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Ear, Nose, Mouth, and Throat Disorders TABLE 58. Causes of Hearing Loss Cause Description Conductive Hearing Loss" Cerumen impaction May completely obstruct the ear canal Otosclerosis Associated with overgrowth of bone in the middle ear Tympanic membrane perforation Often heals without intervention Cholesteatoma Abnormal growth of keratinized squamous epithelium in the middle ear (see Figure 23) Sensorineural Hearing Lossb Presbycusis Age-related hearing loss; often symmetric, high-frequency loss Sudden sensorineural hearing loss Often idiopathic, more often unilateral Meniere disease Classically, triad of sensorineural hearing loss, tinnitus, and vertigo; not all are necessarily present at once, may fluctuate Acoustic neuroma Benign tumor of Schwann cell sheath surrounding the vestibular or cochlear nerve Noise May be related to chronic noise exposure or sudden, short noise blast exposure Ototoxic drugs Antibiotics (aminoglycosides, erythromycin, vancomycin) Chemotherapeutic agents (cisplatin, carboplatin, vincristine) Loop diuretics Anti-inflammatory agents (aspirin, NSAlDs, quinine) Mixed or Causing Either Conductive or Sensorineural Hearing Loss lnfection Labyrinthitis, otitis media, chronic otitis Head trauma May be caused by ossicular disruption, leading to conductive hearing loss, or by auditory nerve injury, causing sensorineural hearing loss 'Conductive hearing loss is inadequate mechanical transmission of sound through the tympanic membrane and ossicles of the middle ear bSensorineural hearing loss is deficit or injury of the vestibulocochlear nerue.

Otosclerosis Associated with overgrowth of bone in the middle ear Tympanic membrane perforation Often heals without intervention Cholesteatoma Abnormal growth of keratinized squamous epithelium in the middle ear (see Figure 23) Sensorineural Hearing Lossb Presbycusis Age-related hearing loss; often symmetric, high-frequency loss Sudden sensorineural hearing loss Often idiopathic, more often unilateral Meniere disease Classically, triad of sensorineural hearing loss, tinnitus, and vertigo; not all are necessarily present at once, may fluctuate Acoustic neuroma Benign tumor of Schwann cell sheath surrounding the vestibular or cochlear nerve Noise May be related to chronic noise exposure or sudden, short noise blast exposure Ototoxic drugs Antibiotics (aminoglycosides, erythromycin, vancomycin) Chemotherapeutic agents (cisplatin, carboplatin, vincristine) Loop diuretics Anti-inflammatory agents (aspirin, NSAlDs, quinine) Mixed or Causing Either Conductive or Sensorineural Hearing Loss lnfection Labyrinthitis, otitis media, chronic otitis Head trauma May be caused by ossicular disruption, leading to conductive hearing loss, or by auditory nerve injury, causing sensorineural hearing loss 'Conductive hearing loss is inadequate mechanical transmission of sound through the tympanic membrane and ossicles of the middle ear bSensorineural hearing loss is deficit or injury of the vestibulocochlear nerue. TABLE 59. Screening Maneuvers to Assess Hearing Screening Maneuver Technique Positive LR Negative LR for >25 dB for >25 dB Hearing Loss Hearing Loss Patient Self-Assessment Single-item screening" Patient answers "yes" or "no" to the following question: "Do you 3 0.4 {eel you have hearing loss?" or "Would you say that you have any difficulty hearing?" Hearing Handicap lnventory for Patient answers a 10-item question set, with options of "yes," 3.5b 0.52 the Elderly-Screening Versionb "no," or "sometimes." Clinician Examination Finger rub test' The examiner gently rubs two fingers togeth er at a distance of 10. 0.75 1 5 cm (6 in)from the patient's ear. A positive result is failure to

TABLE 59. Screening Maneuvers to Assess Hearing Screening Maneuver Technique Positive LR Negative LR for >25 dB for >25 dB Hearing Loss Hearing Loss Patient Self-Assessment Single-item screening" Patient answers "yes" or "no" to the following question: "Do you 3 0.4 {eel you have hearing loss?" or "Would you say that you have any difficulty hearing?" Hearing Handicap lnventory for Patient answers a 10-item question set, with options of "yes," 3.5b 0.52 the Elderly-Screening Versionb "no," or "sometimes." Clinician Examination Finger rub test' The examiner gently rubs two fingers togeth er at a distance of 10. 0.75 1 5 cm (6 in)from the patient's ear. A positive result is failure to respond to two or more of six {inger rubs. Whispered voice testb The examiner stands 2 ft from patient's ear and masks the untested 5.1 0.03 ear by occluding the canal and rubbing the tragus. The examiner whispers six sets of three letter, number, or word combinations. A positivetest result isthe inabilityto repeatthree sets correctly. Watch tick testc The examiner holds a ticking watch at a distance of 15 cm (6 in) 70 0.57 from patient's ear. A positive result is {ailure to respond to two or more of six presentations of the ticking watch. Hand-held audiometerd The examiner holds the device in the patient's ear while the 3.1-5.8 0.1-0.4 patient indicates awareness of each tone. A positive test result is a failure to identify the 1 000-Hz or 2000-Hz frequency in both ears or the 1 000-Hz and 2000-Hz frequency in one ear.

respond to two or more of six {inger rubs. Whispered voice testb The examiner stands 2 ft from patient's ear and masks the untested 5.1 0.03 ear by occluding the canal and rubbing the tragus. The examiner whispers six sets of three letter, number, or word combinations. A positivetest result isthe inabilityto repeatthree sets correctly. Watch tick testc The examiner holds a ticking watch at a distance of 15 cm (6 in) 70 0.57 from patient's ear. A positive result is {ailure to respond to two or more of six presentations of the ticking watch. Hand-held audiometerd The examiner holds the device in the patient's ear while the 3.1-5.8 0.1-0.4 patient indicates awareness of each tone. A positive test result is a failure to identify the 1 000-Hz or 2000-Hz frequency in both ears or the 1 000-Hz and 2000-Hz frequency in one ear. LR = likelihood ratio. uBased on 6 studies. bBased on 4 studies. .Based on I study. dBased on 2 studies. 76

