Clinical Medicine - Final Exam - Fortie and White ENT

diagnosis of Caries

-clinical, can see it

Clinical presentation of Chronic Otitis Media

-timeline: has to be 2 weeks of drainage to call it this -can have symptoms for months, might not have drainage all day everyday, TM has not healed

testing for Sialolithiasis

1 - X-ray 2 - sometimes see erythema or stones 4 - release of fluid when you push it out

treatment of bacterial rhinitis

1 - amoxicillin +/-; Augmentin, doxycycline for 5-7 days 2 - Second line: Augmentin

complications of Cholesteatoma

1 - hearing loss 2 - vertigo 3 - CN palsy 4 - if deep and spreading more can cause brain abscess 5 - meningitis

instigators causing anterior epistaxis

1 - local trauma 2 - hypertension 3 - extreme dryness 4 - atrophic rhinitis 5 - foreign body

2 treatments for anterior epistaxis

1 - oxymetazoline nasal spray 2 - Premarin Cream for recurrent anterior bleeds

diagnosing Strep - Bacterial pharyngitis

1. Centor criteria - point system to help lead you to highly suspect strep, can guide cultures, rapid strep swabs (test is 80-90% sensitive, not perfect)

Anterior epistaxis apply local pressure for

10 minutes

otitis externa can be hard to distinguish with

AOM

Schwann cell derived benign tumor on the auditory nerve (8th cranial nerve) that causes vertigo, tinnitus, and hearing loss

Acoustic Neuroma

Schwann cell derived tumor

Acoustic Neuroma

anatomical deformity of nasal septum, turbinates exacerbates - frequent minor anterior nose bleeds

Atrophic Rhinitis

Conductive vs sensorineural hearing loss

Conductive hearing loss - hearing loss of the outer ear; sensorineural hearing loss - hearing loss of the inner ear

caution of Anterior epistaxis in elderly and COPD patients

SaO2 issues

treatment of Viral Pharyngitis - Epstein barr virus

Tylenol - symptomatic, over the counter, warm salt water gargle

thrush

candiasis

trauma

trauma

perforated tympanic membrane Causes

trauma, barrel trauma (explosions, changes in altitude), fluid build up, severe loud noises = get history to see risk factors

management of Perforated Tympanic Membrane

treat infection, topical antibiotics, make sure they are all counseled on not getting water in your ear

32 yo female, fevers, was treated for otitis media, now has pain behind ear - treatment

treating for mastoiditis, need IV antibiotics

epiglottitis - tripod posture

tripoding "lening this way so its easier to breathe"

used to test mobility of TM

tympanometry

thrush in an infant

- scrape it will tend to bleed

complication of Gingivitis

- tooth loss, local infection that can occur as well, can spread into alveolar bone but not as common

Bacterial pharyngitis is common in

-all ages -schools, day cares

treatment of Mastoiditis

-antibiotics - IV -sometimes have to drain it -Vancomycin* -start broad until figuring it out, cephalosporins as well -get ENT consult and treat right away or it can lead to severe illness

diagnosis Gingivitis

-probe it -Culture if need be

prevention of Candiasis

1 - educate elderly on washing/cleaning dentures 2 - immune status checks 3 - won't have thrush without some other reason/other disease process

clinical presentation of Herpes Simplex

1 - initial infection is asymptomatic 2 - prodromal 3 - can be painful, iterating, get very big 4 - sometimes multiple in same spot 5 - kids can have fever, drooling, decreased oral intake, it hurts, bothers them, they stop eating

Foreign objects in ear

1-discharge, erythema 2-obvious foreign body 3- swelling, otitis externa now 4 - go to ENT

Acoustic Neuroma risk factors

1. occupational exposure - music 2. Childhood exposure to radiation of head and neck 3. neurofibromatosis type II

complications of Acute Otitis Media (AOM)

1. perforation - can open up - hearing loss if scarring happens on TM, hearing loss later --> can effect bones on inside if they can't move as well 2. can develop acute mastoiditis - invading airways around the ear - facial nerve paralysis

medications that can cause anterior epistaxis

ASA, warfarin, dabigastrin

plaques from bacteria can colonize on surface of teeth

Caries

2 types of Chronic Otitis Media

Central and Anular -Anular is around borders, seen more frequently for perforation

Sialadenitis

Inflammation of the salivary gland (usually unilateral)

Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears).

Meniere's Disease

effusion but no sign of infection, common in children, can effect speech and hearing early in life

Otitis Media with Effusion

loss of attachment of alveolar bone

Periodontitis

ring of tonsillar tissue in back of mouth

Waldeyer's ring

Xerostomia

define

fracture - dental trauma

something is broken in teeth or surrounding bone

Cholesteatoma risk factors

(most common in children average age of 5) -recurrent otitis media, frequent tubes, craniofacial abdnormalities, down syndrome

risk factors for Otitis media with Effusion

- can occur after URI infection or traveling -undiagnosed acute otitis media

Infectious rhinitis - Viral Rhinitis

- common "cold" --mild to moderate congestion and clear rhinorrhea

cause of Apthous Stomatitis

- idiopathic: more common in childhood - decrease as we get older

bacterial rhinitis

- more apt to be ethmoid sinusitis causing a rhinosinusitis -same bacteria that cause acute otitis media usually --S Pneumonia, H influenzas, M Catarrhalis (so treat w same you would treat ear infections w)

know

-Eustachian tube and adenoids together, adenoids are removed sometimes to protect eustachian tubes, if adenoids enlarge can occlude eustachian tube. Nasal valves - close when you are swimming so water doesn't go up your nose. in elderly - -nasal valves collapse which doesn't impact much except it decreases air flow through their nose. when airway is obstructed bilaterally - drops oxygen saturation by 10% which isn't a big deal except in elderly people which can make a big dif

Causes of angular cheilitis

-acute or chronic inflammation at angle of lips 1 - from chronic lip licking 2 - fingers in mouth 3 - impetigo 4 - ill fitting dentures in adults can cause this = irritation, poor hygiene, oral candidiasis = angular cuditis

peritonsillar abscess

-antibiotics and drain

Meniere's Disease

-any age but usually 20-40 years old -basically idiopathic -could be blocked ducts

prevention of tinnitus

-avoid loud noise exposure -good ear protection

etiologies of nasal septal perforation

-bilateral preseptal hematoma are worrisome it can cause nasal septal perforations

look

-chronic rhinosinusitis - turbinate edema = before and after picture

..

