HEENT

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27 terms · PA 550 objective cards

Otitis Media

Disease/Condition: Otitis Media
Definition: Painful infection of middle ear
Etiology Cause- pathophys contributing to development of this disease: presence of middle ear effusion and infection.
-Viral
-S. pneumo *most common
-H. influenza
-M. catarrhalis
Epidemiology- population groups at risk for this condition:
-children especially infants
-peak 6-15 months
-Native americans
Presenting symptoms/PE: A diagnosis requires 1. hx of acute onset of signs and symptoms(pulling on ear, irritability, fever, otorrhea) 2. Presence of middle ear effusion 3. Signs and symptoms of middle ear inflammation (bulging of TM, limited or absent mobility of TM, air-fluid level behind TM, otorrhea)
-Erythema of TM, otalgia
**Effects sleep!!.
Diagnostic studies & significant results with rationale: none needed, could culture the organism
Treatment: Pain Reduction NSAIDS, weight bases acetaminophen
Ab therapy
Age Certain Dx. Uncertain Dx.
<6 mo. Abx. Therapy Abx. Therapy
6mo. to 2 yrs Abx. Therapy Abx. if severe; Non-severe optional observation
> 2 yrs Abx. Therapy Abx. if severe; Non-severe optional observation
Mainly used: PCN, Cephalosporins, Z-pack
Unique Pearl:

Rhinorrhea

Disease/Condition: Rhinorrhea (Vasomotor rhinitis)
Etiology Cause-: Persistent watery mucus discharge from the nose most commonly causes by allergies or viral infection
-increased cholinergic glandular secretory activity (runners)
Epidemiology- population groups at risk for this condition:
-Pregnancy- due to progesterone and estrogen induced glandular secretion, augmented by nasal vascular pooling from vasodilation and increased blood volume
- Previous nasal trauma
-GERD
-autonomic stimulation due to emotion or sexual arousal
Presenting symptoms: Clear runny drainage from nose, nasal blockage, congestion, sneezing, pruritus, conjunctival irritation
Physical findings: HEENT - rhinorrhea, enlarged tonsils, post nasal drip, erythematous nasal mucosa
Diagnostic studies & significant results with rationale: No specific testing, could do serum IgE levels (should be normal) RAST testing or referral to allergist
Differential Diagnosis: Allergic Rhinitis, hormonal, infection, occupational, emotional, exercise induced, FOREIGN BODIES in kids, deviated septum, nasal tumors.
Immunologic conditions - sjogren, sarcoidosis, Wegener granulomatosis
Treatment: No single agent uniformly effective.
-Avoid triggers
-Exercise -vasodilatory effect
-Step wise approach -
Step one - Antihistaime, topical anticholinergics, ICS (nasonex, rhinocort, flonase)
Step two- topical cromolyn sodium,
Step three - try a different antihistaime, or ICS
Step four - reconsider accuracy of initial diagnosis or consider empiric use of topical decongestants, oral decongestants and antihistaime.
Unique Pearl:

Laryngitis

Disease/Condition: Laryngitis
Definition: Hoarseness resolving within 2 weeks
-abrupt onset
-usually caused by rhinovirus
Etiology Cause- Viral *most common
-bacterial
-fungi -Candida most common
- noninfectious causes- excessive use of voice, allergic exposure, trauma, irritation, excessive smoke, GERD
Epidemiology- occupational use of voice
-smoking
-immunocompromised
-adult population more so
Presenting symptoms: persistant unexplained changes in vocal quality, fever, dry sore throat, hoarseness, dry NPC, dyspahgia, headache, neck pain, ear ache
Physical Exam: Normal, may have some edema and erythema in oropharynx
Diagnostic studies & significant results with rationale: Direct larygnoscopy if mass is a concern, throat culture
Differential: Acute bacterial infection, irritant exposure, laryngeal CA, GERD, vocal nodule, TB
Treatment: Pain Reduction: Supportive care - rest, humidification, analgesics for pain and discomfort, warm salt water gargles, throat lozenges.
Bacterial= PCN
Unique Pearl:

Labyrinthitis

Disease/Condition: Labyrinithitis- is an ear disorder that involves irritation and swelling of the inner ear.
Cause/Etiology- pathophys contributing to development of this disease:
It commonly occurs after an ear infection ( otitis media ) or an upper respiratory infection. It may also occur after an allergy, cholesteatoma, or taking certain drugs that are dangerous to the inner ear.
During labyrinthitis, the parts of the inner ear become irritated and inflamed. This interferes with their function, which includes the ability to keep your balance.
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Fatigue, excessive alcohol, Hx. Allergies, smoking, stress, ASA
Presenting symptoms:
Vertigo, dizziness, hearing loss, loss of balance, nausea/vomiting, tinnitis
Unique physical exam findings:
hearing loss
Diagnostic studies & significant results with rationale:
EEG, electronystagmography, MRI, caloric stimulation
Differentials:
Meniere's disease, inner ear infection, vertigo
Treatment:
Labyrinthitis usually goes away within a few weeks. Treatment involves reducing symptoms, such as spinning sensations. Medications that may reduce symptoms include antihistamines, corticosteroids, and valium.