Ear, Nose, Mouth, and Throat Disorders TABLE 60. Distinguishing Between Conductive and persistent, bothersome tinnitus, providing relief from the Sensorineural Hearing Loss With the Weber and Rinne Tests related stress and management of the perception of tinnitus. Condition WeberTesf Rinne Testb Result Cognitive behavioral therapy is an eff'ective therapy fbr Result tinnitus but may be limited by availability and lack of Conductive Louder in the Decreased in the affected reimbursement. hearing loss affected ear ear (bone conduction > air conduction) Sensori neural Louder in the As loud or louder in the Otitis Media and Otitis Externa hearing loss unaffected ear affected ear (air conduction > Patients with acute otitis media (AOM) usually present with bone conduction) unilateral ear pain and diminished hearing along with bulging 'A256 Hz vibrating tuning fork (although a 5 1 2-Hz tu ning fork may be used) is ; applied to the forehead or scalp at the midline, and the patient is asked if the or intense ery,thema of the tympanic membrane. Otitis media sound is louder n one ear or the other; a normal test result shows no laterallzatton with effusion is often mistaken for AOM in adults (Figure 24); r'A512-Hzvibratingtuningforkisappliedtothemastodprocessof theaffected it is characterized by the presence of fluid in the middle ear ear until it is no longer heard. The fork is then repositioned outside of the external auditory canal, and the patient is asked if he or she can again hear the tuning fork; without acute inflammation or signs of systemic illness. AOM with a normal test result, air conduction is greater thao bone conduction, and the tuning fork can be heard. is rare in adults, and although numerous guidelines exist for treatment of AOM in children, management in adults is less clear. The Choosing Wisely Canada initiative recommends observation initially for uncomplicated AOM in adults and include oral glucocorticoids within 2 weeks of onset, although children. If antibiotics are prescribed, amoxicillin or amoxicillin strong evidence ofefficacy is lacking. clavulanic acid provides coverage fbr the most common organ t(EY P0ta{Ts isms. Fever, posterior ear pain, and facial nerve paralysis are HVC . Simple and effective tests for hearing loss, such as eval- rare but suggest complications, such as mastoiditis, and may uating whether a patient can hear a whispered voice or require urgent imaging and surgical consultation. Patients single question screening (for example, "Do you have with recurrent AOM or persistent hearing loss should be difficulty with your hearing?"), can be performed in referred to an otolaryngologist. the office. Acute otitis externa (AOE) (Figure 25) is diffuse inf]am- mation of the external ear canal and may involve the pinna e Sudden onset hearing loss (within ZZ hours) requires and tragus, with rapid onset within the preceding 3 weeks. In urgent referral to an audiologist, MRI of the retrocochlear 98u1, of cases of AOE, the cause is bacterial infection, most structures, and consideration of oral glucocorticoids. commonly with P.seudomo,'los or Staphylococcus oureus. Symptoms include otalgia, pruritus, and ear fullness. The his tory should include assessment for immunocompromising Tinnitus conditions (such as diabetes mellitus, HIV int'ection, or cancer Tinnitus is the conscious perception of sound (most com chemotherapy); history of radiation; and tympanostomy tubes monly buzzing or ringing) without an external source. The or perforation of the tympanic membrane, which may alter history should include onset, duration, quality (including choice of treatment. On physical examination, the classic sign pulsatile nature and laterality), associated symptoms (such as hearing loss, vertigo, imbalance, depression. or anxiety), noise and medication exposures (such as loop diuretics or aminoglycosides), and the effect on quality of lif'e. Physicat examination should include otoscopy, auscultation over the periauricular region and neck for vascular lesions, and neu' rologic examination. Audiologic assessment is reasonable for patients presenting with tinnitus, but prompt assessment, imaging, and evaluation by an otolaryngologist should be considered in patients with unilateral or pulsatile tinnitus, asymmetric or sudden hearing loss, or focal neurologic symptoms. Treatment involves addressing the underlying condition, including insomnia and depression, which can worsen tinni tus. Medications and herbal supplements have not been shown to be beneflcial. Hearing aids may be helpful in treating tin FIGURE 24. Otoscopicfindings of otitis media with effusion arefluid nitus associated with hearing loss by producing a masking (often yellowish, but sometimes clear), and visible behind a retracted effect. Similarly. sound therapy, which includes masking of the tympanic membrane. Viscous bubbles may also be seen, particularly during tinnitus with external sound generators, may be helpful fbr pneumatic otoscopy.

