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ENT - Coggle Diagram

- - - - viral>bacterial
      - fever to 104, tonsillar exudate
    - - viral 90%
      - temp >101, pharyngeal erythema, soft palate petechiae, anterior cervical LAD, sore throat, cough, rhinorrhea, hoarseness, sneezing, conjunctivitis, N/V/D, myalgias, pharyngeal hyperemia, pharyngeal exudate, pharyngeal/gingival vesicles/ulcers
      - Adenoviral
        
        common cause of exudative pharyngitis in children
        
        patchy exudate, scratchy dry throat, dysphagia, fever, chills, malaise, conjunctivitis, otitis media
        
        rapid onset
        
        management: (self-limiting) topical pain relief, nasal spray, warm saltwater gargles, increase fluid intake, analgesics
      - Infectious Mononucleosis (EBV)
        
        adolescents, higher socioeconomic groups, industrialized socities
        
        low contagion --> intimate contact
        
        avoid ampicillin
        
        shaggy white, purple tonsillar exudate extending into nasopharynx, marked posterior cervical LAD, nausea, anorexia, hepatosplenomegaly, fever (low-grade), malaise
      - GABHS
        
        most common in 5-15yo
        
        peak prevalence during winter and early spring
        
        rapid onset of pain, fever, malaise, fatigue, swollen mucosa, erythematous mucosa, uvular edema, tonsillar exudate, studded follicles, tender cervical LAD
        
        management: penicillin
      - Scarlet Fever
        
        sandpaper rash, strawberry tongue
        
        management: penicillin
      - Diphtheria
        
        uncommon
        
        consider in European, Russian and immunocompromised pts with pharyngitis
        
        grey pseudomembrane covering tonsils and palate
        
        management: antitoxin and penicillin
    - - most commonly encountered head and neck abscess
      - highest rates in teens and young adults
      - develops from spread of bacterial tonsillitis to peritonsillar space
      - increasing pharyngeal pain, unilateral pain radiating to ear, dysphagia, difficulty handling secretions and trismus, unilateral erythema and swelling to anterior tonsillar pillar and soft palate, deviation of uvula to opposite side, cervical LAD, tonsillar exudates and fluctuance
      - management: needle aspiration or incision and drainage of peritonsillar space, parenteral antibiotics, rehydration, analgesia, good oral hygiene, tonsillectomy
  - - - usually viral (adenovirus and influenza) but also Moraxella catarrhalis and H. influenza
    - - vocal abuse, trauma to throat (polyps, nodules, tumors), infectious or toxic exposure
  - - - common in young adults
      - reddened and swollen gingival margins w/ blunted interdental papillae
    - - adolescents and young adults
      - acute onset, associated with stress, fever, malaise, LAD, ulcerated interdental papillae
    - - deeper tissues holding teeth in place become inflamed destroying attachment of teeth
    - - Dilantin, pregnancy, leukemia, puberty
      - hyperplasia enlarges gums
  - - - sharp intermittent pain of short duration provoked by hot, cold, sweets or biting; remove stimulus --> pain is gone
      - management: remove loose filling material, debris, decay, dry with cotton pellets, pack with zinc oxide-eugenol, ibuprofen, refer to dentist
    - - throbbing, continuous pain that is usually spontaneous
      - management: same as for reversible and requires prompt dental care
  - - - does not involve deeper supporting periodontal structures
      - marginal gingiva
      - entrapped food and plaque debris within a gingival pocket with subsequent bacterial overgrowth
      - localized swelling, erythema, tenderness, fluctuance, spontaneous purulent drainage, express pus with gentle digital pressure, afebrile
    - - associated with carious or nonviable tooth
      - acute pain, swelling, mild tooth elevation, exquisite sensitivity to percussion, sensitivity w/ chewing
      - erodes cortical bone if allowed to progress
      - management: Panorex, NSAIDs, narcotic analgesics, PO antibiotics, dental follow-up, I&D, irrigation, prompt referral for parulis
    - - food and debris trapped between overlying gingival flap and crown of tooth with gingival flap becomes irritated and inflamed
      - foul taste, difficulty closing jaw, fever, swelling of cheek and angle of jaw, localized LAD
      - potential for spread to deep cervical spaces
      - management: superficial I&D, irrigation, good analgesia, PO antibiotics, refer to oral maxillofacial surgeon
    - - between buccinator muscle and overlying superficial fascia and skin
      - maxillary 2nd and 3rd molars usual source
      - infection erodes through alveolar bone into buccal space
      - unilateral facial swelling with erythema and tenderness to the cheek; naso-labial folds spared
      - management: penicillin, NSAIDs, narcotic analgesics, dental or oral surgical consult for I&D, extraction, endodontics
    - - between the anterior surface of the maxilla and levator labii superioris
      - infection erodes through alveolar bone into canine space
      - unilateral facial pain, erythema, swelling lateral to nose, obliteration of naso-labial folds, severe upper lip swelling may cause drooling, severe lower eyelid swelling may cause closure
      - management: x-rays, CT, parenteral antibiotics
    - - will not be able to feel sharp angle of mandible
      - bilateral --> Ludwig's angina
        