Common Cold

Disease/Condition: Common cold- involves a runny nose, nasal congestion, and sneezing. You may also have a sore throat, cough, headache, or other symptoms.
Cause/Etiology- pathophys contributing to development of this disease:
A cold virus spreads through tiny, air droplets that are released when the sick person sneezes, coughs, or blows their nose.
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Children > adults per/year
Presenting symptoms:
nasal congestion, runny nose, scratchy throat, sneezing, cough, headache, muscle ache, sore throat, fever (children)
Unique physical exam findings:
decreased appetite
Diagnostic studies & significant results with rationale:
viral vs bacteria infection (rapid test)
Differentials:
Viral URI, sinusitis, allergies, post nasal drip
Treatment:
OTC symptom relief, antibiotics (infection), antiviral, zinc, vit. C

Allergic Rhinitis

Disease/Condition: Allergic rhinitis is a collection of symptoms, mostly in the nose and eyes, which occur when you breathe in an allergen, such as dust, dander, or pollen.
Cause/Etiology- pathophys contributing to development of this disease:
Allergic reactions, IgE release of histamines and inflammatory response.
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Asthmatics
Presenting symptoms:
runny nose, sneezing, eye tearing, stuffy nose, cough, headache, puffiness, sore throat, rhinitis
Unique physical exam findings:
dark circles under eyes, clogged ears, decrease smell
Diagnostic studies & significant results with rationale:
Allergies
Differentials:
Viral URI, sinusitis, allergies, post nasal drip
Treatment:
Antihistamines (oral, nasal), immunization shots, corticosteroids, decongestants, leukotriene modifiers.

Peritonsillar Abcess

Disease/Condition: Peritonsillar abscess (Quinsy)- a collection of infected material in the area around the tonsils
Cause/Etiology- pathophys contributing to development of this disease:
Peritonsillar abscess is a complication of tonsillitis. It is most often caused by a type of bacteria called group A beta-hemolytic streptococcus.
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Older Children, adolescents, young adults
Presenting symptoms:
Chills, pain/difficulty opening mouth, drooling, fever, headache, muffled voice, sore throat, tenderness (glands)
Unique physical exam findings:
swelling unilaterally, on roof of mouth, midline shift of uvula,
Diagnostic studies & significant results with rationale:
CT
Differentials:
Viral URI, sinusitis, allergies, post nasal drip, tonsillitis, pharyngitis, strept throat
Treatment:
aspiration of abscess, Antibiotics, tonsilectomy

Otitis Externa

Disease/Condition: Otitis External
Definiton: Painful erythema and edema of the ear canal skin, often with purulent exudate.
Cause-pathophys: Excessive moisture predisposes canal to topical gram negative rod bacteria (Pseudomonas Aeruginosa and/or Staphlococcus Aureus) or fungal infection (Aspergillus).
Epidemiology-population at risk: those with recent water exposure or mechanical trauma (cotton applicators).
Presenting symptoms: Otalgia, erythema/swelling of the external auditory canal, fever, lymphadenopathy anterior to the tragus and otorrhea.
Unique physical exam findings: Scant to thick white mucus with bacterial infection. Fluffy, white to off-white discharge, but may be black, gray, bluish-green or yellow; small black or white conidiophores on WHITE HYPHAE associated with fungal Aspergillus. Pain with auricle manipulation. In contrast to otitis media, the TM moves normally with pneumatic otoscopy.
Diagnostic studies & significant results with rationale: none.
Differentials: otitis media, eustachitis, mastoiditis, foreign body/impacted cerumen.
Treatment: Pain reduction with NSAID or codeine; cleaning debris from the canal when possible; antibiotic along with corticosteroid (Neomycin, polymyxin B, and hydrocortisone (Cortisporin Otic)) or antibiotic alone if it will get to site of infection (Ofloxacin (Floxin Otic); Ciprofloxacin (Ciloxan, Cipro HC Otic)). Prevention: topical application of acidifying solution inserted into canal or via ear wick.
Unique Pearl: NEVER flush ear canal unless TM can be visualized. If perforated TM use Ofloxacin (Floxin Otic) because corticosteroids can be ototoxic. Disease/Condition: Otitis External

