Disorders of the Ear, Nose, Throat

1
Disorders of the Ear, Nose, Throat Mouth

• Chapter 10
• Medical Considerations

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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

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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

4
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

5
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

6
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

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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

8
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

9
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

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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

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EARS

• OE
• Differential DX
• OM
• TMJ
• Dental disease
• Trigeminal or glossopharyngeal neuralgia
• Parotitis
• Impetigo
• Herpes zoster
• Insect bites
• Mastoiditis
• Rupture of membrane
• Excessive cerumen buildup (wax)

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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

13
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

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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

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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

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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

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EARS

• OME symptoms
• Stuffiness, fullness, decreased hearing, pain is
  rare, may have popping. Rarely vertigo
• Usually a history of recent URI, allergies

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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

19
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

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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

21
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)

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Rhinitis

• Epidemiology/Causes
• 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

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Rhinitis

• Epidemiology/Causes
• Atrophic rhinitis affects older adults, but
  symptoms may begin in the teens
• VIRAL URIs 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,
  beta-adrenergic antagonists, some
  anti-inflammatory agents, even asa

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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

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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

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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

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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

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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

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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.

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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.

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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

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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

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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
  mitesdusting

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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

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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

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Sinusitis

• Sinusitis Patho
• Vast majority of acute sinusitis are caused by
  the same viruses found in URIs
• 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

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Sinusitis

• Sinusitis Patho continued
• Pathogens
• Streptococcus pneumoniae, haemophilus influenzae,
  Moraxella catarrhalis, streptococcus pyogenes,
  staph aureus

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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

39
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 CTs may be very helpful
• Shows air-fluid levels and more than 4mm of
  mucosal thickening
• Stains or cultures of mucus may be indicated
• Allergy testing

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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

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Sinusitis

• Sinusitis- management
• Amoxil
• Biaxin
• Vantin
• Omnicef
• Levaquin
• Augmentin
• Ceftin
• Cleocin
• Review the therapeutic handouts

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Sinusitis

• Sinusitis follow up
• Varies per provider
• 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

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Sinusitis

• Sinusitis patient education
• Should focus on the worsening of symptoms
• Avoid all contributing factors
• Smoke, allergens, antihistamine
• Increase fluids

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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

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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

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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

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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

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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

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Pharyngitis

• Subjective findings
• 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

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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

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Pharyngitis

• Objective for pharyngitis
• 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

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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

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Pharyngitis

• Management depends on the cause
• Home care with symptom management
• Voice rest, humidification, saline, viscous
  Xylocaine, gargles, cool mist, lozenges, sprays,
  Acetaminophen, codeine, warm compresses for lymph
  nodes
• Antibiotics for bacterial causes
• See therapeutics handout
• Antifungal for candida
• Diflucan, nystatin
• Be sure and assess immune status if no known
  cause is found
• Viral illnesses
• May use antivirals in some cases- IE Flu- use
  Tamiflu
• Abscess- hospital IV antibiotics and maybe surgery

54
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

55
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

56
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

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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

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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

59
Temporomandibular Joint (TMJ) Disease

• Questionnaires for screening- Example questions
• 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

60
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

61
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 self-help 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

62
TMJ

• Follow up and referral
• Refer to a specialist is best idea for real TMJ
  disease

63
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, high-risk minority, resident or
  employee in a prison or long term care facility,
  employee on a health care facility

64
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

65
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

66
Gingivitis

• Inflammation of the gingiva
• It may be characterized by edema, erythema,
  bleeding, and occasionally pain
• Gingivitis is usually reversible with appropriate
  therapy

67
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.

68
Oral Trauma

• What happened
• Tooth/jaw/lip/tongue hurt
• What hit you
• How long ago
• Where are the teeth

69
Oral Trauma

• Teeth
• Avulsed (knocked out, loose)
• Fractured
• Chipped
• Intrusion
• Jaw/face feel for crunchy sensation
• Mucosal/tongue injury

70
Tooth Anatomy
71
Avulsed Teeth
72
Fractured Teeth
73
Intrusion
74
Tongue/Mucosal Trauma
75
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

76
Oral Trauma

• Tongue
• Well approximated, nothing
• Bleeding ? direct pressure with gauze
• Gaping need repair
• Mucosal
• Well approximated, nothing
• Gaping and vermillion border need repair

77
Oral Trauma

• Dental injuries
• Dentist for most injuries
• Baby teeth may need nothing
• Tongue/Mucosa
• Most need nothing
• Doctor if gaping or severe bleeding

78
Nose Bleeds

79
Nose Bleeds

• How much blood, how long
• What has been done to stop bleeding
• Trauma
• Blunt
• Picking
• Upper respiratory infection/Allergies
• History of Bleeding

80
Nose Bleeds

• Nose
• Fracture (usually at bridge)
• Active bleeding
• Which side? Always the same?
• Throat
• Neurologic
• Vision

81
Nose Bleeds

• Pinch x 10-20 minutes
• Ice
• Nose plugs
• Dont blow nose
• Afrin if available
• No picking

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