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Nose & Throat


Acute sinusitis: etiology Big 3, SA
Unilateral foul smelling or purulent nasal discharge in a pediatric patient Nasal Foreign body
HA, sinus pressure, yellow – green nasal discharge Sinusitis
Sneezing, clear rhinorrhea, post-nasal drip, nasal congestion seasonal occurance Allergic rhinitis. Effective Tx includes H1 antagonists, mast cell stabilizers (eg nedocromil), steroid sprays
Pale, edematous, boggy turbinates Allergic rhinitis
Fever/URI; potentially life threatening = <3 mos; 101F (38.3C)
Viral rhinitis (3-8/yr): etiology rhino, corona; more bronchial = adenovirus, RSV
Viral rhinitis (50% of URIs) transmission hand, inhaled droplet; incubation 2-5 days; sx resolve 5-7 days
Viral rhinitis tx tylenol; ibuprofen if >6 mos; no ASA; sudafed/ phenylephrine; poss Afrin >2 yo; DM for cough; No Role for antihistamines
FDA: viral rhinitis tx no cough/cold meds for kids <2 yo
Purulent rhinitis s/s persistent mucopurulent nasal d/c and irreg fever; often GAS / SP
Rhinosinusitis: 2 presentations in kids 1: ≥10 days nasal congestion, purulent nasal drainage and/or persistent cough; 2: abrupt onset w/ fever >101F, facial pain & purulent nasal drainage
Rhinosinusitis agents: Big 3, esp SP (declining) & H flu
Chronic Rhinosinusitis agents: alpha-hemolytic strep; SA; GN anaerobes
Mild-mod Rhinosinusitis tx 10-14d for acute (4-6 wks for chronic). Amox 500 TID; if allergy, 3G ceph or macrolide or Bactrim
Frontal osteomyelitis secondary to frontal sinusitis = Pott puffy tumor; surgical drainage & IV Abx
Rhinosinusitis: indications for referral need surgical drainage; need polypectomy; recurrent sinusitis (esp w/ exacerbation of asthma); rare/ resistant microbe; intracranial or orbital complications; suspected immunodeficiency
Sinusitis Emergencies Periorbital cellulitis; Brain Abscess; orbital abscess
Non-displaced nasal fracture: mgmt does not require reduction
Refractory sinus problem characterized by saddle nose deformity, may be: Wegener
Flat or raised white oral lesion that cannot be rubbed off, more likely in a smoker = Leukoplakia (need to rule out oral cancer)
Gray pharyngeal pseudomembrane, rash, splenomegaly, supraclavicular LAD Diphtheria
commonly associated with an alveolar bone fracture Lateral luxations
Intrusive luxations of teeth Most serious; do not manipulate initially, allow it to extrude itself or refer (orthodontist)
Post extraction alveolar osteitis, aka: dry socket; Plain films to R/O retained root tip
ANUG is most associated with: HIV, stress, malnutrition, and/or prior ulcerative gingivitis; life threatening if left untreated
ANUG tx Chlorhexidine or half-strength H2O2 rinses, debridement by oral surgeon or ENT, PO flagyl TID (vs PCN or tetracycline)
Can be d/t hereditary C1 esterase inhibitor deficiency, allergic rxn, ACEI, or idiopathic Angioedema
Tonsillitis tx GP coverage: Amox, EES, Quinolones, Bactrim
Parapharyngeal / peritonsillar Abscess sx Nuchal rigidity, stridor; sore throat (usually more on one side), trismus, drooling
Acute viral laryngotracheitis, aka ___; sx/tx Croup; stridor, seal-like cough; Glucocorticoids, Nebulized epinephrine
Epiglottitis etiology HIB (no. 1), GAS, staph
Epiglottitis sx Trismus, drooling, dysphagia; Lateral Neck X-Ray will show Thumb Sign
Airway Foreign bodies: surgical intervention: rigid bronchoscopy
Mandible Dislocation sx Jaw pain, trismus, malocclusion; anterior dislocation is the most common; Can also have posterior, lateral, or superior dislocations
