1
Q
Normal TM Anatomy
A
2
Q
Normal Ear anatomy
A
3
Q
Labyrinth
A
bony & membranous part of inner ear consists of
- Cochlea = responsible for hearing converting wave impulses from middle ear to auditory nerve impulses
- Vestibular system = 3 semicircular canals originating in vestibular responsible for balance
4
Q
Auditory Physical Exam Tests
A
- Normal
- Weber (no lateralization)
- Rinne (+ = AC > BC)
- Sensorineural loss (inner ear)
- Weber (lateraize to NORMAL ear)
- Rinne (Normal: AC > BC. Difficult hearing own voice & deciphering words)
- Conduction loss (middle/external ear)
- Weber (lateralize to AFFECTED ear)
- Rinne (- = BC >/= AC)
- sensoriNeural laterizes to Normal ear + Normal Rinne (think N for neural)
- Sensorineural hearing loss = Presbyacusis - age related (MC), chronic loud noise exposure, CNS lesions (acoustic neuroma), Labyrinthitis, Meniere’s syndrome
- Conductive hearing loss = defect in sound conduction via obstruction from foreign body or cecum impaction (MC); damage of ossicles (otosclerosis, cholesteatoma); Mastoiditis, otitis media
5
Q
Romberg Tests
A
- eyes open, three sensory systems provide input to cerebellum to maintain truncal stability. = vision, proprioception, and vestibular sense.
- If there is a mild lesion in the vestibular or proprioception systems, the patient is usually able to compensate with the eyes open. When the patient closes their eyes, however, visual input is removed and instability can be brought out.
- If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain this position even with their eyes open.
- Note that instability can also be seen with lesions in other parts of the nervous system such as the upper or lower motor neurons or the basal ganglia, so these should be tested for separately in other parts of the exam.
6
Q
Caloric Tests
A
- Ice cold or warm water or air is irrigated into the external auditory canal, usually using a syringe. temperature difference b/w body and injected water creates a convective current in the endolymph of the nearby horizontal semicircular canal. Hot and cold water produce currents in opposite directions and therefore a horizontal nystagmus in opposite directions.In patients with an intact brainstem:
- water is warm (44 °C or above) endolymph in the ipsilateral horizontal canal rises => increased rate of firing in vestibular afferent nerve (mimics head turn to ipsilateral side) => Both eyes turn toward the contralateral ear c horizontal nystagmus to ipsilateral ear.
- water is cold, relative to body temperature (30 °C or below), the endolymph falls c/n semicircular canal => decreasing rate of vestibular afferent firing => eyes turn toward ipsilateral ear c horizontal nystagmus to contralateral ear
- Absent reactive eye movement suggests vestibular weakness of horizontal semicircular canal of stimulated side
- comatose patients c cerebral damage, the fast phase of nystagmus will be absent as this is controlled by the cerebrum.
- cold water irrigation => deviation of eyes toward ear being irrigated
- If both phases are absent, suggests the patient’s brainstem reflexes are also damaged and carries a very poor prognosis
- COWS: Cold Opposite, Warm Same.
- Cold water = FAST phase of nystagmus to the side Opposite from the cold water filled ear
- Warm water = FAST phase of nystagmus to the Same side as the warm water filled ear
In other words: Contralateral when cold is applied and ipsilateral when warm is applied
7
Q
Dix-Hallpike positional test
A
Used to test vertigo pts
- patients lowered quickly to supine position, c neck extended by clinician
- Modified maneuver to targets posterior semicircular canal = patient moving from seated position to side-lying c/o head extending off the examination table, head rotated 45 degrees away from the side being tested, and the eyes are examined for nystagmus.
- For pts anxious about eliciting vertigo sxs, lack ROM.
