness with palpation. Displacement upon palpation. Radiographic tests - Lateral x-rays confirm

trauma

Supportive tx; septal hematoma refer ENT emergently. (septal widening may indicate septal hematoma. Refer to prevent saddle nose deformity). Cold compresses. Reduction of the fx is done 4-8 days after the injury to allow swelling to decrease. Repair is needed if obstruction of the airway

sinusitis

Inflammation of the sinus cavities. Can be acute or chronic. Usually occurs after an upper respiratory infection (URI). Risk factors include: Recent URI, chronic sinusitis, smoking, history or trauma or foreign body

sinusitis

Causes: Strep pneumoniae, H. flu, M. catarrhalis, S. aureus. It could also be due to a dental infection. Foreign bodies. Viruses: rhinovirus, influenza/parainfluenza, RSV, adenovirus, coronavirus, enterovirus. Viral more common than Bacterial

acute sinusitis

Presentation: HA, facial pain (can increase with leaning forward), discolored drainage, purulent drainage, fever, malaise, Tender to palpation, opacification of the sinus with transillumination. Bacterial infection, unilateral or bilateral nasal obstruction, purulent rhinorrhea, facial pain/pressure, congestion in the turbinates. Toothache. 2 major factors or one major factor and 2 minor factors, or purulence (cecil's)

acute sinusitis

Sinus films are not generally useful. CT scan - may show opacification. Referral:
More than 3 cases of sinusitis per year. Severe infection that fails to be treated by abx. Persistent infection despite a few adequate trials of abx

uncomplicated

Sinusitis: _____ <7 days is symptomatic treatment. Saline nasal spray. Hot packs, steam. Topical decongestant for a 2-3 day period and monitor. Oral decongestant. Antipyretic

bacterial

Acute Sinusitis : _____ >7 days/purulent, facial pain, tooth pain. Symptomatic treatment and abx. Antibiotics: amoxicillin 500mg TID for 10 days, F/u to ensure resolution. Second line tx: Augmentin 875mg TID or clindamycin 300mg TID for anaerobe coverage. Macrolides, cephalosporin, fluroquinolones

focal

Acute _____ Sinusitis: any duration. Toxic appearance, severe facial pain, toothache, unilateral redness/edema, temp >38 C. Antibiotic treatment and consultation to ENT

acute sinusitis

Complications: Osteomyelitis, cavernous sinus thrombosis, orbital cellulitis, meningitis, brain abscess

chronic sinusitis

Often with multiple organisms including: M. catarrhalis, H. flu, S. pneumoniae, S. aureus, variety of anaerobes. Chronic viral, bacterial, allergen, fungal organisms. Osteomeatal complex obstruction. Persistent infection with mucosal thickening. Factors: smoking (alters mucosal transport less cilia), nasal polyps

chronic sinusitis

presentation: Represents persistent low grade infection. Persistent nasal obstruction, drainage thick and discolored and copious in morning, thins in the evening. Persistent mucosal thickening. Intermittent or constant facial pressure. Pain usually absent

chronic sinusitis

CT will confirm diagnosis. Allergy testing may be needed to rule out chronic allergic rhinitis

chronic sinusitis

Antibiotics alone not good enough. Decongestants and intranasal steroids, treat 3-4 weeks. Topical steroid sprays. Antibiotics: 3-4 weeks. Augmentin, cephalosporins, macrolides, clindamycin. Refer for surgery after 1-2 months of treatment. widespread destruction of sinus walls to create open chamber to nasal cavity

mucocele

dilation of chamber w/ mucus retention

potts puffy tumor

complication of frontal sinusitis with swelling in forehead due to osteomyelitis in frontal bone

fungal/mycotic sinusitis

Almost exclusively in immunocompromised or diabetic patients. More common in warm, humid climates. Consider if typical treatment fails. Causes: Aspergillus is most common, Coccidiomycosis, histoplasmosis, sporotrichosis, cryptococcosis, and others
Tx: Surgical Drainage is the treatment of choice

