NOSE AND THROAT

1. NOSE AND THROAT • SIOM Western Clinical Science • Fall 2012, • Dr. Gonzales ND, LAc

2. NOSE

3. Epistaxis • a nose bleed • may be primary or secondary, in children tends to be mild and in adults often requires nasal packing

4. Epistaxis • usually following an internal or external trauma eg. punch, pick, insertion of foreign body, low humidity, cold, allergies, sinusitis • Sometimes due to polyps, acute or chronic sinusitis or rhinitis, chemical inhalation • People on anticoagulants, with hypertension, long-term aspirin use, in dry climates or high altitudes, scurvy, vitamin-K deficiency and blood dyscrasias can be predisposed to epistaxis • complications include shock and aspiration

5. Epistaxis • signs and symptoms: blood from nostrils comes from the anterior nose and the blood is bright red • Blood from the back of the throat comes from the posterior area of the nose can be bright red or dark red • usually unilateral - unless due to dyscrasia or trauma • Severe cases - blood in corners of eyes, middle ear and behind nasal septum • Other symptoms relate to severity - dizziness, light-headedness, respiratory difficulty to hypotension, bounding pulse, dyspnea and palor • Bleeding is severe when it continues more than 10 minutes after pressure is applied. It is unlikely that someone will bleed to death.

6. Epistaxis labs • Just for your edification/if someone comes to your office with frequent nosebleeds or unremitting nosebleed: • HCT/Hgb • platelets - decreased in dyscrasias • PTT - will be increased in anti-coagulant use and with blood dyscrasias

7. Treatment of epistaxis • mild nosebleeds treated with gentle squeezing of bridge of nose while patient leans slightly forward • Anterior - cotton ball soaked in epi and pressure • Posterior - packing nasal passage with gauze and antibiotics if it remains in place longer than 24 hours • Elevate patient’s head to 45 degrees, apply ice to the nose add gentle pressure. If it bleeds longer than 10 minutes send out.

8. Septal Perforation and Deviation

9. Septal Perforation • a hole in the nasal septum between the two nares in the anterior cartilaginous septum • often caused by trauma (usually nose picking), repeated cauterization, perichondritis, tuberculosis, syphilis, chemical irritants (eg. cocaine), chronic infections, untreated septal hematoma... • can lead to infection and deformity • can be asymptomatic though there can be an inhalation whistle. A large perforation can cause epistaxis, crusting, watery discharge, rhinitis

10. Perforation diagnosis and Treatment • Diagnosis: based on clinical features and inspection with nasal speculum and pen light • Treatment: symptomatic - vaseline for nasal mucosa, decongestants, antibiotics preventing infection, sometimes surgery to seal hole

11. Nasal septal deviation • a shift of the nasal septum from the midline common in adults • can obstruct the passage of air through the nostrils • develops through normal growth, a fall or blow to the nose or surgery

12. Deviated nasal septum • Signs and Symptoms: crooked nose, nasal obstruction, stertor, fullness in the face, SOB, nasal discharge, infection, epistaxis, headache • Diagnosis: symptoms and inspection with nasal speculum and pen light • Treatment: corrective surgery, analgesics, nasal packing, cautery, vasoconstrictors

13. sinusitis

14. Sinusitis • inflammation of the paranasal sinuses • there are four classifications - acute, subacute, chronic and allergic. • hyperplastic sinusitis is a combination of acute and allergic sinusitis or rhinitis

15. Sinusitis • Causes and Incidence: • generally caused by viral or bacterial infection. Pneumococci or streptococci, H. influenzae and M. catarrhalis (acute) • Staphylococci and gram-negative bacteria often cause chronic infections or infect patient’s in intensive care • people who have conditions that interfere with sinus drainage and ventilation are predisposed to infection eg. edema, septal deviation, polyps, DM, CF, chronic steroid use • history of asthma, overuse of nasal decongestants, foreign body, frequent swimming, GERD, air pollution

16. Sinusitis Complications • Consider anatomy, physiology, blood supply. Sinusitis can be quite dangerous if prolonged, untreated or in a patient with decreased immune function. • meningitis • cavernous and sinus thrombosis • bacteremia, septicemia • brain abscess • osteomyelitis • mucocele • orbital cellulitis

18. Sinusitis signs and symptoms • ACUTE: nasal congestion with pressure on affected side. Nasal discharge that may become purulent. Associated - fever, malaise, headache, sore throat • pain is associated with involved sinus • if discharge lasts longer than 3 weeks the infection may be subacute and be associated with vague facial pain, fatigue and non-productive cough • CHRONIC: discharge is more mucopurulent and continuous • ALLERGIC: sneezing, frontal headache, watery discharge, itchy nose • HYPERPLASTIC: bacteria grows on allergic tissue tissue edema and chronic stuffiness and headache.