Nasal Polyps

Disease/Condition: Nasal Polyps
Definiton: Pale, edematous, mucosally covered masses commonly seen in patients with allergic rhinitis.
Cause-pathophys: Chronic inflammation leads to hyperplasia of the instranasal
Epidemiology-population at risk: commonly seen in patients with allergic rhinitis, but not always. Children with cystic fibrosis (board question).
Presenting symptoms: Increasing nasal congestion, hyposmia to anosmia (changes in taste), and persistent postnasal drainage. Headaches, facial pain, obstructive sleep apnea.
Unique physical exam findings: Fleshy translucent mass.
Diagnostic studies & significant results with rationale: none.
Differentials:
Treatment: Underlying cause if known or refer to allergist/pulmonologist. Anti-inflammatory (oral or topical corticosteroids). Surgical referral. In patients with a history of asthma, aspirin should be avoided as it may precipitate bronchospasm, known as triad asthma (Samter triad).
Unique Pearl:

Gingivitis

Disease/Condition: Gingivits
Definiton: Inflammatory process limited to the mucosal epithelial tissue surrounding the cervical portion of the teeth and alveolar processes.
Cause-pathophys: Accumulation of microbial plaques.
Epidemiology-population at risk: People with poor oral hygiene.
Presenting symptoms: Bleeding with brushing.
Unique physical exam findings: hyperemia of the gingivae (inflammation of the gums)
Diagnostic studies & significant results with rationale: none.
Differentials:
Treatment: Dental hygiene; periodic professional cleanings.
Unique Pearl:

Sialadenitis

Disease/Condition: Sialadenitis (Parotid Stones)
Definiton: Ductal obstruction with salivary stasis and possible secondary infection.
Cause-pathophys: Formation and deposition of calculi within the ductile system (Stensen's duct) of the the gland most commonly caused by salivary stagnation, epithelial injury along the duct, or precipitation of calcium salts. Wharton's duct from the submaxillary gland is the most common location for stone formation. The causative oraganism for suppurative sialadenitis is S. aureus.
Epidemiology-population at risk: Sjogren syndrome may contribute.
Presenting symptoms: Colicky postprandial swelling of the gland.
Unique physical exam findings: Palpable mass.
Diagnostic studies & significant results with rationale:
Differentials: Tumor
Treatment: Hydration, warm compresses, and gland massage. Sialagogues like lemon drops to increase salivation. Antibiotics only if infection is present. Surgery.
Unique Pearl:

Meniere's Disease

Disease/Condition:
Meniere's disease (endolymphatic hydrops)

Cause- pathophys contributing to development of this disease:
-specific cause is unknown
-distention of the endolymphatic compartment of the inner ear due to over accumulation of endolymph
-two known causes syphilis and trauma

Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
-age 40-60

Presenting symptoms: wax and wane
-Triad of symtoms: tinnitus (blowing in quality), vertigo (lasting 20 min-hrs,) fluctuating sensorineural hearing loss (low frequency, unilateral)—can become permanent
-N/V

Unique physical exam findings:
-May have hearing loss

Diagnostic studies & significant results with rationale:
-No lab studies specific toward Meniere's, direct labs to R/O other conditions
-can do CT, MRI to r/o tumor or demyelinating disorders
-audiometry, otoscopy, caloric testing (electronystagmogram)

Differentials:
-benign postural vertigo, labrynthitis, headache migraine, otitis media, TIA, vestibular neuronitis

Treatment
-low salt diet
-diuretics (acetazolamide)
-Refractory cases- intratympanic corticosteroid injections, endolymphatic sac decompression, or vestibular ablation (tympanic gentimicin, vestibular nerve section, surgical labrynthectomy).

Unique Pearl:
-If a pt has these symptoms in the absence of hearing fluctuations→migraine-associated dizziness

Nasal Foreign Body

Disease/Condition:
Foreign body

Cause- pathophys contributing to development of this disease:
-Inorganic (plastic/metal) or organic (food, rubber, wood, and sponge) object that is typically lodged ANTERIOR to the middle turbinate or BELOW the inferior turbinate that causes nasal mucosa irritation.
-Aspiration of foreign bodies into the trachea or bronchi

Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
-Nasal: Children 2-5 years old
-Tracheal & bronchi: elderly adults that wear dentures

Presenting symptoms:
-Inflammation, epistaxix, sneezing, snoring, sinusitis, stridor, wheezing, fever

Unique physical exam findings:
-Nasal mucosa swelling, difficulty breathing (stridor)

Diagnostic studies & significant results with rationale:
-Tracheal & bronchi obstruction—CXR
-Nasal- Direct visualization of foreign body

Differentials:

Treatment:
-Nasal: Direct instrumentation (hemostats, alligator forceps, or bayonet forcept) easily visualized, nonspherical and nonfriable foreing bodies. Balloon catheters, positive pressure, suction or magents.
-IRRIGATION NOT RECOMMENDED due to risk of aspiration and choking
-Tracheal & bronchi: deed to be removed under general anesthesia with bronchoscopy

Epiglotitis

Disease/Condition:
Epiglotitis (supraglotittis)

Cause- pathophys contributing to development of this disease:
-Bacterial: HiB
-Viral

Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
-More common in children
-Diabetics