TABLE 60. Distinguishing Between Conductive and persistent, bothersome tinnitus, providing relief from the Sensorineural Hearing Loss With the Weber and Rinne Tests related stress and management of the perception of tinnitus. Condition WeberTesf Rinne Testb Result Cognitive behavioral therapy is an eff'ective therapy fbr Result tinnitus but may be limited by availability and lack of Conductive Louder in the Decreased in the affected reimbursement. hearing loss affected ear ear (bone conduction > air conduction) Sensori neural Louder in the As loud or louder in the Otitis Media and Otitis Externa hearing loss unaffected ear affected ear (air conduction > Patients with acute otitis media (AOM) usually present with bone conduction) unilateral ear pain and diminished hearing along with bulging 'A256 Hz vibrating tuning fork (although a 5 1 2-Hz tu ning fork may be used) is ; applied to the forehead or scalp at the midline, and the patient is asked if the or intense ery,thema of the tympanic membrane. Otitis media sound is louder n one ear or the other; a normal test result shows no laterallzatton with effusion is often mistaken for AOM in adults (Figure 24); r'A512-Hzvibratingtuningforkisappliedtothemastodprocessof theaffected it is characterized by the presence of fluid in the middle ear ear until it is no longer heard. The fork is then repositioned outside of the external auditory canal, and the patient is asked if he or she can again hear the tuning fork; without acute inflammation or signs of systemic illness. AOM with a normal test result, air conduction is greater thao bone conduction, and the tuning fork can be heard. is rare in adults, and although numerous guidelines exist for treatment of AOM in children, management in adults is less clear. The Choosing Wisely Canada initiative recommends observation initially for uncomplicated AOM in adults and include oral glucocorticoids within 2 weeks of onset, although children. If antibiotics are prescribed, amoxicillin or amoxicillin strong evidence ofefficacy is lacking. clavulanic acid provides coverage fbr the most common organ t(EY P0ta{Ts isms. Fever, posterior ear pain, and facial nerve paralysis are HVC . Simple and effective tests for hearing loss, such as eval- rare but suggest complications, such as mastoiditis, and may uating whether a patient can hear a whispered voice or require urgent imaging and surgical consultation. Patients single question screening (for example, "Do you have with recurrent AOM or persistent hearing loss should be difficulty with your hearing?"), can be performed in referred to an otolaryngologist. the office. Acute otitis externa (AOE) (Figure 25) is diffuse inf]am- mation of the external ear canal and may involve the pinna e Sudden onset hearing loss (within ZZ hours) requires and tragus, with rapid onset within the preceding 3 weeks. In urgent referral to an audiologist, MRI of the retrocochlear 98u1, of cases of AOE, the cause is bacterial infection, most structures, and consideration of oral glucocorticoids. commonly with P.seudomo,'los or Staphylococcus oureus. Symptoms include otalgia, pruritus, and ear fullness. The his tory should include assessment for immunocompromising Tinnitus conditions (such as diabetes mellitus, HIV int'ection, or cancer Tinnitus is the conscious perception of sound (most com chemotherapy); history of radiation; and tympanostomy tubes monly buzzing or ringing) without an external source. The or perforation of the tympanic membrane, which may alter history should include onset, duration, quality (including choice of treatment. On physical examination, the classic sign pulsatile nature and laterality), associated symptoms (such as hearing loss, vertigo, imbalance, depression. or anxiety), noise and medication exposures (such as loop diuretics or aminoglycosides), and the effect on quality of lif'e. Physicat examination should include otoscopy, auscultation over the periauricular region and neck for vascular lesions, and neu' rologic examination. Audiologic assessment is reasonable for patients presenting with tinnitus, but prompt assessment, imaging, and evaluation by an otolaryngologist should be considered in patients with unilateral or pulsatile tinnitus, asymmetric or sudden hearing loss, or focal neurologic symptoms. Treatment involves addressing the underlying condition, including insomnia and depression, which can worsen tinni tus. Medications and herbal supplements have not been shown to be beneflcial. Hearing aids may be helpful in treating tin FIGURE 24. Otoscopicfindings of otitis media with effusion arefluid nitus associated with hearing loss by producing a masking (often yellowish, but sometimes clear), and visible behind a retracted effect. Similarly. sound therapy, which includes masking of the tympanic membrane. Viscous bubbles may also be seen, particularly during tinnitus with external sound generators, may be helpful fbr pneumatic otoscopy. 77

Ear, Nose, Mouth, and Throat Disorders may become inadequate, and cerumen accumulation may cause pain. itching, tinnitus, or hearing loss. When symptomatic, cerumen can be removed by topi cal cerumenolytics, irrigation, or manual removal. Topical agents and irrigation should be avoided in the presence ol a perforated tympanic membrane; mechanical removal is preferred in these instances. The American Academy of Otolaryngology recommends counseling patients not to insert any foreign object into the ear canal because it can worsen cerumen impaction by pushing wax deeper into the canal, causing lacerations, trauma. and perforation of the tympanic membrane.

may become inadequate, and cerumen accumulation may cause pain. itching, tinnitus, or hearing loss. When symptomatic, cerumen can be removed by topi cal cerumenolytics, irrigation, or manual removal. Topical agents and irrigation should be avoided in the presence ol a perforated tympanic membrane; mechanical removal is preferred in these instances. The American Academy of Otolaryngology recommends counseling patients not to insert any foreign object into the ear canal because it can worsen cerumen impaction by pushing wax deeper into the canal, causing lacerations, trauma. and perforation of the tympanic membrane. Epistaxis Epistaxis is a common problem affecting up to 60'7, of the U.S. population, with 6'2, of affected patients requiring medical attention. Ninety percent of epistaxis cases originate in the anterior nasal septum in the Kiesselbach plexus (Figure 26). Posterior bleeding, although less common, is more likely to F I G UR E 2 5. Typical findings in the external auditory canal of a patient with result in significant hemorrhage. The history should include otitis externa, including erythema and edema. assessment for timing and frequency of epistaxis, local trauma, nose picking, intranasal medications and anticoagulant/anti of AOE is tenderness with pushing on the tragus or pulling on platelet use, arid environments, infection, intranasal drug use the pinna. (cocaine), family and personal history of bleeding disorders, Topical treatments, including antibiotics, glucocorti and relevant comorbidities. coids, antiseptics (acetic acid), and combination therapies, Anterior bleeding can be managed with compression of are first line management for uncomplicated AOE; systemic the alae (lower one third of the nose) for at least 5 minutes. antibiotics are ineffective and should be avoided. Quinolone If the bleeding site can be identified on anterior rhinoscopy, drops are preferred in the case of a nonintact tympanic use of topical vasoconstrictors, such as oxymetazoline, and membrane. Patients should be instructed on proper tech nasal cautery may be useful. If bleeding continues, nasal nique for instillation of ear drops, including cleaning excess packing with an inflatable tamponade device or a foam debris before instilling the drops and then lying down with the affected ear facing upward, remaining in this position for 3 to 5 minutes. lmmunocompromised patients require Anterior €$ffridal arE y topical and systemic therapy and are at increased risk for h*nrior deeper infections, including bone involvement (malignant od{rmridal artery

