Download Sheet #4 / Hussain Al jumaie

24/2/2015
GS sheet 4
Hussein Al-Jemaie
Otalgia
What do we mean by otalgia? Pain in ear.
Anatomy of ear:
The ear is divided into 3 parts: the inner part, middle part, external part.
The external part divided into: external auditory canal and the concha ..
The middle part composed of 3 parts: malleus,incus,stapes.
The inner part .......
We have primary otalgia and secondary otalgia..
Primary otalgia: is a pain because of a disease involving the ear itself .
Secondary otalgia: we have a disease
and the pain is referred to the ear.
The pain is outside the ear and we have several nerves that transfer the pain from distal part of the
body to the ear. Those nerves are trigeminal nerve, facial nerve, glssopharyngeal nerve, vagus
nerve, cervical plexus (posterior part mainly c2,c3)
Now, primary otalgia, there are specific diseases or conditiins that cause primary otalgia, those are
involving the ear like .............otitis externa (mainly otitis media)
Secondary otalgia mainly referred pain from trigeminal nerve (sensory) like tooth pain,
malocclusion , impacted wisdom tooth dental caries , dental infection ,TMJ arthritis ,TMJ disease ,
and acute sinusitis.
Now, regarding the facial nerve, certain conditions cause referred pain and otalgia mainly herpes
zoster it is viral infection caused by vercilla zoster virus. It due to the reactivation of virus in the
.............. ganglion of the facial nerve.
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Hussein Al-Jemaie
Glssopharyngeal nerve referred otalgia mainly because of oral cavity disease like tonsillitis,
preitonsilar abscess and glossopgaryngeal neuralgia .. WE WILL TALK ABOUT THE LATER
VAGUS NERVE, this nerve transfer any disease or ulcer in the larynx or just below to oropharynx
as a referred otalgia due to the activation or irritation of the vagus nerve.
Posterior part of the cervical plexus mainly c2 and c3 : we have cervical disc lesions and cervical
........ arthritis will cause referred otalgia.
Now, we will talk about the anatomy of the nose
External part: divided into bony part and cartilaginous part.
bony part: nasal bones
And just distal to nasal bones is the upper lateral cartilages and lower lateral cartilages and in
between them we have multiple sesamoid cartilages that have a role in the shape and formity of the
nose.
Now, the 2 nasal cavities are separated by the nasal septum which is divided into posterior bony part
and anterior cartilaginous part.
Each nasal cavity is composed of 3 parts: first the vestibule and its lined by skin and small part ........
, second the respiratory part is considered histologically to have respiratory mucosa , and the upper
part (3rd part) is the olfactory epithelium which is the sensory organ that sense the smell through the
olfactory nerve
Now, regarding the lateral wall of the nose, it has three turbinate or conchae , the inferior, middle,
superior. Regarding these turbinate, underneath each of those we have meatus (a small opening that
drain mucus and pus from the sinuses) .
Now, regarding the superior meatus, it proceed posteriorly to the sphenoid sinus. The middle meatus
drain from the paranasal sinuses: frontal, posterior ethmoidal, maxillary sinuses. The inferior
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Hussein Al-Jemaie
meatus, it just drain from lacrimal duct (from the internet: the inferior meatus is the largest of the
and lies below the inferior concha and above the nasal cavity. It extend most of the length of the
nasal cavities lateral wall. it presents anteriorly the lower orifice of the nasolacrimal canal)
Anatomy of the paranasal sinuses: they are 4 pairs
The maxillary, sphenoid, ethmoid, and the frontal.
Now regarding the maxillary sinus, it is the largest sinus and it opens in the middle meatus in the
lateral wall, it is closely related to upper 6 and 7.
The frontal sinus, it opens in middle meatus also...
the ethmoidal sinus is divided into anterior ethmoidal and posterior ethmoidal by the middle
................
The sphenoid sinus just open into the sphenoedmoidal reccess which is considered a posterior
groove in the paranasal sinuses.
