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Home , Allergic conjunctivitis, Chalazion

Physical Assessment: An Let’s Talk Interactive Workshop for College Health Nurses About Some

Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Common Family Nurse Practitioner Owner – Wright & Associates Family Healthcare Problems

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History (continued) Complaint: History • Present status of visual function • Chief complaint – Corrective , glasses and use – Last eye examination • HPI, including the following associated • Medications symptoms: –Systemic – Pain, itching, discharge, tearing, blurring, visual –Ocular acuity changes, foreign body sensation, • , halo vision •Past history –Ocular disease Wright, 2010 –Systemic disease Wright, 2010

Physical Examination History (continued) •Eyebrows • Surgeries (if pertinent) – Note quantity and distribution of hair – Note any scaling or lesions • Family History –Ocular diseases **Eyebrows are symmetrical and evenly distributed; No – StSystem ic diseases dry ne ss, sca ling, or thinning of the lat eral 1/3.

**Thinning of the lateral 1/3 of the eyebrow- hypothyroidism **Scaling-seborrheic dermatitis

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Wright, 2010 1 Abnormalities of Eyelids • Lids should close in unison to cover the entire eye – Upper lid margin rests on the superior border of the • Widening of the palpebral fissure – Lower lid margin rests on the inferior border of the iris – Hyperthyroidism (Exopthalmus) – Palpebral fissure: Space between the upper and lower lid • Decrease in palpebral fissure size – Dehydration (Endopthalmus) ** Lids close in unison to cover entire eye. The upper • lid margin is at the superior border of the iris and – Cranial Nerve III Dysfunction the lower lid is at the inferior border of the iris. – Muscular Dystrophy

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Exopthalamus Ptosis

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Abnormalities of the Lid Margins Lid Margins • Lesions: Hordeolum, • Lid Margins • : Allergic , Crying, Infection – Skin tone • : Inversion of Lid Margin – Inversion or Eversion – Spasm or scarring of the lid – LiLesions – often invert and irritate the and ** The lid margins are appropriately colored; No • : Eversion of Lid Margin lesions, edema, inversion or eversion. –Aging – Exposes the conjunctiva to bacteria – Eye does not drain properly-tearing

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Wright, 2010 2 Entropion Ectropion

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Eyelashes Abnormalities of Eyelashes •Note • Thinning – Color – Make-up – Distribution – Trichotillomania – Direction in which they point – Alopecia –Discharge •Discharge – Conjunctivitis **Eyelashes are ____ in color, evenly – distributed, outward pointing; No discharge – or thinning.

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Blepharitis Dacryocystitis

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Wright, 2010 3 Conjunctiva Normal Conjunctiva •Conjunctiva – Clear covering over the visible parts of the eye (except the cornea) – Protective covering for the eye • Bulbar – Clear covering and the blood vessels that cover the • Palpebral Conjunctiva – Thin covering above and below the eyeball – Forms deep recesses that fold forward to join the

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Conjunctiva Abnormalities of the Conjunctiva • Bulbar and Palpebral Conjunctiva • – Conjunctivitis, Irritation from , Iritis, – Color • Pallor – Injection –Anemia – Lesions • Lesions – Foreign bodies – : An opaque, triangul ar sh aped conjunctival lesion usuall y seen nasally and able to extend over the cornea. May interfere with vision. **Conjunctiva is clear and appropriately colored; No – : Yellow nodules usually seen at 3 and 9 o’clock on the injection, pallor, lesions, or foreign bodies. conjunctiva. No visual changes.

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Pinguecula Pterygium

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Wright, 2010 4 Sclera Sclera •Sclera – White portion of the eye – May look buff-colored or pale yellow in the periphery •Note – Color –Texture – Lesions

**Sclera are white, smooth; No lesions or icterus.

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Abnormalities of Excessive Vomitting Causing Subconjunctival Hemorrhages Sclera • Yellow sclera – Physiologic or pathologic jaundice – Resolving subconjunctival hemorrhage • RdRed appearing sclera – Subconjunctival Hemorrhages

Note: It is actually the bulbar conjunctiva not the sclera that becomes jaundiced or red. Wright, 2010 Wright, 2010

•Cornea Cornea Cornea – Portion of the anterior aspect of the eye which when viewed from the side, protrudes forward – Transparent covering that protects the eye – Avascular covering over the iris and • Note (Use a penlight and view from the side) – Appearance –Shiny – Lesions – Corneal Light Reflex

