1. Disorders of the Ear, Nose, Throat & Mouth
Chapter 10
Medical Considerations

2. EARS
Otitis Externa- a painful inflammation of the membranous lining of the auditory canal and/or contiguous structures.
Refers to acute and chronic inflammatory process
It may be diffuse or localized
Is largely benign and self-limiting
Invasive otitis externa is a potentially life threatneing situation

3. EARS OE continued Epidemiology
10-20% more common in the summer months
Patho- inflammation is most commonly caused by microbial infection. Colonization of the external ear is prevented immune and anatomic mechanisms

4. EARS OE patho continued
Squamous epithelia of the canal constantly slough, while hair follicles sweep laterally, cleaning and act as a barrier. The canal maintains an acidic pH and repels moisture and the presence of normal flora inhibit the overgrowth of virulent bacteria. If any of this is broken compromised there may be colonization by bacteria

5. EARS OE patho continued Bacteria
Pseudomonas aeruginosa is most common of diffuse infections and most cases of invasive OE
Staphylococcus aureus typically causes a localized infection from a hair follicle
Streptococcus pyogenes associated with local infection presenting as folliculitis
Polymicrobial infection found in up to 1/3 of cases of diffuse disease

6. EARS OE patho continued Other causes of OE Fungal agents
Aspergillus niger- usually local infection, but can cause invasive infection
Pityrosporum
Candida albicans
Hyperkeratotic processes
Eczema, psoriasis, seborrheic, or contact dermatitis

7. EARS OE
Necrotizing Otis externa is the most severe infectious form of OE
Bacterial infection extends from the skin of canal into soft tissue or bone
Cranial nerves may be involved
Pseudomonas is most common

8. EAR OE Presenting complaints
severe ear pain (otalgia) of sudden or acute onset
Pain worse at night
Worse with pulling on the pinna or earlobe or pushing on tragus
Severe cases- pain with chewing
May have purulent discharge may be noted
Chronic OM
May present with dryness and itching

9. EAR Otitis Media (OM) Physical findings Tenderness with palpation
Otoscopic exam- canal appears swollen and red with drainage with bacterial infections
Diffuse cases present with complete involvement
Localized cases present with focal lesion
Pseudomonas produces a copious green exudate
Staphylococcal produces yellow crusting in purulent exudate
Fungal infections presents as a fluffy, white or black malodorous growth
Except in invasive disease there is no lymphadenopathy
TMJ pain indicates invasive disease

10. EAR OE Diagnostic testing Rarely needed
Cultures may be done of discharge if indicated in healthy patients
CT or MRI may be needed if suspect invasive disease

11. EARS OE Differential DX OM TMJ Dental disease
Trigeminal or glossopharyngeal neuralgia
Parotitis
Impetigo
Herpes zoster
Insect bites
Mastoiditis
Rupture of membrane
Excessive cerumen buildup (wax)

12. EARS Management and Treatments Pain meds Heat or ice
Keep dry- no swimming for 7 days
Treatment for basic OE
Irrigation if indicated
Pain drops
Antibiotic drops
Ciprodex, Floxin Cortisporin
May need a wick if very swollen

13. EARS
Otitis Media- OM- inflammation of the structures in the middle ear.
Otitis media with effusion –OME involves the transudation of plasma from middle ear blood vessels leading to chronic fluid; this can be chronic
Acute Otitis Media-AOM is infection in the middle ear

14. EARS OM
Epidemiology
Accounts for 2-3% of all family practice office visits. Number of visits increases in the winter. More common in colder weather and in children.
Contributing factors include; allergies, rhinitis, pharyngitis due to swelling of upper airway membranes. Most common factor is upper airway infections (colds), caused by many different viruses.
Influenza, RSV, pneumovirus, adenovirus

15. EARS OM
Patho-bacterial infection (or viral) by nasopharyngeal microorganisms follows eustachian tube dysfunction in which the isthmus becomes obstructed. Inflammation results in response to the bacterial products such as endotoxins, creating infection behind the tympanic membrane in the middle ear

16. EARS
OME
Patho- caused by collection of plasma fluid from engorged blood vessels resulting from the loss of Eustachian tube patency, either from swelling of the lining or direct blockage
Pathogens
Streptococcus pneumoniae, haemophilus influenzae, Moraxella catarrhalis are most common. Less common are streptococcus pyogenes and aureus
Up to ½ are viral

17. EARS
OME symptoms
Stuffiness, fullness, decreased hearing, pain is rare, may have popping. Rarely vertigo
Usually a history of recent URI, allergies