invasive mycoses

Rapidly progressive and destructive process can cause necrosis of nose and facial soft tissue. Apergillosis and mucormycoses. Fever, facial pain, bloody nasal drainage, facial swelling. Necrotic tissue of the skin or septum. ENT referral and I&D. Debridement of necrotic tissue and systemic antifungal

deviated septum

Deviation from midline from trauma or disproportionate growth between the facial skeleton and nasal septum. Trauma or development. May lead to ostial obstruction or sinusitis

deviated septum

Unilateral or bilateral obstruction with symptoms. Diagnosis made by history and physical. Anterior deviations with worse symptoms than posterior. Treatment:
only required if there is obstruction present. Septal deformity is a minor elective surgical procedure under local anesthesia. External nasal deformity may undergo rhinoplasty

turbinate hyperplasia

Caused by allergic rhinitis, nonallergic rhinitis, septal deviation, exposure to tobacco smoke, irritants, and pollutants; certain drugs (B-blockers, reserpine, hormones). Frequent cocaine use similar to rebound effect of topical decongestants

turbinate hyperplasia

Diagnosis based on history of chronic nasal obstruction associated with turbinate hypertrophy. Failure to respond to decongestants, antihistamines, or intranasal steroids leads to different surgeries to correct

nasal vestibulitis

Staph aureus infection around hair follicle in nasal vestibule; associated with excessive nose blowing or digital manipulation. Scabbing around the hair follicle. Management is limiting digitally induced nasal trauma, antibiotic ointment (bactroban) and/or antibiotics. DM, immune deficiency or progressive infection may need to use IV antibiotics to prevent spread of infection to cavernous sinus

nasal polyps

Inflammatory disorder of unknown etiology. Possibly due to chronic inflammation. Histamine may play a role. Often seen with allergic rhinitis. May be single or multiple. Originate from sinus mucosa, appearing gray translucent pedunculated masses. Symptoms are obstruction, hyposmia, anosmia, congestion, infections. Nasal phonations and complain of constant congestion

nasal polyps

Dx: Made by rhinoscopy or nasal endoscopy. Bx to r/o malignancy if there is a unilateral or solitary mass. Tx: Management aim is control of symptoms; topical/oral steroids. Surgery where indicated. Frequently recur. ENT for surgery

Samter's Triad

nasal polyps, asthma, ASA sensitivity and is difficult to treat. Caused by aspirin allergy that begins midlife. Treat asthma, polypectomy, avoid aspirin. Related to upregulation of leukotrienes caused by prostaglandin blockade

rhinitis

inflammation of the nasal mucosa

allergic rhinitis

Cause: Immunoglobulin E-mediated reactivity to airborne antigens (pollen, mold, dander, dust). Common in patients with a history of atopy. Presentation: Includes intermittent obstruction, clear rhinnorrhea or post nasal drainage, sneezing, watery eyes, pruritus of nose, eyes, palate. Sx similar to the common cold. Often seasonal. Allergic shiners, scratchy/itchy/watery eyes, sneezing, nasal congestion, dry cough, pale, boggy mucosa
Increased IgE levels. Eosinophils on nasal smear

allergic rhinitis

Tx: Avoid allergens: tree pollens in spring; grasses in midsummer; weeds in fall, Animal danders, dust mites, mold-perennial symptoms with less pruritus. Responds to antihistamines. Cromolyn sodium (Crolom) mast cell stabilizer. Leukotriene receptor antagonist: Montelukast (Singulair). Nasal Steroids Fluticasone propionate (Flonase), Nasacort, Nasonex. Systemic corticosteroids. Nasal saline spray. Nasal antihistamine: Azelastine (Astelin). Nasal anticholinergics: Atrovent Nasal Spray

nonallergic rhinitis

Same symptoms as allergic rhinitis but allergy testing is negative. No eosinophils on nasal smear. Tx with decongestants

vasomotor rhinitis

Increased secretion of mucus from the nasal mucosa. May be from changes in temperature or humidity, odors, alcohol, or from a neurovascular imbalance. Bogginess of the nasal mucosa with complaints of stuffiness and rhinorrhea
Symptoms can clear quickly. tx: Avoid the irritant. Decongestants