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Wright, 2010 5 Cornea Cornea

**Cornea are smooth, transparent, and shiny; No lesions or opacities. Corneal light reflex is symmetric bilaterally.

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Corneal Abrasion Abnormalities of the Cornea

•Arc – Corneal arcus or – Thin gray-white arc or circle that lies close to the edge of the cornea or edge of the iris – Causes: aging, african americans, hyperlipidemia •Abrasion – Mild injury to the cornea – Causes include foreign body, trauma, contact lens – Symptoms: pain, photophobia, discharge

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Herpes Simplex Abnormalities of the Cornea

• Corneal Ulceration •Opacities – – Scarring • Asymmetric Corneal Light Reflex – ( or )

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Wright, 2010 6 Asymmetric Corneal Light Reflex

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Exodeviation •Iris Iris – Colored portion of the eye – Contains muscle that surround the pupil and control pupillary size –These muscles are innervated by CN III •Note – Appearance –Shape

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Iris •Note Iris – Color –Detail –Anterior Chamber

** Iris is round, symmetric, ____ in color, and with clear detail. The anterior chamber is without blood or pus.

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Wright, 2010 7 Abnormalities of the Iris Abnormalities of the Iris • : Blood in the anterior chamber • Iris Color Is Not Identical –Trauma – Heterochromia Iridis • Hypopion: Pus in the anterior chamber – If this is seen, suspect Horner’s syndrome – Infection –Horner’s syyypndrome: Sympathetic nerve • Anterior (formerly, iritis): disruption, most often in the neck. Iris is lighter – Moderate pain, decreased vision, pupil is small and will in color, ptosis of eyelid, loss of sweating on become irregular over time forehead, and pupil is smaller (all on the – Becomes irregular because the swelling distorts the pupil affected side) – Associated with many systemic disorders • , SLE, Ankylosing spondylitis •Brushfield Spots – Down’s Syndrome Wright, 2010 Wright, 2010

Pupils •Pupils •Note – Normally round – Symmetry – Range in size from 3-7 mm –Newborn – Allow images and light to enter •Resppgonse to direct light – They change in size to adjust for light and to –Older child focus on an image • Response to direct and consensual light •Note –Size ** Pupils are ____mm, round, regular and equal bilaterally and respond briskly to direct and –Shape consensual light. – Regularity Wright, 2010 Wright, 2010

Accommodation Abnormalities of the Pupils • 3 things occur when a person changes focus from a distant to a near object • Aniscoria: Inequality of the pupils – The pupils constrict – Normal Variation: Respond normally to light – The converge – Increase in Intracranial Pressure – The lenses become convex (can not view this) – AtAcute AlAngle Closure Glaucoma • Procedure • Severe pain – Have person focus on an object on a distant wall. Then place an object 10 cm in front of the face. Have the • Decreased vision individual switch focus from the distant object to the • Pupil is dilated near object. Have them continue to follow the object as • Cornea is cloudy it is brought in toward the nose. • Increase in Wright, 2010 Wright, 2010

Wright, 2010 8 Abnormalities of the Pupils Visual Acuity • – Equally constricted pupils • Visual Acuity – Drugs, morphine, bright light – Test of central vision • – Controlled by cranial nerve II (Optic) – Use a Snellen Chart (wall or hand-held) – Equally dilated pupils • Stand 20 feet from wall chart – Anticholinergic agents, mushrooms, increased • Place hand held Snellen 13 inches from face intracranial pressure • Inability to accommodate – Cranial nerve defect (III, IV, VI)

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Visual Acuity Visual Acuity •Child •Infants – Vision: 20/200 at 1 year old, 20/40 at 3, 20/30 at 4-5 – Central vision is present, may just see light years of age – Optimum distance for visualization: 8-12 inches – No test that accurately measures acuity in child < 3 – Assess by checking direct and consensual response to – Can test using a hand-held Snellen chart or a wall light, blinking, extending the head in response to a chart bright light (Optical blink reflex) and blinking in – Letters and Lazy E are the best tests response to a quick movement of an object toward the eye • Older Child and Adult • 2-4 weeks, should be able to fixate on objects – Adult visual acuity is reached at approximately 6 years • 5-6 weeks, coordinated eye movements of age