Epistaxis Epistaxis is a common problem affecting up to 60'7, of the U.S. population, with 6'2, of affected patients requiring medical attention. Ninety percent of epistaxis cases originate in the anterior nasal septum in the Kiesselbach plexus (Figure 26). Posterior bleeding, although less common, is more likely to F I G UR E 2 5. Typical findings in the external auditory canal of a patient with result in significant hemorrhage. The history should include otitis externa, including erythema and edema. assessment for timing and frequency of epistaxis, local trauma, nose picking, intranasal medications and anticoagulant/anti of AOE is tenderness with pushing on the tragus or pulling on platelet use, arid environments, infection, intranasal drug use the pinna. (cocaine), family and personal history of bleeding disorders, Topical treatments, including antibiotics, glucocorti and relevant comorbidities. coids, antiseptics (acetic acid), and combination therapies, Anterior bleeding can be managed with compression of are first line management for uncomplicated AOE; systemic the alae (lower one third of the nose) for at least 5 minutes. antibiotics are ineffective and should be avoided. Quinolone If the bleeding site can be identified on anterior rhinoscopy, drops are preferred in the case of a nonintact tympanic use of topical vasoconstrictors, such as oxymetazoline, and membrane. Patients should be instructed on proper tech nasal cautery may be useful. If bleeding continues, nasal nique for instillation of ear drops, including cleaning excess packing with an inflatable tamponade device or a foam debris before instilling the drops and then lying down with the affected ear facing upward, remaining in this position for 3 to 5 minutes. lmmunocompromised patients require Anterior €$ffridal arE y topical and systemic therapy and are at increased risk for h*nrior deeper infections, including bone involvement (malignant od{rmridal artery otitis externa), which requires urgent referral to an otolaryngologist. Kidbadr's phxrd Litdet am t(EY ?Oatrs HVC . The Choosing Wisely Canada initiative recommends observation initially for uncomplicated acute otitis media in adults and children; if antibiotics are pre scribed. amoxicillin or amoxicillin-clavulanic acid Sphanopahim artery provides coverage for the most common organisms. . Topical treatments, including antibiotics, glucocorticoids, SupGrior L.bi.l antiseptics (acetic acid), and combination therapies, are arnery GEt6 first line management for uncomplicated acute otitis pCdimart ry externa.

otitis externa), which requires urgent referral to an otolaryngologist. Kidbadr's phxrd Litdet am t(EY ?Oatrs HVC . The Choosing Wisely Canada initiative recommends observation initially for uncomplicated acute otitis media in adults and children; if antibiotics are pre scribed. amoxicillin or amoxicillin-clavulanic acid Sphanopahim artery provides coverage for the most common organisms. . Topical treatments, including antibiotics, glucocorticoids, SupGrior L.bi.l antiseptics (acetic acid), and combination therapies, are arnery GEt6 first line management for uncomplicated acute otitis pCdimart ry externa. IIGURE 26. Vascularsupplyofthe nasal septum. Notethe Little'sarea/ Kiesselbach s plexus in the anterior septum, which is responsible for 90% ol Cerumen lmpaction epistaxis cases.

IIGURE 26. Vascularsupplyofthe nasal septum. Notethe Little'sarea/ Kiesselbach s plexus in the anterior septum, which is responsible for 90% ol Cerumen lmpaction epistaxis cases. Cerumen helps to protect, clean, and lubricate the external [,lodiiied with permission lromTunkel DE,Anne S, Payne SC, etal. Clinical practice guideline: nosebleed (epistaxis) executrvesummaryotolaryngolHeadNeckSurg.2020;162:825.IPMID:31910122]d0i:10.1177l auditory canal. Its normal expulsion, assisted by jaw movement, 0194599819889955 78

Ear, Nose, Mouth, and Throat Disorders polymer tampon may be necessary. Refractory or recurrent TABLE 61 " ,Acute Sinusitis Treatments' bleeding may rarely require embolization or surgical ligation lndications for Antibiotic First-Line Penicillin in consultation with an otolaryngologist. patients with Treatment Therapyb Allergy recurrent bleeding or unilateral epistaxis should undergo Persistent symptoms Amoxicillin- Doxycycline nasal endoscopy. Patients with recurrent personal or family of >1 0 days' duration clavulanate (adults only) history of bilateral nosebleeds should be examined for oral or amoxicillin Onset of severe symptoms or mucosal or nasal telangiectasias, with consideration of refer or signs of high fever >39 oC ral to an otolaryngologist to rule out hereditary hemorrhagic (1 02.2 "F) with purulent Levofloxacin or nasal discharge or facial moxifloxacin telangiectasias. (adults only) pain lasting for >3 Posterior bleeding may cause substantial blood loss. consecutive days or Patients with persistent or recurrent bleeding not controlled Onset o{ worsening Clindamycin by packing or nasal cauterization should be evaluated by an symptoms after a typical otolaryngologist for consideration of arlerial ligation or endo viral illness that lasted 5 days after initially vascular embolization. improving ("double sickening") f,rY P0rtI r Anterior epistaxis can be managed with compression of the "There is limited evidence to guide therapy, panicularly in adults, and guidelines from major professional societies differ. alae (lower one third of the nose) for at least 5 minutes. l'Adjunctive therapy, such as intranasal saline irrigation or intranasal glucocorticoids, has been shown to alleviate symptoms and potentially decrease antibiotic use