rhinitis medicamentosa

Overuse of decongestant drops or sprays (phenylephrine and oxymetazoline). Rebound congestion prompts increased use of the agent which creates a vicious cycle. Presentation: Severe congestion and pain. Minimal discharge. Tx: Discontinue the irritant. Consider topical steroids during the withdrawal period

turbinate engorgement

elevations in estrogen during pregnancy causes this

sarcoidosis

noncaseating septal nodules on bx. tx is systemic steroids

wegener's granulomatosis

septal ulcers, turbinate hypertrophy, vasculitis. tx is cyclophosphamide

tuberculosis

beefy, red mucosa w/ ulcerations and exudates. + ppd, caseating granulomas. tx is isoniazid, rifampid, ethambutol

nasopharyngeal

_____ tumors may present as neck masses, hearing loss, OM, diplopia, other visual disturbance, epistaxis, nasal obstruction

sinus

_____ tumors may present as sinusitis, epistaxis, toothache, proptosis, cheek swelling, facial pain/numbness/tingling

parotid gland

largest salivary gland, opening into the oral cavity via Stenson's Duct (parotid duct) which penetrates the buccinator muscle (opens bilaterally at the area of the second upper molar)

submandibular gland

located in submandibular triangle, opening in floor of mouth (Wharton's Duct)

sublingual gland

smallest salivary gland, lies above mylohyoid muscle

hard palate

separates oral cavity from nasal cavity and is a bony plate covered with mucous membrane

soft palate

(part of oropharynx) muscular tissue covered with mucous membrane, plays a role in swallowing and vocal resonance

oropharynx

includes soft palate, anterior & posterior tonsillar pillars, tonsils, base of tongue, posterior pharyngeal wall

tongue

helps form floor of mouth; divided into anterior 2/3 and posterior 1/3 at the V-shaped sulcus terminalis. Muscle, nerve, vessels enter through the base

t

t/f: Most oral cavity conditions diagnosed from H & P. Dentures should be removed

200

_____ primary oral cavity lesions/dz. also secondary abnormalities can occur

disease processes affecting the oral cavity

Herpangina, Aphthous stomatitis, Aphthous ulcer, Herpes Zoster, Herpes simplex, Cheilitis sicca, Angular Cheilitis, Hand-foot-mouth disease, Candidiasis, Acute tonsillitis, Peritonsillar abscess, Torus palatinus or mandibularis, Infectious mononucleosis, Tonsillar hypertrophy, Acute pharyngitis, Papilloma, Basal cell carcinoma lip, Squamous cell carcinoma, Sjogren's syndrome, Fissured tongue, Geographic tongue, Tongue carcinoma, Leukoplakia, Erythroplakia

torus palatinus

bump on palate

torus mandibularis

bump on mandible

ankyloglossia

tongue tie (tight frenulum)

torus palatinus

Exostosis or outgrowth of bone. Incidental finding upon examination. Hard bony growth with intact mucosa. Palatinus: 20-25%. Mandibularis: 6-8%. No tx

hemangiomas

Vascular tumor that appears at birth. Grows until puberty and spontaneously resolves. Consider steroid injection or surgical removal if obstructive or cosmetic problem

ranula

Small painless mucocele that forms at outlet of sublingual glands. Soft compressible blue mass overlying vein on floor of mouth. Treat by making a pouch. Marsupialization

phenytoin (dilantin)

drug induced condition with gingival hyperplasia is caused by

tetracycline (sumycin)

drug induced condition with yellow discoloration of the teeth if given before about 8 years old is caused by

chemotherapy

drug induced stomatitis or mucositis is caused by

steven johnson syndrome

drug induced condition with oral involvement

vitamin c deficiency

bleeding gums and gingivitis. scurvy. is caused by

vitamin b2 deficiency

atrophic glossitis, angular chelitis and gingivostomatosis is caused by

vitamin b3 (niacin) deficiency

pellegra. beefy tongue w/ ulcerations and loss of papillae is caused by

vitamin b12 deficiency

pernicious anemia. smooth, beefy red tongue w/ pale mucosa and loss of papillae +/- ulcers is caused by