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Visual Acuity Abnormalities of Visual Acuity • Absence of a direct or consensual response to light, absence of blinking, negative optical blink reflex, or failure Visua l Acu ity is ____ OD, ____ OS, an d to blink when an object is moved quickly ____OU (corrected or uncorrected) toward the eye: Blindness • Asymmetric Visual Acuity:

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Wright, 2010 9 Non-vision Threatening Causes of Red Eye

• Differential falls into the following categories • Subconjunctival hemorrhage – Infections with or without trauma (conjunctivitis) – Inflammation with or without trauma (uveitis) • Hordeolum – Vascular ((jsubconjunctival hemorrha g)ge) • Chalazion –Systemic diseases • Blepharitis – Allergies –Chemical • Conjunctivitis – Acute glaucoma • Dry eyes • Corneal abrasions

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Hordeolum Hordeolum • Etiology • Physical examination – Obstruction of the glands of Zeiss – Erythematous, tender nodule on the margin of – Staphylococcal aureus is the most common the eyelid causative organism – Surrounding edema • History •Treatment – Swollen, red, painful lesion on the lid margin – Warm compresses-20 minutes qid – Itchiness of the eyelid – Antimicrobial ointment or drops – Good eye hygiene and handwashing

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Hordeola Hordeola

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Wright, 2010 10 Internal Hordeola Chalazion • Etiology – Obstructed meibomian glands – Chronic inflammatory lesion that grows inward as it enlarges – May become infected • History – Lesion on the outside of the eye – May become slightly inflamed – Usually non-tender

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Chalazion Chalazion • Physical examination – May or may not visualize a nodule on the outside of the eyelid – Visible on the inside of the lid – May become erythematous, tender and edematous •Treatment –None – Antimicrobial agent if infected – Surgical management

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Chalazion Chalazion

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Wright, 2010 11 Case Study 1: TM Chalazion Removal • TM is a 19 y.o.w.m student with a 2 day history of yellow discharge & redness in both eyes. – Began approximately 2 weeks after developing a cold – Associated with a mild blurring of the vision and itching – Denies pain, photophobia, otheotherr visual changes, headache – Has done nothing to treat – Meds: none; Allergies: NKDA, NKEA – PMH: Noncontributory – PE: Visual acuity 20/20 OD, OS, OU; 4 mm preauricular node

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• EtiologyViral Conjunctivitis Viral Conjunctivitis – Adenovirus is the most common cause •Signs – 40 strains available – Normal visual acuity, PERRLA, EOMI, Fund nl – Recent studies have shown that they can remain viable – Mucoid-slightly watery discharge on plastic and metal surfaces for up to 1 month – Mild, diffuse in jec tion •Symptoms – Preauricular lymphadenopathy – Watery discharge, foreign body sensation, redness – URI symptoms are common including sore throat and •Treatment fever – Symptomatic only – Often bilateral – Cool compresses – Strict eye hygiene Wright, 2010 Wright, 2010

Viral Conjunctivitis Viral Conjunctivitis

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Wright, 2010 12 Viral Conjunctivitis Bacterial Conjunctivitis • Etiology – Staphylococcal – Streptococcus pneumoniae/pyogenes – Haemophilus influenzae – Neisseria • Symptoms – Redness, swelling, purulent discharge, itching – No symptoms until eye complaints began

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•SignsBacterial Conjunctivitis Bacterial Conjunctivitis – Normal visual acuity, PERRLA, EOMI, Fund nl – Diffuse injection –No ciliaryyj injection – Unilateral at onset •Treatment – Topical antimicrobials x 5-7 days – Warm compresses qid x 10-20 minutes – Strict eye hygiene given contagion

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Vision Threatening Red Eye Bacterial Conjunctivitis Disorders • Corneal Infections or Ulcerations •Hyphema •Hypopion • Iritis/Uveitis • Acute Angle Closure Glaucoma • • Chemical injury (particularly-alkali)

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Wright, 2010 13 Case Study 3: TY TY is a 6 yowm who presents with his mom Hyphema for an evaluation of (R) pink eye. Began • Definition this am. Denies discharge, itching, recent – Bleeding into the anterior chamber of the iris URI. Mom denies trauma but does report – Causes include trauma or surgery strange occurrence yesterday. He failed •Symptom s to respond to her calling. When he finally – Pain, red eye, blood in anterior chamber came, he reported being asleep outside. – Blurred or Absent vision PE: Absent red reflex-OD; Visual acuity •Signs 20/100 (OD); 20/30 (OS); Pupil-slightly – Absence of the red reflex constricted (OD). Unable to view the – Blood in the anterior chamber fundus (OD) Wright, 2010 – Increased IOP Wright, 2010

