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179 terms

HEENT: Nose and paranasal sinuses

STUDY
PLAY
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
Group A Beta Hemolytic Strep
most important strep to tx. Presentation: Fever > 100.4 or 38 C, tender anterior cervical adenopathy, lack of cough and presence of pharyngo-tonsillar exudates. 3 out of 4 suggest Strep. 2 out of 4 indicate need to culture. Children and adults. Additional sx: Pharyngeal erythema with red palatine tonsils and arch; yellow exudate, painful adenopathy, chills, malaise, painful glands in neck; Sudden onset intense throat pain, odynophagia, cough +/- coryza, and rhinorrhea suggestive that is clear
Group A Beta Hemolytic Strep
Penicillin as PCN VK250mg TID or 500mg TID for 5-10 days. Cefuroxime 250mg BID for 5-10 days. Erythromycin
Group A Beta Hemolytic Strep
Complications: rheumatic fever, tonsillar abscess
tonsillar hypertrophy
Excessive reactive proliferation of tonsil tissue. Mouth breathing, eating difficulties, snoring, sleep disorder, change in speech resonance. Children and adults. Increase in volume of tonsils, cervical adenopathy; if unilateral refer to ENT. Progressive with worsening upper airway symptoms. Tx:
Surgery if dental, facial abnormality, airway obstruction, dysphagia, sleep disorders
viral
The most common cause of pharyngitis is a _____ infection. Rapid strep or throat culture
glomerulonephritis
Treating strep throat is key to help decrease transmission to others. Also to prevent rheumatic fever and acute _____.
Mono spot if suspect mono: fatigue, teenagers
penicillin
_____ abx used for strep pharyngitis. macrolides if allergic. consider tonsillectomy if tonsillitis recurs
fissured tongue
Normal variant in 11% of the population. Differential: Psoriasis, myxedema, acromegaly, Sjogren syndrome. Presentation: Usually painless, except if food debris in grooves lead to irritation. Numerous small furrows on dorsal and lateral tongue. Tx: No concern unless evaluation reveals other pathology. Hygiene; stretch/flatten fissures, clean surface with toothbrush
geographic tongue
Also known as benign migratory glossitis. Idiopathic. No specific cause. Possible link with psoriasis. 25% tenderness and burning. Discrete, irregular areas of desquamation, white to yellow in color, resembling a "map." Regression and recurrence. Well-defined areas of atrophied filiform papillae bordered by arcs of normal or hyperplastic filiform papillae. Tx: No specific treatment. Reassurance. Vit. B12 complex
oral candidiasis: thrush
Often in immunocompromised or with use of broad spectrum antibiotics. Burning pain of the tongue, inside cheeks, throat. Can be scraped off and the area underneath will be red, friable, raw. Tx: Nystatin (antifungal) swish and swallow. Clortrimazole, Fluconazole
black hairy tongue
Benign condition. Defective desquamation of filiform papillae resulting in hair-like projections on the dorsum of tongue. Elongation of the papillae. White, yellow, green, brown, or black. Associated with heavy tobacco use, systemic antibiotic therapy, poor oral hygiene, systemic steroids. Asymptomatic or gagging, altered taste. Tx: eliminate cause. Oral hygiene;
sialolithiasis
Calculi in salivary gland, principally submandibular gland (80%). Mainly middle aged males. Recurrent swelling and pain especially with eating. Reduces in size once done eating. Palpation may reveal calculus. X-ray may show location. May require surgical excision. Some pass spontaneously. Try to milk the stone out. May require analgesic, antibiotic
Acute Suppurative Sialoadenitis
Can affect parotid, submandibular, or sublingual. caused by any factor that reduces flow of saliva allowing for retrograde infection of salivary gland (age, poor hygiene, medication). Acute onset of pain, swelling often associated with fever, swollen gland with erythema. Fever. Swollen, tender gland with overlying erythema
Acute Suppurative Sialoadenitis
Obtain a culture. Empiric antibiotics like cloxacillin or dicloxacillin; improve salivary flow; volume repletion; milking gland. Moist heat. No improvement 2-3 days CT to Rule out abscess, mass lesion, or impacted sialolith requiring surgery