Presenting symptoms: wax and wane
-Children present with onset of symptoms <24hr, high fever, sore throat, tachycardia, drooling while sitting forward
-Sore throat, odynophagia (pain on swallowing)

Unique physical exam findings:
-Respiratory distress, inspiratory stridor, chest wall retractions
*may be minimal findings

Diagnostic studies & significant results with rationale:
-Lateral CXR→ thumb print
-Adults→ direct laryngoscopy → swollen erythematous epiglottis "cherry red"

Differentials:
-Foreign body, anaphylaxis, pertussis, pharyngitis, peritonsillar abcess, croup

Treatment
-Hospitalization: culture & IV antibiotics
-ceftizoxime 1-2g IV Q8-12 hr, or Cefuroxime 750-1500 mg IV Q8,
-dexamethasone 4-10 mg as initial bolus then 4 mg IV Q6
-Protect airway
-Continuous pulse ox

Stomatitis

Disease/Condition:
-Stomatitis

Cause- pathophys contributing to development of this disease:
- Contact with allergens
-Herpetic → initial burning followed by typical small vesicle rupture and forms scabs
-Coxsackievirus- common children <6

Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
-Elderly secondary to denture use

Presenting symptoms:
-Burning sensation, pain, paresthesia, numbness, bad taste, excessive salivation, perioral itching

Unique physical exam findings:
-Erythematous lesions, erosions, ulceration, leukoplakia like lesions, oral lichenoid rxn, contact urticaria

Diagnostic studies & significant results with rationale:
-Allergy testing (patch testing)
-Biopsy →refer to dermatologist

Differentials:
-Canker sore, erythema multiforme, syphilitic chancre, carcinoma

Treatment
-Removal of allergen or offending agent
-Symptomatic control (Ice)
-Corticosteroids (topical or systemic-rare)

Mastoiditis

Disease/Condition:
Mastoidsitis (Emergent condition)
Definition:
Inflammation of mastoid air cells of the temporal bone.
• Actue mastoiditis following otitis media
• Chronic mastoiditis secondary to partial treatment with antibiotics.
Cause- pathophys contributing to development of this disease:
Complication of Otitis media.
Purulent exudates accumulation in mastoid air cells resulting in bone erosion and abscess like cavities.
Streptococcus pneumonia
Haemophilus influenza.
Moraxella catarrhalis.
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Low incidence since the introduction of antimicrobials drugs.
75% occur in the Fall and Winter.
Most common: 2 months - 18 years (Peaks between 6 and 13 months)
Males = females
Presenting symptoms:
Fever, middle ear fluid, vertigo, nystagmus.
Postauriclar throbbing pain and tenderness, erythema, edema.
Otalgia, otorrhea, increased hearing loss.
Displaced (from pus) pinna in conjunction with acute otitis media.
Unique physical exam findings:
Acute: bulging erythematous TM, tenderness, erythema and edema of the mastoid area, post-auricular fluctuance, protrusion of the auricle.
Chronic: May be asymptomatic, TM normal/infected, recurrent or persistent fever
Diagnostic studies & significant results with rationale:
CBC with diff: leukocytosis,
Erythrocyte sedimentation rate: ↑ESR
Culture: determine causative agent (S.Pneumoniae, H.Influenzae, M.Catarrhalis)
X-Ray: lag behind the symptoms. Clouding of mastoid air cells.
CT Scan: Confirmation diagnosis and identify intracranial complication
Lumbar puncture: rule out other complication.
Differentials:
Recurrent or chronic Otitis media: DON't MISS
Otitis media, otitis externa, labyrinthitis, petrositis, Jugular vein thrombisis, subperiosteal abscess, Herbes zoster octicus (Ramsay Hunt syndrome), epidural abscess, meningitis.
Treatment: (RX, Supportive measures, consults, Patient teaching)
Myringotomy: Drain fluids, allows for cultures.
Antibiotics: Begin tx while waiting for cultures.
• Acute: IV Vancomycin and 3rd generation cephalosporin (ceftrixone) or a penicillinase-resistance penicillin (ampicillin-sulbactam). With intracranial complication: antibiotic the crosses the BBB.
o 7-10 days of tx: with improvement with IV, change to oral antibiotic: clindamycin plus a d3rd generation cephalosporin (cefpodoxime) or penicillinase-resistant penicillin (amoxicillin-clavulanic acid) to complete a 4 week cycle.
• Chronic: need to cover Gram - organisms: Staphylococcus aureaus: Gentamicin or 3rd generation cephalosporin.
o Tx for up to 6 weeks.
o MRSA: vancomycin should be added.
o Pseudomonas: piperacillin-tazobactam may be added.
• Acetaminophen: comfort and reduce pain and fever.
• Mastoidectomy.
• Topical corticosteroid-antibiotic: hydorsocortisone-neomycin-polymxin B: used in cases of perforation or after myringotomy to reduce swelling.
Unique Pearl:
Consider in patient presenting with otitis media complicated by mastoid tenderness or a change in mental status. Immediate CT scan is the diagnostic evaluation of choice