- Results
- positive test = pt reports reproduction of vertigo and clinician observation nystagmus => dx BPPV
- negative test = benign positional vertigo less likely & central nervous system problem
8
Q
Otitis Media
- Def
- Etiology
- Path
- RF
- HPI
- PE
- Management
A
- Def = infection of middle ear (tympanic only) occurs in children due to reflux/decrease clearance from nasopharynx into middle ear
- Acute OM (+effusion for days)
- OM w/effusion (days to 3 mo)
- Chronic OM (>3 mo)
- Etiology = URI (Strep. Pneumoniae > Hemophilus influenzae (+ conjunctivitis)> Maroxella catarrhalis > Strep pyogenes (same as bronchitis & sinusitis), or viral (can’t distinguish)
- Path = URI => Eustachain tube edema => negative pressure => transudation of fluid & mucous in middle ear => 2ry colonization by bacteria & flora
- RF = young, Eustachian tube dysfunction, day care, pacifier/bottule use, parental smoking, not being breastfed
- HPI = unilateral ear pain, relieved w/ pinna pulling
- Fever, Otalgia, ear tuggin, conductive hearing loss, stuffiness
- If TM perforation => rapid relief of pain + otorrhea (usually heals in 1-2 days)
- Dx
- Bulging, erythematous TM c effusion & decreased TM mobility(dx) on Pneumatic otoscopy
- Loss of landmarks
- Bullae on TM => suspect mycoplasma
- Tx
- Mild & > 2 yo, NSAIDs and wait
- Severe or fever abx = Amoxicillin x 10 days (adults), Cefixime (children)
- Recurrent
- Amoxicillin + Clavulanate (augmentin) x 10 days
- WU Fe deficeicny anemia & CT scan
- Penicillin allergy w/o anaphylaxis = 2nd gen Cephlosporin (eg. Cefpozil) x 3 days
- Penicillin allergy w/ anaphylaxis = Azithromycin (Z-Pack/Zmax) - also used to tx bronchitis
- bilateral effusion > 3 mos & bilateral hearing deficiency = Refer to ENT for surgical management
- Chronic (3 OM/6 mo OR 4 OM/yr) = tympanoplasty (ear tube insertions)
9
Q
Otitis Media: Dx & Tx
- Mild & ____
- Severe or ____
- Recurrent
- _____ allergy w/o anaphylaxis
- _____ allergy w/ anaphylaxis
- Bilateral effusion > __
- Chronic ____
A
- Dx effusion = Pneumatic otoscopy +/- tympanometry = immobile TM dx
- Tx
- Mild & > 2 yo, NSAIDs and wait
- Severe or fever= Amoxicillin x 10 days
- Recurrent = Amoxicillin + Clavulanate (augmentin) x 10 days
- Penicillin allergy w/o anaphylaxis = 2nd gen Cephlosporin (eg. Cefpozil) x 3 days
- Penicillin allergy w/ anaphylaxis = Azithromycin (Z-Pack/Zmax) - also used to tx bronchitis
- bilateral effusion > 3 mos & bilateral hearing deficiency = Refer to ENT for surgical management
- Chronic (3 OM/6 mo OR 4 OM/yr) = tympanoplasty (ear tube insertions)
10
Q
Name & describe HPI/PE
A
- Acute OM (+effusion for days)
- Prior URI, unilateral ear pain, relieved w/pinna pulling, fever, irritability, Erythematous Bulging Tympanic membrane, loss of light reflex (due to fluid)
11
Q
Name & describe HPI/PE
A
OM w/effusion (days -3 mo)
- fluid behind TM w/o presence of infection, a result of chronic eustachian tube dysfunction, previous AOM, or barotrauma, Asymptomatic, decrease hearing, Aural fullness
- Dull Air bubbles
12
Q
Name & describe HPI/PE
A
Chronic OM (effusion >3 mo or recurrent OM)
- frequent AOM w/otorrhea as a result of TM perforation or tube placement => Hearing loss