polymer tampon may be necessary. Refractory or recurrent TABLE 61 " ,Acute Sinusitis Treatments' bleeding may rarely require embolization or surgical ligation lndications for Antibiotic First-Line Penicillin in consultation with an otolaryngologist. patients with Treatment Therapyb Allergy recurrent bleeding or unilateral epistaxis should undergo Persistent symptoms Amoxicillin- Doxycycline nasal endoscopy. Patients with recurrent personal or family of >1 0 days' duration clavulanate (adults only) history of bilateral nosebleeds should be examined for oral or amoxicillin Onset of severe symptoms or mucosal or nasal telangiectasias, with consideration of refer or signs of high fever >39 oC ral to an otolaryngologist to rule out hereditary hemorrhagic (1 02.2 "F) with purulent Levofloxacin or nasal discharge or facial moxifloxacin telangiectasias. (adults only) pain lasting for >3 Posterior bleeding may cause substantial blood loss. consecutive days or Patients with persistent or recurrent bleeding not controlled Onset o{ worsening Clindamycin by packing or nasal cauterization should be evaluated by an symptoms after a typical otolaryngologist for consideration of arlerial ligation or endo viral illness that lasted 5 days after initially vascular embolization. improving ("double sickening") f,rY P0rtI r Anterior epistaxis can be managed with compression of the "There is limited evidence to guide therapy, panicularly in adults, and guidelines from major professional societies differ. alae (lower one third of the nose) for at least 5 minutes. l'Adjunctive therapy, such as intranasal saline irrigation or intranasal glucocorticoids, has been shown to alleviate symptoms and potentially decrease antibiotic use Upper Respiratory Tract lnfection The Common Cold and regimens are described in Table 61. Patients who are Most upper respiratory tract infections are caused by viruses seriously ill, deteriorate despite appropriate antibiotic ther that infiltrate epithelial cells, leading to activation of inflam apy, or have recurrent episodes should be evaluated by an matory mechanisms that account for symptoms of fever, otolaryngologist. cough, and congestion caused by overproduction of mucosal Chronic sinusitis manifests with at least 12 r.r,eeks of nasal secretions. Rhinoviruses are the cause of most cases of the congestion with purulent drainage, diminished sense of smell, common cold. Symptoms of uncomplicated infection may or facial pain or pressure. It may be associated with nasal poly persist for up to 2 weeks after initial infection. Virus transmis- posis (with a strong association with asthma). Demonstration sion is via inhalation or direct contact with secretions infected of mucosal involvement by nasal endoscopy or imaging (typi- with viral particles. Hand hygiene through frequent washing cally CT) is necessary for diagnosis. Treatment includes gluco or use of alcohol based rubs is an effective means of prevent corticoids and antibiot ics. ing transmission. Treatment goals are focused on reducing the severity of discomfort caused by frequent coughing, sneezing, Rhinitis and subjective malaise. Antibiotic therapy is ineffective and is Allergic rhinitis involves sneezing, congestion, and rhinorrhea not recommended for either shortening duration of symptoms often linked to a seasonal allergen or other exposure. or preventing bacterial superinf'ection. Medical therapy should Nonallergic rhinitis occurs in response to nonallergic stimuli, be directed by symptoms. Analgesics may help with myalgia such as spicy loods and irritants. First line treatment ol aller and headache, whereas nasal symptoms may respond to intra gic and nonallergic rhinitis consists of avoiding precipitating nasal cromolyn, intranasal ipratropium, or combination factors and monotherapy with intranasal glucocorticoids. An decongestant/antihistamines. There is little evidence to sup- intranasal antihistamine is another option; combination ther- port the use of expectorants or mucolytics. Over-the counter apy with intranasal glucocorticoid and antihistamine may be zinc-containing intranasal products should be avoided owing used for more significant symptoms. Nonsedating oral antihis to the risk for permanent anosmia. tamines are another option. Leukotriene receptor antagonists are less effective and may cause adverse effects. Rhinitis medi Sinusitis camentosa is chronic rhinitis resulting from inappropriate Acute rhinosinusitis presents with nasal congestion, purulent long term use oftopical nasal decongestants. Treatment con- nasal discharge, facial pain/pressure, fever, or cough of less sists of cessation of the decongestant with the addition of than 4 weeks' duration. Most cases are caused by viruses, intranasal glucocorticoids when needed. allergies, or irritants. It is usually self limited; therapies that may relieve symptoms include systemic or topical deconges Pharyngitis tants, saline nasal irrigation, mucolytics, intranasal glucocor Acute pharyngitis presents as sore throat that may worsen ticoids, and antihistamines, all targeted to the patient's with swallowing; symptoms lzpically last less than 1 week. specific symptoms. Avoidance of unnecessary antibiotics rep Most cases are viral in etiolory; only 5'1, to 15% of pharyngitis resents high value care. Indications for antibiotic treatment cases are caused by bacteria, most often group A Srreptococcus

Upper Respiratory Tract lnfection The Common Cold and regimens are described in Table 61. Patients who are Most upper respiratory tract infections are caused by viruses seriously ill, deteriorate despite appropriate antibiotic ther that infiltrate epithelial cells, leading to activation of inflam apy, or have recurrent episodes should be evaluated by an matory mechanisms that account for symptoms of fever, otolaryngologist. cough, and congestion caused by overproduction of mucosal Chronic sinusitis manifests with at least 12 r.r,eeks of nasal secretions. Rhinoviruses are the cause of most cases of the congestion with purulent drainage, diminished sense of smell, common cold. Symptoms of uncomplicated infection may or facial pain or pressure. It may be associated with nasal poly persist for up to 2 weeks after initial infection. Virus transmis- posis (with a strong association with asthma). Demonstration sion is via inhalation or direct contact with secretions infected of mucosal involvement by nasal endoscopy or imaging (typi- with viral particles. Hand hygiene through frequent washing cally CT) is necessary for diagnosis. Treatment includes gluco or use of alcohol based rubs is an effective means of prevent corticoids and antibiot ics. ing transmission. Treatment goals are focused on reducing the severity of discomfort caused by frequent coughing, sneezing, Rhinitis and subjective malaise. Antibiotic therapy is ineffective and is Allergic rhinitis involves sneezing, congestion, and rhinorrhea not recommended for either shortening duration of symptoms often linked to a seasonal allergen or other exposure. or preventing bacterial superinf'ection. Medical therapy should Nonallergic rhinitis occurs in response to nonallergic stimuli, be directed by symptoms. Analgesics may help with myalgia such as spicy loods and irritants. First line treatment ol aller and headache, whereas nasal symptoms may respond to intra gic and nonallergic rhinitis consists of avoiding precipitating nasal cromolyn, intranasal ipratropium, or combination factors and monotherapy with intranasal glucocorticoids. An decongestant/antihistamines. There is little evidence to sup- intranasal antihistamine is another option; combination ther- port the use of expectorants or mucolytics. Over-the counter apy with intranasal glucocorticoid and antihistamine may be zinc-containing intranasal products should be avoided owing used for more significant symptoms. Nonsedating oral antihis to the risk for permanent anosmia. tamines are another option. Leukotriene receptor antagonists are less effective and may cause adverse effects. Rhinitis medi Sinusitis camentosa is chronic rhinitis resulting from inappropriate Acute rhinosinusitis presents with nasal congestion, purulent long term use oftopical nasal decongestants. Treatment con- nasal discharge, facial pain/pressure, fever, or cough of less sists of cessation of the decongestant with the addition of than 4 weeks' duration. Most cases are caused by viruses, intranasal glucocorticoids when needed. allergies, or irritants. It is usually self limited; therapies that may relieve symptoms include systemic or topical deconges Pharyngitis tants, saline nasal irrigation, mucolytics, intranasal glucocor Acute pharyngitis presents as sore throat that may worsen ticoids, and antihistamines, all targeted to the patient's with swallowing; symptoms lzpically last less than 1 week. specific symptoms. Avoidance of unnecessary antibiotics rep Most cases are viral in etiolory; only 5'1, to 15% of pharyngitis resents high value care. Indications for antibiotic treatment cases are caused by bacteria, most often group A Srreptococcus 79

