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Respiratory/Musculoskeletal > CM- Nose, SInuses, Mouth, Larynx > Flashcards

CM- Nose, SInuses, Mouth, Larynx Flashcards

1
Q

For the physical exam of the nose, what are the external examinations and internal examinations performed?

A

External:

  1. dorsum- look for gross deviations, crepitus (popping under skin), step-offs btw bone edges
  2. palpate sinuses- inflammation causes tenderness

Internal:

  1. Mucousa
  2. Septum- if widened–>septum hematoma
  3. Turbinates
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2
Q

For nasal exam, what are the 3 techniques the examiner can choose from?

A
  1. Nasal speculum with head mirror
  2. otoscope
  3. endoscope with fiberoptic light source
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3
Q

In a nasal exam, what is sometimes sprayed into the nose?

What is the benefit and what is the drawback?

A

Vasoconstrictor (phenylephrine)

Benefit:
1. shrinks turbinates so more light can enter the nasal cavity
2. can visualize MORE turbinates. W/o you may only see inferior
Drawback:
Changes the patients baseline nasal congestion

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4
Q

What is the only way the superior turbinate can be seen in a physical examination of the nose?

A

With a sinus endoscope

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5
Q

What is rhinophyma?

A

Hypertrophy of sebaceous tissue on nasal skin producing bulbous projections from the nasal tip

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6
Q

On physical exam of the nose, what 4 possible findings are associated with the septum?

A
  1. deviation
  2. hematoma
  3. perforation (Wegener’s, cocaine)
  4. Telangiectasia
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7
Q

On physical exam of the nose, what 3 possible findings are associated with the nostril?

A
  1. foreign bodies
  2. polyp- translucent white/yellow mass
  3. Neoplasm
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8
Q

On physical exam of the nose, what findings are associated with the turbinates?

A
  1. dry, crusty, engorged mucosa

2. red, pink, blue-tinged

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9
Q

On physical exam, what findings are associated with the face?

A
  1. tenderness around sinuses

2. edema

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10
Q

What is the technique for examining the sinuses on physical exam?

A
  1. palpate frontal and maxillary
  2. endoscope for maxillary, ant. ethmoid, frontal outflow
  3. CT scan
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11
Q

In addition to the physical exam, what ancillary studies can be helpful when examining the nose?
When is each warranted?

A
  1. CT:
    - chronic sinusitis to see if there is need for surgery
    - bony structures (sinuses, skull base)
  2. MRI:
    - concerned about a mass or destructive process
    - soft tissue (encephalocele, etc)
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12
Q

What tools are needed to perform a proper examination of the mouth?
How should the patient be positioned?

A

Light source, 2 tongue depressors

The patient should be positioned at eye level

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13
Q

What should be inspected during a mouth exam?

A
  1. general condition of mucosa (dry, red, friable, tender, lesions)
  2. Status of dentition (teeth missing, dentures, caries)
  3. Subunits
  4. Salivary ducts and flow
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14
Q

What should be palpated in the examination of the mouth?

A
  1. tongue
  2. floor of the mouth
  3. sulci
  4. submandibular gland
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15
Q

In addition to the physical exam of the mouth, what ancillary studies can be done?
What are the indications for each?

A
  1. X-ray- dental exam, nasopharyngeal/retropharyngeal processes, foreign bodies
  2. CT with contrast - FIRST CHOICE for oral cavity, oropharyngeal masses/ infections
  3. MRI- better soft tissue details (depth of invasion of a tongue mass)
  4. Swallow studies
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16
Q

What is the first choice technique for imaging OC/OP masses and infectious processes?

A

CT with contrast because they give soft tissue and bony detail
(ex. mass abutting the mandible and you want to know if there is bony invasion)

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17
Q

What are the 3 ways to examine the larynx on physical exam?
What tools are needed for each?
Which is most common?

A
  1. mirror laryngoscopy:
    - head mirror, angled mirror at back of throat
    - gauze
    - light source
  2. ** fiberoptic laryngoscopy:
    - light source
    - fiberoptic scope
    - decongestant
  3. direct laryngoscopy
    - laryngoscope
    - light source
    - anesthesia
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18
Q

Why are fiberoptic laryngoscopies more common than direct?