Acute Nonsuppurative Sialoadenitis
Typically viral infection most common cause mumps. EBV, coxsackievirus, HIV. Tx is supportive
Sjogren's Syndrome
Autoimmune; classic triad of xerostomia (oral dryness), dry eyes, connective tissue disorder (RA most common). Swelling of parotid/submandibular gland bilaterally, arthritis, laryngitis. May be tender or firm. More common in women, dry lips or mouth, viscous mucus when expressed from salivary ducts. Diminished salivary flow. Atrophy of tongue papillae
Sjogren's Syndrome
Biopsy of labial salivary gland. Antibody testing. AntiSSA (Ro) and anti-SSB (La). Course is Progressive; rheumatology evaluation. Local and symptomatic, humidification and hydration, Avoidance of anything that decreases salivary flow. Supportive Treatment
Xerostomia
dry mouth, many causes. may lead to pain, dysphagia, altered taste, and dental caries
ptyalism
Hypersalivation or drooling. Usually due to a secondary condition. Pregnancy, Graves disease, heavy metal poisoning, epilepsy, CVA. Treat the underlying condition
leukoplakia
white patches that cannot be removed
erythroplasia
ominous mucosal change, velvety red patch, floor of mouth, ventral tongue, soft palate, tonsil, high rate of dysplasia, always biopsy
verrucous carcinoma
low grade variant of SCC, found in oral cavity and larynx, resembles wart, non invasive cancer
leukoplakia
Denotes white patch or plaque on mucous membrane. Cause: Most common inciting agent is cigarette smoking. Tobacco smoked or smokeless. Alcohol use. Trauma. Iron deficiency anemia. Patient usually >40 years old. Usually males
leukoplakia
May be asymptomatic, hoarseness, voice changes. May be Isolated to vocal cords or larynx diffusely. Keratinization of the mucosa occurs. It may involve dysplastic epithelial changes. Painless white patch on the tongue, inside cheek, lower lip, floor of the mouth and it CANNOT be scraped off
leukoplakia
May be considered a premalignant lesion. Carcinoma develops in 2% to 6%. Erythroplakia has a 60% rate of changing to malignancy. Excisional biopsy both diagnostic and therapeutic, especially in those with a history of alcohol and tobacco use. Laryngoscopy to observe for recurrence or progression
erythroplakia
possible dysplastic lesion. velvety red patch, floor of mouth, ventral tongue, soft palate, tonsil, high rate of dysplasia. tx: bx to determine tx. referral to ENT
basal cell carcinoma of lips
prolonged exposure to sunlight. Lesions ulcerates, heals over, then breaks down again; history of ultraviolet light exposure. Crusting ulcer with heaped or rolled borders; induration. Untreated lesions enlarge, infiltrate adjacent and deeper tissues. Biopsy for diagnosis; each lesion considered separately when choosing therapy
squamous cell carcinoma
Lack specific etiology; tobacco , alcohol, poor oral hygiene, syphilis implicated. Usually painless ulcer unless nerves or periosteum involved; fetid breath. Ulcerated lesion with raised borders; palpation of mouth and tongue mandatory; if trismus (lock jaw: tonic contraction) noted suspect deep invasion. Comprise 95% of oral cancers. Biopsy for diagnosis; therapy depends on staging
tongue carcinoma
Associated with tobacco, alcohol use. Initial painless mass or ulcer becoming painful; difficulty with speech, eating; referred ear pain; weight loss. Ulcer or mass with induration and raised borders; fetid breath; firm tongue; neck mass. Metastasis common. Staging biopsy for diagnosis and treatment
Salivary Gland Carcinoma
Parotid gland is the most common site of involvement. Any age but most common between 55-65 years of age. Many tumors of the parotid are benign. The 3 most common types of malignant tumors of the salivary glands are; adenoid cystic carcinoma, mucoepidermoid cancer, adenocarcinoma. Adenoid cystic carcinoma can spread hematogenously, and along the nerves. Alcohol and tobacco are the main causes. Surgical removal and possibly radiation. Response rates of 20-35%, but some prolonged responses are occasionally seen