Epistaxis

Disease/Condition:
Epistaxis
Definition:
Acute hemorrhage that most commonly occurs in the anterior portion of the nasal cavity in association with the septum (Kiesselbach plexus) due to local trauma. Other locations: anterior and posterior ethmoidal artery, sphenopalatine arter.
Cause- pathophys contributing to development of this disease:
Nasal trauma: nose picking, foreign bodies, forcesful nose blowing, rhinitis, drying of the nasal mucosa from low humidity, supplemental nasal oxygen, deviation of the nasal septum, htn. Atherosclerotic disease, hereditary hemorrhagic telangiectasia (Isker-Weber-Rendu sysndrome), inhales nasal cocain, etoh use. Anticoagulation meds don't cause epstaxis: they ↑recurrence of epstaxis, > difficulty controlling bleeding.
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Bimodal incidence: 2-10 years and 50-80 years.
Presenting symptoms:
Visualization of blood
Unique physical exam findings:
Blood, HTN.
Diagnostic studies & significant results with rationale:
Hgb and Hct:
Platelets:
BUN and creatinine:
Prothrombin time and partial tromboplastin time
Type and crossmatching of blood products

Differentials:
Trauma, medication (nasal sprays, NSAIDs, anticoagulants, antiplatelets) Nasal polyps, Cocaine use, coagulopathy (hemophilia, liver disease, disseminated intravascular coagulation, thrombocytopenia, systemic disorder (HTN, uremia), infection, anatomic malformations, Rhinitis, nasal polyps, local neoplasms (benign and malignant), desiccation, foreign body.

Treatment: (RX, Supportive measures, consults, Patient teaching)
Pressure application to entire nose for 10 minutes. Topical antithetic (lidocaine) with chemical cautery (silver nitrate stick).
Nasal packing with pain, infection control and followup.
• Anterior Nasal Packing
• Posterior Packing: need to refer to ENT specialist.
Surgical ligation
Unique Pearl:
Silver nitrate cauterization: Can lead to septal perforation and should be discourages.
Complications of nasal packing: aspiration, dislodged packing, infection, nasal trauma.

Diptheria

Disease/Condition:
Diphtheria: Nasal, laryngeal, pharyngeal and cutaneous forms.
Definition:
Acute infection caused by Corynebacterium diphtheria that attacks the respiratory tract but may involve any mucous membrane or skin wound.
Cause- pathophys contributing to development of this disease:
C.diphtheriae spread by respiratory secretions.
Exotoxin produced by the organism causes myocarditis and neuropathy.
No previous vaccination
Vaccine induced immunity - immunity wanes over time. Adults who have not had a booster may be at risk.
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Many adults in developed and developing countries are now susceptible to diphtheria.
Travel to areas with a high incidence, recent immigration from endemic area (SE Asia, former Soviet Union).
Most common in children.
Males = females
> minority racial groups/disadvantages socioeconomic groups.
Cutaneous diphtheria: most common in homeless, alcoholics, poor medical care access.
Presenting symptoms:
Fever, halitosis, tachycardia, anxiety. Sore throat, nausea, HA, dysphagia, SOB.
Cutaneous diphtheria: lesions are often painful.
Unique physical exam findings:
Nasal: Infection produces few symptoms other than a nasal discharge.
Laryngeal infection: upper airway and bronchial obstruction.
Pharyngeal diphtheria: erythema, edema, thick, gray, leathery membrane may cover the tonsils, soft palate, oropharynx, nasopharyns and/or uvula.
Myocarditis and neuropathy: common serious complications.
Scraping the pseudomembrane causes bleeding ("Bull's neck"), respiratory stridor, wheezing, cyanosis, accessory muscle use and retractions.
Diagnostic studies & significant results with rationale:
Culture: determine causative agent C. diphtheriae.
Differentials:
S. Pharyngitis
Infectious Mononucleosis
Adenovirus
Herpes simplex.
Vincent angina,, pharyngitis due to Arcanobacterious haemolyticum and candidiasis.
Treatment: (RX, Supportive measures, consults, Patient teaching)
Secure airway.
Antitoxin: Obtained from the CDC/Test for hypersensitivity before administering.
Penicilling 250mg orally 4x day or erythromycin 500mg oral 4 x day for 14 days is effective to eradicate the organism but is NOT a substitute for the antitoxing.
Unique Pearl:
Must be reported to the local or state health department. Pt must be referred immediately to prevent a national health emergency. Must be place in respiratory isolation, examine family contacts, monitor for myocarditis.