Ear, Nose, Mouth, and Throat Disorders pAogenes. Features suggesting the more common viral cause include concomitant cough, conjunctivitis, corga, hoarse- ness, and oral ulcers. Patients with viral pharyngitis should be treated conservatively with symptom control (such as analge- sics [NSAIDs or acetaminophenl, lozenges or topical sprays, and increased environmental humidity). In bacterial pharyn gitis, appropriate antibiotic treatment reduces the risk for rheumatic fever, suppurative complications (such as periton- sillar or retropharyngeal abscess), duration of symptoms, and transmission. The Centor criteria (fever by history tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough) can help guide the need for testing and treatment of bacterial pharyngitis. Because the Centor criteria have a low positive predictive value for determining the pres ence of group A streptococcal infection, the best strateg/ may be to use the criteria to identi$z patients who have a Iow prob- FIG U RE 2 7. Endoscopic image o{ epiglottitis shows hyperemic and engorged ability of infection. The Infectious Diseases Society of surrounding structures, occluding portions of the airway. American suggests that patients with fewer than 3 Centor cri Reproduced from Wikimedia Commons. Epiglottilis endoscopy. Digltal image. hnps://commons.wikimedia.org/ teria do not need to be tested. Patients with a Centor score of 1 wiki/File:Epiglottitis endoscopy.jpg.June20,20l3.AccessedJune26,2021.

pAogenes. Features suggesting the more common viral cause include concomitant cough, conjunctivitis, corga, hoarse- ness, and oral ulcers. Patients with viral pharyngitis should be treated conservatively with symptom control (such as analge- sics [NSAIDs or acetaminophenl, lozenges or topical sprays, and increased environmental humidity). In bacterial pharyn gitis, appropriate antibiotic treatment reduces the risk for rheumatic fever, suppurative complications (such as periton- sillar or retropharyngeal abscess), duration of symptoms, and transmission. The Centor criteria (fever by history tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough) can help guide the need for testing and treatment of bacterial pharyngitis. Because the Centor criteria have a low positive predictive value for determining the pres ence of group A streptococcal infection, the best strateg/ may be to use the criteria to identi$z patients who have a Iow prob- FIG U RE 2 7. Endoscopic image o{ epiglottitis shows hyperemic and engorged ability of infection. The Infectious Diseases Society of surrounding structures, occluding portions of the airway. American suggests that patients with fewer than 3 Centor cri Reproduced from Wikimedia Commons. Epiglottilis endoscopy. Digltal image. hnps://commons.wikimedia.org/ teria do not need to be tested. Patients with a Centor score of 1 wiki/File:Epiglottitis endoscopy.jpg.June20,20l3.AccessedJune26,2021. or less do not need to be tested; patients with two criteria can be considered for testing. Patients with three or more Centor Patients with epiglottitis typically appear seriously ill, with criteria should be tested by using a rapid antigen detection excessive salivation due to difficulty managing oral secretions, test. Antibiotic treatment is reserved for patients with positive tachypnea and stridor, and severe odynophagia and dysphagia. test results; penicillin and amoxicillin are first line therapies. Although adults with acute epiglottitis are less likely than Throat culture should be considered in patients who are at children to progress to airway obstruction, if severe acute epi high risk for complications (immunocompromised state) in glottitis is suspected and airway obstruction seems imminent, the setting of high clinical suspicion but negative results on airway control should precede diagnostic evaluation. On phys rapid antigen detection testing. ical examination, the epiglottitis and surrounding structures Fusobecterium necrophorum infection can cause appear hyperemic and engorged, occluding portions of the Lemierre syndrome, a rare suppurative complication of phar airway (Figure 27). Radiographic imaging with ultrasonogra- yngitis caused by local spread ofinfection with resultant septic phy or plain radiography may be helpful in gauging the sever thrombosis of the internal jugular vein. Preexisting immuno- ity of neck tissue inflammation and predicting likelihood of suppression is not the rule, and it typically occurs in otherwise progression. Patients rarely require intubation or tracheos- healthyyoung adults. Clinicians should suspect Lemierre syn tomy; hospital admission is recommended. often to an ICU drome in patients with severe pharyngitis and neck pain and setting and with surgical consultation, in the event that tra in those who do not respond to appropriate antibiotics. cheostomy or intubation is required. Treatment consists of Diagnosis is made with contrast CT of the neck. immediate parenteral antibiotic therapy and regular airway (EY POI I{TS reassessment. Parenteral glucocorticoids may have a role in some cases to reduce airway inflammation, but their use is not HVC o Acute rhinosinusitis is usually caused by viruses, aller- yet standardized. gies, or irritants, and avoidance of unnecessary antibi- otics represents high value care. XEY POIilT