So the anterior sinuses are maxillary, frontal, ant. ethmoidal. And the posterior sinuses are the post.
ethmoidal and the sphenoid.
facial pain:
Now facial pain is considered a neuro pain, denral pain , TMJ pain, facial pain of ........ origin.
Neuro pain :
1)primary neurolagia: divided into typical such as trigeminal neurolagia or glossopharyngeal
neurolagia and atypical called atypical facial neurolagia.
2) secondary neurolagia: centric and post synthetic neurolagia.
Dental pain:
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Hussein Al-Jemaie
Mainly caused by impacted wisdom teeth. Many patients come to our clinics complaining od facial
dental pain and one of the differential diagnosises is impacted wisdom tooth.
Dental infection and dental extractions can also cause facial pain.
Mainly we can differentiate between these pain by taking good history to know the history of the
pain.
Now, facial pain of ear origin maybe because of acute otitis media, otitis externa, and acute sinusitis
.
TMJ can cause facial pain and referred otalgia.
Otitis externa or external otitis
It is an inflammatory process that involving the external auditory canal and the external ear. The
cause can be bacterial, fungal, and mixed.(maybe due to systemic diseases but rare)
The pain is sever and throbbing that usually interfere with jaw movement and pressure on the
??????? so that’s why its cause referred otalgia
Acute sinusitis:the pain in acute sinusitis is
a constant feature of acute sinusitis
. each sinus has a unique
characteristics of pain. maxillary sinusitis pain mainly over the cheeks and that is increased with
bending and coughing . the ethmoidal pain is mainly found between the eyes or the inner canthi of
the eyes. frontal pain found over the forehead and causes defacting? headache or the office hours
headache. sphenoid pain is deeply seated and causes posterior occipital headache and really associated
with occipital headache all the time.
Atypical facial neuralgia:
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Hussein Al-Jemaie
Its caused by unnecessary dental extractions, the pathology is not always known. we may
refer any patient to dentist to perform an extraction, but the main problem (pain) do not
resolve so it is atypical facial neuralgia.
Most of these patients having atypical facial neurolagia are females and they have
psychological factors (psychological factors plays a role in this disease).
Its characterized by recurrent pain (continuous burning) over the cheeks and ears and it could
be by pathogen.
Now, epistaxis ‫الرعاف‬
Its bleeding from the nose and it could be from the septum, lateral walls, nasopharyx.and the
vestibule.
Dental causes of epistaxis : traumatic dental extraction, maxillofacial trauma, antral fistulae
m dental maxillary sinusitis and tumors of dental origin .
Treatment of epistaxis: first we should control the bleeding as soon as we have the patient
coming to the emergency department complaining of epistaxis we should give him some
instructions first we should punch off the nose and punching should be in the cartilaginous
part of the nose not over the bony part it’s a common mistake. So punch off the nose and
pulling down the face.
After that we should use suctioning to evacuate blood from the nasal cavity and then we
apply adrenaline of congesting packs in order to identify the source of the bleeding (we put
the adrenaline in the nasal cavity we swab the gauze by adrenalin and we apply them inside
the nasal cavity, we use the tip to apply it most posteriorly).
After that we should identify the source of bleeding if we identified the source of the
bleeding we go directly for cotalization??. Catalization is divided into electrical and cavited .
Now, if we couldn't identify the source of the bleeding and we have still epistaxis either
anterior or posterior we go for nasal packs that is luted with Vaseline or wetable lubricant
and should be inserted inside the nasal cavity over days.
Now, if we fail to control epistaxis by nasal packs, mainly we apply pressure on the vessels
to contract them and stop epistaxis.
If we failed to control epistaxis using this method we could go for imaging, ligation or
embolization and sometimes we go for surgeries in order to stop epistaxis .
Most common sites for epistaxis :
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Is the anterior part of the nasal septum called nitils area or cusedarsplexus (not sure about it)
is the connection between different plexus that is found in the anterior part of the nasal
septum so it is the common part to have epistaxis in young and old patient .
