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Common Head and Neck The following relationships exist related to this presentation: Problems in Primary Care ►Paul A. Kedeshian, MD: No financial relationships to disclose. SPEAKER Paul A. Kedeshian, MD Off-Label/Investigational Discussion ►In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations.

Eustachian Tube (ET) Eustachian Tube (ET) Dysfunction Dysfunction

 Diagnosis of ET  Diagnosis of ET dysfunction depends dysfunction depends upon: upon: – Subjective symptoms – Ruling out presence of aural fullness of middle ear and/or ear effusion “popping” (with or  Tympanogram usually without a history of will reveal reduced environmental middle ear pressure allergies) – Careful otoscopic examination of the tympanic membrane with pneumatic insufflation to rule out effusion

Eustachian Tube (ET) Middle Ear Effusion Dysfunction

 Treatment  Diagnosis of middle ear effusion: – Nasal steroids/saline lavage – Otalgia with hearing loss – Antihistamines/Decongestants – Otoscopic examination reveals middle ear – Insufflation of ET effusion with absent – Oral corticosteroids movement – In an adult, a mass in the – GERD treatment nasopharynx must be considered as a possible – Middle ear ventilation tube placement (only in etiology rare instances) Middle Ear Effusion Middle Ear Effusion

 Audiogram will  Treatment demonstrate a – Oral antibiotics conductive hearing – Oral corticosteroids loss with a “flat” – Middle ear pressure tympanogram equalization tube (PET) placement if persists

Tympanosclerosis (aka Hemotympanum Myringosclerosis)

 Bloody middle ear  White plaque-like effusion usually deposit on tympanic secondary to trauma membrane (TM)  Workup should include surface CT scan of temporal bones and audiogram – Usually secondary to frequent otitis media  Blood will usually reabsorb spontaneously  No treatment over 4-12 weeks necessary (unless  If no resolution, PET is impairment of TM indicated mobility is noted)

Tympanic Membrane Tympanic Membrane Perforation Perforation

 Occurs secondary to  Treatment should pressure and/or fluid include: accumulation in the – Oral antibiotics middle ear (can be – Ear drops – Dry ear precautions post head trauma)

 Conductive hearing  If perforation is small loss and/or post-traumatic, may spontaneously heal  Potential for otorrhea in 3-8 weeks without and recurrent middle surgery ear infections Otitis Externa Otitis Externa

 Infection of external  Treatment should auditory canal (EAC) include: – Exquisitely painful – Oral antibiotics with – Severe canal edema (conductive hearing loss) anti-Psudomonal – History of EAC trauma coverage nearly always elicited – Otowick placement – Multiple bacterial species – Otic drops with anti- (including Pseudomonas) Pseudomonal are usually present coverage

Otitis Externa Exostosis

 Higher incidence in  Hypertrophy of the bony immunocompromised external auditory canal populations  Secondary to chronic exposure to cold water  If any facial nerve (surfing, ocean swimming) weakness or cranial  No treatment needed unless neuropathies are near-total EAC occlusion present, possibility of and/or secondary conductive “malignant otitis hearing loss externa” (skull base  Need for meticulous ear cleaning after water osteomyelitis) must be exposure considered

Nasal Polyps Nasal Polyps

 Inflammatory growths  Diagnosis also associated with chronic depends upon allergies radiographic  Can cause anatomic appearance of sinuses obstruction of sinus ostia with secondary (limited CT scan) acute sinusitis  Associated with asthma and aspirin allergy (Sampter’s triad) Nasal Polyps Nasal Septal Hematoma

 Treatment  Usually secondary to – Antibiotics trauma – Oral corticosteroids  Not always an associated nasal bone – Antihistamines/Decongestants fracture – Nasal/sinus lavage  Needle aspiration – Surgery and/or incision and  High incidence of recurrence drainage

Nasal Septal Hematoma Mucocele

 If hematoma is left  Accumulation of mucous in submucosal undrained, secondary space compromise of the  Most common on labial vascular supply to and buccal surfaces nasal dorsal cartilage  Usually secondary to can result is so-called dental trauma saddle nose deformity  Occasional superinfection in which case surgical excision may be indicated

