Disorders of the Ear, Nose, Throat
& Mouth
Chapter 10
Medical Considerations
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
 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
EARS
 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
EARS
 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
EARS
 OE

Necrotizing Otis externa is the most severe
infectious form of OE
Bacterial infection extends from the skin of canal into
soft tissue or bone
 Cranial nerves may be involved
 Pseudomonas is most common

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
 Otitis Media (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 needed
 Cultures may be done of discharge if indicated in
healthy patients
 CT or MRI may be needed if suspect invasive disease

EARS
 OE

Differential DX

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


OM
TMJ
Dental disease
Trigeminal or glossopharyngeal neuralgia
Parotitis
Impetigo
Herpes zoster
Insect bites
Mastoiditis
Rupture of membrane
Excessive cerumen buildup (wax)
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
 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
EARS
 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
EARS
 OME symptoms


Stuffiness, fullness, decreased hearing, pain is
rare, may have popping. Rarely vertigo
Usually a history of recent URI, allergies
EARS
 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
 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
 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



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
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
 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, betaadrenergic 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


Type I hypersensitivity to airborne irritants affecting the eyes,
nose, sinuses, throat, and bronchi
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
 May also be caused by food allergies
Rhinitis
 Rhinitis Patho continued


Vasomotor rhinitis is chronic, noninfectious process of
unknown etiology, 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
 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
Rhinitis
 Rhinitis follow up


Recheck as needed
Advise patient of possible complications and
their symptoms to indicate need for follow up



OM, 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
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 pain
 Pain is worse with coughing
 Area of pain corresponds the sinus affected
 Develop over at least 2 weeks of URI symptoms
 Nasal 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

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
Shows air-fluid levels and more than 4mm of mucosal thickening
Stains or cultures of mucus may be indicated
Allergy testing
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- management
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Amoxil
Biaxin
Vantin
Omnicef
Levaquin
Augmentin
Ceftin
Cleocin

Review the therapeutic handouts
Sinusitis
 Sinusitis follow up

Varies per provider

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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

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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
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
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
Pharyngitis
 Subjective findings
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
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

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
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Inflamed throat, erythematous
Conjunctivitis is associated with adenovirus
Exudates and large tonsils occur rarely with viral illness
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



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


Antibiotics for bacterial causes



Diflucan, nystatin
Be sure and assess immune status if no known cause is found
Viral illnesses


See therapeutics handout
Antifungal for candida


Voice rest, humidification, saline, viscous Xylocaine, gargles,
cool mist, lozenges, sprays, Acetaminophen, codeine, warm
compresses for lymph nodes
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 pharyngitis
prevention, replace toothbrushes
do 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
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


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



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 technique

Start 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 selfhelp 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
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, highrisk 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 HIV
 People recently exposed to active TB
 Persons with organ transplants
 Persons 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
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