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ClinMed- Nose & Paranasal Sinuses
Terms in this set (126)
function of nose and paranasal sinuses
respiration, conduction and purifying inspired air and olfaction
nasal obstruction can be caused by ----
deviated nasal septum, turbinate enlargement, polyps, or mass lesions
unilateral nasal drainage means
localized-- unilateral sinusitis, CSF leak
patient presents with severe facial pain w/swelling over sinuses and purulent drainage
patient complains of intermittent facial pressure associated with changes in weather, humidity, or other environmental factors
complete loss of olfaction
decrease in sense of smell
altered sense of smell
sensation of unpleasant smell (sinusitis)
hallucination of smells
decreased sense of smell in aging
A child following a URI presents with complete loss of smell
examples of allergic symptoms relating to nose
nSneezing, nasal or ocular pruritus, bilateral clear watery or mucoid nasal drainage, nasal congestion, pruritus of upper palate and ears, dry scratchy erythematous conjunctiva
allergies relating to season of year
spring- tree pollen
fall- weed pollen
Phenylephrine can cause
diuretics can cause ---- in nose
thicken, more tenacious secretions-
beta blockers, reserpine, exogenous estrogen can cause ----
how does tobacco smoke affect nose
congestion of turbinates, destruction of cilia, alteration in mucous secretion cells of the nasal mucosa
*****increase nasal congestion and thick post nasal drainage
condition that is caused by break in prominent capillary vessels along kiesselbach's plexus
how to tx anterior epistaxis
-inspect and evacuate clots by suction
- apply firm pressure to nares and identify site of bleeding/anesthetize/cauterize
- topical vasoconstrictive agents oxymetazoline - persistent
anterior vs posterior epistaxis
anterior- kisselbach's plexus- less serious and more common
posterior- woodruff's plexus - more blood seen and obstruction to breathing- often not visualized
tx of posterior epistaxis
- ENT consult
- posterior pakcing
- supplemental oxygen and monitored for hypoxemia + antibiotic
patient presents with inflammation of nasal mucosa nad paranasal sinuses with miild fatigue, congestion, low grade fever, and clear rhinorrhea.
causes of common cold
Rhinovirus, coronavirus, respiratory syncytial virus (RSV),
how to treat common cold
management = supportive
***antipyretics, analgesics, decongestants/adrenergic agents, antihistamine
18 year old presents with fever, HA, severe achiness, exhaustion, and chest discomfort
influenza- vaccination- supportive and antiviral meds can decrase duration of symptoms if started within 48 hours of onset
how does trauma to nasal bone present
epistaxis from intranasal mucosal tears + bruising + tenderness w/palpation + displacement
treatment of trauma to nose
supportive-- cold compresses, reduction of fracture after swelling decreases (4-8 days)
a 24 year old patient who smokes presents with HA, facial pain, discolored drainage, fever, and malaise. Area around sinuses is tender on palpation.
acute sinusitis (viral)
treatment of uncomplicated sinusitis vs complicated
uncomplicated (<10 days)- symptomatic- saline nasal spray, hot packs, steam, topical decongestant, antihistamines, oral decongestant, antipyretics
bacterial (>10 days or >7 days and no improvement): as above + antibiotics (augmentin, doxycycline, levofloxacin, moxifloxacin)
patient presents with unilateral nasal obstruction, purulent rhinorrhea, facial pressure, turbinate congestion, and fever of 103 following URI. Diagnosis? Treatment?
acute sinusitis (bacterial)
Tx: symptomatic tx + augmentin or doxycycline
what constitutes reasoning to use higher doses in patients that have bacterial acute sinusitis
-Fail initial treatment
-Antibiotic use in the past month
-Hospitalization in past 5 days (and check for MRSA)
when to refer patient who has acute sinusitis
-- more than 3 cases of sinusitis per year
-- severe infection that fails antibiotic tx
-- persistent infection despite few adequate trials of antibiotics
complications of acute sinusitis
nOsteomyelitis, cavernous sinus thrombosis, orbital cellulitis, meningitis, brain abscess, pitting edema (very close to brain)
patient who smokes presents with persistent nasal obstruction, thick/discolored drainage in the morning, and intermitted facial pressure. Labs to confirm? Diagnosis? Treatment?