iron deficiency

smooth, red tongue with loss of papillae, angular cheilitis and pale/grey colored oral mucosa is caused by

acromegaly

macroglossia with wide spaced teeth is caused by

amyloidosis

macroglossia with yellow nodules on dorsal and lateral surfaces is caused by

menopause

atrophic mucosa and gingivostomatitis is caused by

papilloma

caused by hpv. nonpainful mass. single or multiple raspberry-like masses. predilection for mucocutaneous junctions. excisional bx w/ histologic examination

vincent's disease/angina

Trench mouth. Polymicrobial infection of gums leading to inflammation, bleeding, deep ulceration and necrotic gums. Overpopulation of oral bacteria and poor hygiene, smoking, poor diet or lifestyle. Spirochetes, Bacteroides. Presents with pain, fever, halitosis. Tx: oral hygiene, antibiotic

herpangina

Cause: Coxsackievirus A; Fall and Summer. Presentation: Severe sore throat, odynophagia, sudden high fever, malaise, dysphagia, vomiting, anorexia. Child is irritable due to pain. Primarily children less than 5 years old. Oropharynx has numerous small vesicles that are gray/white with red halos, then become flat. Linear arrangement on the palate, uvula, tonsillar pillars. Diffuse pharyngeal hyperemia. Oropharynx! Usually less than one week. Acute onset. tx:
Self-limiting; supportive and symptomatic treatment with antipyretics, fluids

aphthous ulcer

aka canker sore. idiopathic. possible associate w/ viral causes. presentation: Buccal mucosa, single, multiple. Painful round ulcer with red halo. Covered by yellowish exudate. Typically recurrent. Older children and adults. Most common nontraumatic ulceration of the oral mucosa. Pain is often disproportionate to their size. Minor ulcers often resolve in 7-10 days

aphthous ulcer

Self-limited. Supportive treatment with anti-inflammatories. Topical steroid rinse or topical steroids. Benadryl, Lidocaine, Maalox swish and spit Recurrence is common

aphthous stomatitis

Affects 20% of the population. Occur on all areas of the oral mucosa except the hard palate, gingiva, and vermilion which are keratinized. They are in 3 clinical forms: Minor, Major, and herpetiform. Failure to resolve should prompt incisional biopsy to exclude neoplasia

Primary Herpetic Gingivostomatitis

Herpes simplex virus type I most commonly. Presentation: painful oral lesions. Children most common. Most people are exposed during childhood. Many painful lesions on the buccal and gingival mucosa. Vesicles coalesce to form ulcers. May have fever, arthralgia, malaise, cervical lymphadenopathy. Fever and malaise, any oral mucosal site. Tx: Self-limited and Lasts 7-14 days. Treatment supportive and symptomatic. Early treatment with acyclovir suspension swish and swallow can shorten duration

hsv-1

cold sores: secondary lesions. Recurrent, episodic eruptions of yellowish fluid filled vesicles on upper/lower lip, nose. Most common: lip. Less common on the keratinized mucosa of the gingiva or hard palate. Usually a prodrome of tingling, burning or itching occurs before the episode. Stress, immunosuppression, trauma, sunlight exposure. Topical acyclovir ointment can be affective for mucosal lesions. Systemic acyclovir within 72 hours of onset can help. Fluids, rest, analgesics, antipyretics. Avoid herpetic whitlow

herpes zoster

Varicella-zoster virus. Presentation:
Extremely painful; burning; may have fever; malaise. Early adults with impaired host defenses. Unilateral vesicles on buccal mucosa, tongue, uvula, pharynx, larynx, erosions after eruptions. tx: Self-limited and Lasts 7-14 days. Antiviral drugs; symptomatic treatment

solar cheilitis

Exogenous damage by weather, drying, solar radiation. Presentation: Especially bottom lip. Atrophic, pale appearance. Slightly firm and swollen. Mainly white, fair individuals. Related to sun exposure. Dry, fissured, reddened or scaling lip mucosa. Can ulcerate. Tx: Symptomatic. Chapstick, Vaseline, sun-blocking lip balm. Consider biopsy and referral if severe

angular cheilitis

Infection: Often Candida or Staph. Thumb sucking. Sagging face and loss of teeth. Presentation: Dry, burning at the corners of mouth. Often associated with oral candidiasis. Macerated, deep fissures at the mouth corners. Tx: Identify and treat the cause. Clotrimazole 1% cream if the etiology is Candida