-common to see it this way in elderly (beat red)

Physical exam: Otitis externa

-ear is sensitive -PUSHING ON TRAGUS RLY HURTS**** -important to look at TM and inside the ear -*important to look at TM and inside the ear INSIDE MEMBRANE: -may look irritated, all outside the membrane***, TM can be irritated but not rly effused, swelling distal to TM **canal is swelling

Clinical presentation: Chronic Otitis Media

-effusion in middle ear - perforate = protective mechanism -perforation does NOT HEAL** -a lot of drainage that keeps coming and bc of that the TM cannot heal -Usually TM heals on its own in other disorders, with this the perforation can stick around on TM fora long time and doesn't respond to treatments

Otitis Media with Effusion epidemiology

-effusion with no sign of infection -common in children -can effect speech and hearing early in life = speech delay

Nasal polyps

-gray shiny polyp - typically begins up high by eye - starts to swell (usually from allergens) --> redundant mucous membrane pushes itself and is more exposed to allergens and continues to grow/propagate -->takes time -looks like a peeled grape

treatment of tinnitus

-hearing aids can filter exogenous noise -electrical/magnetic stimulation -Lidocaine can give temporary relief not used much -Benzos rly just sedate -Hypnosis -Counseling, acupuncture

clinical presentation: Otitis Media with Effusion

-hearing loss -possibly discomfort, not constant pain all day long, can feel like ear is underwater -fluid impairing ability of TM

Otitis Media with Effusion treatment

-if for more than 3 months, get otyologist referral, speech eval. watch and wait - kids with it should have hearing exams every 3 months -if structural abnormality is suspected, possibly surgical referral to drain fluid out

severe oral candidiasis

-immunocompromised

Epley maneuver

-in patients with benign paroxysmal positional vertigo (BPPV) due to posterior canal canalithiasis -the particle repositioning maneuver encourages the calcium carbonate debris to migrate toward the common crus of the anterior and posterior canals and exit into the utricular vanity

Periodontitis

-loss of attachment of alveolar bone -important to get gingivitis treated so it doesn't lead to this -Periodontilar ligament tooth is no longer secured - start losing teeth -can occur over weeks or years

risk factors for Chronic Otitis media

-lower socioeconomic status -less access to care, poor nutrition -increased smoking -Immunocompromised like diabetics, on medication making them immunocompromised

Vestibular disorders - dizziness

-more inner ear -common in ER -ask what dizziness means to them -Vertigo = common category of dizziness - spinning sensation -get history

Physical exam: Chronic Otitis Media

-not a lot of signs of infection or pain -culture fluid if antibiotics not working

Congenital cholesteatoma

-nothing we can do in primary care, refer to ENT to have it surgically removed.

presentation of Sialolithiasis

-pain -worse when eating -little swelling

gingivitis

-periodontal disease -peaks in adolescence

diagnosis of Mastoiditis

-physical exam, history -CAT scan with IV contrast --> to know if its an abscess or just fluid to help guide treatment for ENT

choleastoma: etiology/pathogenesis

-retraction pocket in ear that is filling with keratin and making a mass behind TM -very RARE -can have granulation tissue erosion -can be a complication of other disorders -can be congenital *most common in children average age of 5

Waldeyer's ring

-ring of exposed lymph nodes in oropharynx: idea being that whatever we ingest/inhale will go right over these lymph tissues --> sending signals to immune system

exam of Apthous Stomatitis

-round, clearly defined small painful ulcers with gray base

treatment of Cholesteatoma

-some ENTs will place tubes to help it drain on its own or go in surgically to remove it and reconstruct if neighboring structures have eroded

normal paranasal sinuses

-someone with non airrated frontal sinus - frontal sinus never grew

concerns for Parotitis

-spread and get aseptic meningitis, encephalitis, bacterial thrombosis

risk factors of Otitis externa

-trauma to canal, tell patients not to use cute tips, wax is good and normal -Changes in acidity levels in ear, fluid stuck **people who are in water a lot, more common in summer months bc kids are in water

Nasal fracture

-tremendous amount of edema occurs -need to be fixed within 12 hours or edema becomes so severe you cannot work with it -have to be hit pretty high up to break the bone

Septal hematoma

-use nasal speculum to see *vertically* -this is a nasal septal hematoma - pt has bled between nasal septal cartilage under membrane that covers it --> refer to surgeon - drain the hematoma and pack the nose so that mucous membrane isn't separated from perichondrium

know

-usking endoscope to see up in nose -can see lateral side of nose -pus is seen - consistent with sinusitis

mastoiditis risk factors

-usually in school aged children -rare, bc we are good at treating AOM -postauricular erythema - ear is down and out more, looking head on, infection and swelling displacing the ear