Mandibular fx tx Nondisplaced fx: closed reduction; Displaced or condylar fx: ORIF; Wire Osteosynthesis for 6 weeks
Strep throat complications rheumatic fever, Ludwig angina, tonsillar abscess
Centor criteria are for dx of: (strep) pharyngitis; >38C, cervical LAD, no cough, +exudates
Burning pain in tongue, cheek, throat; whitish can be scraped off oral candidiasis; immunocompromised pts; magic mouthwash w/antifungal
Whitish, cannot be scraped off: leukoplakia; bx to r/o cancer (5% malignant; erythroplakia more likely malignant)
Epiglottitis tx controlled intubation & IV Abx
Temporal bone fx: complications hearing loss, facial paralysis, CSF leak, vertigo, TM perforation, nystagmus
Temporal bone fx: dx CT Temporal Bone, non-contrasted; ENT Consult
If pt has polyps and asthma: do not give ASA (risk of bronchospasm)
posterior epistaxis: usual source is: nasal branch of sphenopalatine artery (condition assoc with HTN and athersclerosis)
Nasal foreign body: if it contains battery: emergency: must remove within 4 hrs
Sinusitis diagnostic studies X-rays: Caldwell (frontal), submentovertical (ethmoid), Waters (maxillary), lateral (sphenoid)
HSV-1 (cold sore) dx studies Tzanck smear (+ shows multinucleated giant cells)
HSV-1 (cold sore) tx Self limiting. May give acyclovir 200mg 5x/day x5D, or famcyclovir 125mg BID x5D, or valacyclovir 500mg BID x5D
Gingival ulceration/edema, grayish membrane over inflamed gingiva, fever, LAD, malaise = ANUG (2/2 variety of spirochetes & fusiform bacilli = normal oral flora)
Parotitis dx studies Check RF, anti-SS-A & anti-SS-B. Sialography. Ultrasound. If suspected malignancy, CT & MRI with contrast
Sialadenitis bug = SA
Erythroplakia vs Leukoplakia: which is more likely to be malignant? Erythroplakia
Reddish velvety lesion on oral mucosa or tongue; presents with erythema = Erythroplakia
Erythroplakia/Leukoplakia pathology Increased keratin layer thickness, neovascularization. If epithelial dysplasia is present, lesion is considered precancerous
Erythroplakia/Leukoplakia management ENT referral. May try beta-carotene, retinoids, vitamin E
Most common cancer of the tongue = SCC (M>F, older pts, often FH aerodigestive cancers)
Most common location of cancer of the tongue = lateral
Painful, indurated plaque on tongue that becomes nonhealing ulcer; may have LAD & otalgia, odynophagia = cancer of tongue
Tongue SCC workup Bx, CT w/contrast, CXR, LFT, ?bone scan, ?PET
Laryngitis bugs Usually viral (adeno, flu; RSV, Coxcackie, rhinovirus); H flu, M cat
Pharyngitis/Tonsillitis: 80% are caused by: Viral (adeno, HSV, rhino, corona). Usually in winter/spring
Pharyngitis/Tonsillitis: bacteria: GABHS, mycoplasma, Group G & C Strep, N gono, Chlamydia
Pharyngitis w/petechiae of soft palate, strawberry tongue +/- scarlatiniform rash = Strep
Bacterial Pharyngitis tx PenVK or Ceftin; erythromycin (if suspect mycoplasma or Chlamydia). Amox or azithro if compliance concern
Acute inflammation of supraglottic larynx = Epiglottitis
Epiglottitis: typical pts Kids 2-7 yo (usually H flu type B), may occur in adults, especially with DM
Rapid onset of high fever, ST, odynophagia, drooling, inspiratory stridor, tripoding, hoarseness, restlessness, in kids = Epiglottitis
Epiglottitis tx Secure airway; ENT referral ASAP; NT intubation if needed; ICU, O2. IV Abx (Ceftin / ceftizoxime) +/- Decadron
Peripharyngeal cellulitis/abscess mgmt I&D of abscess. Admit if severe pain, dyspnea, trismus. Peds: IV hydration & Abx. Broad-spectrum cephalosporin. May try Clinda + PO Amox to prevent abscess formation
Created by: Adam Barnard Adam Barnard