A

Direct require anesthesia and the patient will not be able to phonate for you so you cannot assess function/mobility of the vocal cords

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19
Q

What is evaluated in the laryngeal exam? (5)

A
  1. mucosal appearance
  2. Patency of the airway (glottis chick >4mm)
  3. Movement of the cords (“EEE”)
  4. Mucousal lesions/ masses
  5. neck palpation- cartilage tenderness may indicate infection, muscle tenderness may indicate muscle strain or tension dysphonia
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20
Q

What ancillary studies can be done to assess the larynx?

A
  1. Lateral X-ray films show narrowing of airway or thickening of epiglottis (epiglottitis)
  2. AP X-ray for croup (harsh barking cough)
  3. CT/MRI for neoplasms/stenosis
  4. Barium swallow for dysphagia
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21
Q

What is rhinitis medicamentosa?

How can it be prevented?

A

A condition caused by dependence on nasal decongestants like aphrin and neosynephrine.
Tachyphylaxis (decrease in response to drug) occurs and the nose becomes even more congested than before.

This can be avoided by limiting the use of decongestant sprays to only 3 days at a time

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22
Q

What are the 3 main situations where you would have clear rhinorrhea?

A
  1. allergic rhinitis
  2. viral rhinitis
  3. in the setting of trauma, CSF leakage
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23
Q

What are the 3 ways you can tell the rhinorrhea is CSF and not viral/allergic rhinitis?

A
  1. CSF has a higher glucose content
  2. B-2-transferrin is in CSF not mucus
  3. “ring sign”- when dropped on a paper towel, blood goes to the middle and CSF forms a clear peripheral ring
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24
Q

What clinical situations would you be likely to see thick, green, foul-smelling rhinorrhea?

A
  1. chronic sinusitis

2. foreign body that has been in the nose several days

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25
Q

What clinical situations are associated with facial pain, pressure and headache?

A
  1. Acute sinusitis (maxillary sinusitis even causes paresthesia of upper teeth)
  2. allergic rhinitis
  3. Chronic sinusitis (intermittent)
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26
Q

What is the clinical presentation of someone with CSF rhinorrhea?

A 
They have just been in trauma and have clear rhinorrhea. 
Make sure it is not mucus by:
1. glucose test
2. B-2-transferrin test
3. Ring sign
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27
Q

What is the clinical presentation of allergic rhinitis?

A
  1. clear rhinorrhea
  2. coughing, sneezing, watery eyes, palatal pruritis
  3. congestion due to inflammation of nasal mucosa
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28
Q

What is the clinical presentation of viral rhinitis?

A
  1. clear rhinorrhea
  2. fever
  3. congestion- inflammation of nasal mucousa
29
Q

What is the clinical presentation of chronic sinusitis?

A
  1. green, foul-smelling rhinorrhea

2. INTERMITTENT face pain and headache (acute has constant face pain/headache)

30
Q

What are the 2 nose/sinus clinical situations associated with fever?

A
  1. viral rhinitis

2. acute sinusitis

31
Q

How do you differentiate viral from allergic rhinitis?

A

Viral- fever

Allergic- “allergic symptoms” like sneezing, palatal pruritis, water eyes

32
Q

What is the difference between congestion and obstruction?

What is the usual cause of each?

A

Congestion is “stuffiness” where there is partial blockage or cyclical blockage. Air still gets in, but the flow is decreased. Usually caused by inflammation
Obstruction- no air is getting in. Complete blockage usually caused by a structural problem

33
Q

What are the 4 causes most commonly associated with nasal congestion?

A
  1. allergies
  2. viral URI
  3. rhinosinusitis (+/- polyps)
  4. rhinitis medicamentosa
34
Q

What are the 5 situations commonly associated with nasal obstruction?

A
  1. choanal atresia
  2. foreign bodies
  3. deviated septum
  4. neoplasm
  5. polyps
35
Q

What is the most common cause of epistaxis?

A

Trauma to the mucosa due to:

  1. excess rubbing, picking (“digital”)
  2. actual trauma (punched, hit by a ball, etc)
36
Q

What clinical presentation would someone getting nosebleeds due to coagulation problems have?