Vestibular Neuritis PE

-vestibular imbalance, nystagmus -Gait instability -can still get up (not weakness) not neurological its vestibular -Gait instability, nystagmus, sometimes hearing loss rule out: bleed, stroke, etc. in exam

oropharyngeal candiasis

-what you would expect to see in elderly - beat red shiny, uncomfortable --> expect to see under dentures **Nystatin swish and swallow to treat, and clean dentures

etiology of Otitis Media with effusion

-won't see bacteria, no evidence of infection

bacterial tracheitis

-yellow is adherent debris in the trachea from bacterial infection maybe -extends down into trachea

treatment for Gingivitis

1 - Clorohexadine rinses are good treatment, keep under control 2 - Penicillin, antibiotics, clindamycin, augmente if needed*

treatment for Strep - bacterial pharyngitis

1 - Penicillin - 10 days 2 - for kids: prefer Amoxicillin - can use cephalosporins if penicillin allergies

multiple forms of Candidiasis

1 - Pseudomembranous = more common with white plaques that develop on buccal mucosa, tongue 2 - Atropic = underneath dentures, erythematous area without plaques

treatment: Xerostomia

1 - Pylocarpine, zylodogs? 2 - Stope medications that are causing this side effect 3 - treat bc lack of saliva can effect teeth, gums, taste of food, how they swallow, eat, big quality of life measure

rhinitis etiologies (7)

1 - allergic 2 - drugs 3 - pregnancy (hormonal) - estrogen receptors in nose 4 - bvasomotor 5 - infectious (viral, bacterial) 6 - environmental factors 7 - aging - atrophic rhinitis

Dental abscess clinical presentation

1 - bacteria trapped between tooth and gingiva - swelling 2 - sometimes whole face is popped out - facial swelling, sore, tender, can have fever, tachycardia, sick, swelling

treatment of Angular Cheilitis

1 - bacterial treat with bactrian topical 7-10 days 2 - Good education, hygiene

Parotitis pathology

1 - can be bacterial - suddenly comes on, becomes firm, more red, more sick, fever, tachycardia, can radiate to other areas, more toxic signs 2 - viral = typically more swelling angle of mandible obscured - inflamed inside

diagnosis of Angular Cheilitis

1 - clinical 2 - KOH prep if suspicious of yeast, 3 - yellow crusting plaques around lips can be impetigo

diagnosis of Candidiasis

1 - clinical 2 - KOH prep look under microscope 3 - simple will treat with Nystatin swish and swallow 4 - lozenges

diagnosing Herpes Simplex

1 - clinical (see it) 2 - Tzanc smear - expensive, not usually done 3 - viral culture - doesn't make sense to do this

PE Xerostomia

1 - cobble stoning appearance of tongue 2- dry mouth, not a lot of moisture 3- teeth and neck look for adenopathy, see if localized or other systemic findings

Herpes simplex

1 - common 2 - cold sores, Herpes Type I 3 - can undergo latency 4 - survives in neural ganglia 5 - trigger = fever, colds sometimes, sunlight, food stress

candiasis risk factors

1 - common with dentures 2 - diabetics 3 - patients on chemo radiation 4 - inhaled glucocortisoids (mouth spray)

risk factors: Sialolithiasis

1 - dehydration 2 - diuretics 3 - slow down salivary flow 4 - trauma 5 - smoking

treatments for Coxackie virus

1 - diagnose clinically (seen in day cares a lot 2 - CDC doesn't recommend missing daycare if you have it 3 - no serious complications

dental trauma treatment

1 - dont try to put baby tooth back in - can damage bud of tooth that's forming underneath 2 - get them to dentist asap, manage other trauma 3 - if permanent tooth get it back in asap - hold gauze on it 4 - if cant put it in keep it in a moist medium to keep the tooth alive 5 - can splint a tooth like putty and piece it back into place as a temporary measure til you get to dentist

treatment for insect in ear

1 - drop of lidacane will paralyze insect and flush it out 2 - numb it, paralyze it, bug will come out easily (dont just go in with tweezers)

Rhinitis due to environmental factors

1 - dusty workplace 2 - toxic fumes 3 - wood stoves (dryness and particulate material) 4 - irritants with hobbies, factories *smoking more difficult but use Saline NS, corticosteroid NS

Xerostomia risk factors

1 - dye effect of medication 2 - SSRIs, tobacco, antihistamines 3 - chemical/radiation therapy can effect glands and dry them out 4 - autoimmune disorders

diagnosing Peritonsilar abscess

1 - get counts, labs 2 - CT imaging is done to tell extent of abscess, with IV contrast 3 - worry about airway closure - ENT drains 4 - complication = aspiration pneumonia, choking

Otitis Media with Effusion Complications

1 - hearing loss with young kids 2 - cholestiotoma = scarring along membrane

Risk factors for Acute Otitis Media

1 - history of ear infections 2 - smoking in the home 3 - pacifier use 4 - early onset (younger age) = more likely to have more occurrences in young years 5 - URI - anything causing inflammation and draining down eustachian tube (fluid retained in middle ear = breeding ground for infection)

Vasomotor Rhinitis

1 - imbalance of autonomic NS activity in elderly 2 - chronic dry nasal mucosa, clear rhinorrhea 3 - often confused with allergic rhinitis (AR) --AR uncommon in elderly

Parotitis

1 - inflammation of parotid gland (can be bacterial, mumps can cause this) 2 - type of Sialadenitis 3 - Staph aureus more often causes this 4 - can post op happen in elderly = dry mouth predisposes to inflammation of these glands