Diagnosis: chronic sinusitis
Tx: antibiotics (augmentin) + decongestants and intranasal steroids + surgery after 1-2 months of tx
causes of acute sinusitis
strep pneumoniae, H. flu, m. catarrhalis, s. aureus-- Recent URI, chronic sinusitis, smoking, history or trauma or foreign body
tx of chronic sinusitis
augmentin+ Decongestants and intranasal steroids + surgery if no improvement
a diabetic patient presents with retention of mucous, swelling and pitting edema of sinus area.
causes of mycotic sinusitis
treatment of mycotic sinusitis
what organisms cause invasive mycoses
nAspergillosis and mucormycoses
patient presents with fever, facial pain and swelling, bloody nasal drainage, and necrosis of septum. diagnosis and treatment?
diagnosis: invasive mycoses
Treatment: ent refer + I&D, debridement of necrotic tissue
causes of deviated septums
Deviation from midline from trauma or disproportionate growth between the facial skeleton and nasal septum
Trauma or development
how to treat deviated septum
-- septal deformity surgery
-- rhinoplasty for external nasal deformity/blockage
causes of tuberinate hyperplasia
allergic rhinitis, nonallergic rhinitis, septal deviation, exposure to tobacco smoke, irritants, and pollutants; certain drugs (beta blockers, hormones)
how to treat enlarged turbinates?
-- if no response to decongestants, antihistamines, or intranasal steroids--> surgery
diabetic patient presents with scabbing around hair follicles in nasal vestibule. what is cause? Diagnosis? treatment?
cause: S. aureus
diagnosis: nasal vestibulitis
Tx: limiting nasal trauma (from fingers), antibiotic ointment and/or antibiotics
for immunocompromised: IV antibiotics to prevent infection to cavernous sinus
patient presents with a gray translucent pedunculated mass and complains of obstruction, hyposmia, congestion, anosmia.
diagnosis and treatment of nasal polyps
diagnosis: rhinoscopy or nasal endoscopy -- biopsy to rule out malignancy
tx: control of symptoms, topical/oral steroids, surgery (by ENT)
what is Samter's Triad
nasal polyps, asthma, aspirin sensitivity
Treat asthma, polypectomy, avoid aspirin.
patient with history of atopy presents with intermittent obstruction, clear rhinorrhea, congestion, sneezing, watery/scratchy eyes, and itching of nose.
allergic rhinitis -- eosinophils present on nasal smear
Tx: avoid allergens, antihistamines, leukotriene receptor antagonist (montelukast) or nasal steroid flucticasone propionate (flnase)
tx of allergic rhinitis
Leukotriene receptor antagonist: Montelukast (Singulair)
Nasal Steroids Fluticasone propionate (Flonase), Nasacort, Nasonex
Nasal saline spray (azelastine, atrovent)
tx of nonallergic rhinitis
decongestants and nasal saline sprays
patient presents with bogginess of nasal mucosa w/complaints of stuffiness and rhinorrhea.
vasomotor rhinitis -- avoid irritant and decongestants
caused by overuse of decongestants and presents as severe congestion and pain with minimal discharge.
Rhinitis Medicamentosa-- discontinue irritant and topical steroids during withdrawal period
how does granulomatosis with polyangiitis (wegener's granulomatosis) present in the nose
nSeptal ulcers, turbinate hypertrophy, vasculitis.
nBeefy, red mucosa with ulcerations and exudates. +PPD, caseating granulomas.
tuberculosis-- isoniazid, rifampin, ethambutol
treatment of TB
Isoniazid, rifampin, ethambutol
patient presents with mass that causes hearing loss, diplopia, visual disturbances, and nasal obstruction
patient presetns with mass. complains of nose bleeds, toothaches, proptosis, swelling of cheeks, and facial pain
smallest salivary gland lies above mylohyoid muscle
Hard bony growth with intact mucosa found on palate
torus palatinus-- reassurance (benign)
Hard bony growth with intact mucosa found on mandible
tongue-tie; a defect of the tongue characterized by a short, thick frenulum
nVascular tumor that appears at birth. Grows until puberty and spontaneously resolves
hemangioma- steroid injection or surgical removal if obstruction
Small, soft, painless, blue mucocele that forms at outlet of sublingual glands.
ranula- tx w/Marsupialization
phenytoin causes ---- in mouth
tetracycline causes -- in mouth
npermanent yellow, gray or brown discoloration of the teeth if given before about 8 years old.