19. sinusitis diagnosis • nasal examination shows inflammation and pus • TTP on maxillary or frontal sinuses • transillumination looks dark as compared to normal sinuses which transilluminate • Other measures used: U/S, CT, x-ray can show cloudiness and complications

20. Sinusitis treatment • decongestants • antibiotics: commonly amoxicillin or amoxicillin/clavulanate, azithromycin • local applications of heat can decrease pain, heat would increase congestion - better hot/cold application. • allergic - remove allergen, antihistamines, steroids • remember to tell patient to drink plenty of fluids - increasing fluidity of discharge • make sure to watch for - chills, fever, vomitting, edema of forehead or eyes, double/blurred vision, change in personality

21. Sinusitis • remind patients who are on antibiotics to finish the course - preventing antibiotic resistance. • check-in with patient to make sure infection is not spreading/is under control • sinusitis is easily treatable but can be dangerous due to anatomic location, blood supply and the thinness of the bones in the cranium

22. nasal polyps

23. Nasal polyps • benign, edematous, multiple, mobile, bilateral growths. May become numerous or enlarged enough to distend nasal passages and deform bony framework causing obstructed airway. • Causes and Incidence: frequently caused by chronic allergy with mucus edema, chronic sinusitis or rhinitis, infection. Often in adults, rarely in children. • Complications: airway obstruction • Signs and Symptoms: obstruction causing anosmia, sensation of fullness, discharge, headache, SOB • Diagnosis: nasal speculum shows dry mucosa with grey growths • Treatment: steroids applied topically. Short course oral, treat underlying cause. Local astringent application to shrink tissue. Usually - polypectomy

24. Nasal Papillomas • benign tissue overgrowth,, can be associated with squamous cell cancer. • Inverted Papillomas: arise from epithelium and grow into the underlying tissue usually at the junction of maxillary sinus and antrum • Exophytic papillomas arise from the epithelium and are usually on the surface of the nasal septum

25. Nasal papillomas • may be a benign precursor to neoplasm or response to tissue injury, viral infection. Usually in males. • Complications: nasal drainage, infection, rarely severe respiratory distress • Signs and Symptoms: symptoms are those of unilateral nasal obstruction, epistaxis often occurs with exophytic papillomas • Diagnosis: examination of nasal mucosa. Inverted appear large and edematous while exophytic are raised and attached by a base to the nasal mucosa • Treatment: wide surgical excision, pain relievers and decongestants

26. Adenoid hyperplasia • common childhood condition AKA adenoid hypertrophy. Enlargement of the lymphoid tissue of the nasopharynx • commonly accompany tonsilitis

27. Adenoid hyperplasia • Causes and incidence: unknown, hereditary, frequent infection or chronic infection, allergies, inflammation • Complications: OM, conductive hearing loss, sinusitis, cor pulmonale, pulmonary hypertension • Signs and Symptoms: respiratory obstruction eg. mouth breathing, voice changes, facial changes

28. Adenoid hyperplasia • Diagnosis: nasopharyngoscopy or rhinoscopy confirms. • Treatment: adenoidectomy. Removal eliminates recurrent nasal infections and ear complications and reverses secondary hearing loss.

29. Velopharyn-geal insufficiency • inherited palate abnormality, acquired via tonsillectomy/adenoidectomy. • you won’t see it...great picture though

30. Throat - pharyngitis

31. pharyngitis • the most common throat ailment often accompanies the common cold, due to chronic or acute pharyngeal inflammation

32. pharyngitis • frequently due to a viral infection, sometimes bacteria (b-hemolytic strep, mycoplasma and chlamydia are the most common bacterial infections) • tends to occur in adults who work in dusty or dry environments, excessive voice use, use tobacco and/or alcohol, have allergies or chronic sinusitis • Complications: OM, sinusitis, mastoiditis, rheumatic fever, nephritis

33. pharyngitis • Signs and Symptoms: a sort throat with some difficulty swallowing. It’s more painful to swallow saliva than food. There may be a sensation of a lump in the throat and a constant urge to swallow. There may be mild fever, headache, myalgia, coryza and rhinorrhea. Usually resolves in 3-10 days • Diagnosis: generalized redness of posterior wall with inflammation, edema and yellow or white follicles of mucous membranes. Exudate is usually only present in lympoid tissue. Culture may be performed to determine bacterial organism.