Hyphema Hyphema •Signs – Decreased visual acuity – Injected conjunctiva (mild-severe)

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Complication of Hyphema Hyphema •Treatment – Always assume that the is ruptured as 25% have other serious ocular injuries – Shield the eyyye and refer immediately – Can lead to devastating visual complications including blood staining of the cornea, glaucoma, atrophy of the

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Wright, 2010 14 Reasons to Refer Immediately Blowout Fracture • Sudden unilateral loss of vision • Lacerations that involve the lid margin or tear duct apparatus • Ocular pain, photophobia, ciliary injection • Corneal ulceration • Hyphema or Hypopion • Pupillary distortion • Central or deep foreign body

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Blowout-Fracture Aerosol Can Explosion

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John...

• John is a 19 year old male who is new to the practice. Presents with a 3-day history of right Otitis Media ear pain, nasal discharge and fever of 102. Increa se d irr ita bility, decrea se d sleep an d appetite. Last urine-2 hours ago. – PE: Ears: Canals pale white. Right TM erythem, edem and without movement. Left TM-slightly retracted. Nasal mucosa pink. Tonsils pink: no exudate. Nodes: nonpalpable, nontender; Lungs: clear bilaterally

Wright, 2010 15 Ear Canal Otitis Media • Anatomy Overview : • Symptoms – The external canal is an S-shaped pathway leading to the – Fever middle ear –Pain – It is approximately 2. 5 cm long, covered with a thin layer of – Disc harge from ear very sensitive skin. – Tugging or batting at the ear – The canal is protected and lubricated with cerumen, – Irritability, crying, lethargy secreted by the sebaceous glands in the distal 1/3 of the – Decreased appetite canal. – Decreased sleep – Recent URI

Otitis Media Ears •Auricles • Signs –Position – Red, bulging tympanic membrane –Size – Retracted with pus, fluid or air bubbles – Lesions – **Auricles are level with the outer canthus of the eye – No movement with insufflation and symmetric. They are proportionate in size to the – Inability to see normal landmarks body without lesions or deformities – Occasionally-hole in the tympanic membrane

Abnormalities of the Auricle EARS • Small or Low-Set Ears: Congenital Defects •Ear Canal – Before age 6, pull auricle down, back, and out – Accutane exposure in utero – Color • Large Protruding Ears: Fragile X Syndrome – Lesions –Discharge • Protruding Ears: Mastoiditis –Foreign body – **Ear canals are pale white with a _____amount of hair present. There are no lesions, discharge or foreign bodies

Wright, 2010 16 EARS Abnormalities of the Ear Canal • Erythema and discharge: Otitis • Tympanic Membrane – Color externa – Appearance •Foreiggyn body –Bony Landmarks • Cerumen – Cone of Light – Insufflation •Cholesteatoma – **Tympanic membrane is pearly gray, moveable, and intact AU. The bony landmarks are clearly visible. The cone of light is at 5 o’clock on the right and 7 o’clock on the left. There is no erythema, perforations, or retractions.

Variations of Tympanic Abnormalities of the Tympanic Membrane Normal TM Membrane • Erythematous, Bulging TM: Otitis Media

Acute OM • Retracted TM: Eustachian Tube Dysfunction, Serous OM Otitis Me dia • BllBullae on TM: BllBullous Myringitis with Effusion • Perforation: Trauma, OM, Flying

AOM Acute OM • S. pneumoniae • H. influenzae –Gram-positive – Gram-negative bacilli • =>40% amoxicillin- diplococci resistant via beta- • => 25% PCN- lactamase production resistant via altered • M. Catarrhalis protein- binding sites – 90-95% beta-lactamase producing • Very unlikely to resolve on own – Likely to resolve on own • Usually the sickest

Wright, 2010 17 Pathogens Responsible Bullous Myringitis for Otitis Media •Mycoplasma • S. Pneumoniae •Intensely painful – Children: 25-36%; Adults: 20-35% •Treatment is with a macrolide • H. Influenzae – Children: 15-23%; Adults 6-26% • M. Catarrhalis – Children: 15-20%; Adults: 2% •Viral