Hand-Foot-and-Mouth Disease

Viral: Coxsackievirus. Presentation: Sore mouth, low grade fever, coryza. Young children, 6 months to 5 years. Vesicular lesions of skin; small, multiple, vesicular and ulcerative oral lesions, also on the hands and feet. Tx: Self-limiting; usually 1-2 weeks. No specific treatment; local measures

mumps

Paramyxovirus. Presentation: Rare since vaccine. Bilateral salivary gland enlargement and salivary hypofunction. Mild temperature elevation, malaise, sudden distention and pain. Diffuse swelling over the parotid glands. Tx: Hydration, analgesics. Symptomatic treatment. Recurrent Parotitis of childhood. Unilateral or bilateral parotid enlargement. Salivary secretion may be reduced, but usually without prominent signs or symptoms

recurrent parotitis

_____ _____ of childhood. Unilateral or bilateral parotid enlargement. Salivary secretion may be reduced, but usually without prominent signs or symptoms

pharyngitis

a broad term. Sore throat. Many causes. Bacterial, viral and other origins

tonsillitis

enlargement of the tonsils and inflammation

peritonsillar abscess

Inflammatory infiltration and abscess formation. Presentation: Severe unilateral throat pain, fever, malaise, difficulty eating, drooling, fetid breath. Any age; peak times second to fourth decades. Erythema and bulging of peritonsillar area, uvula deviation, fluctuance of soft palate. Asymmetric and unilateral palatal swelling and uvular deviation. Tender cervical adenopathy. Usually has exudates. May appear as a sore throat, then symptom free, then worsening. Patient has a "hot potato voice" (voice sounds like they are talking with hot food in their mouth)

peritonsillar abscess

ENT referral for Needle aspiration, I&D, antibiotics: amoxicillin plus metronidazole. Often polymicrobial. May require tonsillectomy (infection started superficial and extends. May erode into internal carotid artery: Bleeding quinsy)

acute viral pharyngitis

Pharyngitis is Primarily viral. May turn into a bacterial infection. Presentation: Children and adults. Gradual onset often with a cold. Usually lack exudate. Fever is low grade, lymphadenopathy occasionally present. Dry, red, thickened pharyngeal mucosa; exudate occasionally. Often tonsillar enlargement, halitosis, fever, dysphagia, odynophaghia

acute viral pharyngitis

tx: Culture can be done. Rapid strep or throat culture. Analgesics, local measures. Score <1 observe. 2-3culture and tx. >4tx

infectious mononucleosis

Epstein-Barr virus. Presentation: Severe sore throat, odynophagia, fever, malaise, Headache. Primarily adolescents and young adults. Bilateral posterior cervical lymph nodes, huge tonsils, exudate on tonsils, leukocytosis, atypical lymphocytes. Soft palate petechiae

infectious mononucleosis

Course Usually 10-21 days. Avoid contact sports for 6-8 weeks. Monospot test and CBC with differential

bacterial pharyngitis/tonsillitis

Group A B-hemolytic streptococci. M. catarrhalis, H. influenza, S. aureus. Presentation: Raw, dry, burning throat, adenopathy in children. Children (3-14 is common) and adults. Fever present. Dry, red, thickened pharyngeal mucosa; exudates. +/-Tonsillar swelling.

bacterial pharyngitis/tonsillitis

Dx: Rapid Strep. Throat culture. Tx: Cefuroxime 250mg BID for 5-10 days. Penicillin as PCN VK250mg TID or 500mg TID for 5-10 days. Analgesics

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