Minocycline can cause what relating to mouth
blue, green or gray discoloration of teeth
vitamin C deficiency
scurvy-- bleeding gums and gingivitis
vitamin B2 Deficiency symptoms of mouth
atrophic glossitis, angular chelitis and gingivostomatosis
vitamin B3 Deficiency symptoms of mouth
Pellegra: beefy tongue with ulcerations and loss of papillae
vitamin B12 deficiency + oral symptoms
Pernicious anemia: smooth, beefy red tongue with pale mucosa and loss of papillae +/- ulcers
nsmooth, red tongue with loss of papillae, angular cheilitis and pale/grey colored oral mucosa
macroglossia with wide spaced teeth
macroglossia with yellow nodules on dorsal and lateral surfaces
manopause can affect the mouth how?
atrophic mucosa and gingivostomatitis
Acute necrotizing ulcerative gingivitis that leads to inflammation, bleeding, deep ulceration, and necrotic gums
patient presents with deep ulcers in oral mucosa, fever, and bad breath. reports smoking and rarely brushes teeth
tx: oral hygiene + antibiotic
a 4 year old patient complains of sore throat, painful swallowing, high fever, malaise, and vomiting and in a lot of pain. on exam, numerous small gray-white vesicles. presents on oropharynx in linear arrangement.
herpangina -- self limiting symptomatic --- push fluids!!!!
older child presents with single, painful, round ucler with red halo covered by yellowish exudate
tx of aphthous ulcer/stomatitis
Self-limited. Supportive treatment with anti-inflammatories. Topical steroid rinse, Benadryl, Lidocaine, Maalox swish and spit
for few ulcers= aphthasol
what oral medication to avoid in kids <2 years old
benzocaine + tetracycline
1 year old patient presents with painful oral lesions on buccal and gingival mucosa.
Primary Herpetic Gingivostomatitis (HSV-1)
tx of Primary Herpetic Gingivostomatitis
self limited + acyclovir to shorten duration
Recurrent, episodic eruptions of yellowish fluid filled vesicles on upper/lower lip, nose
cold sores- secondary Herpetic Gingivostomatitis
tx: topical acylovir ointment + fluids, rest analgesics, antipyretics
patient presents with extremely painful, burning, unilateral vesicles on buccal mucosa, tongue, and uvula. fever is present.
Herpes Zoster-- antiviral drugs + symptomatic
a fair skinned individual with lots of sun exposure presents with dry, fissured, reddened area of bottom lip with atrophic and pale appearance.
Solar Cheilitis-- chapstick, vaseline
a 3 year old child presents with drug, burning corners on sides of mouth with maceration. mother says that child sucks his thumb a lot.
angular cheilitis - treat cause
causes of angular cheilitis
nInfection: Often Candida or Staph
nSagging face and loss of teeth
a 4 year old male presents with sore mouth, low grade fever, and coryza. on examination, vesicular lesions are found in oropharynx along with hands and feet.
hand-foot-mouth disease- self limiting
child presents with bilateral salivary gland enlargement/swelling and salivary hypofunction. low grade fever and pain are also present.
mumps (paramyovirus)-- hydration+ analgesics (symptomatic tx)
complications of mumps
31 year old patient complains of swelling of palate, uvula deviation, fever, malaise, and drooling. complains of difficulty eating and throat pain on one side. Diagnosis and Tx?
ENT refer for needle aspiration, I&D, antitbiotics (ampicillin sulbactam or clindamycin)
tx of peritonsilar abscess
ENT referral for Needle aspiration, I&D, antibiotics.