Duration of Treatment for Treatment for Otitis AOM Media • Regimens evaluated – Numerous treatment options were evaluated • Plan • Treatment success evaluated at 12–14 days – Therapeutic • Results • Decongestants/: not shown to – Similar response in all patients between short- be effective course (eg, 5 days) and standard-course (eg, 10 • Auralgam: analgesic for the ear days) therapy • Warm compresses – Patients <2 years old and those in a daycare setting may achieve better results with 10-day •NSAIDs/Tylenol therapy

Otitis Media •Plan – Educational Acute Bacterial Rhinosinusitis • No smoke exposure • Finish all medication Diagnosis, Guidelines, and • Consider ventilation tubes Treatment

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Wright, 2010 18 Incidence of Acute Bacterial Maria Rhinosinusitis (ABRS) • 21 year old female with an 11 day history of nasal discharge; Initially clear. Within last 3 days has • 31 to 35 million cases annually become green, thick. Significant amount of post- • Highest in Midwest and South nasal drip and pain over both cheeks. Temp: 99.6- 101. Denies ear pain, st, cough, sob. Had 1 sinus •Higgpghest in Fall, Winter, and Spring infection 3 years ago. • Incidence increased by almost 20% in past 11 years – PMH: Noncontributory (Nonsmoker, No allergies) – 15 million office visits per year – PE: Nasal mucosa erythem, green discharge. Maxillary- 2+ tender.

Need Reference:

Costs of Acute Bacterial New Definition of Rhinosinusitis (ABRS) Rhinosinusitis Take into consideration: • Fifth most common diagnosis for which are prescribed – Accounted for 7% to 12% of all ppprescriptions from 1985 to 1992 – Over 70 million restricted days of activity • 250,000 surgeries per year Mucosa of Fluids that lie both nose and within cavities of sinuses nose and sinuses

Sinus and Health Partnership. Otolaryngol Head Neck Surg 2000;123(1 part 2):S12):S1––S32.S32.

Acute Bacterial Pathophysiology of ABRS Rhinosinusitis • Normally, bacteria is removed from the sinuses by the mucous and the action of the cilia • Same pathogens as Acute Otitis Media • Ostia of a sinus becomes blocked – S. pneumoniae (31%) – H. Influenzae (21%) • Bacteria is normally present in the sinus – M. Catarrhalis (2%) • Once the sinus opening is blocked, the bacteria is – Group A strep (2%) trapped and begins to grow in number – Anaerobes (6%) • Mucosa of the sinuses become inflamed and swollen; The body responds by sending to the area • Result: Increased production of thick, green discharge; Pain in affected sinus(es)

Wright, 2010 19 CT Findings in Maxillary Diagnosis of ABRS Sinusitis A diagnosis of ABRS may be made in adults or children with symptoms of a viral upper respiratory infection that have not improved after 10 days or have worsened after 5 to 7 days Symptoms: • Headache • Fever • Facial pain/pressure • Halitosis • Nasal drainage •Cough • Fatigue • Nasal congestion • Maxillary dental pain • Postnasal drip • Ear fullness/pressure • Hyposmia/anosmia

Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg 2000;123(1 part 2):S12):S1––S32.S32.

NOSE AND SINUSES •Skeleton – Structure –Midline

Nose and Sinuses – **Skeleton is straight and midline without deformities or deviations.

Nose and Sinuses NOSE AND SINUSES •External •Nares –Vestibule –Patency –Ala Nasi –Foreign Body – BidBridge –Tip – **Nares are patent. No foreign bodies – Columnella – **Discharge from one nare: Foreign body

Wright, 2010 20 Anatomy and Physiology NOSE AND SINUSES • Internal •Septum – Air enters the nasal cavity through the nares bilaterally –Position – Air then passes into a widened area known as the –Perforation vestibule and then on to the nasopharynx – **Septum is midline and intact without – Septum deviations, ulcerations, or perforations. • Medial wall of the nasal cavity – **Deviation may be present in some children, • Supported by bone and cartilage particularly after a nasal fracture or birth • Covered with mucous membranes process, and may interfere with nasal • Well supplied with blood breathing.