Pharyngitis/Tonsillitis: Viral/Bacterial

Disease/Condition:
Pharyngitis/Tonsilitis: Viral/Bacterial
Definition:
Inflammation of the pharynx that causes a sore throat.
Cause- pathophys contributing to development of this disease:
Pharyngitis/Tonsilitis: Viral is the most common
• Rhinovirus, adenovirus, parainfluenza virus, coxsackievirus, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, respiratory syncytial virus.
Pharyngitis/Tonsilitis: Bacterial
• Group A B-hemolytic streptococcal infections, S. pyogenes, Neisseria gonorrhoeae, C.diphtheriae, H.influenzae, M.catarrhalis, nontypable haemophilus.
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Streptococcal infection occurs mostly in pts between the ages of 5 - 18 years.
Uncommon in < 3 yo but possible. Usually viral.
Individuals with a positive family history of rheumatic fever have a higher incidence of rheumatic complications if streptococcal infections are untreated.
Presenting symptoms:
Overall: sore throat, difficulty swallowing, fever, erythema of the tonsils and posterior pharynx, lymphadenopathy, rhinitis and cough.
Infection that penetrates the tonsilar capsule → cellulitis and peritonsillar abscess (a medical emergency).
\Unique physical exam findings:
Viral pharyngitis: Insidious onset, ofter\n with coryza, usually lacking exudates. Fever is low grade, lymphadenopathy may or may not be present.
Streptococcal pharyngitis: Bacterial
• Centor Critea: fever (> 38C ), anterior cervical lymphadenopathy/tenderness, LACK a cough, pharyngotonsilar exudates.
• Acute onset, pharyngeal pain, chill, abdominal pain, tonsillar swelling.
Diagnostic studies & significant results with rationale:
Rapid step: rule out viral. If negative and the diagnosis is still suspicious, culture.
CBC: support bacterial infection.
Epstein-Barr virus serologic profile or mono-spot.
Differentials:
Mononucleosis: shaggy white-purple tonsillar exudates, often extending into the nasopharynx.
Diphtheria: rare. low-grade fever, and an ill patient with a gray tonsillar pseudomembrane.
Epiglottitis:
Treatment: (RX, Supportive measures, consults, Patient teaching
Viral: Supportive - acetaminophen/ibuprofen, saltwater gargling, soft, cool foods.
Bacterial: Penicillin V, Erythromyic (alternative for pcn allergic), azithromyic (alternative to pcn erythromycin resistant streptococcal strains.
Resistant to tetracyclines and sulfonamides.
Unique Pearl:
Pt with a sore throat that appears ill and is drooling: suspect epiglottitis (NEVER examine throat if suspected due to risk of precipitating respiratory obstruction.
If a pt has dysphagia and develops rash on amoxicillin: suspect acute Mono and STOP antibiotic.
Sore throat with severe rhinitis is secondary to irritative pharyngitis and does not require antibiotics.
Don't use ASA to txt ever in children/teenagers due to Reye sysndrome.

Hearing Impairment

Disease/Condition: Hearing impairment
Cause/Etiology- pathophys contributing to development of this disease:
Conductive: dysfunction of the middle ear often from obstruction (cerumen is most common), mass loading (effusion), stiffness (otosclerosis), or discontinuity (ossicular disruption). Also often due to transient Eustachian tube dysfunction from URI. Usually correctable.
Sensory: deterioration of the cochlea, esp loss of hair cells in the organ of corti. Gradual onset, progressive, increased with increased age. Often from increased noise exposure, head trauma, or systemic diseases (SLE, Cogan syndrome, Wegener granulomatosis). Usually not correctible, can be stabilized or prevented. Exception is sudden sensory hearing loss which may respond to corticosteroids.
Neural: lesions involving the VIII cranial nerve. Least clinically recognized form of hearing loss. Examples include acoustic neuroma, MS, and auditory neuropathy.
Epidemiology- population groups at risk for this condition: No race predilection. More common in males. Adults mostly. Conductive in children with frequent otitis media infections.
Presenting symptoms: occasionally complaints of ear pain if infected or impacted. Other times complaints of reduced hearing or no complaints.
Unique physical exam findings: Weber test lateralizes to louder to ear with conductive loss radiates louder to better ear in sensorineural loss. Rinne in conductive loss bone conduction will be > air conduction.
Diagnostic studies & significant results with rationale: Sensorineural air conduction will be > bone conduction. Audiometric studies with conductive losses, gaps will be noted between air and bone conduction ranges. Sensorineural will have roughly equal losses in both. MRI is best test to find reason for sensorineural loss.
Differentials: need to investigate type and cause
Treatment: depends on cause. Remove cerumen. Occasionally corticosteroids for sudden sensory hearing loss. Treat cause (tumor etc) for neural losses if possible. Hearing aids (sound amplification) or cochlear implants. Hearing rehab - improving speech comprehension.
Clinical Pearl: refer all for audiologic eval unless cause is very simple (i.e. cerumen impaction)