Oral Leukoplakia Oral Leukoplakia

 “White plaque”  Workup should include  Presents most thorough examination commonly on lateral of mucosa of upper aspect of tongue and aerodigestive tract buccal mucosa (especially in tobacco- users)  Associated with trauma or chronic  Biopsy of areas of inflammation/irritation erythroplakia more important than  Low (less than 5%) premalignant potential representative sampling Torus Palatini and Torus Geographic Tongue Mandibularis

 Asymmetric  Bony overgrowths hypertrophy of papillae present in palate and of tongue inner cortex of  Unknown etiology mandible  Rarely symptomatic  Unknown etiology  Treatment with  Unless overlying antifungal or antibiotic mucosa becomes therapy not indicated inflamed, no treatment indicated for these  May be exacerbated by GERD benign lesions

Tonsillitis Tonsillitis

 Infection of palatine  Treatment with antibiotics for acute tonsillar tissue infections  Exudate in acute  Oral corticosteroids if severe hypertrophy cases with odynophagia  Chronic presence of  Surgical excision indicated if frequent cryptic enlargement, infections, secondary hypertrophy and airway obstruction, halitosis, or noticeable tonsoliths (tonsil asymmetry stones)

Tonsillar Lymphoma Peritonsillar Abscess

 Lymphoma (usually B-  Acute, suppurative infection with the submucosal space cell type) that develops around tonsils within the lymphoid  Will always be uvular tissue of the palatine deviation, bulging of soft palate, trismus, and muffled- tonsils (part of sounding voice ’ Waldeyer s ring)  Treatment involves either  Important to keep high needle aspiration and/or incision and drainage with index of suspicion if oral antibiotics and significant asymmetry, corticosteroids cervical adenopathy,  Can re-accumulate following constitutional needle aspiration symptoms Submandibular Parotitis Sialoadenitis/Sialolithiasis

 Inflammation of the parotid  Acute inflammation of ductal system with submandibular salivary associated swelling, pain, gland erythema, fevers  Can be secondary to  Increased incidence in dehydration (as in parotitis) diabetics but can occur but more commonly due to secondary to episode of sialolith (stone) dehydration  Physical exam can often  Rarely can occur secondary palpate stone along course of to parotid stone (sialolith) submandibular duct (within  Treatment includes the floor of mouth) antibiotics, hydration, oral  Treatment is same as for sialogogues, heat and parotitis except that frequent massage directly over the infections with an associated involved gland sialolith mandate surgical excision of gland

Parotid Neoplasm Second Branchial Cleft Cyst

 Firm mass within the . painless, fluctuant mass substance of parotid salivary gland in the lateral aspect of  Approximately 80% benign the neck that is situated  Presence of ipsilateral facial deep to the nerve weakness, pain, or sternomastoid muscle adenopathy increase likelihood of malignancy . most common branchial  Diagnostic workup should cleft anomaly (95%) include MRI of parotid gland followed by fine needle . often becomes apparent aspiration biopsy after recent URI  Treatment involves surgical excision of gland

Second Branchial Cleft Cyst Thyroglossal Duct Cyst

. May be a connection  most common with ipsilateral tonsil congenital neck . Surgical excision of the mass (70%) cyst may therefore  elevates on mandate concomitant protrusion of tongue tonsillectomy or swallowing  may develop draining sinus on skin surface Thyroglossal Duct Cyst Bell’s Palsy

 Usually present at or  Paralysis of all just inferior to the branches (upper and hyoid bone lower) of facial nerve – may be associated with ectopic thyroid  Sudden onset tissue (1-2%)  Viral prodrome therefore imaging to (usually) confirm the presence  Diagnosis of exclusion of normal thyroid tissue is  Must rule out presence recommended of co-existing  Treatment is surgical mastoiditis, otitis excision (Sistrunk externa, parotid tumor Procedure)

Bell’s Palsy

 Likely secondary to infection of facial nerve with herpes simplex virus  Treatment includes oral corticosteroids and possibly with an antiviral medication with reassessment after 7-10 days