Coxackie virus sores are found

1 - intramurally, plantar and palmar regions as well 2 - oval papules, spares lips and gingiva

treatment of Herpes Simplex

1 - intraoral use, Aziclovir like any herpes infection 2 - patients with them, can take it right away to decrease duration and amount of lesions 3 - with kids treat pain - lidocaine on it and benedryl -mix and use with cue tip on sore 4 - sometimes ppl in prodrome phase (feel it but dont see it yet) blast it with laser and they won't get it again bc this is when the virus is actually active at the skin

risk factors for Parotitis

1 - intubation for a long time - dries out 2 - dehydrated patients 3- recent teeth cleaning - if not immunized = big risk factor

risk factors for Caries

1 - lack of salivary flow for those with gland disfunction 2 - smoking, poor dental hygiene, can be asymptomatic 3 - erode further and further - can cause lots of pain

PE for acoustic Neuroma

1 - look at CNs to see if other findings 2-indential finding sometimes - get optometry referral/scans 3 - multifactorial - looking to get others involved like neurology 4. picked up on MRI

diagnosing Xerostomia

1 - lots of panels like Chogrins and other immune testing (not common though) 2 - Whole salivometry (collect for 15 min) to measure how much to see if they are producing enough or if not 3 - salivary gland biopsy 4 - imaging by testing function of glands to get idea of how much uptake of nuclei they are getting MRI for that

treatment of Sialolithiasis

1 - milk the duct 2 - lemon drops to stimulate salivary flow 3 - try to push it out 4 - if obstructed can cause back flow 5 - chronic can make gland unfunctional

Chronic sinusitis physiology

1 - more than 12 weeks duration 2 - presents as chronic obstruction, congestion 3 - Mucosa typically garaged, thickened, and cilia spotty throughout sinus mucosa 4 - tobacco smokers

physiology of allergic rhinitis

1 - nasal mucosal edema, congestion, rhinorrhea 2 - allergic "salute" (crease across nose) nasal crease; allergic "shinners" 3 - may have avascular polyps originating in ethmoid sinuses and extending into nasal airway 4 - unilateral c/c bilateral

treatment of Vasomotor Rhinitis

1 - none very satisfactor 2 - saline nasal spray, corticosteroid NS, Azelastine NS, ipratropium NS 3. avoid contributing meds

presentation of Oral/Throat cancer

1 - oral lesions/masses that do not heal well 2 - lesions that are scary, don't heal, dentures aren't fitting anymore so aren't wearing them 3 - can be painful ulcers on tongue/lip, referred ear pain, hoarseness, dysphagia, sore throat that can accompany oral/throat cancer

Complications of Viral Pharyngitis - Epstein-Barr virus

1 - other organ involvement, spleen enlargement 2 - risk for splenic rupture in contact sports 3 - watch if airway is compromised/obstructed

presentation of Apthous Stomatitis

1 - painful oral lesions, no other signs of disease 2 - can have recurrent outbreaks, some can be more common than others

diagnosing Oral/Throat cancer

1 - persistent papules 2 - lesions should biopsy esp if at increased risk 3 - use mirrors to see all of mouth 4 - palpate mucosa - should be part of annual physicals - look for those things 5 - CT, MRI, PET scans to see if lesions are anywhere else

diagnosing Viral Pharyngitis - Epstein barr Virus

1 - pharyngeal erythema, swelling 2 - can do a swab 3 - check lymph nodes, mono = posterior lymphadenopathy** 4 - Pancreatitis - check liver and spleen 5 - elevation in liver enzymes if mono 6 **blood test for leukocytosis - increase in monocytes 7 - HETEROPHILE testing - rapid test to identify mono - has strong false neg rate early on - 1 week later you will see it - not even worth testing it when they have the bad symptoms - have to wait 1 week

prevention of Caries

1 - placed with well water need to put fluoride in water to prevent cavity formation 2 - regular brushing, flossing --> when it starts eroding and invade neighboring tissues, gingiva, bone = abscess can form

Leukoplakia presentation

1 - precancerous lesion 2 - looks like pseudomembranous thrush 3 - CANNOT be scraped off**

symptoms of Peritonsilar abscess

1 - preceded by pharyngitis, tonsillitis = leads to abscess 2 - can show up without previous infection 3 - severe sore throat 4 - **hot potato voice 5 - fatigue, irritability, feel sick 6 - unilateral swelling, uvula is not midline 7 - uvula is pushed over 8 - Trismus - can't open mouth all the way - thing is in soft tissues

risk factors for Leukoplakia

1 - repeated trauma (dif bite in mouth) 2 - education, frequent monitoring

risk factors for Apthous Stomatitis

1 - run in family 2 - trauma from biting cheek 3 - therapy, medicine, food can cause 4 - comorbid disorders

PE of Candiasis

1 - sore in mouth, hurts to ear 2 - very red, sores at corner of mouth 3 - hurts to wear dentures

Coxackie virus

1 - sores (usually in mouth), fever, not eating well, tired, malaise, sore throat 2 - common in kids

Viral pharyngitis - Epstein barr virus (herpes virus)

1 - starts with malaise - prodromal period, low grade fever, tonsillar swelling, nausea, vomiting, anorexia 2 - pharyngeal erythema, swelling 3 - posterior lymphadenopathy

treatment for Chronic Rhinosinusitis

1 - stop tobacco 2 - address underlying, usually nasal, issues (allergies, NSD, polyps, turbinate disorders, etc)

treatment of Acoustic Neuroma

1 - surgical removal 2 - radiation, observation if harder to get to

PE for dental abscess

1 - swelling, fluctuant, sometimes just red, sometimes may not see it but you can 2 - fluctuant = bounces like a balloon 3 - indurated = firm, doesn't give

Centor Criteria (pharyngeal disease)