Tinnitus

Disease/Condition: Tinnitis
Cause/Etiology- pathophys contributing to development of this disease:
Perception of abnormal ear or head noises. Exposure to loud noises for extended periods. Other causes of hearing loss can be factor in development. Occasionally muscle spasm in middle ear.
Epidemiology- population groups at risk for this condition: No race predilection. More common in males. Adults mostly. Conductive in children with frequent otitis media infections.
Presenting symptoms: Intermittent mild high pitched sounds from seconds to minutes is common. May occasionally be severe and interfere with sleep.
Unique physical exam findings: good history with detailed description of sound, timing, duration, association with other findings.
Diagnostic studies & significant results with rationale: Weber, Rinne, Audiometric studies, auditory brainstem-evoked response testing, MRI
Differentials: Meniere's disease, other types of hearing loss
Treatment: Most important is avoid excessive noise, avoid ototoxic medications. Sometimes masking the sound with soft music or white noise may be helpful. Antidepressant meds (i.e. Nortriptyline at 50mg PO qhs) have shown to be most helpful medication. Transcranial magnetic stimulation helps some patients.
Clinical Pearl: Often indicates sensory hearing loss

Sinusitis

Disease/Condition: Sinusitis
Cause/Etiology- pathophys contributing to development of this disease:
Most commonly viral, may be bacterial (mostly commonly due to Strep pneumo or H. influenza), less commonly fungal(i.e. mucor, absidia, rhizopus, or aspergillus) in immunocompromised esp
Epidemiology- population groups at risk for this condition:
No race or gender predilection. Mostly in adults. More common during winter months.
Presenting symptoms: pain/tenderness over maxillary or frontal sinuses. Fever, malaise, halitosis, headache. Feeling of "congestion", rhinorrhea (typically clear to white when viral, yellow to green when bacterial), history of recent viral rhinitis, occasionally ear or tooth pain, cough and sore throat from post nasal drip that are worse at night
Unique physical exam findings: pain elicited with sinus palpation or percussion, possible reduction in transillumination if tested, swollen red moist turbinates sometimes, yellow or greenish mucoid discharge if bacterial sometimes.
Diagnostic studies & significant results with rationale: Diagnosis usually by history and exam findings alone, standard sinus radiographs NOT recommended, Coronal CT scans (w/o contrast) if needed to evaluate more complicated cases, if malignancy is suspected use MRI with gadolinium instead of or in addition to CT.
Differentials: viral rhinitis, nasal polyps, allergic rhinitis, malignancy, abscess, foreign body, headache variants, osteomyelitis (i.e. Pott's puffy tumor)
Treatment: viral (typically <7 days/mild) - oral or topical decongestant or nasal lavage (saline rinses), bacterial (consider >7 days/ mod-severe sx) - antibiotic (i.e. amoxicillin, augmentin, Bactrim, azithromycin as last resort due to broad spectrum), IV antibiotics if severe, refer if
Clinical Pearl: invasive fungal sinus infection is medical and surgical emergency

Mononucleosis

Disease/Condition: Mononucleosis
Cause/Etiology- pathophys contributing to development of this disease:
Epstein Barr Virus, generally transmitted by saliva or genital secretions
Epidemiology- population groups at risk for this condition:
Usually between 10 and 35 years of age,
Presenting symptoms: Fever, sore throat, fatigue, malaise, anorexia and myalgia.
Unique physical exam findings: lymphadenopathy (esp post cervical chain), Splenomegaly in up to 50% of pts, occasional maculopapular or petechial rash esp with recent use of ampicillin, sometimes exudative pharyngitis, tonsillitis, gingivitis, or soft palatal petechiae. Sometimes present with hepatitis, cholestasis, or other severe neurological symptoms. If severe splenomegaly, hospitalization or close observation is recommended.
Diagnostic studies & significant results with rationale: Positive Monospot(heterophil agglutination) test (if within 4 weeks onset of symptoms), CBC / differential - granulocytopenia, lymphocytic leukocytosis with "atypical lymphocytes", sometimes hemolytic anemia or thrombocytopenia, PCR for EBV DNA (from CSF) if associated with malignancy
Differentials: CMV infection, toxoplasmosis, influenza, HIV, syphilis, rubella, drug hypersensitivity reaction, acute viral/bacterial pharyngitis, adenovirus, mycoplasma infection
Treatment: acetaminophen or NSAID use for pain symptoms, Corticosteroid use is NOT recommended, if + for beta hemolytic strep from throat culture - tx with penicillin or erythromycin. Avoid contact sports and other strenuous activity for at least 4 weeks.
Clinical Pearl: aka. "the kissing disease", Splenic rupture is potential complication - NEED TO AVOID CONTACT SPORTS ETC

Impacted Cerumen

Disease/Condition:
Impacted cerumen
Definition:
Earwax accumulates and occludes canal of one or both ears