Now, regarding the maxillary sinusitis , the etiology is:
1) URI- genic or nasal causes: its almost always the cause of maxillary sinusitis it consist of
80% of maxillary sinusitis.
URIgenic it means upper respiratory tract infection by viral or bacterial infection that causes
inflammation of the nasal cavity and the Ostia of the nasal cavity leading to ……………
Regarding the dental causes of maxillary sinusitis it causes always 10% of max. sinusitis. Its
divided into periapical abscess of upper second premolar and upper first, second molars as
you know these teeth are near the floor of the max. Sinus so any infection or abscess
involving those teeth will cause referred sinusitis and drainage into the maxillary sinus .
Now, for the extractions we may end up with oroantaral fistula so we have an opening
between the oral cavity and the nasal cavity and this will lead to recurrent infection .
Now, traumatic causes like foreign bodies may cause max. sinusitis.
Clinical picture of maxillary sinusitis:
As we said before it is an infection and inflammation so we should see systemic
manifestations such as fever , fatigue, malaise , facial pain and …………
Now, regarding the pain its specific for the maxillary sinus. Its over the cheeks and radiates
to teeth on dig down, coughing , ………
On examination we have (mucopargo struch) just drain from the max. sinus into the nasal
cavity this could be drain anteriorly through the nostrils or could drain posteriorly through
the post nasal strip and the oropharynx.
Now, in dental infections the discharge is characteristically unilateral, malodorous due to an
aerobic dental organisms.
Chronic maxillary sinusitis:
The diagnosis is usually clinical diagnosis, we have major and minor criteria .
If we have 2 major or 1major and 2 minors , the we have chronic sinusitis .
Mainly we have nasal and postnasal (mucous) discharge , nasal obstruction , facial pain and
headache and we have hyposmia or glossomia which is decreased sense of smell.
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Hussein Al-Jemaie
Investigation:In the acute sinusitis there is no need to for etiological or any type of investigations since it is
clinical diagnosis but if we want to aid our diagnosis with any radiological evidence we go
for plain radiology . what we can see in acute sinusitis in radiograph?
As it is an acute infection we will see air fluid bevel in the sinus. The view we take is
circumomental view of the maxillary sinus .
Now, regarding the chronic sinusitis, the radiological evidence to aid our diagnosis is the CT
scan . it is mainly clinical diagnosis but we can conform our diagnosis by CT scan.
CT scans are divided into coronal and axial cuts and that will aid in our diagnosis. (pic in
slides)As we see over here this is a coronal CT scan involving the nose and the paranasal
cavities . this is the nasal septum as we can see very close to max. sinus . these are the
ethmoidal sinuses , those are the inferior turbinate and those are the inferior turbinates.
Treatment of acute sinusitis:
As we said its an infection so we need an antibiotic , and the drug of choice is the
amoxicillin but due to the resistance we use the combination of amoxicillin with clavulanate
acid (Augmentin) . also we aid our treatment with nasal decongestant and supportive
treatment such as vitamin C and fluids.
Now, chronic sinusitis is divided into medical managements and surgical managements.
Medical management of chronic sinusitis:
We give antibiotics and go for one month and the drug of choice is clarithromycin .
If medical treatment fails we go for surgical
treatment :
The surgery of choice for chronic sinusitis is the functional endoscopic sinus surgery .
Now, another method we use to treat chronic sinusitis is called cold weather
approach. Its used by dentist or maxillofacial surgeons. its called cold weather due to
dental …………. Procedure. First of all it is sublabia accrosstomy . Now, we have the
sublabial incision of the upper lip and we go directly to the anterior wall of the maxillary
sinus .
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GS sheet 4
Hussein Al-Jemaie
Indication of cold weather approach:
1) foreign body in the maxillary sinus .
2) an accessible point in the ptyrgopalatine fossa .
3) insertion of submucosal implants.
4) some portions that the endoscope cant reach such as cysts and tumors.
Complications of cold weather approach:
1) it may cause sublabial oroantral fistula.