1 - tonsillar exudates 2 - tender anterior cervical adenopathy 3 - fever by history 4 - absence of cough 0-1 = low likelihood, don't treat, don't swab, treat as virus 2+ many dif options, some will rapid test everyone with 2 or more 3-4 empirically treat and not test

treatment for Parotitis

1 - tylenol for pain 2- admission if high fever, purulent drainage may need IV antibiotics

treating dental abscess in mouth

1 - use a syringe, aspirate it out, keep it from getting in their mouth - relieves pressure 2 - -put on antibiotics after *need antibiotics bc mouth is dirty exposed place 3 - pain control is a big issue, nerve block - inferior alveolar block - injection in back = walk out in zero pain, blocks nerves they feel 100% better, get antibiotics going 4 - tylenol and ibuprofen at the same time can give just as much pain relief as narcotic medication 5 - dental blocks are great - person comes in knowing they aren't getting narcotics unless you really need them 6 - follow up with dentist: antibiotics: penicillin is great to start with, if infection big abscess facial swelling - go to clindamycin, gladly also covers lots of gram negs in mouth

Atrophic(thick dry crusts) rhinitis

1 - usually in elderly 2 - anatomical deformity of nasal septum, turbinates exacerbates 3 - dry nose 4 - frequent minor (or more severe) anterior nose bleeds 5 - treatment options: premarin cream, corticosteroid nasal spray **breathe about 80% through one side of nose, 20% through other side, = switch every 4 hours --> when you have a cold it disrupts normal rates through each nostril **we all have some degree of nasal septal deviation --> when you need nasal septal deviation its bc its compromising something

mumps presentation

1 - viral presentation, prodromal period, fever, headache, malaise, start getting parotitis bilaterally**, swelling, irritation, pain there as well, earache pain of mandible occasionally

Strep complications

1 - want to prevent complications but dont want to treat with antibiotics unless necessary 2 - Rheumatic fever - can cause carditis, scarlet fever, sandpaper rash, streptococcal toxic shock syndrome - peritonsillar abscesses

diagnosing Parotitis

1- viral is self limiting 2 - antibody testing - mumps PCR testing, rapid 3- bacterial - grab culture to guide treatment 4 - imaging - CAT scan for abscess, ultrasound

clinical presentation of Cholesteatoma

1-can be asymptomatic, just see abnormal behind membrane 2-may complain of hearing loss 3- bc big lesion behind TM 4-ear drainage, erosion exam: 1. otoscopy - not a lot of discharge - make sure you see TM - perforation, deeper traction pocket- granulation and skin degree there

Meniere's disease treatment

1-chronic disease, usually treating symptoms 2-can be put on sodium restriction and other personal triggers identified to eliminate in life = less exacerbation 3-can treat nausea/vertigo 4-hydrochlorizide to maintain ion homeostasis and abnormal fluid levels

clinical presentation of Meniere's Disease

1-episodic vertigo 2- onset and offset - distinct vertigo episodes 3 - can have hearing loss with it like tinnitus - nausea, active symptoms and remissions - symptoms that go away, come back and go away 4 - hearing loss starts mild and gets worse overtime 5 - CNS issues can cause these symptoms as well

presentation of gingivitis

1-fever, swelling, asymptomatic - some bleeding when flossing or brushing teeth 2-discoloration - blue/purple of gingiva 3-can show systemic signs if infection is really bad

Leukoplakia pathology

1-from hyperplasia, squamous epithelium - dysplasia, carcinoma, can become invasive, cells start changing, change structure, metastatic later 2-can be benign, just inflammatory = 20% progress to be cancer within 10 years** 3 - asymptomatic sometimes - incidental finding

pathogenesis of Mastoiditis

1-infection spreads from ear (mastoid air cells) to cause infection, abscess 2-fluid levels in Mastoids for most acute Otitis media 3-mastoid air cells = airy open bone easy for fluid to get into - will erode away with abscess

symptoms of Periodontitis

1-loss of attachment of alveolar bone 2-pt may look healthy, no signs of infection, some incidental finding - see there are lost teeth 3-check probe depth to see if there is decay 4-stick sharp object to see depth - if bleeding a lot can be getting this

gingivitis risk factors

1-pregnancy 2-some meds can cause this 3- nutritional status can cause this if malnourished

Acute sinusitis symptoms

1-purulence, dental/facial pain, unilateral sinus tenderness 2-initial improvement but then worsening symptoms 3 - one or both nares 4 - usually URI precedes 5 - 10 days to 4 weeks of symptoms

Niceria gonnorhea symptoms

1-type of bacterial pharyngitis 2-very severe in tonsils 3 - tonsils are totally white (dif from strep) 4 - has SEVERE EXUDATE = think about gonnorhia or chlamydia as potential agents 5 - fevers, exudate of tonsils, other UTI symptoms as well sometimes 6 - peritonsillar abscess, blood with angina - swelling of submandibular compressed airway (swelling)

treatment for Otitis Externa

1-usually antibiotics, apply topically 2-use ear wicks - slip it inside to get drops down where they need to go, put 1 drop of sterile water, put drops on top that which medicine to get it all the way in

treatment: Chronic Otitis media

1. -stop drainage so TM can heal on its own 2. eradicate infection/fluid 3. use tubes - suction to pull fluid out, try to keep ear clean so membrane can heal (may have to suction many times a day) 4. Antibiotic: olfloxacin to cover pseudomonas, sometimes have to be on drops for weeks to eradicate it 5. oral toilet to clean out otoria (discharge) 6. NSAIDs for pain - immunoglycosides can be toxic so prob don't use it 7. Systemic antibiotics if needed 8. More treatment: surgery to try to repair the TM, night need to put tubes in, might need to repair bones if there was an erosion

paranasal sinuses = pathophysiology

1. Aeration - painful if not aerated (maxillary sinuses sometimes cant see obstruction of outflow tract to the sinus --> nothing can get out or in--> mucous membrane absorbs air in cavity which makes a vacuum and can be very uncomfortable - ppl want antibiotics for it but they won't help - more likely rhinitis thats blocking, treat with nasal spray) -aeration may be disrupted by nasal disorders (edema) -may have small maxillary ostea -cilia are very sensitive to toxins 2. Mucosa -respiratory epithelium continuous with nasal mucosa 3. Trauma -Frontal sinuses (in front of preorbital section of brain), ethmoid (very thin wall to orbit), maxillary sinuses susceptible (bc our dentition is there, its very forward, susceptible to trauma) --extension to orbit or cranial fossa

