1. Disorders of the Ear, Nose, Throat & Mouth
Chapter 11
Pathology

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 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

5. 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

6. 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

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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

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

27. 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.

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

29. 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

30. Tooth Anatomy

31. Avulsed Teeth

32. Fractured Teeth

33. Intrusion

34. Tongue/Mucosal Trauma

35. 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

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

37. 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

38. Nose Bleeds

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

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

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