        very serious
        
        painful induration, febrile, trismus, dysphonia, odynophagia, dysphagia and drooling, potential airway compromise
        
        strep, staph, bacteroides species
        
        management: call oral-maxillofacial surgery or ENT, IV penicillin, ICU
  - - - common type of nontraumatic ulcers
      - unknown etiology
      - classification:
        
        minor
        
        prodrome tingling, burning, freely moveable mucosa, white papule ulcerates w/ raised yellow border surrounded by erythema, painful
        
        resolves 7-10 days
        
        major
        
        moveable mucosa, soft palate, tongue, tonsils, more pain, 1-3 cm, 1-10 ulcers present
        
        herpetiform
        
        10-100 ulcers present, 1-3 cm, coalesce to form larger ulcers, scar
      - management: topical anesthetics, glucocorticoids, oral retinoids, colchicine, yogurt, buttermilk, lactobacillus, capsules
    - - presents acutely as primary or recurrence
      - painful eruptions on oral mucosa, tongue, palate, vermillion borders, gingiva
      - vesicular lesion ruptures to form tender ulcer with yellow crust and erythematous margin; severe pain can cause odynophagia and drooling, no scarring
      - lasts 7-10 days
      - RF: oral trauma, sunburn, stress, febrile illness
      - recurrent may have aura of tingling, itching, burning prior to vesicle formation
      - management: rehydrate, pain control, topical analgesics, acyclovir po and topical valacyclovir, treat secondary infections
    - - painful hemorrhagic oral ulcers in association with anorectal and conjunctival lesions
    - - begins in mouth in 50% of cases
      - blistering disease, positive Nikolsky's sign, mucous membrane bullae, erosions, ulcerations
    - - autoimmune disease
      - genital and oral ulceration; aphthous ulcers 2-20mm, shallow or deep; very painful, persists for weeks, fibrosis
      - management; corticosteroids
- - - - often preceded by an acute suppurative OM
      - may be asymptomatic, mild otalgia, feeling of fullness, popping, crackling sounds when chewing, hearing loss, dull TM, decreased TM mobility, TM retracted
      - management: decongestants, Valsalva for insufflation, pressure equalization tubes if SOM >3 mo.
    - - acute exudative disease of middle ear involving bacteria
      - clinical stages: hyperemia, exudation, suppuration, resolution, coalescence
      - otalgia, otorrhea, aural pressure, cough, nasal discharge, decreased hearing, fever, vertigo, TM erythema, decreased TM mobility, full or bulging TM, discharge if TM perforated, obscured bony landmarks, fever
      - management: amoxicillin, augmentin, myringotomy for complications
      - complication: mastoiditis
        
        untreated ASOM
        
        pain, fever, drainage, discharge changes from thick to thin and very foul smelling, mastoid tenderness, erythema
        
        management: surgery
    - - associated w/ TM perforation
      - types of perforations:
        
        central
        
        marginal
        
        attic (pars flaccida area; think cholesteatoma)
      - infections with mixed anaerobes, pseudomonas, proteus and staph aureus, PURULENT DISCHARGE
      - management: remove infected debris (done by ENT), avoid water exposure, topic otic antibiotics, surgical reconstruction of TM
  - - - disruption of mechanical conduction of sound from the external environment
      - external ear
        
        otitis externa
        
        RF: excess moisture, trauma, irritants, self-cleaning, primary skin conditions, coexisting disease (T1DM, T2DM, leukopenia, malnutrition)
        
        pruritis, tenderness/pain, foul-smelling otic discharge, crusting around canal opening, LAD, CN VII & IX-XII involvement
        
        management: mild (acetic agent + topical corticosteroid), moderate (add broad spectrum antibiotic), sever w/ cellulitis or adenitis (add oral antibiotic), fungal (acetic agent + topical corticosteroid + antifungal), herpes (topical & systemic acyclovir)
        
        external canal bony exostosis
        
        prolonged exposure to cold water (swimmers, scuba divers, surfers)
        
        management: large and symptomatic exostoses surgically removed
        
        tumors
        
        congenital atresias of canal
        
        management: surgery
        
        cerumen occlusion
        
        management: suction and irrigation if soft; Colace drops or cerumenex if hardened
      - tympanic membrane
        
        middle ear infection (see otitis media)
        
