PANCE Blueprint EENT (7%)

Infectious and inflammatory disorders (PEARLS)

Aphthous ulcers (ReelDx) Single or multiple small, shallow ulcers with a yellow-gray fibrinoid center with red halos, a biopsy should be considered for ulcers lasting more than 3 weeks

TX: viscous lidocaine 2–5% applied to ulcer QID after meals until healed

Candidiasis (ReelDx) Immunocompromised, young patients

  • Painful, white fluffy patches that can be scraped off and may bleed when scraped (candidiasis can "come off") leaving an erythematous, friable base
  • Potassium Hydroxide (KOH) prep for diagnosis

TX: Antifungals, which are available in several forms (i.e., ketoconazole or fluconazole orally, clotrimazole troches, nystatin liquid rinses)

Deep neck infection Deep neck space infections most commonly arise from a septic focus of the mandibular teeth, tonsils, parotid gland, deep cervical lymph nodes, middle ear, or sinuses

  • Classic manifestations of these infections include high fever, systemic toxicity, and local signs of erythema, edema, and fluctuance
  • Computed tomography (CT) is the imaging modality of choice for the diagnosis of deep neck space infection
  • The most common organisms isolated from deep neck space infections are viridans streptococci

TX: Antibiotics, aspiration or surgical drainage should be performed

Epiglottitis Unvaccinated patient leaning forward, drooling, stridor and distress (tripod position, muffled voice)

TX: Secure airway, admit, IV Ceftriaxone, and IV fluids

Herpes simplex (ReelDx) HSV type 1, vesicular lesions all in the same stage of development, a prodromal period of tingling discomfort or itching

TX: Symptomatic treatment with antipyretics and analgesia is recommended. IV hydration is sometimes needed in cases of decreased oral intake

  • Oral acyclovir (15 mg/kg/dose five times per day for 7–10 days; max 200 mg per dose) may decrease the duration of illness if started within 72 hours at the onset of symptoms
Laryngitis Almost always viral, hoarseness following a URI

  • M.cat, H.flu
  • Consider squamous cell carcinoma if hoarseness persists > 2 weeks, history of ETOH and or smoking, laryngoscopy is required for symptoms persisting > 3 weeks
  • Absence of pain or sore throat

TX: Relax voice (vocal rest), supportive therapy

  • Oral or IM corticosteroids may also hasten recovery for performers but requires vocal fold evaluation before starting therapy
  • Bacterial → erythromycin, cefuroxime, or Augmentin for cough or hoarseness
Peritonsillar abscess (ReelDx) Presents with a severe sore throat, lateral uvula displacement, bulging tonsillar pillar

  • Hot potato (muffled) voice and deviation of the uvula to one side
  • + Streptococcus pyogenes

TX: Aspiration, incision and drainage, and/or antibiotics

  • Parenteral amoxicillin, amoxicillin-sulbactam, and clindamycin
  • In less severe cases, oral antibiotics can be used for 7 to 10 days (i.e., amoxicillin, amoxicillin-clavulanate, clindamycin)
  • Tonsillectomy may also be considered in about 10% of patients
Pharyngitis (ReelDx) Usually viral - adenovirus most common

  • Mononucleosis: Epstein Barr virus, fever, sore throat, lymphadenopathy, splenomegaly, atypical lymphocytes, + heterophile agglutination test (monospot)
  • Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis
  • Fungal in patients using inhaled steroids

Strep pharyngitis

  • Group A B-hemolytic streptococci (GABHS)
  • Centor criteria: 1. Absence of a cough, 2. exudates, 3. fever (> 100.4 F), 4. cervical lymphadenopathy
  • Not suggestive of strep - coryza, hoarseness, and cough
  • If  3 out of 4 Centor criteria are met get a rapid streptococcal test (sensitivity > 90%)
  • If negative → throat culture is the gold standard

TX:

  • Group A Strep: Penicillin is first line, azithromycin if penicillin allergic. Complications: Rheumatic fever and post-strep glomerulonephritis
  • Viral: supportive
  • Mononucleosis: Symptomatic and avoid contact sports, antibiotics such as amoxicillin or ampicillin may cause a rash
  • Fungal: clotrimazole, miconazole, or nystatin
  • Gonorrhea pharyngitis: follows the same principles for the approach to therapy of uncomplicated urogenital gonococcal infections, with a preferred regimen of intramuscular ceftriaxone (250 mg) and azithromycin as a second agent
Diseases of the teeth and gums (ReelDx) (Prev Lesson)
(Next Lesson) Aphthous ulcers (ReelDx + Lecture)
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