Ear Nose and Throat

Ear Nose and Throat

Debbie King CFNP CPNP8800

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 potentially life threatening

Malignant OE-- now know as Necrotizing OE

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OE continued Epidemiology

2-3 % of family practice office visit 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

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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

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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

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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

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OE Necrotizing Otis externa is the most severe

infectious form of OEBacterial infection extends from the skin of canal into

soft tissue or boneCranial nerves may be involvedPseudomonas is most commonMay have bad outcomes!

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

EAR 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

EAR

OE Diagnostic testing

Rarely neededCultures may be done of discharge if indicated in

healthy patientsCT or MRI may be needed if suspect invasive disease

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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)

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Management and Treatments Pain meds Heat or ice Keep dry- no swimming ECT… for 7 days Treatment for basic OE

Irrigation if indicated Pain drops Antibiotic drops

Ciprodex, Floxin Cortisporin May need a wick if very swollen

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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

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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

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

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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

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OME symptoms Stuffiness, fullness, decreased hearing, pain is

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

Remember the great photos provided in the therapeutics lectures on OM

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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

EARS

Objective OME- mucous membranes of nose and mouth

red/swollen, with recent history of URI. TM may be dull AOM- yellow-orange, maybe fiery red and bulging with

an area of yellow noted. Bone landmarks and cone of light are not seen. Grayish/white collection of tissue on or behind the TM may be a cholesteatoma. There may be adenopathy of the preauricular and/posterior cervical. With an infected ear and pain at the mastoid bone- more work up may be needed

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

EARS

Differentials for OM OE Barotrauma TMJ Mastoiditis (always with AOM) Cerumen impaction Parotitis

EARS Otitis Management/Follow-up

OM 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

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 Allergic 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 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

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

Rhinitis

Rhinitis Patho continued Allergic rhinitis

results from immunoglobulin E (IgE) mediated type I hypersensitivity to airborne irritants affecting the eyes, nose, sinuses, throat, and bronchi

IgE 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- wow that sounds BAD May also be caused by food allergies

Rhinitis

Rhinitis Patho continued Vasomotor rhinitis is chronic, noninfectious process of

unknown etiology without accompanying eosinophilia, 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

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

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!!

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.

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.

Rhinitis

Rhinitis testing Not usually indicated CBC- may show

Eosinophilia in allergic rhinitis IgE and skin testing for allergic Atrophic may be confirmed by biopsy Usually diagnosis is made on history and exam

Rhinitis

Rhinitis differentials Sinusitis Foreign body Nasal polyps Deviated septum Cocaine snorting, inhalant abuse Sarcoidosis Hormonal changes Thyroid disease

Rhinitis

Rhinitis treatments Centers on

relieve of symptomsSelf care measuresEnvironmental issues

HA- acetaminophen Rhinorrhea- decongestants Coughs -dextromethorphan ? , Or codeine

Rhinitis

Treatments continued 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

Rhinitis

Rhinitis follow up Recheck as needed Advise patient of possible complications and

their symptoms to indicate need for follow upOM, sinusitis, high fevers, restless sleeping, asthma,

allergic attacks Referral as needed to allergist for skin testing Referral to an ENT as needed

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,….ECT..

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

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

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

Sinusitis

Sinusitis Patho continued Pathogens

Streptococcus pneumoniae, haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes, staph aureus

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 objective findings 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 CBC to look for leukocyte elevation Stains or cultures of mucus may be indicated Allergy testing

Sinusitis

Sinusitis Differentials Dental abscess Migraine Trigeminal neuralgia Any of the – rhinitis Viral URI

Sinusitis diagnosis URI for 7 days plus two or more

Colored mucus, facial pain, headache, documented history, fever over 102, tooth pain

Sinusitis

Sinusitis Management Remember this is usually VIRAL! Supportive care is most helpful

Sinus rinse Few meds are helpful

Sudafed, nasal spray, expectorants, Rarely use steroids –po, or antihistamines

Localized sinus infections are self limited

Sinusitis

Sinusitis- management Amoxil Biaxin Vantin Omnicef Levaquin Augmentin Ceftin Cleocin

Review the therapeutic handouts

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

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

Epidemiology 8% of all office visits Viral more common in cold weather GABHS 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

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 GABHS is 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

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

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, but GABHS is common

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

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….

Pharyngitis

Objective for pharyngitis Inflamed throat, erythematous Conjunctivitis is associated with adenovirus Exudates and large tonsils occur rarely with viral illness EBV may present with 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

Pharyngitis

Testing Not needed often, due to the self-limited nature of these

illnesses Best test is a rapid strep test with a back up throat swab culture To justify a rapid test the patient should have tow or three of

the following Fever over 100.5, tonsillar exudes, tender anterior cervical

lymphadenopathy, absence of cough Patients meeting four of these may be treated empirically Throat swab is gold standard test

Anti-streptolysin or ASO for blood detection of strep

Pharyngitis Testing continued

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 Differential diagnosis

Stomatitis Postnasal drip Rhinitis Sinusitis Epiglottitis Tonsillar malignancy Strep Streptococcal cell wall M protein Many different viral pathogens Irritation from drugs, meds, smoke, ect

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

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

Pharyngitis

Education for pharyngitisprevention, replace toothbrushesdo not share food or drinks, avoid irritants, avoid allergens, avoid heavy lifting or contact sports with mono, always complete all medications

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


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


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


Questionnaires for screening- Example questions Do you 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


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


Testing Ruling out other underlying conditions

CBC, CMP, ESR, rheumatoid factor, TSH, X-RAY Diagnosis may be made by history and exam Refer to;

Dentist, otolaryngologist, oral surgeon They may order CT which gives the best picture of the

osseous structures, or MRI to show arthritic changes or disk displacement


Differential diagnosis Must sort out the list of contributing factors and potential

symptoms Accurate DX is essential Disorders of the intra-cranial structures should be ruled

out New or changes in symptoms must be assessed

I.e.; weight loss, ataxia, fever, seizures, paralysis, vertigo


Differentials continued Sinusitis, arthritis, glaucoma, lyme disease, OM,

OE, temporal arteritis, neuralgia, mastoiditis, abscess, migraine, anxiety, depression, hematoma-- to name a few


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 PT 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

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

TB

Interpretation of TB skin testing Greater than 5 mm is positive for the following

People with HIV, or risk factors for HIVPeople recently exposed to active TBPersons with organ transplantsPersons with chest film indicating healed TB

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

TB

Greater than 15 mm Everyone else

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Ear Nose and Throat