18. EARS
AOM- symptoms
Deep pain, fever, sometimes decreased hearing, discharge with a perf, sometimes dizziness or ringing in the ear
Recurrent AOM means there is clearing of the infection between episodes
Chronic OM- presents with history of repeated bouts of AOM followed by effusion with hearing loss being the biggest concern

19. EARS
Diagnostic Tests
Tests are rarely needed. Should use pneumatic otoscopy. Tympanogram may be helpful otitis with effusion. Cultures are rarely done, but are helpful. X-ray or CT of sinuses or of mastoid area maybe indicated. CBC with severe illness maybe indicated. Hearing tests are needed in some cases or at follow-up

20. EARS Otitis Management/Follow-up OM OME
If over 2 years, watchful waiting for three days
If present longer than three days treat for most common organism
Recheck children in 2-3 weeks, adults if pain or other symptoms return
OME
Watchful waiting is indicated, recheck every 4-6 weeks for 3-4 months
Steroids are sometimes used for 7 days
Nasal steroids used more often for 3 months
Rarely an antibiotic is tried

21. Rhinitis
Rhinitis or coryza –inflammation of the nasal mucosa with congestion, rhinorrhea, sneezing, pruritus, post nasal drip
Allergic
Seasonal or perennial
Nonallergic
Infectious, irritant related, vasomotor, hormone-related, associated with medication, or atrophic
May be chronic or acute
Most common types
Viral
Perennial (hay fever)

22. Rhinitis Epidemiology/Causes
Actual prevalence is undocumented, but is very common
Occurs at least as much as the common cold
Estimated million American adults suffer
Seasonal allergic rhinitis parallels pollen production fall/spring
Allergy occurs in all age groups
Most common in adults years
Non allergic rhinitis may be acute or chronic
Chronic maybe associated with bacterial sinusitis

23. Rhinitis Epidemiology/Causes
Atrophic rhinitis affects older adults, but symptoms may begin in the teens
VIRAL URI’s are more frequent in families with young children
Exposure to offending allergens is the main risk factor of allergic rhinitis
Vasomotor rhinitis is aggravated by low humidity, sudden temperature or pressure change, cold air, strong odors, stress, smoke
Certain drugs may precipitate rhinitis- ACE, beta-adrenergic antagonists, some anti-inflammatory agents, even asa

24. Rhinitis Rhinitis Patho Viral
Viral replication in the nasopharynx with varying degrees of nasotracheal inflammation. Associated with viral upper respiratory tract infection (COLD)
Etiologic agents
Rhinovirus, influenza, parainfluenza, respiratory syncytial, coronavirus, adenovirus, echovirus, coxsackievirus
Most rhinosinusitis is viral
Bacterial super-infection rarely occurs

25. Rhinitis Rhinitis Patho continued Allergic rhinitis
Type I hypersensitivity to airborne irritants affecting the eyes, nose, sinuses, throat, and bronchi
Antibodies bind to eosinophils and basophils in the bloodstream and the mucosal mast cells. These leukocytes degranulate, releasing chemo inflammatory substances including histamine, leukotrienes, prostaglandin's, slow-reacting substance of anaphylaxis, and erythrocyte chemotactic factor, resulting in increased vasodilatation, capillary permeability, mucus production, smooth muscle contraction and eosinophilia
May also be caused by food allergies

26. Rhinitis Rhinitis Patho continued
Vasomotor rhinitis is chronic, noninfectious process of unknown etiology, characterized by periods of abnormal autonomic responsiveness and vascular engorgement unrelated so specific allergens
Causes include- hormonal changes, medication overuse, bacterial infection-which can cause atrophic rhinitis

27. Rhinitis Rhinitis – symptoms
Viral-malaise, HA, substernal tightness, rare fever, sneezing and coughing
Allergic-itching of all upper air way mucosa, watery eyes, sore throat, sneezing, coughing
Vasomotor-watery nasal discharge, nasal speech, mouth breathing, nasal obstruction that switches sides

28. Rhinitis Rhinitis –objective findings
Viral- nasal mucosa appears erythematous, throat will appear erythematous and edematous, external nose may appear erythematous, with a crease across the nose (allergic salute). May have swollen turbinates and tonsils. On palpation, the nasal mucosa appear friable.
With a secondary bacterial infection the discharge may be green/yellow – in adults only. Color is children does not matter

29. Rhinitis
Allergic – mucosa are pale, boggy (swollen) and may look bluish. Yellowish, gray or red mucosa may also be seen. Polyps of various colors may be seen with chronic perennial rhinitis. Conjunctivae are inflamed with palpebral conjunctiva and cobble-stoned in appearance. Dark circles under the eyes (allergic shiners) may be seen. Wrinkles across the bridge of the nose may be seen.