        TM perforation
        
        scar tissue and calcium deposition within TM
        
        tympanosclerosis
        
        focal thickening of TM
        
        barotrauma
        
        Eustachian tube dysfunction creating negative middle ear pressure
      - middle ear
        
        otosclerosis
        
        bony fusion of stapes
        
        ossicular discontinuity, fracture or subluxation
        
        cholesteatoma
        
        collection of squamous epithelium collecting in TM causing destruction of ossicles and erosion of inner ear structures
        
        complications: labyrinthitis, meningitis, brain abscess
    - - disorders within cochlea and auditory nerve
      - Meniere's
        
        endolymphatic compartment of inner ear is distended
        
        fluctuating low frequency hearing loss and tinnitus
        
        electrocochleography
      - loss of hair cells from the organ of Corti causing deterioration of the cochlea
      - NOT CORRECTABLE
      - noise trauma
      - PREVENTION IS KEY
      - Presbycusis
        
        progressive, symmetric hearing loss of aging
        
        gradual degeneration of cochlear structures; loss more severe in higher frequency
      - Ototoxicity
        
        primarily reversible
        
        antimicrobials (erythromycin, quinine, chloroquine)
        
        carbon monoxide diuretics (furosemide, mannitol, ethacrynic acid)
        
        NSAIDs and salicylates
        
        primarily irreversible
        
        antimicrobials (aminoglycosides, vancomycin)
        
        antineoplastics (cisplatin, vincristine, bleomycin)
        
        bromates heavy metals (arsenic, mercury, lead)
        
        hydrocarbons (toluene, xylene, styrene)
    - - disorder of retrocochlear region (8th CN and central pathways)
      - acoustic neuroma
      - multiple sclerosis
      - cerebrovascular disease
- - - - Dennie-Morgan lines, allergic shiners, allergic salute, transverse nasal crease, cobblestoning
      - RF: maternal smoking, indoor allergens
      - sneezing, rhinorrhea, nasal obstruction accompanied by itching eyes and nose, postnasal drip, cough
      - complications: allergic conjunctivitis, asthma, atopic dermatitis, acute otitis media, sinusitis
      - management: avoid triggers/allergens, corticosteroids, antihistamines, decongestants, immunotherapy
    - - Vasomotor rhinitis
        
        chronic presence of symptoms of rhinitis with no specific etiology (diagnosis of exclusion)
        
        drug induced, temperature/humidity, emotional, hormonal
        
        sneezing, rhinorrhea, nasal congestion, postnasal drip, boggy, edematous and erythematous turbinates
        
        management: intranasal glucocorticoids, intranasal antihistamine
      - Rhinitis medicamentosa
        
        regular use of decongestant nasal spray (Afrin) leads to rebound vasodilation/nasal congestion
        
        swollen, red nasal mucous membranes
        
        management: withdrawal of medication (limit to 3 days)
      - Viral rhinitis
        
        RF: chronic underlying disease, smoking
        
        aka common cold
        
        headache, malaise, body aches, cough, nasal congestion, sneezing
        
        rhinoviruses, parainfluenza, coronavirus, RSV, adenoviruses
        
        complications: asthma exacerbation, acute otitis media, rhinosinusitis-bacterial superinfection, bronchitis, bronchiolitis, pneumonia
        
        management: (supportive) analgesics, antipyretics, decongestants, antihistamines, antitussives
  - - - symptomatic inflammation of nasal cavity and paranasal sinuses
      - RF: older age, smoking, air travel, changes in barometric pressure, asthma/allergies, dental disease, immunodeficiency
      - purulent nasal drainage, nasal obstruction, facial pressure/pain, anosmia, fever, cough, headache, Eustachian tube dysfunction, ear pressure/fullness
      - Viral
        
        rhinovirus, influenza, parainfluenza
        
        resolves 7-10 days
        
        management: (symptomatic) analgesics, saline irrigation, IN glucocorticoids
      - Bacterial
        
        RF: viral URI or rhinosinusitis, obstruction of nose, impaired immune function, cigarette smoke
        
        strep. pneumo, H. influenza, Moraxella catarrhalis
        
        biphasic pattern of symptoms
        
        present 10 days-4 weeks
        
        management: analgesics, IN steroids, nasal irrigation, watchful waiting, antibiotics
        
        complications: preseptal cellulitis, orbital cellulitis, intracranial abscess, meningitis
      - outcomes: resolution, complication, chronic
    - - RF: immunodeficiency
      - purulent nasal drainage, nasal obstruction, facial pressure or pain, reduced smell, fatigue, myalgia
      - persists 12 weeks or longer despite medical management
      - endoscopy or CT required for diagnosis
      - management: antimicrobial (3-4 weeks), anti-inflammatory, nasal irrigation, decongestants, surgery (failure of medical treatment after 4-6 weeks, obstruction present, erosion/extension beyond sinus cavities)