Common Head and Neck Problems in Primary Care
Learning Objectives
1. Recognize and diagnose various ENT problems encountered in the outpatient primary care setting
2. Describe management strategies for ENT problems that primary care physicians can employ
3. Identify circumstances in which referral to an ENT specialist might be warranted
Faculty
Paul A. Kedeshian, MD Associate Clinical Professor Department of Head and Neck Surgery David Geffen School of Medicine at UCLA Los Angeles, California
Slides are current as of the time of printing and may differ from the live presentation due to copyright issues. Please reference www.pri-med.com/west for the most up-to-date version of slide sets. West Annual Conference Anaheim, California April 27-30, 2016
Eustachian Tube (ET) Dysfunction
Diagnosis of ET ENT in Primary Care dysfunction depends upon: – Subjective symptoms of aural fullness Paul A. Kedeshian, MD and/or ear “popping” (with or Associate Clinical Professor without a history of David Geffen School of Medicine at UCLA environmental Department of Head and Neck Surgery allergies) – Careful otoscopic examination of the tympanic membrane with pneumatic insufflation to rule out effusion
Eustachian Tube (ET) Eustachian Tube (ET) Dysfunction Dysfunction
Diagnosis of ET dysfunction depends Treatment upon: – Nasal steroids/saline lavage – Ruling out presence of middle ear – Antihistamines/Decongestants effusion – Insufflation of ET Tympanogram usually will reveal reduced – Oral corticosteroids middle ear pressure – GERD treatment – Middle ear ventilation tube placement (only in rare instances)
Middle Ear Effusion Middle Ear Effusion
Diagnosis of middle ear Audiogram will effusion: demonstrate a – Otalgia with hearing loss conductive hearing – Otoscopic examination reveals middle ear loss with a “flat” effusion with absent tympanogram movement – In an adult, a mass in the nasopharynx must be considered as a possible etiology Middle Ear Effusion Hemotympanum
Treatment Bloody middle ear effusion usually – Oral antibiotics secondary to trauma – Oral corticosteroids Workup should include – Middle ear pressure CT scan of temporal equalization tube bones and audiogram (PET) placement if Blood will usually persists reabsorb spontaneously over 4-12 weeks If no resolution, PET is indicated
Tympanosclerosis (aka Tympanic Membrane Myringosclerosis) Perforation
White plaque-like Occurs secondary to deposit on tympanic pressure and/or fluid membrane (TM) accumulation in the surface middle ear (can be – Usually secondary to post head trauma) frequent otitis media Conductive hearing No treatment loss necessary (unless Potential for otorrhea impairment of TM and recurrent middle mobility is noted) ear infections
Tympanic Membrane Otitis Externa Perforation
Treatment should Infection of external include: auditory canal (EAC) – Oral antibiotics – Exquisitely painful – Ear drops – Severe canal edema – Dry ear precautions (conductive hearing loss) – History of EAC trauma If perforation is small nearly always elicited and/or post-traumatic, – Multiple bacterial species may spontaneously heal (including Pseudomonas) in 3-8 weeks without are usually present surgery Otitis Externa Otitis Externa
Treatment should Higher incidence in immunocompromised include: populations – Oral antibiotics with If any facial nerve anti-Psudomonal weakness or cranial coverage neuropathies are – Otowick placement present, possibility of “malignant otitis – Otic drops with anti- externa” (skull base Pseudomonal osteomyelitis) must be coverage considered
Exostosis Nasal Polyps
Hypertrophy of the bony Inflammatory growths external auditory canal associated with chronic Secondary to chronic exposure to cold water allergies (surfing, ocean swimming) Can cause anatomic No treatment needed unless obstruction of sinus near-total EAC occlusion and/or secondary conductive ostia with secondary hearing loss acute sinusitis Need for meticulous ear Associated with asthma cleaning after water exposure and aspirin allergy (Sampter’s triad)
Nasal Polyps Nasal Polyps
Diagnosis also Treatment depends upon – Antibiotics radiographic – Oral corticosteroids appearance of sinuses (limited CT scan) – Antihistamines/Decongestants – Nasal/sinus lavage – Surgery High incidence of recurrence Nasal Septal Hematoma Nasal Septal Hematoma