2) it may cause trauma to the roots of teeth .
3) it may injure the nerves and blood supply .
4) it may cause devitalization of teeth .
5) it may infraorbital neuralgia due to trauma to infraorbital nerve .
Now, regarding the oroantral fistula:
What do we mean by fistula? (its an epithelial communication between the oral cavity and
the antrum of the sinus).
Types of oroantral fistulae: alveolar, sublabial, and oncolatal.
Alveolar is the commonest type and usually follows traumatic extractions so you should be
cautions with your procedures because it may cause oroantral fistula.
Sublabial may arias as a complication from cold weather procedure
Oncolatal mainly due to systemic diseases syphilis, malignancy and following ………….
Operation.
Clinical picture of alveolar fistula:
Mild epistaxis at the time of extraction , escape of blood or fluid from the nose , escape of air
from the fistula itself during blowing from the nose .
(usually the main feature seen in oroantral fistula or alveolar fistula is unilateral nasal
discharge with a bad odor)
Also, we may have pain over the cheeks .
Investigations: (usually its clinical diagnosis)
X-rays , CT scan in order to determine the disease itself .
Treatment of oroantral fistula:
It’s a recent fistula so diagnoses as soon as possible by right of the dental procedure we will
go for direct of primary closure. if we have bone fistula but its small we go for closure . now
closure is refreshing the edges of mucosa lining the oral cavity and we have to suture that
mucosa . now if we have a large oroantral fistula we should first of all clean the wound area
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Hussein Al-Jemaie
involving the maxillary sinus using oral antibiotics or endoscopic sinus surgery procedures
then we will go for the aid of flap in order to close the fistula.(the flap could be palatal flap
or buccal flaps mainly are used to close the oroantral fistula)
Ectopic teeth:
Ectopic teeth is a common cause of causing nasal discharge and epistaxis . ectopic teeth
could be cogental or traumatic . (25.15-25.30)
The clinical picture of ectopic teeth is unilateral nasal obstruction, unilateral nasal discharge.
The treatment of ectopic tooth into the nasal cavity is removal.
Benign tumors:
Benign tumors of the head and neck or the face ..
Osteoma :
Its considered the commest benign tumors of the head and neck . it maybe asymptomatic
(mostly asymptomatic up to 90%) and is accidentally found on CT scans and plain
radiograph or x-rays.
Fibrous dysplasia:
Slowly growing bony swelling of the cheeks in young adults. Actually it involves the maxilla
and the mandible and it of common presentations in certain areas .
Maxillary carcinoma:
You should know that maxillary carcinoma is the most common malignant tumor of
paranasal sinuses .
The most common type of malignant tumor to the paranasal sinuses is squamous cell
carcinoma. Mainly affects males and the ……….. sinus is one decides of focal primaries in
head and neck .
Clinical picture of maxillary carcinoma:
We have unilateral nasal obstruction , discharge , and epistaxis. Also, we have swelling of
the face, proptosis, and loss of hear .
CT scan and MRI is important in the diagnosis of paranasal sinusitis carcinomas. They give
us an idea about the extension of the disease and its used for (spaging webcum??) of patient
having carcinoma.
Treatment of maxillary carcinoma :
Surgical, chemotherapy, radiotherapy or combined approach both surgical with
chemotherapy and radiotherapy.
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GS sheet 4
Hussein Al-Jemaie
As we can see here the use of the nasal endoscope we can see a mass originating from the
right maxillary sinus and the CT scan coronal view shows opacification of the max. sinus
discharging of the maxillary sinus Ostia and the floor of the orbit .
Halitosis: (bad breath)
The causes maybe related to oral , nasal , and GIT .
Oral causes: mainly because of dental caries , dental infection, abscess , and poor oral
hygiene .
Now, extraoral causes of halitosis sinuses may cause halitosis due to chronic infection.
Chronic infection will lead to chronic nasal discharge and this will cause chronic post nasal
drip that will cause halitosis.
Now, Tonsils, chronic tonsillitis is the main cause of halitosis.