A
  1. anticoagulant meds
  2. low platelets
  3. hemophilia
  4. vWF disease
37
Q

What clinical presentation would someone getting nosebleeds due to high blood pressure present with?

A

HTN and nosebleeds that do not really spontaneously start but have trouble stopping
Usually in an older individual (than may be on anticoagulants for the hypertension)

38
Q

How do allergies predispose to recurrent nosebleeds?

A

The tissue is inflamed and irritated so:

  1. nose is more full of blood
  2. more prome to rubbing/blowing
39
Q

What is JNA?

What would be the clinical presentation of someone with it?

A

Juvenile Nasal Angiofibroma - vascular mass seen in adolescent boys with unilateral, frequent, severe nosebleeds.

40
Q

What is the remedy for nosebleeds?

A

moisture, bland ointments, avoidance of trauma

41
Q

When a patient is congested, how could you tell if it was due to polyps or foreign objects?

A

Foreign objects- green, foul smelling rhinorrhea, usually unilateral
Polyps- congestion and obstruction due to inflammation and structural blockage, clear pedunculated masses in patients with:
1. allergic rhinitis
2. chronic sinusitis

42
Q

What are the most common symptoms people present with for OC/OP issues?

A
  1. pain- sore throat, ulcer
  2. visible lesions-mass, white spot
  3. halitosis
  4. snoring (large tonsils)
  5. xerostomia (dry mouth)
  6. dysphagia (difficulty swallowing)
  7. odynophagia (pain swallowing)
  8. weight loss/fever
  9. bleeding gums (gingivitis)
  10. Otalgia (OP cancer that has referred pain to the ear from CN IX)
43
Q

What 5 questions narrow the differential when a patient presents with an OC/OP problem like a sore throat?

A
  1. How long has it been going on?
  2. Can you point to where it hurts?
  3. Sore, burning, irritation, or frank?
  4. Associated symptoms? (fever, pain swallowing, trouble swallowing, big lymph nodes, lump in throat)
  5. History of meds exposure/chemo/antibiotics?
44
Q

A patient presents with painful ulcers that have been present for a few days, come and go, may be exacerbated by stress. On exam you see scattered white/fibrinous ulcers with erythematous bases. Usually you see multiple lesions which are round and similar in size. What is the most likely diagnosis?

A

Aphtous ulcer (canker sore)

45
Q

A patient presents with a constant burning sensation along tongue. No dysphagia/odynophagia per se. On exam you see a red smooth tongue which has lost the typical filiform papilla. What is the likely diagnosis?

A

Glossitis

46
Q

When examining a mouth you incidentally note a white patch in the patients mouth. What is the likely diagnosis?

A

Leukoplakia

47
Q

A patient presents with sore throat for few days, odynophagia (more than dysphagia), +/- fevers.
On exam you note erythema of tonsils and palate, sometimes petichiae, sometimes exudates along tonsils.
What is the likely diagnosis?

A

Streptococcal pharyngitis

48
Q

A patient presents with sore throat for few days, usually one side more than the other, odynophagia (more than dysphagia), +/- fevers, +++ trismus and muffled voice.
On exam you note trismus (reduced opening of the jaw), asymmetric soft palate with bulging soft palate.
What is the likely diagnosis?

A

Paratonsillar abscess

49
Q

What is a ranula?

A

A cyst in Wharton’s duct (submandibular) that looks like a frogs throat

50
Q

In what two clinical situations would you be likely to see enlargement of salivary glands?

A
  1. Sjogren’s syndrome

2. bulimia

51
Q

How can you differentiate thrush from leukoplakia?

A

Thrush is a white coating to the tongue and mucus membrane that can be scraped off and is a sign of candida fungal infection in an immunocompromised patient who has taken broad spectrum antibiotics.

Leukoplakia cannot be scraped off and is idiopathic (although more frequent in smokers)

52
Q 
What is the appearance of :
1. streptococcal infection
2. allergy/post nasal drip
3. peritonsillar abscess
4. carcinoma 
on the pharynx?
A
  1. white plaque on reddened pharynx
  2. yellow lymphoid follicles
  3. painful, red bulge that deviates uvula
  4. roughed, ulcerated areas in mucosa
53
Q

Are laryngeal cancers of the glottis or supraglottis more likely to metastasize? Why?