Ampicillin sulbactam or clindamycin. IV
a 12 year old child presents with low grade fever, red and dry pharyngeal mucosa w/enlarged tonsils and dysphagia.
acute viral pharyngitis
tx of viral pharyngitis
analgesics and local measures
a 17 year old patient complains of sore throat, being tired all the time and HA. on exam, posterior cervical lymph nodes are enlarged along with tonsils. petechiae are present on soft palate
7 yo presents with fever, dry/red pharyngeal mucosa with exudates and swelling of tonsils. complains of burning throad
causes of bacterial pharyngitis
Group A B-hemolytic streptococci, diphtheria, N. gonorrhea, pertussis, bactrim
treatment of bacterial pharyngitis
analgesics and symptomatic tx + antibiotics if identified
diphtheria: antitoxin with PCN
s. aureus: bactrim
15 year old presents with fever of 101, tender anterior cervical adenopathy, and exudation of tonsil-pharyngeal area. complains on throat pain but no cough is present.
Group A Beta Hemolytic Strep
tx of Group A Beta Hemolytic Strep
amoxicillin, penicillin, clindamycin
complications of Group A Beta Hemolytic Strep
rheumatic fever, tonsillar abscess, PANDAS
nExcessive reactive proliferation of tonsil tissue
patient presents with difficulty with eating, snoring, sleep troubles, and changes in speech resonance. what could this be caused by?
tonsilar hypertrophy -- surgery
Numerous small painless furrows on dorsal and lateral tongue
fissured tongue-- hygiene
nWell-defined areas of atrophied filiform papillae bordered by arcs of normal or hyperplastic filiform papillae
geographic tongue (no specific cause)
reassruance + b12 if deficient
patient with GI illness presents with burning pain of tongue, inside cheeks, and throat. on exam, scrapable white substance is found.
thrush-- nystatin swish and swallow
Defective desquamation of filiform papillae resulting in hair-like projections on the dorsum of tongue associated with heavy tobacco use, systemic antibiotic/steroid use, and poor oral hygiene
black hairy tongue-- treat cause + oral hygiene
patient presents with recurrent swelling and pain with eating of submandibular salivary gland
sialolithiasis-- surgical excision (spontaneous disappearance) or analgesic, antibiotic
patient complains of pain and swelling of salivary glands. fever and erythema is present.
acute suppurative sialoadenitis
treatment of acute suppurative sialoadenititis
culture--> empiric antibiotics (cephalexin/dicloxacillin), volume repleting, moist heat
CT if no improvement in 2-3 days --> surgery
cause of Acute Nonsuppurative Sialoadenitis
viral- EBV, coxsackievirus, HIV
classic triad of xerostomia , dry eyes, connective tissue disorder with swelling of parotid glands bilaterally, arthritis
tx of sjogren's syndrome
biopsy of salivary gland, antibody testing, antiSSA and anti-SSB
nLocal and symptomatic, humidification and hydration, Avoidance of anything that decreases salivary flow
dry mouth that leads to pain and difficulty swallowing
nHypersalivation or drooling due to grave's disease, heavy metal poisoning, epilepsy, stroke, or pregnancy
low grade variant of SCC, found in oral cavity and larynx, resembles wart, non invasive cancer
60 year old patient who has smoked since he was 16 presents with hoarseness, voice changes and painless white patch on tongue that cannot be scraped off
leukoplakia -- excisional biopsy
F/U: laryngoscopy for observation for recurrence or progression
patient presents with velvety red patch on floor of mouth.
erythroplakia-- high rate of dysplasia-- biopsy and ENT refer
how does BCC of lip present?
--Lesions ulcerates, heals over, then breaks down again; history of ultraviolet light exposure
--Crusting ulcer with heaped or rolled borders; induration
SCC of the lip:
--painless ulcer with raised borders
+/- trismus (deep invasion)
Initial painless mass or ulcer becoming painful and induration is present; difficulty with speech, eating; referred ear pain; weight loss
tongue carcinoma -- staging biopsy
most common site of involvement for salivary gland carcinoma
most common types of malignant tumors of salivary glands
adenoid cystic carcinoma, mucoepidermoid cancer, adenocarcinoma
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