Pharmacological treatments for Chronic Rhinosinusitis

1. Antibiotics: Amoxicillin, eugmentin, doxycycline, levofloxacin 2. Oxymetazoline NS for 3-4 days only 3. Antihistamines +/i 4. fluids 5. Corticosteroid nasal spray

Physical exam findings: Acute Otitis Media

1. Bulging TM, sometimes just erythema, fever, middle ear effusion **red TM does not always mean AOM 2. history is critical - bulging, erythema, and fever = diagnosis 3. tubes in place can make you less likely to get otitis media

treatment of allergic rhinitis

1. antihistamines - PO v tropical NS 2. decongestants - Systemic, topical 3. Nasal corticosteroid sprays 4. referral for immunotherapy

clinical types of ringing in ears

1. bruits 2. endogenous, maskable tinnitis 3. exogenous tinnitus 4. slow brainstem tinnitus

Drug-Caused Rhinitis (nasal congestion)

1. cocaine abuse 2. anticholinergic meds 3. overuse of oxymetazalone NS (farina NS) 4. Reserpine (blood pressure med thats not used much) 5. Beta blockers (can cause nasal congestion/dry mouth) 6. hydralazine (vasodilator - it has to be taken once every 2 hours = can get tephyphylaxixs from it - not used much) 7. OCP's (has estrogen) 8. ACE inhibitors 9. PDE-5 inhibitors (Viagra) treatment = change meds

Clinical Presentation: Acute Otitis Media

1. ear hurts constantly, vague 2. Adults - more specific, can tell you for how long

symptoms of Acoustic Neuroma

1. hearing loss thats chronic for several years, tinnitus, unsteadiness, not usually vertigo

Barosinusitis (3)

1. negative air pressire in one or more sinus cavities 2. acute forms with rapid change in ambient pressure 3. chronic forms with obstruction of (usually) maxillary sinus ostia --chronic pain

Treatment: Acute Otitis Media

1. pain control, NSAIDs 2. large portion are viral and resolve on their own 3. if better after 2 days leave it alone, if worse = prescription 4. less than 6 mo w symptoms - start treating with antibiotic 5. if over 6 months old to 2 years old = watch and wait 6. If has had penicillin in past 30 days then augmenting. but *amoxicillin* is usually first line for AOM

Viral pharyngitis symptoms

1. sore throat, other respiratory symptoms, ear pain, sometimes fever, influenza usually fever 2. ear pain, fever sometimes 3. muscle aches, fever, myalgia

1 - Pseudomembranous = more common with white plaques that develop on buccal mucosa, tongue 2 - Atropic = underneath dentures, erythematous area without plaques

2 types of Candiasis

periodontitis = loss of attachment greater than

6 mm

Nasal polyps in nostril

?

drugs

?

sinus CT scan

?

Meniere's Disease

Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears).

acute/chronic inflammation at angles of lips, caused by fungus or bacterial infection (or trauma)

Angular Cheilitis

most common cause of mouth sores

Apthous Stomatitis

otoscopic examination tip

COMPLETES (Color, Other conditions, Mobility, Position, Lighting, Entire Surface, Translucency, External auditory canal and auricle, Seal)

to evaluate for Chronic Rhinosinusitis, use

CT (not plain films)

will sometimes see these sores on mucosa, tongue, papule on hands and feet

Coxackie Virus

1 - intramurally, plantar and palmar regions as well 2 - oval papules, spares lips and gingiva

Coxackie virus

inflammatory erythematous ulcer base on corner of mouth

Herpes simplex type 1

trismus

Inability to open the jaw due to pain

where most children's nose bleeds occur and why

Kiesselbach's plexus where arteries are meeting from facial artery, ethmoidal arteries, sphenopalatine artery. where if nasal mucosa gets thin and it cracks - can open up vessel and start bleeding. estrogen receptors here - this is why we can use estrogen cream to combat anterior nasal bleeds

imaging for Vestibular Neuritis

MRI, CT if needed

complication of Chronic Otitis Media

Mastoiditis can occur as complication

sinusitis astral puncture

Maxillary sinusitis --> lateral wall of sinus can be numbed up with cocaine? and can rinse the sinus out

Bacterial pharyngitis type (not strep)

Niceria gonnorhea

-loss of attachment of alveolar bone -important to get gingivitis treated so it doesn't lead to this -Periodontilar ligament tooth is no longer secured - start losing teeth -can occur over weeks or years

Periodontitis

when you use a speculum to make a seal on ear, so you can see mobility of tympanic membrane

Pneumatic Otoscopy

hearing loss in older age, normal, common *lose higher frequency first

Presbycusis

more common type of Candiasis with white plaques that develop on buccal mucosa, tongue

Pseudomembranous

Acoustic Neuroma

Schwann cell derived benign tumor on the auditory nerve (8th cranial nerve) that causes vertigo, tinnitus, and hearing loss

Inflammation of the salivary gland (usually unilateral)

Sialadenitis

presence of salivary stones (calcifications)

Sialolithiasis

type of Sialadenitis with stagnant calcification in gland

Sialolithiasis

Viral pharyngitis - Influenza treatment

Tamaflu/tamavir = have risk factors, prob don't give it bc it doesn't woke that well, only reduces duration by a day or 2 and symptoms a little bit, risk factors not worth it

granulation tissue in a child with chronic tympanovstomy tube otorrhea

Tube held in place. on the left the tube has developed granulation around it - can address with ear drops and ENT referral to get it cleared up.