or less do not need to be tested; patients with two criteria can be considered for testing. Patients with three or more Centor Patients with epiglottitis typically appear seriously ill, with criteria should be tested by using a rapid antigen detection excessive salivation due to difficulty managing oral secretions, test. Antibiotic treatment is reserved for patients with positive tachypnea and stridor, and severe odynophagia and dysphagia. test results; penicillin and amoxicillin are first line therapies. Although adults with acute epiglottitis are less likely than Throat culture should be considered in patients who are at children to progress to airway obstruction, if severe acute epi high risk for complications (immunocompromised state) in glottitis is suspected and airway obstruction seems imminent, the setting of high clinical suspicion but negative results on airway control should precede diagnostic evaluation. On phys rapid antigen detection testing. ical examination, the epiglottitis and surrounding structures Fusobecterium necrophorum infection can cause appear hyperemic and engorged, occluding portions of the Lemierre syndrome, a rare suppurative complication of phar airway (Figure 27). Radiographic imaging with ultrasonogra- yngitis caused by local spread ofinfection with resultant septic phy or plain radiography may be helpful in gauging the sever thrombosis of the internal jugular vein. Preexisting immuno- ity of neck tissue inflammation and predicting likelihood of suppression is not the rule, and it typically occurs in otherwise progression. Patients rarely require intubation or tracheos- healthyyoung adults. Clinicians should suspect Lemierre syn tomy; hospital admission is recommended. often to an ICU drome in patients with severe pharyngitis and neck pain and setting and with surgical consultation, in the event that tra in those who do not respond to appropriate antibiotics. cheostomy or intubation is required. Treatment consists of Diagnosis is made with contrast CT of the neck. immediate parenteral antibiotic therapy and regular airway (EY POI I{TS reassessment. Parenteral glucocorticoids may have a role in some cases to reduce airway inflammation, but their use is not HVC o Acute rhinosinusitis is usually caused by viruses, aller- yet standardized. gies, or irritants, and avoidance of unnecessary antibi- otics represents high value care. XEY POIilT HVC r Patients with acute pharyngitis who present with fewer . Treatment of epiglottitis consists of immediate parenteral than three Centor criteria do not need to be tested or antibiotic therapy and regular airway reassessment; intu treated for bacterial pharyngitis. bation or tracheostomy is rarely required.

HVC r Patients with acute pharyngitis who present with fewer . Treatment of epiglottitis consists of immediate parenteral than three Centor criteria do not need to be tested or antibiotic therapy and regular airway reassessment; intu treated for bacterial pharyngitis. bation or tracheostomy is rarely required. Epiglottitis Salivary Gland Disorders Epiglottitis is a rare, severe inflammatory response to upper The salivary glands include the major (parotid, submandibu- respiratory tract infection that can cause partial or complete lar, and sublingual) salivary glands and thousands of minor airway obstruction; it requires emergent identification and salivary glands. Disorders ofthe salivary gland includes sialad- intervention. Immunization wittr Haemophilus influenzae enitis, salivary gland stones (sialolithiasis), and salivary gland type B vaccine has shifted the causative agents from this classic tumors. bacterial strain to a broad range of community-acquired res- Acute sialadenitis typically presents with sudden onset piratory pathogens, including Streptococcus pneumoniae. ofacute pain and swelling ofthe affected salivary gland and 80

Ear, Nose, Mouth, and Throat Disorders may be accompanied by fever, chills, and malaise. Sialadenitis typically has a bacterial cause, most commonly Staphylococcus eureus; less common causes include viral infection (mumps, cytomegalovirus, HIV), mycobacterial infection, and recent radiation therapy. Conditions that decrease salivary flow increase the risk for sialadenitis; these include volume depletion, Sjdgren syndrome, poor oral hygiene, sialolithiasis, malnourishment, prior radia- tion therapy, and use of anticholinergic medications. Physical examination often reveals tenderness and ery thema over the affected gland. The parotid gland can be palpated from the earlobe forward to the gumline of the second upper molar, where the Stensen duct opens. The Wharton duct, the opening of the submandibular gland, can be felt along the floor or the mouth when palpating i from posterior to anterior. Stones may be palpated and are typically tender, small, and hard, whereas tumors are typi cally firm and nontender. Manual palpation may result in pus exuding from the duct's orifice, whereas a healthy t I G U R E 2 8. Dental caries (cavities or tooth decay) represents localized gland exudes clear saliva. Purulent drainage can be cul destruction of dental hard tissues and appears as black or brown spots on the tured to direct antibiotic therapy. An obstructed duct, how- surface of the tooth(arrowsl. ever, will excrete no fluid on palpation. Management of Modified from Neryal. Tooth with extensive evidence of dental caries. Digital image. htrpsr/commons. wikimedia.0rg/wiki/File:Toothdecay_(1).jpg.Jaruary21,2004.AccessedJune26,2021. sialadenitis and sialolithiasis includes stimulation of saliva production with warm compresses and sialagogues (sour Licensed under the Creative Commons Attribution ShareAlike 3.0 Unp0rted (CC 8Y'SA 3.0) lnternational License (httpsJ/(reativecommons.org/licenses/by-sa/3.0/deed.en). candies or vitamin C lozenges); salivary gland massage; increased fluid intake; oral hygiene; and, in cases ofbacte- rial sialadenitis, antibiotics. Recurrent sialolithiasis can on examination (Figure 28). Pulpitis occurs when the erosion result in chronic sialadenitis, and chronic obstruction can extends down to the pulp cavity, requiring removal of the car- lead to salivary gland atrophy. ies and placement of a filling. If untreated, the erosion can Salivary gland tumors most commonly present as a affect the root or cause periodontitis requiring root canal or painless salivary gland mass; facial paralysis and lymphad- tooth extraction, or an abscess requiring incision and enopathy increase concern for malignancy. Previous radia- drainage. tion therapy, smoking history, and viral infection Ludwig angina is a life-threatening infection of the floor (Epstein-Barr virus, HIV human papillomavirus) are com- of the mouth and should be suspected in patients with sub- mon causes. Contrast-enhanced CT or MRI and tissue mandibular swelling and edema of the mouth floor, drooling, biopsy, typically with fine needle aspiration, are the first neck pain, dysphagia, or dysphonia. Ludwig angina often steps in evaluation. originates from the second and third lower molar teeth and can cause airway obstruction caused by supraglottic edema. The causative pathogen is usually Viridians streptococci. o Management of sialadenitis and sialolithiasis includes Treatment requires urgent CT; blood cultures; airway manage- stimulation of saliva production with warm compresses ment precautions; broad-spectrum antibiotic therapy; and, if and sialagogues (sour candies or vitamin C lozenges); sal- indicated, surgical drainage. ivary gland massage; increased fluid intake; oral hygiene; Nearly half of U.S. adults have periodontal disease, which and, in cases ofbacterial sialadenitis, antibiotics. is associated with increased risk for diabetes and cardiovascu- lar disease. Gingivitis (inflammation of the gums) is the initial manifestation of periodontal disease (Figure 29). Gingivitis is Oral Health reversible with routine dental visits and cleanings, brushing Dental Disease and lnfections with fluoride toothpaste, flossing, fluoride varnish anticavity Poor oral hygiene is one of most common chronic conditions treatment. and use of chlorhexidine oral rinses. Periodontitis in the United States and affects overall health and quality of affects the periodontal ligament and presents with halitosis, life. Dental caries are caused by bacteria. Certain foods and inflamed gums that bleed easily, tooth sensitivity, and pain. beverages (especially those containing sugar) leave bacteria in Treatment is the same as that for gingivitis with the addition the mouth, creating an acidic environment that erodes enamel ofscaling and root planning. and dentin, causing tooth sensitivity or pain and inflamma- Necrotizing ulcerative gingivitis, formerly called Vincent tion. The stained pits and fissures of dental caries can be seen angina, is characterized by halitosis, oral pain, and ulcerated