34. Pharyngitis • Treatment: acute viral - warm salt water gargles, and symptomatic relief. Bacterial requires antibiotic treatment to avoid sequelae of untreated infection - namely rheumatic fever and mitral valve prolapse. Chronic pharyngitis requires symptomatic relief and removal of underlying cause eg. smoke/allergen. *Remember that bacterial infections tend to have profuse exudate.

35. Tonsillitis • please do not start tongue diagnosis!

36. Tonsillitis • acute or chronic inflammation of the tonsils. If uncomplicated then it should self resolve within 4-6 days. Tonsils tend to hypertrophy in childhood and atrophy at puberty. • usually due to group A beta-hemolytic streptococci but can be due to infection with other bacteria or viruses. • Complications: chronic upper airway obstruction, sleep apnea, cor pulmonale, failure to thrive, eating/swallowing disorders, febrile seizures, OM, cardiac valvular disease, peritonsillar abscess, bacterial endocarditis, cervical lymph nose abscess

37. tonsillitis • considering the complications it might be best to treat quickly and effectively! • Signs and Symptoms: begins with mild to severe sore throat and there may be dysphagia, fever, swelling of lymph nodes and glands in the submandibular area, myalgias, chills, malaise, pain that can refer to the ears. • Diagnosis: examination of the throat, visibly swollen tonsils that show white or yellow exudate. Need to do a culture to rule out mononucleosis and diphtheria.

38. tonsillitis • Treatment: rest, fluids, NSAIDS, antibiotics. Chronic cases may result in tonsillectomy after the infection has resolved for 3 to 4 weeks. • offer cold drinks/ice/popsicles to help increase fluid intake.

39. throat abscess

40. throat abscess • the previous picture was of a peritonsillar abscess which can be quite dangerous as you can see. An abscess can also be present retropharyngeally. This is when an abscess forms in areas of connective tissue around the pharynx. • if treated the prognosis is good • Causes and Incidence: peritonsillar abscess arises from acute tonisillitis. Acute Retropharyngeal abscess comes from infections in the retropharyngeal lymph glands often post-URI bacterial infection. This happens in young children as the lymph glands start to atrophy after 2 years of age. Chronic retropharyngeal abscess can occur at any age but is related to tuberculosis of the cervical spine.

42. throat abscess • Complications: airway obstruction, cellulitis, endocarditis, pericarditis, pleural effusion and pneumonia • Signs and Symptoms: severe throat pain, ear pain on the same side as the abscess. Patient’s can experience difficulty opening their mouths, malaise, dysphagia and drooling, fever, chils, rancid breath*, muffled speech, localized or systemic sepsis. • Diagnosis: begins with bacterial pharyngitis, there will be swelling of the soft palate on the affected side. The uvula will be displaced to the opposite side affected. • Treatment: broad spectrum antibiotics early in infection. In late stages excision and drainage and treatment with antibiotics is necessary.

43. Vocal cord paralysis

44. Vocal cord paralysis • results from disease or injury to the superior or common laryngeal nerve. Can be congenital. This happens frequently during thyroidectomy, from a thoracic aortic aneurysm or from an enlarged atrium due to mitral valve stenosis. • Complications: airway obstruction, respiratory failure • Signs and Symptoms: most commonly unilateral which results in vocal weakness and hoarseness. If bilateral it can cause incapacitating airway obstruction. • Diagnosis: history and vocal features.

45. Vocal Cord Paralysis • Treatment: unilateral paralysis is treated with teflon injection into the paralyzed side to bring it closer to the opposite side - strengthening the vocal cord and preventing aspiration. Other interesting operations are used such as thyroplasty and arytenoidectomy.

46. Vocal cord nodules and polyps • more likely something you could :see”

47. vocal cord nodules and polyps • Nodules are the result of hypertrophy of fibrous tissue at the point where the cords forcibly come together. Polyps are subepithelia edematous masses. If continued voice abuse occurs they recur.

48. vocal cord polyps and nodules • Causes and Incidence: usually the result of voice abuse - most common in teachers, musicians, sports fans and energetic children who continually shout while playing. • Complications: permanent hoarseness • Signs and Symptoms: produce painless hoarseness or “huskyness”. • Diagnois: persistent hoarseness, visualization • Treatment: conservative for small nodules/polyps includes voice rest and training to decrease use. Surgical removal occurs if conservative therapy fails. If bilateral lesions are present surgery is done in two stages to prevent laryngeal web formation.

49. Laryngeal Web Post surgery • best picture i could find - you can just make out the true vocal cords

50. Laryngitis