NOSE AND SINUSES Anatomy and Physiology •Mucosa •Turbinates – Color – 3 sets: Inferior, middle and superior –Discharge –Edema – Located laterally –Polyps –Bony structures – **Mucosa is pink and with out disch arge, edema, eryth ema, or – Protrude into the nasal cavity lesions. –Functions – **Erythematous Mucosa: Viral or Bacterial Infection: • Increases surface area of the nose & mucosa – **Pale, Boggy Mucosa or Polyps: Allergic • Cleans the air • Warms the air • Humidification

NOSE AND SINUSES Sinuses •Turbinates • 4 sets of sinuses – Maxillary – Color –Ethmoid –Edema – Sphenoid – Discharge – Frontal – **Lower and middle turbinates are darker in color than the mucosa and without edema or discharge. – **Erythematous, Edematous Turbinates: Sinusitis – **All are present at birth, except the frontal, which develops at 1 year of age – **Pale, Boggy Turbinates:

Wright, 2010 21 Anatomy Slide NOSE AND SINUSES •Sinuses – Maxillary –Frontal •Tenderness •Erythema • Transillumination • **Frontal and Maxillary sinuses are nontender and without erythema or edema • **Tenderness: Sinusitis • **Erythema: Abscess

Accessed at AAAAI Patient Resource Center.

Treatment of Acute Management Strategies Bacterial Rhinosinusitis in ABRS • Nonpharmacologic Therapies •Decongestants – Can be very helpful for a number of individuals – Nasal lavage • Antihistamines –Cold steam vaporizer – Should not be used unless allerg ic componen t – Increased water intake – 2nd generation antihistamines • Topical • Corticosteroids • Antimicrobials

Impact of Allergic Rhinitis in the United States

• 17 million individuals have allergic rhinitis – This accounts for 14% of the US population Allergic Rhinitis – Recent prevalence studies show that it may be present in 31.5% of all adults • 10-20% of this number is children – Most common chronic medical condition of childhood • 79.5 million Americans have undiagnosed allergic rhinitis

Wright, 2010 22 Physical Examination Findings in the Symptoms of Allergic Rhinitis Individual With Allergic Rhinitis •Cough • Nasal congestion • Watery discharge in • Mouth breathing • Pale, boggy mucosa and • Sneezing nose and eyes •Fatigue turbinates • Profuse watery • Irritability • Allergic shiners • Ulcerations on nasal discharggfe fro m nose mucosa and/or eyes • Decreased appetite • Allergic salute • Decreased hearing • Pharyngeal edema • Itching of nose, eyes, • Conjunctival injection and palate •Hoarse voice • Lymphoid tissue • Frequent clearing of • Decreased smell • Cobblestoning • Nasal polyps the throat • Sniffling • Allergic facies • Long eye lashes •Nose picking •Epistaxis •Grimacing or • Dennie’s lines •High arched palate twitching

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Pharyngitis Pharyngitis • Epidemiology • Epidemiology – 30 million patients seen yearly in US for pharyngitis – Tonsils are small in infancy – Increase in size until approximately 10 years of – Most often seen in colder months age andthd then they regress – Peak age: 5-8 years; however with increase in # of – Pathogens for pharyngitis spread via person to children in daycare at younger age, it is occurring in person younger children – Pathogen – Tonsils serve as our 1st line of defense against • Group A Beta hemolytic strep respiratory pathogens • 1/3-1/2 of cases in children aged 2 - 14 • Non-group A strep • Viral pharyngitis: 1/2 of cases in infants < 2

Wright, 2010 24 Pharyngitis Pharyngitis • Epidemiology • Symptoms – Group A Beta Hemolytic Strep – Group A Beta Hemolytic Strep • Most interest because of its association with severe • Rapid onset of sore throat complications • Fever 103-104 • Peritonsillar abscesses, , post- • Swollen glands streptococcal glomerulonephritis - complications • Children often complain of abdominal pain • Rheumatic fever: 20/100,000 people in early 1900’s, • Usually-no URI symptoms now 1:100,000 • Headache • Recent increase in cases • Decreased appetite • Many cases in individuals without sore throat • Dysphagia • Irritability

Pharyngitis MOUTH • Anatomy and Physiology • Symptoms –Lips – Viral Pharyngitis –Tongue • Usually not a severe sore throat –Mucosa –Uvula • Low grade temp –Tonsils • Mild swollen glands – Posterior Pharynx • Associated with URI symptoms – Dentition –Gingiva

MOUTH MOUTH • Anatomy and Physiology •Lips –Lips – Color –Tongue –Moisture –Mucosa – Lesions –Uvula –Abnormalities –Tonsils – Posterior Pharynx • **Lips are appropriately colored and moist; No – Dentition lesions or abnormalities –Gingiva