may be accompanied by fever, chills, and malaise. Sialadenitis typically has a bacterial cause, most commonly Staphylococcus eureus; less common causes include viral infection (mumps, cytomegalovirus, HIV), mycobacterial infection, and recent radiation therapy. Conditions that decrease salivary flow increase the risk for sialadenitis; these include volume depletion, Sjdgren syndrome, poor oral hygiene, sialolithiasis, malnourishment, prior radia- tion therapy, and use of anticholinergic medications. Physical examination often reveals tenderness and ery thema over the affected gland. The parotid gland can be palpated from the earlobe forward to the gumline of the second upper molar, where the Stensen duct opens. The Wharton duct, the opening of the submandibular gland, can be felt along the floor or the mouth when palpating i from posterior to anterior. Stones may be palpated and are typically tender, small, and hard, whereas tumors are typi cally firm and nontender. Manual palpation may result in pus exuding from the duct's orifice, whereas a healthy t I G U R E 2 8. Dental caries (cavities or tooth decay) represents localized gland exudes clear saliva. Purulent drainage can be cul destruction of dental hard tissues and appears as black or brown spots on the tured to direct antibiotic therapy. An obstructed duct, how- surface of the tooth(arrowsl. ever, will excrete no fluid on palpation. Management of Modified from Neryal. Tooth with extensive evidence of dental caries. Digital image. htrpsr/commons. wikimedia.0rg/wiki/File:Toothdecay_(1).jpg.Jaruary21,2004.AccessedJune26,2021. sialadenitis and sialolithiasis includes stimulation of saliva production with warm compresses and sialagogues (sour Licensed under the Creative Commons Attribution ShareAlike 3.0 Unp0rted (CC 8Y'SA 3.0) lnternational License (httpsJ/(reativecommons.org/licenses/by-sa/3.0/deed.en). candies or vitamin C lozenges); salivary gland massage; increased fluid intake; oral hygiene; and, in cases ofbacte- rial sialadenitis, antibiotics. Recurrent sialolithiasis can on examination (Figure 28). Pulpitis occurs when the erosion result in chronic sialadenitis, and chronic obstruction can extends down to the pulp cavity, requiring removal of the car- lead to salivary gland atrophy. ies and placement of a filling. If untreated, the erosion can Salivary gland tumors most commonly present as a affect the root or cause periodontitis requiring root canal or painless salivary gland mass; facial paralysis and lymphad- tooth extraction, or an abscess requiring incision and enopathy increase concern for malignancy. Previous radia- drainage. tion therapy, smoking history, and viral infection Ludwig angina is a life-threatening infection of the floor (Epstein-Barr virus, HIV human papillomavirus) are com- of the mouth and should be suspected in patients with sub- mon causes. Contrast-enhanced CT or MRI and tissue mandibular swelling and edema of the mouth floor, drooling, biopsy, typically with fine needle aspiration, are the first neck pain, dysphagia, or dysphonia. Ludwig angina often steps in evaluation. originates from the second and third lower molar teeth and can cause airway obstruction caused by supraglottic edema. The causative pathogen is usually Viridians streptococci. o Management of sialadenitis and sialolithiasis includes Treatment requires urgent CT; blood cultures; airway manage- stimulation of saliva production with warm compresses ment precautions; broad-spectrum antibiotic therapy; and, if and sialagogues (sour candies or vitamin C lozenges); sal- indicated, surgical drainage. ivary gland massage; increased fluid intake; oral hygiene; Nearly half of U.S. adults have periodontal disease, which and, in cases ofbacterial sialadenitis, antibiotics. is associated with increased risk for diabetes and cardiovascu- lar disease. Gingivitis (inflammation of the gums) is the initial manifestation of periodontal disease (Figure 29). Gingivitis is Oral Health reversible with routine dental visits and cleanings, brushing Dental Disease and lnfections with fluoride toothpaste, flossing, fluoride varnish anticavity Poor oral hygiene is one of most common chronic conditions treatment. and use of chlorhexidine oral rinses. Periodontitis in the United States and affects overall health and quality of affects the periodontal ligament and presents with halitosis, life. Dental caries are caused by bacteria. Certain foods and inflamed gums that bleed easily, tooth sensitivity, and pain. beverages (especially those containing sugar) leave bacteria in Treatment is the same as that for gingivitis with the addition the mouth, creating an acidic environment that erodes enamel ofscaling and root planning. and dentin, causing tooth sensitivity or pain and inflamma- Necrotizing ulcerative gingivitis, formerly called Vincent tion. The stained pits and fissures of dental caries can be seen angina, is characterized by halitosis, oral pain, and ulcerated 81