30. Rhinitis
Vasomotor rhinitis- nasal mucosa will be anywhere from bright red to bluish with swollen turbinates
Atrophic rhinitis appear crusted with dried mucus or blood from repeated bouts of epistasis.

31. Rhinitis Treatments Allergic rhinitis
Avoid the triggers
Antihistamines
Allegra, Claritin, Clarinex, Zyrtec, Astelin
Nasal steroids
Flonase, Nasonex, Nasacort
Leukotriene receptor antagonists
Singular
Desensitizing immunotherapy
Atrophic- bacitracin to nares, saline, irrigation

32. Rhinitis Rhinitis follow up Recheck as needed
Advise patient of possible complications and their symptoms to indicate need for follow up
OM, sinusitis, high fevers, restless sleeping, asthma, allergic attacks
Referral as needed to allergist for skin testing
Referral to an ENT as needed

33. Rhinitis Rhinitis –patient education Avoid exposures
People with URI, environmental irritants
Windows doors kept closed, use a HEPA filter air clearer, consider pets outside, clean for mold and dust mites, cover bedding for dust mites…dusting

34. Sinusitis
Sinusitis is an inflammation of the mucous membranes of one or more of the paranasal sinuses; frontal, sphenoid, posterior ethmoid, anterior ethmoid, and maxillary
Acute-abrupt onset of infection and post-therapeutic resolution lasting no more than four weeks
Subacute with a purulent nasal discharge persist despite therapy, lasting 4-12 weeks
Chronic, with episodes of prolonged inflammation with repeated or inadequately treated acute infection lasting greater than 12 consecutive weeks

35. Sinusitis Epidemiology and causes
Frequency of colds accounts for the frequent occurrence of sinusitis. About 0.5 % of all colds are complicated by bacterial infection of one or more of the paranasal sinuses
Acute bacterial sinusitis accounts for 16 million visits a year
Chronic sinusitis is the most common chronic disease in the US

36. Sinusitis Sinusitis – Patho
Vast majority of acute sinusitis are caused by the same viruses found in URI’s
Viral rhinosinusitis is most common
Which is the most common cause for acute bacterial sinusitis, from complications in about 2%
Sneezing sends fluid from the nares and nasal cavity into the sinuses which is a great place for microbial replication
The only reliable way of identifying causative organisms in acute sinusitis is direct sinus aspiration

37. Sinusitis Sinusitis Patho continued Pathogens
Streptococcus pneumoniae, haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes, staph aureus

38. Sinusitis Clinical presentation Gradual onset of symptoms
Pain over the affected sinus, with increasing pain
Pain is worse with coughing
Area of pain corresponds the sinus affected
Develop over at least 2 weeks of URI symptoms
Nasal congestion, runny nose, pressure, cough, sore throat, eye pain, malaise, and fatigue, headache, cough, fever

39. Sinusitis Sinusitis objective findings Sinusitis testing
Purulent secretions, red swollen nasal mucosa, purulent secretions from middle meatus
On palpation there is tenderness
Sinusitis testing
None is usually indicated
X-rays or CT’s may be very helpful
Shows air-fluid levels and more than 4mm of mucosal thickening
Stains or cultures of mucus may be indicated
Allergy testing

40. Sinusitis Sinusitis Management Usually viral
Supportive care is most helpful
Sinus rinse
Few meds are helpful
Sudafed, nasal spray, expectorants,
Rarely use steroids or antihistamines
Localized sinus infections are self limited

41. Sinusitis Sinusitis- management Amoxil Biaxin Vantin Omnicef Levaquin
Augmentin
Ceftin
Cleocin
Review the therapeutic handouts

42. Sinusitis Sinusitis follow up Varies per provider
With increase symptoms recheck
If no better in 5-7 days recheck
With reoccurrence of symptoms shortly after completing medication
Complications to watch for
Visual changes, cellulites, severe fever, aphasia, palsy, seizures, altered mental status, osteomyelitis, swelling, meningitis, empyema, abscess

43. Sinusitis Sinusitis patient education
Should focus on the worsening of symptoms
Avoid all contributing factors
Smoke, allergens, antihistamine
Increase fluids

44. Pharyngitis
Pharyngitis and tonsillitis are generalized inflammatory process of both infectious and non infectious etiology
Most cases are viral and self-limiting
Most cases of pharyngitis are contagious
All cases of tonsillitis are contagious

45. Pharyngitis Epidemiology Causes 8% of all office visits
Viral more common in cold weather
Increases from 10% in fall to 40% in winter
Causes
Herpangina, EBV, URI, postnasal drip, sinusitis, chronic illnesses, leukemia, stress, alcohol, gonorrhea, syphilis, herpes, diphtheria, candida, tobacco, marijuana