13
Q
Otitis Externa
- Def
- Path
- HPI
- PE
- Dx
- Management
- Complications
A
- Def = infection of the outer ear (penna + ear canal)
- Path
- Swimmers ear (or shower) = Excess H20 or local trauma => change ear pH => bacterial overgrowth => MC Pseudomonas, Aspergillus (fungal)
- Digits = Staph or Strep
- HPI = 1-2 day ear pain, pruritis in ear canal, auricular d/c, pressure/fullness, hearing preserved
- PE = Unilateral ear pain, worse c pinna pulling (traction of tragus),
- Dx = Clx of Erythema/edema/debris/angry canal
- Management
- Drying agents = isopropol ROH, acetic acid
- Aminoglycoside abx combo (1st line) = Neomycin + polymyxin + hydrocortisone (contraindicated for TM perforation due to ototoxic)
- TM perforation
- Ciprofloxacin (protects against pseudo) + dexamethasone
- Ofloxacin
- Fungal = Amphotericin B
- Complication
- Malignant Otitis Externa = Osteomyelitis @ skull base 2ry Pseudomonas (MC in DM & immunocomp) = IV abx (ciprofloxacin)
14
Q
Mastoiditis
- Def
- Path
- HPI/PE
- Dx
- Tx
A
- Def = inflammation of mastoid air cells of temporal bone (all pts c AOM have some degree of mastoiditis) b/c they are connected. Mc a cx of prolonged or inadequate AOM tx
- Path = URI, Tymphanoplasty
- PE = deep ear pain (worse at night), Mastoid tenderness, +/- cutaneous abscess (Swelling behind ear + ear ant. rotated)
- Cx = hearing loss, labyrinthitis, vertigo, CN VII paralysis
- Dx = Clx >> CT
- Management
- IV abx (Ampicillin, Cefuroxime) + myringotomy (I&D) => PO abx
- Refractory => mastoidectomy
15
Q
TM rupture
- Etiology
- HPI
- PE/Dx
- Management
- Prognosis
A
- Etiology
- Trauma = physical abuse (red flag), Foreign body, Forceful irrigation
- Infection = AOM, COM
- Middle ear barotrauma (scuba injury)
- HPI = Painful pop, then relief c Otorrhea (drainage)
- PE
- size perforation as percent of membrane
- Traumatic perf lack discharge
- Weber lateralizes to side of perforation
- Management
- Keep ear dry, refer to audiologist
- Tx concurrent OM c abx drops
- Ciprofloxacin (eye drops) + dexamethasone
- Ofloxacin (ear drops)
- Prognosis
- heals spontaneously in 4-6 wks
- Lg or marginal perforation may req surgery
16
Q
Ear Foreign Body
A
Insects must be immobilized prior to removal. Drown insects with mineral oil or viscous lidocaine before attempting removal, After irrigation, if the child is uncomfortable, consider treating with topical pain agents such as benzocaine-antipyrine
17
Q
Tinnitus
- Definition
- Etiology
A
- Ringing in ear (older - persistent, younger - transient)
- Etiology
- 1ry ear condition
- Sensorineural Hearing Loss (Presbycusis, occupational noise exposure) - MC\
- Cecum impaction
- Meniere’s Disease
- Acoustic Neuroma (Vestibular Schwannoma)
- Ototoxic (meds)
- MSK Injury = head/neck injury, TMJ dysfunction
- Neurologic = Multiple Sclerosis, Vestibular Migraine
- Infectious = syphilis
- Metabolic = hypothyroidism, Vit B12 deficiency, DM
- 1ry ear condition
18
Q
Vertigo
- Peripheral
- General HPI
- Etiologies x 4
- Specific HPI/PE + Management
- Central
- Antiemetics
A
N/V caused by sensory conflict mediated by neurotransmitters GABA, ACh, Histamine, Serotonin
- Antihistamines (1st line)