Centor criteria

Used to ID streptococcal pharyngitis, need 3/4: 1. fever, 2. tonsillar exudate, 3. tender anterior cervical LAD, 4. lack of cough

1 - imbalance of autonomic NS activity in elderly 2 - chronic dry nasal mucosa, clear rhinorrhea 3 - often confused with allergic rhinitis (AR)

Vasomotor rhinitis

dry mouth, a glandular disease, typically in elderly adults

Xerostomia

inflammation of the mucosal lining of nasal passages and paranasal sinuses lasting up to 4 wks caused by allergens, environ irritants, and or infection (virus majority)

acute rhinosinusitis

physiology is the same as in acute rhino sinusitis, most viral

acute sinusitis

3 sinus disorders

acute sinusitis, chronic sinusitis, barosinusitis

Peritonsillar abscess is common in

adolsecents/children, do see in young adults

Epistaxis its important to discern

anterior or posterior bleeding

wide range for what is considered normal for

as you get older, vocal cords aren't coming all the way together anymore = ligament losing elasticity

type of Candidiasis that forms underneath dentures, is erythematous area without plaques

atrophic

red smooth tongue is

atropic

- more apt to be ethmoid sinusitis causing a rhinosinusitis -same bacteria that cause acute otitis media usually --S Pneumonia, H influenzas, M Catarrhalis

bacterial rhinitis

Inflammation of the sinus tract in ambient pressure

barosinusitis

negative air pressire in one or more sinus cavities

barosinusitis

pressure-related ear discomfort that can be caused by pressure changes when flying, driving in the mountains, scuba diving, or when the Eustachian tube is blocked

barotrauma

patient with recurrent episodic vertigo can be

benign positional vertigo

caution for Anterior epistaxis in adolescent male:

bleed with co-existing nasal obstruction - juvenile nasopharyngeal angiofibroma

Tympanic membrane barotrauma

can't equilibrate air bc of obstruction = bleeding into airspace = barotrauma

same as cavities, can be genetic cause of lack of enamel or poor enamel

caries

vertigo

causes of vertigo

most common cause of conductive hearing loss in an adult patient***

cerumen impaction

thumb sign

child with enlarged epiglottis - epiglottitis

collection of skin cells and cholesterol in a sac within the middle ear

cholesteatoma

recurrent infection of mastoid cells in middle ear, usually with perforation and fluid

chronic otitis media

1 - more than 12 weeks duration 2 - presents as chronic obstruction, congestion 3 - Mucosa typically garaged, thickened, and cilia spotty throughout sinus mucosa 4 - tobacco smokers

chronic sinusitis

treatment for Periodontitis

clean it out, clean around root - we don't do this

Oral/Throat cancer risk factors

common in elderly males, seeing in younger ppl now 1 - tobacco, alcohol = squamous cell in 80% of cases 2 - tobacco and alcohol = 200x more likely to get oral cancer 3 - HPV 16 infection = 50 fold risk to get this

hearing loss of outer ear

conductive hearing loss

complications of dental trauma

cosmetic

symptoms of Xerostomia

cracked tongue, dry mouth, hard to swallow, hard to talk, no saliva in mouth, more likely to get dental disease, fungal infection can develop with it

Angular Cheilitis

define

Apthous Stomatitis (canker sore)

define

Coxackie virus

define

Leukoplakia

define

Mastoiditis

define

Oral/Throat cancer

define

Otitis Externa

define

Peritonsilar abscess

define

angular cheilitis

define

dental abscess

define

gingivitis

define

bacteria trapped between tooth and gingiva

dental abscess

fluid begins TM, bubble space, erythema from blood vessels at the top =watch and wait, mild to moderate acute otitis media

describe

Coxackie virus

disease?

indurated dental abscess

doesn't drain well, body is working on it

any abscess requires

drainage

Xerostomia

dry mouth, a glandular disease, typically in elderly adults

prevention of periodontitis

education, treat teeth well

feel better in noisy environment bc its masking the ringing in their ears

endogenous, maskable tinnitus

why is nasal mucosal response to elevated hormone levels causing rhinitis in pregnancy?

estrogen receptors in nasal mucosa

feel better in silence, worse when in noisy environments

exogenous tinnitus

triggers for herpes simplex Type 1

fever, colds, sunlight, food, stress

clinical presentation of Mastoiditis

fever, don't feel well, tachycardia, nausea, vomiting, swollen behind ear

red, swollen gum margins that bleed easily

gingivitis

PE for Otitis Media with Effusion

gray, neutral or retracted TM, looking for effusion -no fever, no sign of infection**

treatment for Presbycusis

hearing aids for some, depends on how much damage is there -occassionally surgery - cochlear implants **make sure there is no infection, do otoscopic examination - could be chunk of cerumen ** very common

small vesicles on erythematous base

herpes

18 yo female, fever, fatigue, sore throat, increased atypical lymphocytes. what test?

heterophile test

why dp you lose higher frequency hearing first?

higher freq waves are at the beginning of cochlea so they get the most impact

dif laryngeal lesions

how they effect the airway -vocal cord polyp on C -edema on E -vocal cord nodules F (can see this in singers - nodules can be removed

bruits

if you have a carotid bruit it can cause ringing in ear - listen to carotids all the time

posterior epistaxis =

immediate ENT referral (too far back to be able to get to)

