Disorders of the Ear, Nose, Throat & Mouth

Chapter 11Pathology

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

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

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

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

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

EARS

OME symptoms Stuffiness, fullness, decreased hearing, pain is

rare, may have popping. Rarely vertigo Usually a history of recent URI, allergies

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)

Rhinitis

Epidemiology/Causes Actual prevalence is undocumented, but is very common Occurs at least as much as the common cold Estimated 40-50 million American adults suffer Seasonal allergic rhinitis parallels pollen production

fall/spring Allergy occurs in all age groups

Most common in adults 30-40 years Non allergic rhinitis may be acute or chronic

Chronic maybe associated with bacterial sinusitis

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

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

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

Sinusitis

Clinical presentation Gradual onset of symptoms

Pain over the affected sinus, with increasing painPain is worse with coughingArea of pain corresponds the sinus affectedDevelop over at least 2 weeks of URI symptomsNasal congestion, runny nose, pressure, cough, sore

throat, eye pain, malaise, and fatigue, headache, cough, fever

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

Sinusitis

Sinusitis patient education Should focus on the worsening of symptoms Avoid all contributing factors

Smoke, allergens, antihistamine Increase fluids

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

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

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

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

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

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

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

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 techniqueStart with the mouth closed then open

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

TMJ

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

disease

Gingivitis

Inflammation of the gingiva It may be characterized by edema, erythema,

bleeding, and occasionally pain Gingivitis is usually reversible with

appropriate therapy

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.

Oral Trauma

What happened Tooth/jaw/lip/tongue hurt What hit you How long ago

Where are the teeth

Oral Trauma

Teeth Avulsed (knocked out, loose) Fractured Chipped Intrusion

Jaw/face: feel for “crunchy” sensation Mucosal/tongue injury

Tooth Anatomy

Avulsed Teeth

Fractured Teeth

Intrusion

Tongue/Mucosal Trauma

Oral Trauma

Teeth Avulsion

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

Oral Trauma

Tongue Well approximated, nothing Bleeding direct pressure with gauze Gaping need repair

Mucosal Well approximated, nothing Gaping and vermillion border need repair

Oral Trauma

Dental injuries Dentist for most injuries Baby teeth may need nothing

Tongue/Mucosa Most need nothing Doctor if gaping or severe bleeding

Nose Bleeds

Nose Bleeds

How much blood, how long What has been done to stop bleeding Trauma

Blunt Picking

Upper respiratory infection/Allergies History of Bleeding

Nose Bleeds

Nose Fracture (usually at bridge) Active bleeding

Which side? Always the same?Throat

Neurologic Vision

Nose Bleeds

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