- MOA = blocks emetic response and most have anticholinergic properties
- Meclizine, cyclizine, dimenhydrinate, diphenhydramine
- MOA = blocks emetic response and most have anticholinergic properties
- Dopa Blocker (phenothiazine) = metoclopramide, prochlorperazine IM/rectal; IV promethazine
- MOA = antag D2 receptors used to tx severe N/V
- Often c Benadryl to prevent dystonic rxns (such as parkinsonism sxs). Anticholinergic property of Benadryl prevents/tx dyskinesias
- Anticholinergics = scopolamine. good for motion sickness & recurrent vertigo)
- S/E = dry mouth, blurred vision, urinary retention, constipation
- Benzodiazepines = Lorazepam, Diazepam for refractory pts. Potentiates GABA
19
Q
Treatment for BPPV
A
Epley Maneuver - canalith repositioning to attach to hair cells inside saccule & utricule
20
Q
Cholesteatoma
- Def
- Etiology
- Path
- HPI
- PE/Dx
- Management
A
- Def = Abnormal growth of sq epithelium => mastoid bone erosion
- Etiology
- Congenital = white mass behind TM in asymp child
- Primary acquired = dev due to negative middle ear pressure => retraction of TM
- 2ndary acquired = epithelial cells introduced to middle ear via pressure equalization tube placement or trauma
- Path = chronic ET dysfunction (chronic negative pressure inverts part of the TM causing granulation tissue over time erodes ossicles => conductive hearing loss
- HPI
- Painless Otorrhea (brown/yellow d/c c strong odor)
- Peripheral vertigo
- Conductive hearing loss
- Dx
- Granulation tissue seen c otoscope
- Management
- surgical excision & reconstruction of ossicles
21
Q
Conductive Hearing Loss w/o vertigo
- Etiology x 2
- HPI & Tx
A
- Cecum impaction = Wax impacts external auditory canal may lead to conductive hearing loss
- HPI = slowly progressive hearing loss, +/- tinnitus
- Tx = Hydrogen Peroxide 3%, Carbamide peroxide, irrigation/curette removal/suction
- Ostosclerosis = stapes bone overgrowth => block conduction => conductive hearing loss
- HPI = slowly progressive hearing loss, tinnitus (vertigo uncommon)
- Tx = stapedectomy c prosthesis
22
Q
Sinusitis
- Def
- Path
A
- Def
- Acute = < 4 wks
- MC Rhino virus => Rinosinusitis
- 2ry to URI (Strep Pneumo. > H. influ. > M. cat > Staph. aureus)
- Subacute = 4-12 wks
- Chronic = > 12 wks
- MC. s. aureus, Pseudomonas, anaerobes
- Fungal Aspergillus (necrotic), Wegener’s (necrotic), mucormycosis in DM/immunocomp pts
- Acute = < 4 wks
- Path
- Often occurs c concurrent rhinitis or follows URI, dental infections
- URI => edema => blocks sinus drainage => fluid build up => bacterial colonization
23
Q
Sinusitis: HPI + PE + Dx
A
- HPI
- sinus pain/pressure (worse c bending down & leaning forward), foul/purulent nasal d/c, nasal congestion, HA, fever, malaise (sxs last > 10-14 days)
- Peds = abnormal sxs, bad breath, subacute or abrupt onset
- Bacterial = unilateral sinus pain, early high-grade fever (>38C), bilateral purulent discharge, double course
- Viral = bilateral sinus pain, low-grade fever, bilateral clear copious rhinorrhea
- PE = Maxillary > ethmoid > frontal > sphenoid sinus tenderness c palpation
- Maxillary (MC) = cheek pain/pressure radiates to upper incisors
- Ethmoid = Tenderness to high lateral wall of nose