Mastoiditis

inflammation of the mastoid bone, its a complication of other disorders

rhinitis

inflammation of the mucous membranes of the nose

Periodontitis

inflammation of tissues around a tooth, untreated gingivitis can lead to this

4 yo with bug in ear - treatment

insert with 2% lidocaine and suction or forceps

Meniere's disease

ion disruption of homeostasis - increased endolymph; tinnitus, vertigo, sensorineural hearing loss

Otitis Externa presentation

itching and drainage from the external auditory canal, difficult to visualize the tympanic membrane bc of swelling, manipulation of tragus is painful; associated w swimming, foreign bodies

lymph nodes tender w tonsilitis

jugular digastric lymph node

look

look

luxation in teeth

loss of supporting structure like periodontal ligament, attaches tooth in alveolar bone

loss of supporting structure like periodontal ligament, attaches tooth in alveolar bone

luxation

the ___ divides the TM into anterior and posterior quadrants

malleus

inflammation of the mastoid bone, its a complication of other disorders

mastoiditis

complications of Otitis Externa

meningitis - so its important to get drops all the way in and follow up to make sure it resolves

most common type of inflammatory salivary gland lesion results from blockage or damage to salivary duct resulting in leakage of saliva into surrounding connective tissue big cyst filled with mucin and lined by mucinous columnar epithelium

mucoceles

Meniere's Disease criteria

must have: a. 2 spontaneous episodes of Vertigo that last longer than 20 minutes b. audiometric confirmation of sensory neural hearing loss - work up over the years -tinnitus = diagnosis of exclusion, can take a long time for this diagnosis to be made -should have ear nose and throat exam as well

Herpes simplex

name

Vestibular neuritis symptoms

nausea, vomiting, trouble walking bc of symptoms

slow brainstem tinnitus

non localized sounds, may feel mentally unstable

can suggest vertigo with can be central or peripheral

nystagmus

60 yo male with canker sore on tongue that won't go away for 2 months

oral cancer, immune disorder, etc.

measures standing and supine blood pressure and pulse

orthostatic

checking blood pressure when standing and sitting to see if this is what is causing dizziness

orthostatics

itching and drainage from the external auditory canal, difficult to visualize the tympanic membrane bc of swelling, manipulation of tragus is painful; associated w swimming, foreign bodies

otitis externa

pt with right ear pain and itching, erythema in ear canal. diagnosis? treatment?

otitis externa. Polymyxin B sulfate = common topical antibiotic you would use

inflammation of tissues around a tooth, untreated gingivitis can lead to this

periodontitis

loss of attachment greater than 6 mm

periodontitis

Vertigo can be

peripheral vs central

pathophysiology of Caries

plaques from bacteria can colonize on surface of teeth

mixed presentation of hearing loss

presbycusis

Sialolithiasis

presence of salivary stones (calcifications)

painful creamy white tongue

pseudo

acute bacterial rhinosinusitis

pus and purulence --> sometimes cleared up with oral antibiotics

chronic otitis media

repeated episodes of acute otitis media causing irreversible tissue damage and persistent tympanic membrane perforation -recurrent infection of mastoid cells in middle ear, usually with perforation/fluid -not every perforation is this

white spot = tiny retraction pocket that started filling, white mass behind membrane cholesteatoma = big space occupying lesion

retracted RM

inflammation of the mucous membranes of the nose

rhinitis

inflammation of the nose

rhinitis

nasal mucosal response to elevated hormone levels

rhinitis in pregnancy

discharge from the nose

rhinorrhea

Viral pharyngitis can be caused by

rhinovirus, influenza, Epstein barr virus = many agents that can cause

treatment for rhinitis in pregnancy

saline NS (bc you cant change the # of estrogen receptors)

Caries

same as cavities, can be genetic cause of lack of enamel or poor enamel

diagnosis of Cholesteatoma

see abnormal on exam

classification of lunation injuries

see chart

treatment for Vestibular Neuritis

self limiting, gradually improves over days, can last a week or so w occasional imbalance

hearing loss of the inner ear

sensorineural hearing loss

non localized sounds, may feel mentally unstable

slow brainstem tinnitus

Most common bacterial pharyngitis

strep

treatment for Oral/Throat cancer

surgeons, radiation, etc. = difficult bc mouth effects everything. 1 - radiation and surgery 2 - early identification is key

treatment for Apthous Stomatitis

symptomatic, pain control - warm saline rinse -if happen A LOT see if they are immunosuppressed -having them 3x a year = problematic

Stapes. this is Cholesteatoma -eroded all the way back into stapes

the S is

Dix Hallpike Manuever

the patients head is turned up slightly and at a 45 degree angle and drops quickly and is held for 30 seconds; back up and repeated on the opposite side( Part of the Epley manuever; look a the persons eyes

big lymph nodes are helpful but

they don't tell you what side its on / what infection is

won't see clinically --> this is why you do swish, swirl, AND swallow

thrush in esophagus

Inability to open the jaw due to pain

trismus (common in peritonsilar abscess**)

gold standard for testing mobility of TM but not widely used

tympanometry

Pseudomembranous Candidiasis

type of yeast

Pseudomembranous Candidiasis - white plaque on buccal mucosa

type of yeast

acute epiglottitis

typical

- common "cold" --mild to moderate congestion and clear rhinorrhea

viral rhinitis

fluctuant dental abscess

walled off pocket of fluid/pus, can drain it

Atropic Candidiasis yeast - red from dentures inflamed, irritated

what type of yeast?

60 yo pt, alcohol and tobacco usage, suspicious for oral carcinoma, would have a

white lesion that cannot be removed by scraping