A

Supraglottis is well served by lymphatics so will present with neck metastases
Glottis does not have a lot of lymphatics so if caught early, laryngeal cancers will not metastasize

54
Q

What are the 4 layers of the vocal cords?

Which layer is responsible for changes in the quality of voice (causes hoarseness)?

A
  1. Skin
  2. superficial lamina propria
  3. vocal ligament
  4. vocalis muscle

Anything that disrupts the SLP like scars, edema or a mass will change the quality of the voice

55
Q

How would a patient with post-nasal drip as the main cause of hoarseness present?

A

It is associated with allergic rhinitis.
the hoarseness will be intermittent with:
1. nasal discharge
2. itchy nose and eyes and soft palate

56
Q

If hoarseness last longer than ____weeks it has to be referred to ENT.

A

3 wks

57
Q

If the hoarseness waxes and wanes, what are the three differential diagnoses?

A
  1. post-nasal drip associated
  2. laryngeal reflux
  3. voice misuse
58
Q

If you are examining the larynx and discover lymphadenopathy, what is the most likely diagnosis?

A

cancer

59
Q

What are the differential diagnoses if the patient is experiencing globus?

A
  1. laryngeal reflux

2. neoplasm

60
Q

How do the symptoms differ for a supraglottis neoplasm from a laryngeal neoplasm?

A

Supraglottis- causes dysphagia before hoarseness

Laryngeal- presents with hoarseness

61
Q

What are the 4 differential diagnoses if the patient is presenting with dysphagia?

A
  1. neoplasm
  2. laryngeal or gastroesophageal reflux
  3. neuromuscular disease
  4. structural abnormalities
62
Q

What are the 4 possible causes of laryngeal pain?

A
  1. neoplasm
  2. viral hoarseness
  3. reflux
  4. muscle strain
63
Q

A patient presents with hoarseness and pain swallowing, but NO fever. What is the most likely diagnosis?

A

viral or fungal laryngitis

64
Q

A patient presents with intermittent hoarseness, globus, and chronic clearing of the throat with a cough.
They do not have dysphagia or pain.
What is the most likely cause?

A

Esophageal reflux related

65
Q

What is stridor?

What are the 5 most likely causes?

A

noisy breathing from the laryngeal level that sounds harsh due to the turbulent flow. View it as a sign of life-threatening situation.

  1. infection (epiglottitis)
  2. neoplasms- carcinoma
  3. developmental abnormalities- larygnomalacia/subglottic stenosis
  4. immune- angioedema
  5. trauma
66
Q

What signs/symptoms tell you that you might need to perform a tracheotomy in someone with stridor?

A
  1. increased respiratory rate
  2. accessory muscle usage
  3. pallor OR cyanosis
  4. tripod position
  5. hypoxemia/hypercapnia causing waning consciousness
67
Q

When should a sinus radiograph (xray) be performed? (3 main situations)

A
  • when you are concerned about nasopharyngeal or retropharyngeal processes (adenoid hypertrophy or retropharyngeal thickening)
  • useful for a child when you want to limit radiation and/or they will not comply w/ a longer CT/RMI.
  • Can also pick up foreign bodies in the upper tract
68
Q

When are CT and MRI used in patients with disease of nose, mouth, sinuses and larynx?

A
  1. JNA (juvenile nasal angiofibroma)- very vascular mass typically seen in an adolescent boy w/ frequent sever nose bleeds unilaterally
  2. sinus problems- Use CT 1st, then MRI will help if you’re concerned about a skull-based defect.
  3. Choanal atresia
  4. delineating an acute bacterial sinusitis form allergic or viral rhinitis
  5. evaluation of chronic sinusitis when determining the need for surgery.
  6. CT evaluation of bony structure (e.g. sinuses, skull base dehiscence) and MRIs are more useful for soft tissue
  7. CT neck w/ contrast is the first choice when investigating a OC/OP mass or infectious process.
  8. Neoplasms and stenoses
69
Q

When does one perform lateral neck radiography for patients with nose, mouth, larynx or sinus problems?

A

narrowing airway or thickening epiglottis

Respiratory/Musculoskeletal (36 decks)

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