- Sphenoid = mid head
- Frontal = CN VI palsy
- Dx = clx (CT dx tx of choice, X ray show water view)
24
Q
Sinusitis: Tx
A
- Mild = observe 7 days, 80% improve w/in 2 wks (viral)
- Supportive = Nasal saline rinses, Nasal steroid spray, antihistamine, decongestant, mucolytics, afrin short-term
- Mod-severe failed to improve after 10-14 days or double sickening
- 1st line = Amoxicillin (10-14 days) or Septra or Doxcydoxycycline
- Severe or likely resistant = Amox/Clav (Augmentin) or Levofloxacin
- Recurrent bacterial sinusitis = CT (anatomical, or foreign body in kids)
- Mucormycosis = lipid control, Amphotericin B, Posaconazole
- ED = facial cellulitis, proptosis, vision change, MSE
25
Bacterial or Mucormycosis Sinusitis: Complications
Bacterial = orbital cellulitis or abscess, osteomyelitis (Pott’s puffy tumor), intracranial extension, cavernous sinus thrombosis
Mucormycosis = fungi (Mucor, Rhizopus, Absidia, Cunninghamella) invade sinus =\> CNS =\> black eschar on face
26
Rhinitis
1. Etiologies x 3
2. HPI
3. PE
4. Management
1. Etiology
1. **Allergic MC Rhinitis =\> IgE-mediated mast cell histamine release**
2. **Infectious: rhinovirus MC** infectious cause
3. Vasomotor: nonallergic dilation of bvs
2. HPI
1. Sneezing, nasal congestion/itching, **clear rhinorrhea =\>** Eyes, ears, nose, throat maybe involved
2. **Allergic** **asoc** **c nasal polyps & worse in AM**
3. PE
1. Allergic = **pale/violaceous, inferior turbinates hypertrophy (reversible c vasoconstrictors), nasal polyps c cobblestone mucosa of conjunctiva**
1. **Allergic Shiner"** - caused by venous congestion = \> darkening of skin under eyes
2. **Dennie's lines** = fine creases in lower eyelids
3. Allergic salute = chronic nose wiping =\> Nasal tip transverse crease
4. Prominent Pharyngeal lymphoid tissue =\> **Cobblestoning** fo posterior pharynx due to submucosal hypertrophy of lymphoid tissue
2. Viral = **erythematous turbinates**
4. Management
1. Oral antihistamines (MOA) = decrease itching, sneezing, rhinorrhea
2. Decongestants
3. Intranasal decongestants (using \> 3-5 days may cause rhinitis medicamentosa =\> rebound congestion)
4. Intranasal steroids = **for allergic rhinitis esp c nasal polyps** (mast cell stabilizers)
27
Epistaxis
1. Def
2. Etiologies
3. HPI
4. PE
5. Management
1. Nose bleeds - Anterior \> Posterior
2. Etiology
1. nasal trauma (nose picking, forceful nose blowing), dry mucosa, rhinitis, ETOH, antiplatelet meds
2. Anterior bleeding = **Kiesselbach's Plexus**
3. Posterior bleeding = **Sphenopalatine artery** =\> bleeding in nares & posterior pharynx
3. Management
1. **Direct pressure (1st line)**: \> 10 min, seated and leaning forward to dec venous pressure
2. **Short-acting topical decongestant**: cocaine, phenylephrine, oxymetazoline nasal (Afrin)
3. **Cauterization or nasal packing**: used to tx posterior epistaxis, avoid exercise and spicy foods for few days
**Septal hematoma** **assoc** **c loss of cartilage**
28
Nasal Foreign Body
Purulent, foul-smelling nasal discharge
29
Oral Antihistamines (MOA)
1. Nonsedating
2. Minimal sedating
3. Sedating
1. Nonsedating
1. Cetirizine
2. Fexofen**_adine_**
3. Lorat**_adine_**
2. Minimal sedating