GIT: most of the studies and the recent articles support the halitosis is due to GI disease. the
most common cause of the GI is gastric esophageal reflux (frangula retro … reflex).
Now, tracheobroncial tree , such as bronchitis can lead to halitosis .
You should know that the gastric esophageal reflux disease is a common cause of halitosis
and we should treat those patients with (29.38) in order to avoid the complications .
Trismus:
Trismus by definition is limitation in jaw opening. It has a relation with lateral pterygoid
muscle.
Causes:
1) Dental infections:
2) Impacted wisdoms.
3) Separation around the pharynx such as peritosilar and parapharyngeal.
4) External otitis or otitis externa.
5) Tumors.
Whenever we have a pathology involving the head and neck and around the c- temporary
pterygoid muscles it will cause trismus and limited mouth opening.
Adenoids:
Is a common disease that we practice in our clinics. Most pediatrics age group has large
adenoids and after the age of 7 we have limited adenoids and it just decrease in size.
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Hussein Al-Jemaie
Most of the patients with large adenoids complain of snoring at night and mouth breathing
(most of them are mouth breathers). Now , due to their large adenoids which occupy the post
nasal space or the nasopharynx we have decreased air entering the nose into the nasal cavity
so they will breath from their mouths and we will have an open mouth and dry lips (those are
adenoids features).
Q in exam: all of the following are feature of adenoid except?
So, open mouth, thick dry lips, etched?? Upper lip, protruded incisors, faulty Bite, dental
caries , I ach palate, flat nasolabial fold , mucoid nasal discharge , and inactive labial nasii
(muscle in front of nasal vestibule) due to decreased use of muscles of the nasal cavity.
Investigation:
X-ray shows the post nasal space. it’s a lateral view of the post nasal space that show a large
adenoid.
Treatment:
Actually the treatment of adenoids we go for surgery called adenectomy.
Tonsillitis:
Common emergency.
Acute tonsillitis is an infective process involving the tonsils. It can be divided into :
parenchyma , follicular , membranous , catarrhal .
Most common cause of follicular tonsillitis is streptococcus groups.
Clinical picture:
Fever, sore throat , dysphasia , coated tongue , halitosis , congestive tonsils , large tender
jugulodigastric lymph nodes.
Catarrhal means viral infection.(not superimposed bacterial infection)
Differential diagnosis:
Any disease involving the oropharynx could be differential diagnosis for acute tonsillitis.
Mainly we should identify diphtheria (not a common cause usually), but if you have a patient
with diphtheria having ………. Involving the tonsils can be the oropharynx and when
sloughing the membrane he will experience a severe pain.
Complication of acute tonsillitis:
1) Peritonsillor abscess .
2) Otitis media.
3) Autoimmune disorders.
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Treatment of acute tonsillitis:
Oral antibiotics and systemic antibiotics.
(34.20-34.40)
Peritonsillar abscess: (or wenzy?)
Its puss collection between the capsule of the tonsil and the superior constrictor muscle.
Types: mostly superior upper medial part of the tonsil mainly the soft palate AND lateral
part or inferior part (not common 2% of cases and its due to dental …….. such as infection
or after extractions.
Clinical picture:
Throb pain, trismus, halitosis, fever, and otalgia due to referred pain through the
glossopharyngeal nerve.
Signs of pertonsillar abscess:
Tonsils are congested and pushed medially, pus formation pushes the tonsils medially .the
uvula which is a midline structure is pushed to the contralateral side due to pus formation .
the uvula will be edematous uvula torticolis due to irradiation of sternoclidomastoid muscle.
Also we may have coated tongue.
Complications of wenzy:
Its spread of the abcess or the infection into the salivary structures such as the copharyngeal
abscess and pharyngeal edema and cause septicemia and sepsis.
Treatment of peritonsillar abscess:
If we have minimal pus formation or cellulites we can go for systemic antibiotics (IV
antibiotics) and the drug of choice is ceftriaxon and home care.