46. Pharyngitis Patho 40% of cases have no know cause URI is 30-50%
Influenza, coxsackievirus, enterovirus, RSV, Rhinoviruses, CMV, EBV, HIV
Bacterial typically cause exudates
Which is 20% of sore throats
10-20% of adult cases and could lead to the most serious complications like heart disease, and rheumatic
80 serotypes of streptococcus
Most significant stain based on the M protein which is antiphagocytic, and if a patient becomes immune to this bacteria, it provides protection for future infections of this type

47. Pharyngitis Patho continued
Streptococcus pyogenes strains are more virulent with more renal disease side effects
Streptococcus exotoxins can cause bacteremia, deep tissue cellulitis, toxic shock
Other bacteria
N gonorrhea, H flu, streptococcus pneumoniae
Corynebacterium diphtheria and hemolyticum are associated with epiglottitis
Atypical bacteria
Chlamydia pneumoniae, chlamydia trachomatis, and Mycoplasma pneumonia are also know to cause bronchitis

48. Pharyngitis Patho continued Non-infectious causes of pharyngitis
Trauma, allergies, collagen vascular disease, autoimmune blistering disease, chemical/drug damage, severe dehydration.
Patho of Tonsillitis is usually an infectious disorder, with swelling and exudates with the same causes

49. Pharyngitis Subjective findings
Mild to severe throat pain, tickle or itching
With Strep, Mono, Adenovirus the pain is more severe. May have the feeling of a lump
Dysphagia is seen with H flu
Hoarseness is seen with Chlamydia pneumoniae
Laryngitis and cough are usually viral
Chills and fever more common with bacterial

50. Pharyngitis Subjective continued
Cough and congestion are rarely present
Allergic pharyngitis does not present with fever
Mono has a gradual onset of low grade fever and fatigue
Influenza will have abrupt onset with headache and body pain also, then followed by a cough

51. Pharyngitis Objective for pharyngitis Inflamed throat, erythematous
Conjunctivitis is associated with adenovirus
Exudates and large tonsils occur rarely with viral illness
Exudate and petechiae on the palate and swollen PCN and increase spleen and liver size
Strep produces a white exudate, they may also have a sandpaper rash on their body
C diphtheria has a grayish pseudomembrane over the mucosa of the pharynx
Tonsillitis has swollen posterior lymph glands on either side of the jaw

52. Pharyngitis
Testing
Viral throat swab cultures are used to detect herpes virus as well other viral infections…
Tzanck smear of a exudate is used to detect HSV, and herpes zoster
Blood test may be used for viruses
HSV, EBV, CMV
Candida – KOH potassium hydroxide- looking for hyphal yeast
Mono spot for mono
CBC for infectious pharyngitis
X-ray may be needed to assess for abscess

53. Pharyngitis Management depends on the cause
Home care with symptom management
Voice rest, humidification, saline, viscous Xylocaine, gargles, cool mist, lozenges, sprays, Acetaminophen, codeine, warm compresses for lymph nodes
Antibiotics for bacterial causes
See therapeutics handout
Antifungal for candida
Diflucan, nystatin
Be sure and assess immune status if no known cause is found
Viral illnesses
May use antivirals in some cases- IE; Flu- use Tamiflu
Abscess- hospital IV antibiotics and maybe surgery

54. Pharyngitis Follow and referral
Usually self limiting and improves in few days
If pt fails to improve- recheck in 2-3 days
May repeat cultures as needed
Assess for scarlet or rheumatic fever as needed
Hematuria may occur 1-2 weeks post strep
Monitor kidney function and blood pressure
Mono follow up to assess liver and spleen size
May need to do liver function tests with prolong symptoms or jaundice occurs
Prolonged throat or node pain must be reassessed for abscess or cellulitis
Enlarged tonsils or recurrent infections may indicate a need for tonsillectomy

55. Pharyngitis Education for pharyngitis prevention, replace toothbrushes
do not share food or drinks, avoid irritants, avoid allergens, avoid heavy lifting or contact sports with mono, always complete all medications

56. Temporomandibular Joint (TMJ) Disease
TMJ is a collective term that refers to disorders affecting the masticatory musculature and associated structures. Sometimes know as temporomandibular disorder. TMD is a cluster or related disorder that have many features in common.
The most common is pain in the muscles of mastication, the preauricular and the TMJ
Is a sub classification of musculoskeletal disorder