1. Deslorat_adine_
3. Sedating
1. Brom**_pheniramine_**
2. Chlor**_pheniramine_**
30
Decongestants
1. Oral
2. Nasal
1. Oral
1. Pseudoephedrine
2. Intranasal (using \>3-5 days =\> rhinitis mediacamentosa "rebound congestion")
1. Oxymetazoline (Afrin)
2. Phenylephrine
3. Naphazoline
31
Aphthous Ulcer
1. HPI
2. Mgmt
Canker sore
1. HPI = small round/oval **painful ulcers** (yellow/white/grey center) **c erythematous halos** MC on buccal or labial mucosa (nonkeratinized mucosa), Bx ulcers lasting more than 3 wk
2. Mgmt
1. **Topical analgesics = v**iscous lidocaine 2–5%: Applied to ulcer QID after meals until healed
2. Topical PO steroid (triamcinolone)
3. Vit B & C
4. **Cimetidine** if recurrent
32
Oral Candidiasis
1. Cause
2. HPI
3. Dx
4. Management
1. Cause = **_Candida albicans_** usually due to local/systemic immunocomp state
2. HPI = **white curd-like plaque** (+/- leaves behind erythema/bleeds if scraped)
3. Dx = **KOH smear =\> buddying yeast/hyphae**; often clx dx
4. Mgmt = **Nystatin** (1st line); Fluconozale PO
33
Oral Leukoplakia
1. Cause
2. HPI
3. Dx
4. Management
1. Cause = Pre-ca hyperkeratosis due to chronic irritation (tobacco chew/smoke, ETOH, dentures) up to 6% c dysplasia or squamous cell carcinoma
2. HPI = **white patchy lesions that can't be rubbed off,** PAINLESS
3. Dx = Dx of exclusion
4. Mgmt = cryotherapy, laser ablation
1. If path is along lateral tongue border or buccal mucosa +/- smooth/irregular "hairy" or "feathery" lesions =\> Oral Hairy Leukoplakia caused by Epstein Barr Virus (HHV-4) MC in immunocomp
1. Mgmt = Antiretroviral tx & ablation
34
Oral Erythroplakia
1. Cause = Pre-ca lesions similar to leukoplakia but c erythema. **90% is either dysplastic or squamous cell carcinoma**
35
Oral Herpes Simplex virus
1. Etiology
2. HPI
3. Mgmt
**Acute Herpetic Gingivostomatitis** = MC 6 mos - 5 yrs. Primarily manifestation of HSV-1 in children
1. HPI = sudden onset fever, anorexia =\>gingivitis (gum swelling, friable, bleeding gums); vesicles on oral mucosa, tongue & lips =\> grey/yellow lesions
1. Prodromal period (typically \< 6 h in recurrent HSV-1) of tingling discomfort or itching
2. Mgmt = usually self limiting, severe cases Acyclovir
**Acute Herpetic Pharyngotonsillitis** = Primarily manifestation of HSV-1 in adults
1. HPI = fever, malaise, HA, sore throat
2. PE = vesicles that rupture =\> ulcerative lesions c grayish exudates in posterior pharyngeal mucosa
3. Mgmt = PO hygiene (usually resolves 7-14 days)
36
Sialadenitis
1. Def
2. HPI
3. Management
1. Def = **bacterial infection of parotid or submandibular salivary gland** +/- occur c dehydration, chronic illness, or sialolithiasis (obstructing stone in salivary gland)
2. HPI = Acute swelling of glands esp c meals, tenderness @ duct opening (+/- pus if duct is massaged)
3. Dx = CT, US, or MRI if not obvious clinically. If pux can be expressed, it is sent for gram stain & culture
4. Mgmt = increases salivary flow c **sialogogues** (ex. lemon drops). IV nafcillin if severe
37
Pharyngitis & Tonsillitis: name 6
1. Mononucleosis - atypical lymphocytes, + heterophile agglutination test (monospot). Taking antibiotics such as amoxicillin or ampicillin may cause a rash
2. Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis
3. Fungal cause of pharyngitis in patients using inhaled steroids
4. Throat culture is GOLD STANDARD, Penicillin is first line for Strep. Throat, Azithromycin if Pen allergic.
38
Pharyngitis
1. Path
2. HPI/PE
3. Dx
4. Tx
1. Path
1. Viral (mc) = Adeno, corona, rhino, influenza, parainfluenza,coxsackle
2. Bacterial = Group A strep (left untreated can =\> rheumatic fever)
2. HPI/PE = Sore throat + odynophagia
1. **- C**ough = + 1
2. **E**xudate (tonsilar) = + 1
3. **N**odes = +1
4. **T**emp ≥ 38 Celclus = +1
5. **OR**
1. **** ≤ 13 yo = + 1
2. ≥ 44 yo = - 1
3. Dx
1. ≤ 1 Centor criteria =\> viral =\> no tx
2. 2-3 Centor criteria =\> Rapid strep
1. Rapid strep negative =\> culture or no tx (based on HPI/PE)
2. Rapid strep positive =\> treat
4. Tx
1. Viral = Salt water gargles, Lozenges, NSAIDs
2. Strep = Amoxicillin Clavulante (augmentin)
39
Acute Tonsilitis
1. Path
2. HPI/PE
3. Dx
4. Tx
1. Path
1. Viral = mononucleosis (EBV or CMV)
2. Bacterial = Group A strep (left untreated can =\> rheumatic fever)
2. HPI/PE = Sore throat + odynophagia + Swollen tonsils w/white plaques/exudate
1. Mono = hepatosplenomegally, fatigue, malaise
3. Dx
1. Rapid strep test
2. Monospot test (not + early in disease) + CBC to look for atypical lymphocytes
4. Tx
1. Viral = Salt water gargles, Lozenges, NSAIDs
2. Strep = Amoxicillin Clavulante (augmentin)
1. avoid ampicillin if it could be mono =\> rash
40
Peritonsillar abscess
1. Path
2. HPI/PE
3. Dx
4. Tx
1. Path = tonsilitis =\> cellulitis =\> abcess formation
1. **MC S.pyogenes, S.aureus, Polymicrobial**
2. HPI/PE = dysphagia, pharyngitis, **Muffled "hot potato voice", difficulty handling oral secretions, trismus** (lock jaw), **_uvula deviation to contralateral side_**, tonsilitis, anterior cervical LAD, severe fever, malaise
3. Dx = clx, **CT scan** can differentiate cellulitis vs abscess
4. Tx = urgent referral to ENT for I&D + abx (unasyn or Clindamycin), steroids (for edema)
1. Tonsillectomy indications = recurrent strep/peritonsilar infection, chronic tonsilitis
41
Ludwig's Angina
1. Path
2. HPI/PE
3. Dx
4. Tx
1. Path = bacterial cellulitis of floor of the mouth MC from dental infection (anaerobes)
2. HPI/PE = **swollen & erythema of upper neck & chin** c pus on floor of mouth +/- protruding tongue
3. Dx = clx
4. Tx = call ED transport, life threatening
1. Penicillin + Metronidazole, Clindamycin, Ampicillin/Sulbactam (Unasyn)
42
Laryngitis
Almost always viral, consider squamous cell carcinoma if hoarseness persists \> 2 weeks, history of ETOH and or smoking, Laryngoscopy is required for symptoms persisting \> 3 wk.
43
Epiglottitis
1. Etiology
2. HPI
3. Dx
4. Mgmt
1. Etiology = **H. flu type B (MC)**, S. pneumo. In adults maybe bacterial or viral (esp c DM)
2. HPI = abrupt onset fever, **drooling, dysphagia, distress** (tripod position, muffled voice)
3. Dx
1. Tongue blade NOT used for direct visualization =\> laryngospasm
2. Lateral cervical film - thumb sign (thumbprint sign) = enlarged epiglottis
3. **Laryngoscope** = definitive dx (only in adults), **cherry - red epiglottis**
4. Mgmt = **secure airway b4** increasing anxiety in children;
1. IV abx (**ceftriaxone** +/- Clindamycin) +
2. IV corticosteroids & IV fluids +
3. Rifampin for prophylaxis
44
Diseases of the teeth and gums
1. Gingivitis
2. Gingival Hyperplasia
3. Vincent's Angina
4. Dental abscess
1. Gingivitis: Pt should be counseled about increases risk for cardiovascular events
2. Gingival Hyperplasia: Overgrowing of gums so that it blocks the teeth, commonly caused by medications. Phenytoin, CCB's and Cyclosporine
3. Vincent's Angina: “Trench Mouth” Necrotizing gingivitis: Characterized by the “punched-out” appearance of the gingival papillae
4. Dental abscess: Poor dental health is a risk factor for dental abscess or facial cellulitis, refer the complicated abscess to an oral surgeon for I&D.
45
Glomus tympanicum
Paraganglioma (neuroendocrine tumor) develops in middle ear. Present as reddish bulge behind TM and not a white mass.
46
Tympanosclerosis
Scarring c/in middle ear space. Usually develops in relation to recurrent infection
47
Auricular or Septal Hematoma
Bleeding in potential space b/w cartilage
Tx = I & D + packing
Family Medicine
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