Wright, 2010 25 Abnormalities of the Lips Mouth • Blue: Cyanosis • Abnormal Development: Cleft Lip • Vesicles: Herpes Simplex, Impetigo • Thin Upper Lip: Fetal Alcohol Syndrome

MOUTH Abnormalities of the Tongue •Tongue • Deviation: Cranial Nerve XII Dysfunction – Position –Size •White Coating: Thrush –Deviation • Thick Frenulum: Tongue Tie –Lesions –Coating • Protruding Tongue: Angelman Syndrome –Frenulum • Ulcerations: Thrush, Apthous Stomatitis, •**Tongue is straight, appropriate size and midline. It is lightly papillated without lesions or coating. Frenulum is intact. Coxsackie Virus

MOUTH Abnormalities of Buccal Mucosa •Mucosa •Coating: Thrush – Color – Lesions • Ulcerations: Chewing Tobacco; –Coating Apthous Stomatitis; Hand, Foot, and –Moisture Mouth Disease • **Mucosa is appropriately colored, smooth, and moist without lesions, masses or coating.

Wright, 2010 26 MOUTH MOUTH • Hard and Soft Palate •Uvula –Continuity – Position – Color – Lesions –Lesions •**Hard and Soft Palate are continuous without lesions or • **Uvula is midline and smooth. It rises with phonation and abnormalities. is wihithout lliesions, eryth ema, or ddieviati on. • **Incongruous Hard and Soft Palate: Cleft Palate • Asymmetry: CN X Dysfunction, Tonsillar Abscess • **Ulcerations: Thrush, Apthous Stomatitis, Coxsackie Virus • Erythema: Viral or Bacterial Pharyngitis • **Coating: Thrush

MOUTH Abnormalities of the Tonsils •Tonsils • Erythematous, Edematous: Viral or – Anterior and Posterior Pillars Bacterial Pharyngitis – Color –Edema • Exudate: Bacterial Pharyygngitis, –Exudate Mononucleosis, Viral pharyngitis • **Tonsils are present bilaterally and • Asymmetric Enlargement: Tonsillar without edema, erythema, or exudate. Abscess

MOUTH Pharyngitis • Posterior Pharynx – Color • Signs – Lesions – Group A Beta Hemolytic Strep –Edema • Erythematous, edematous tonsils, uvula –Exudate • Exudate – **Posterior pharynx is pink without lesions, erythema, • Lymphadenopathy exudate, or edema. • Palatal petecchiae – **Lymphoid tissue: Viral or Allergic Illness – **Exudate and Edema: Strep Pharyngitis • Fever • Rash-scarletina

Wright, 2010 27 Pharyngitis Exudative pharyngitis Exudative pharyngitis • Signs Differentials include: – Viral Pharyngitis Strep pharyngitis Peritonsillar abscess • Slightly erythematous tonsils Mononucleosis • Can have exudate Viral pharyngitis • URI physical exam findings

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Scarletina Strawberry Tongue

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Pharyngitis Pharyngitis •Plan Even with a best case scenario, 1/3 - 1/2 of cases of strep –Diagnostic pharyngitis are missed or • Throat culture: 24 hour is the gold standard overdiagnose d using hithistory and • Quick strep: 85-100% specificity; 31-95% physical examination only!!! sensitivity • Must swab both tonsils for best results • Consider mononucleosis MUST DO A THROAT CULTURE

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Wright, 2010 28 Remember… Adolescents/Young Peritonsillar Abscess • Generally begins as an acute febrile Adults with mono URI or pharyngitis have strep • Condition suddenly worsens –Increased fever pharyngitis 50% of –Anorexia – Drooling the time –Dyspnea –Trismus

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Peritonsillar Abscess Peritonsillar Abscess • Physical examination • Physical examination findings – May appear restless – Fiery red asymmetric swelling of one tonsil – Irritable – Uvula is often displaced contralaterally – May lie with head hyperextended to and often forward facilitate respirations – Large, tender lymphadenopathy – Muffled or “hot potato voice” – Stridor may be present – Respiratory distress

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Peritonsillar Abscess Peritonsillar Abscess

Trismus Wright, 2010 Wright, 2010

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Wendy L. Wright, ARNP Family Nurse Practitioner Owner – Wright & Associates Family Healthcare Amherst, NH email: [email protected]

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