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
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Apthous Stomatitis (canker sore)
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Coxackie virus
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Leukoplakia
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Mastoiditis
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Oral/Throat cancer
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Otitis Externa
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Peritonsilar abscess
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angular cheilitis
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dental abscess
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gingivitis
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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