Usually secondary to If hematoma is left trauma undrained, secondary Not always an compromise of the associated nasal bone vascular supply to fracture nasal dorsal cartilage can result is so-called Needle aspiration and/or incision and saddle nose deformity drainage
Mucocele Oral Leukoplakia
Accumulation of “White plaque” mucous in submucosal Presents most space commonly on lateral Most common on labial aspect of tongue and and buccal surfaces buccal mucosa Usually secondary to dental trauma Associated with trauma or chronic Occasional superinfection in which inflammation/irritation case surgical excision Low (less than 5%) may be indicated premalignant potential
Oral Leukoplakia Geographic Tongue
Workup should include Asymmetric thorough examination hypertrophy of papillae of mucosa of upper of tongue aerodigestive tract Unknown etiology (especially in tobacco- Rarely symptomatic users) Treatment with Biopsy of areas of antifungal or antibiotic erythroplakia more therapy not indicated important than representative sampling May be exacerbated by GERD Torus Palatini and Torus Tonsillitis Mandibularis
Bony overgrowths Infection of palatine present in palate and tonsillar tissue inner cortex of mandible Exudate in acute Unknown etiology cases Unless overlying Chronic presence of mucosa becomes cryptic enlargement, inflamed, no treatment hypertrophy and indicated for these tonsoliths (tonsil benign lesions stones)
Tonsillitis Tonsillar Lymphoma
Treatment with Lymphoma (usually B- antibiotics for acute cell type) that develops infections within the lymphoid Oral corticosteroids if tissue of the palatine severe hypertrophy tonsils (part of with odynophagia Waldeyer’s ring) Surgical excision indicated if frequent Important to keep high infections, secondary index of suspicion if airway obstruction, significant asymmetry, halitosis, or noticeable cervical adenopathy, asymmetry constitutional symptoms
Peritonsillar Abscess Parotitis
Acute, suppurative infection Inflammation of the parotid with the submucosal space ductal system with around tonsils associated swelling, pain, Will always be uvular erythema, fevers deviation, bulging of soft Increased incidence in palate, trismus, and muffled- diabetics but can occur sounding voice secondary to episode of Treatment involves either dehydration needle aspiration and/or Rarely can occur secondary incision and drainage with to parotid stone (sialolith) oral antibiotics and Treatment includes corticosteroids antibiotics, hydration, oral Can re-accumulate following sialogogues, heat and needle aspiration massage directly over the involved gland Submandibular Parotid Neoplasm Sialoadenitis/Sialolithiasis
Acute inflammation of Firm mass within the submandibular salivary substance of parotid salivary gland gland Can be secondary to Approximately 80% benign dehydration (as in parotitis) Presence of ipsilateral facial but more commonly due to nerve weakness, pain, or sialolith (stone) adenopathy increase Physical exam can often likelihood of malignancy palpate stone along course of Diagnostic workup should submandibular duct (within include MRI of parotid the floor of mouth) gland followed by fine needle Treatment is same as for aspiration biopsy parotitis except that frequent Treatment involves surgical infections with an associated excision of gland sialolith mandate surgical excision of gland
Second Branchial Cleft Cyst Second Branchial Cleft Cyst
. painless, fluctuant mass . May be a connection in the lateral aspect of with ipsilateral tonsil the neck that is situated deep to the . Surgical excision of the sternomastoid muscle cyst may therefore . most common branchial mandate concomitant cleft anomaly (95%) tonsillectomy . often becomes apparent after recent URI
Thyroglossal Duct Cyst Thyroglossal Duct Cyst
ost common Usually present at or m just inferior to the congenital neck hyoid bone mass (70%) – may be associated with ectopic thyroid elevates on tissue (1-2%) protrusion of tongue therefore imaging to or swallowing confirm the presence of normal thyroid may develop tissue is draining sinus on recommended skin surface Treatment is surgical excision (Sistrunk Procedure) Bell’s Palsy Bell’s Palsy
Paralysis of all Likely secondary to branches (upper and infection of facial lower) of facial nerve nerve with herpes Sudden onset simplex virus Viral prodrome (usually) Treatment includes oral corticosteroids Diagnosis of exclusion and antiviral Must rule out presence of co-existing medication with mastoiditis, otitis reassessment after externa, parotid tumor 7-10 days