57. Temporomandibular Joint (TMJ) Disease
Epidemiology
75% of people have at least one sign of joint dysfunction and 33% have at least one symptom, like face pain
Only about 5% are in need of treatment
Differentiate contributing factors
Predisposing factors- increase the risk
Initiating factors- cause the onset
Perpetuating factors- interfere with healing

58. Temporomandibular Joint (TMJ) Disease
Symptoms
Pain in the preauricular area/or TMJ
Pain, jaw noise, ear symptoms, rarely jaw dislocation
Chewing aggravates
Pain in face or head
Dull pain in temple are
Tinnitus
Sinus symptoms
FB sensation in ear canal
Decreased hearing
Neck or shoulder pain
Visual disturbance
Limited jaw opening
Jaw popping

59. Temporomandibular Joint (TMJ) Disease
Questionnaires for screening- Example questions
Do your jaws make noise
Does using your jaw cause you pain
Have you had jaw joint problems before
Does you jaw ever get stuck
Is opening your mouth difficult or cause pain
With ringing in the ear does opening or closing you mouth change the sound
Do you have frequent headaches, neck aches, or tooth aches

60. Temporomandibular Joint (TMJ) Disease
Physical finding
Complete exam to exclude other problems
Observation of gait, balance, unusual habits
Palpate the muscles of mastication using bimanual technique
Start with the mouth closed then open

61. Temporomandibular Joint (TMJ) Disease
Management
Involves understanding and treating the whole patient
Goals for management- reduction of pain, restorations of acceptable function
Initial TX designed to be palliative and promote healing, with self-help techniques and pharmacotherapy
Adjustment of diet
Education and alteration of oral habits (gum chewing)
ICE/ HEAT
Medications such as pain meds, anti-inflammatory meds, injection of trigger points
Most care will be given by the specialist

62. TMJ Follow up and referral
Refer to a specialist is best idea for real TMJ disease

63. TB TB
Testing
Tuberculin skin test remains the standard test for determining infection with Mycobacteria tuberculosis, but does not distinguish between active and latent infection
Who to test
Patient with signs and symptoms, known contact, high risk, people suspected to have, abnormal chest x-ray, medical conditions that increase risk, pt with HIV, immigrant, medically underserved, high-risk minority, resident or employee in a prison or long term care facility, employee on a health care facility

64. TB Interpretation of TB skin testing
Greater than 5 mm is positive for the following
People with HIV, or risk factors for HIV
People recently exposed to active TB
Persons with organ transplants
Persons with chest film indicating healed TB

65. TB Greater than 10 mm Recent arrivals (less than 5 years)
Foreign born from Africa, Asia, Latin America
Medically underserved low income population and high risk racial ethnic minority populations
IV drug users
Residents and employees of high risk congregate setting
Mycobacteriology lab personnel
Persons with medical conditions known to increase risk of TB

66. Gingivitis Inflammation of the gingiva
It may be characterized by edema, erythema, bleeding, and occasionally pain
Gingivitis is usually reversible with appropriate therapy

67. Periodontitis
An inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both.

68. Oral Trauma What happened Where are the teeth
Tooth/jaw/lip/tongue hurt
What hit you
How long ago
Where are the teeth

69. Oral Trauma Teeth Jaw/face: feel for “crunchy” sensation
Avulsed (knocked out, loose)
Fractured
Chipped
Intrusion
Jaw/face: feel for “crunchy” sensation
Mucosal/tongue injury

70. Tooth Anatomy

71. Avulsed Teeth

72. Fractured Teeth

73. Intrusion

74. Tongue/Mucosal Trauma

75. Oral Trauma Teeth Avulsion Fracture, keep fragment, store as above
Primary teeth
Out, leave out
Loose, straighten or is very loose remove
Permanent teeth
Out, leave out, wash gently, tooth kit
Loose, leave alone
Fracture, keep fragment, store as above

76. Oral Trauma Tongue Mucosal Well approximated, nothing
Bleeding  direct pressure with gauze
Gaping need repair
Mucosal
Gaping and vermillion border need repair

77. Oral Trauma Dental injuries Tongue/Mucosa Dentist for most injuries
Baby teeth may need nothing
Tongue/Mucosa
Most need nothing
Doctor if gaping or severe bleeding

78. Nose Bleeds

79. Nose Bleeds How much blood, how long
What has been done to stop bleeding
Trauma
Blunt
Picking
Upper respiratory infection/Allergies
History of Bleeding

80. Nose Bleeds Nose Neurologic Vision Fracture (usually at bridge)
Active bleeding
Which side? Always the same?
Throat
Neurologic
Vision

81. Nose Bleeds Pinch x 10-20 minutes Ice Nose plugs Don’t blow nose
Afrin if available
No picking