Now, if medical therapy fails and there is big pus seen in the peritonsillar space we will go
for incision and drainage &evaluation of the pus and internal counseling (after the resolution
of the infection we counsel the patient for 6 weeks to 2 month).
Parapharyngeal abscess:
It’s a suppuration in the parapharyngeal space .
Etiology: could be dental infection, peritonsillar abscess , and trauma involving the neck.
Clinical picture :
As a systemic infection pain, fever, malaise, but the sinus tonsils at the pharyngeal wall are
pushed medially away from the abscess formation, tenderness over the neck , trismus .
Complications:
Pharyngeal edema, sepsis, jugular pain, thrombosis.
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Hussein Al-Jemaie
Treatment:
By external drainage and antibiotics.
Retropharyngeal abscess:
Pus formation in the retropharyngeal space (retropharyngeal space is only found-common- in
pediatric patient and is regumentary? At the age of 6)
We may have retropharyngeal abscess in elderly patient and its due to tuberculosis and
malignancy.
Clinical picture:
Difficult feeling and breathing, choking, coughing, and characteristic cyst to one side of the
…..
If we take an x-ray we will see widening in the retropharyngeal space.
Complication:
Stridor and rupture.
'
Treatment:
Drainage and antibiotic.
(Chronic retropharygeal abscess , the underlying cause is usually TB infection or
malignancy)
Ludwig angina:
Infection of the submandibular and submental spaces (and sunlingual from internet). Its
cellulitis not abscesses, so the management first of all will be antibiotics.
We usually in any abscess we go for incision and drainage but here in cellulites we give a
chance for antibiotics because if we go for drainage we will find fragments because cellulites
is fluidly planes in the submandibular and submental regions.(important)
Etiology:
Dental infection (from internet 80% , trauma.)
Most common pathogenic microorganism?
Mixed aerobic and anaerobic staphs.
Clinical picture:
Fever,dysphagia, stridor.
Treatment:
Antibiotics, we never go for incision and drainage, we may need trachestomy.
Ludwig angina due to an inflammatory process involving the oropharynx we should secure
the airways either by inserting an endotracheal tube, if we failed we go for trachestomy.
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Hussein Al-Jemaie
Stridor: )‫(صفير‬
Difficult, noise breathing due to obstructed upper air ways.
Classification:
Inspiratory: mostly in the upper – laryngeal obstruction. )‫(تلجد‬
Expiratory: mostly lower – bronchial obstruction.
Mixed: usually tracheal.
E7fazohom hadol!
Dental causes of stridor: trauma, inflammation, Ludwig angina, tumors, pharyngeal edema,
anesthetic problem.
Treatment of stridor:
We divide the stridor into mild, moderate, and sever.
If its mild or moderate we go for corticosteroids, antibiotics, IV fluids, wet oxygen and face
mask, and inhalers.
If it is sever we can go for endotracheal intubation or treachostomy.
Treachostomy: means parapassing the upper airways, we open an opening in the trachea.
What are the indications for treachostomy?
1) Sever stridor.
2) Obstruction in the upper airways.
3) Retropharyngeal tumor.
4) Foreign bodies.
5) Prolonged intubation (most important indication): unconscious patient for more than 2
weeks and has an intubation, there will be subglottic Stenosis or stenosis in the trachea so we
go directly for treachostomy to avoid his complication.
We will bypass the upper airways to open an opening in the trachea.
Levels of trachostomy:
High, middle, and low.
El mohem t3rafoh min el treachostomy ino prolonged intubation ysawe subglottic stenosis.
Complication of tracheostomy:
Complications related to the procedure and early complications and late complications.
1) during the operation(procedure related) : hemorrhage , apnea, cardiac arrest, (mainly its
phygeal fistula and lymphoid??).
2) Early post operative complication: emphysema, blockage of endotracheal tube, wound
infection.
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3) Late post operative: tracheal stenosis , …… canulation, trachostosis fistula .
Sorry for being late … good luck !
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Hussein Al-Jemaie