Cause- pathophys contributing to development of this disease:
Anatomic changes (stenosis of auditory canal or enlargement of meatus) mechanical (Q tips) Keratosis obturans
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
all ages, more common in children

Presenting symptoms:
Hearing loss, ear itching, pain, tinnitus, cough
Unique physical exam findings:
Wax adherent to tympanic membrane causes hearing loss more likely than if blocking whole meatus
When cerumen removed look for otitis externa or TM perforation
Keratosis Obturans- pearly white plug of compressed keratin fills external ear canal causing erosion of bony canal
Diagnostic studies & significant results with rationale:
Direct visualization of ear canal
Differentials:
Foreign body in external ear
Otitis externa
Keratosis obturans
Treatment: (RX, Supportive measures, consults, Patient teaching)
Cerumenolytics- acetic acid, docusate sodium, (Debrox works best, OTC)

Unique Pearl:
If hearing loss persists, complete hearing eval, and refer to ENT

Vertigo

Disease/Condition:
Vertigo
Definition:
Sensation of movement ("room spinning") when no movement is occurring

Cause- pathophys contributing to development of this disease:
Central origin-cerebrovascular causes, tumors,migrane, neurodegenerative disorders, epilepsy, intoxication, central positional vertigo

Positional origin- BPPV, vestibular neronitis, Meneire's disease, labyrinthine concussion, herpes zoster, perilymphatic fistula, otosclerosis, whiplash, medications
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
>90% of pts dx with peripheral causes. Male and female equal occurrence

Presenting symptoms:
Dizzyness, N/V, hearing loss, rotary illusions, ataxia
Unique physical exam findings:
Nystagmus
Balance abnormalities:
Peripheral- Mild to moderate, able to walk
Central- Severe, unable to walk
Diagnostic studies & significant results with rationale:
Dix-Hallpike maneuver
Orthostatic changes
Differentials:
Acoustic neruoma, Anxiety, BPPV, Cerebellar degeneration,CVA,Labryinthitis, Meneire disease, MS, Perilymphatic fistula, Syphilis, Vascular ischemia, vertiginous migrane, Vestibular neuronitis, ototoxicity
Treatment: (RX, Supportive measures, consults, Patient teaching)
Epley mneuver for BPPV, Migran prophylaxis, SSRI's, Meclizine 12.5-50mg PO q 4-8hr
Drmamine 25-100mg PO, IM, IV q 4-8hr
Phenergan, Reglan, Benzodiazapines

Unique Pearl:
Meclizine TX most effective, may take high dosage

Aphthous ulcers

Disease/Condition:
Aphthous ulcers
Definition:
Painful shallow oral ulcers, also called canker sore

Cause- pathophys contributing to development of this disease:
No single cause identified
Predisposing factors- heredity, local oral trauma, some toothpastes, mineral deficiency, psych stress, smoking cessation

Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
more common in children, incidence decreases with age

Presenting symptoms:
Small painful shallow based oral ulcers
Unique physical exam findings:
• circular shallow ulcers covered by gray membrane surrounded by raised border of inflammation
• minor recurrent aphthous stomatitis presents with 1-5 small ulcers (2-10 mm diameter)
• major recurrent aphthous stomatitis presents with 2 or more large ulcers (> 10 mm diameter)
• herpetiform recurrent aphthous stomatitis presents with 5-100 small ulcers (0.5-3 mm diameter) that coalesce into irregular shape
Diagnostic studies & significant results with rationale:
Rule out infectious, autoimmune, malignant, and medication causes
Differentials:
See above
Treatment: (RX, Supportive measures, consults, Patient teaching)
Identify and eliminate cause,(sharp dental appliance, hard toothbrush, acid foods)
Orajel OTC may be helpful

Parotitis

Disease/Condition:
Parotitis may be acute or chronic
Definition:
Inflamatory and infectious process of the parotid gland

Cause- pathophys contributing to development of this disease:
Gram + most common
Staph aureus, MRSA, S. pneumoniae, S. pyrogenes, H. influenza
Epidemiology- population groups at risk for this condition:
(age, sex, race, co-morbid conditions, lifestyle risks)
Children and adults
Presenting symptoms:
Parotid swelling, reduction in saliva, milky salivary secretion, rarely pus
Sudden onset, may continue for hours or months with exacerbation and transient remission
Low-grade fever
Unique physical exam findings:
Low-grade fever
Facial skin normal or inflamed
Parotid swelling, usually bilateral, swelling and redness of Stensen orifice
Thick grey-white salivary secretion, if abscessed, painful red indurated swelling

Diagnostic studies & significant results with rationale:
Multiple imaging techniques if chronic (panoramic and facial films, CT)
Differentials:
See above
Treatment: (RX, Supportive measures, consults, Patient teaching)
Lemondrops, mouth rinses, analgesics, dexamethasone, parotidectomy if severe
Unique Pearl:

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