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CMDT 2025
CHAPTER 8
2. Bacterial Rhinosinusitis
ESSENTIALS OF DIAGNOSIS
»
Acute onset of symptoms.
»
Purulent yellow-green nasal discharge or
expectoration.
»
Facial pain or pressure over the affected sinus or
sinuses.
»
Nasal obstruction.
»
Associated cough, malaise, fever, and headache.
» General Considerations
Acute ethmoiditis in adults is often accompanied by
Sphenoid sinusitis is usually seen in the setting of pan-
Acute frontal sinusitis may cause pain and tenderness
Hospital-associated sinusitis is a form of acute bacte-
that becomes secondarily infected by bacteria. The largest of
S pneumoniae, other streptococci, H influenzae, and less
» Clinical Findings
A. Symptoms and Signs
B. Imaging
than clinical examination, routine radiographs are not costeffective and are not recommended by the Agency for Health
Care Policy and Research or American Association of
Otolaryngology Guidelines. Consensus guidelines recom-
Acute maxillary sinusitis is the most common form of
OTOLARYNGOLOGY DISORDERS
» Treatment
Antibiotic therapy should be reserved for complicated or
protracted acute bacterial rhinosinusitis. Between 40% and
217
P aeruginosa, S aureus (including methicillin-resistant
» Complications
moniae (age over 65 years, hospitalization in the prior
change in the ocular examination necessitates immediate
CT imaging. Extension in this area may cause orbital cel-
Cavernous sinus thrombosis is heralded by ophthalmo-
218
» When to Refer
CMDT 2025
CHAPTER 8
aureus colonization in hospital patients and an 11% rate of
» When to Admit
• Facial swelling and erythema indicative of facial
• Proptosis.
• Vision change or gaze abnormality indicative of orbital
• Abscess or cavernous sinus involvement.
• Mental status changes suggestive of intracranial
• Failure to respond to appropriate first-line treatment or
3. Nasal Vestibulitis & S aureus
Nasal Colonization
Staphylococcus aureus: a health technology assessment. Ont
4. Invasive Fungal Sinusitis
cerebral mucormycosis (Mucor, Absidia, and Rhizopus
lus. The fungus spreads rapidly through vascular channels
gillus spp. have been reported in patients with untreated
S aureus is the leading nosocomial pathogen, and nasal
Invasive fungal sinusitis represents a medical and
surgical emergency. Once recognized, voriconazole may
OTOLARYNGOLOGY DISORDERS
tor rhinitis (sometimes called senile rhinitis) is caused by
219
ALLERGIC RHINITIS
ESSENTIALS OF DIAGNOSIS
»
Clear rhinorrhea, sneezing, tearing, eye irritation,
and pruritus.
»
Associated symptoms include cough, bronchospasm, and eczematous dermatitis.
»
Environmental allergen exposure in the presence
of allergen-specific IgE.
» General Considerations
have an impact on the occurrence of allergic rhinitis since
» Treatment
A. Intranasal Corticosteroids
Intranasal corticosteroid sprays remain the mainstay of
treatment of allergic rhinitis. They are more effective—and
ing. Side effects are limited, the most annoying being epi-
rhinitis.”
» Clinical Findings
B. Antihistamines
220
CMDT 2025
C. Adjunctive Treatment Measures
CHAPTER 8
OLFACTORY DYSFUNCTION
ESSENTIALS OF DIAGNOSIS
»
Subjective diminished smell or taste sensation.
»
Lack of objective nasal obstruction.
»
Objective decrease in olfaction demonstrated by
testing.
Avoiding or reducing exposure to airborne allergens is the
most effective means of alleviating symptoms of allergic rhinitis. Depending on the allergen, this can be extremely
» General Considerations
» Clinical Findings
OTOLARYNGOLOGY DISORDERS
The University of Pennsylvania Smell Identification Test
(UPSIT) is available commercially and is a simple, self-
» Treatment
221
» Clinical Findings
» Treatment
Most cases of anterior epistaxis may be successfully treated by
direct pressure on the site by compression of the nares continuously for 15 minutes. Venous pressure is reduced in the sit-
EPISTAXIS
ESSENTIALS OF DIAGNOSIS
»
Bleeding from a unilateral anterior nasal cavity
along the septum is most common.
»
Most cases may be successfully treated by direct
pressure on the bleeding site for 15 minutes.
When this is inadequate, topical sympathomimetics and various nasal tamponade methods are
usually effective.
»
Posterior, bilateral, or large-volume epistaxis
should be triaged immediately to a specialist in a
critical care setting.
» General Considerations
222
CMDT 2025
CHAPTER 8
Intranasal examination should be performed in all cases
to rule out septal hematoma, which appears as a widening
» When to Refer
• Patients with recurrent epistaxis, large-volume epi-
• Those with ongoing bleeding beyond 15 minutes should
NASAL TRAUMA
TUMORS & GRANULOMATOUS DISEASE
1. Benign Nasal Tumors
A. Nasal Polyps
triad asthma (Samter triad). Such patients may have an
The nasal pyramid is the most frequently fractured bone in
the body. Fracture is suggested by crepitance or palpably
B. Inverted Papillomas
OTOLARYNGOLOGY DISORDERS
persistent unilateral nasal symptoms or new otitis media
should be thoroughly evaluated with nasal endoscopy and
nasopharyngoscopy. A high index of suspicion remains a key
223
Because squamous cell carcinoma is seen in about 10% of
inverted or schneiderian papillomas, complete excision is
strongly recommended. This usually requires an endoscopic
2. Malignant Nasopharyngeal &
Paranasal Sinus Tumors
Squamous cell carcinoma is the most common cancer found
in the sinuses and nasopharynx. It is especially common in
3. Sinonasal Inflammatory Disease
(Granulomatosis with Polyangiitis & Sarcoidosis)
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CMDT 2025
CHAPTER 8
Sarcoidosis commonly involves the paranasal sinuses
»
Oropharyngeal cancer: Masses arising from the
throat (tonsils, base of tongue, soft palate, or pharyngeal wall) typically presenting with painful
swallowing, persistent ear pain, and weight loss.
Polymorphic reticulosis (midline malignant reticulo-
º
DISEASES OF THE ORAL CAVITY
& PHARYNX
and erythroplakia is important because about 90% of cases of
erythroplakia are either dysplasia or carcinoma. Squamous
cell carcinoma accounts for 90% of oral cancer. Alcohol and
LEUKOPLAKIA, ERYTHROPLAKIA, LICHEN
PLANUS, & OROPHARYNGEAL CANCER
ESSENTIALS OF DIAGNOSIS
»
Leukoplakia: A white plaque-like lesion that cannot be removed by rubbing the mucosal surface.
»
Erythroplakia: Similar to leukoplakia except that it
has a definite erythematous component.
»
Oral lichen planus: Most commonly presents as
lacy leukoplakia but may be erosive; definitive
diagnosis requires biopsy.
»
Oral cancer: Early lesions appear as leukoplakia or
erythroplakia; more advanced lesions will be
larger, painful, and can involve the tongue, gums,
hard palate, inner lining of the lips or cheek. Ulceration may be present.
▲
Figure 8–5. Leukoplakia with moderate dysplasia on
the lateral border of the tongue. (Used, with permission,
from Ellen Eisenberg, DMD, in Usatine RP, Smith MA,
Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medi-
cine, 2nd ed. McGraw-Hill, 2013.)
OTOLARYNGOLOGY DISORDERS
Oral lichen planus is a relatively common (0.5–2% of
225
▲
Figure 8–6. Oral hairy leukoplakia on the side of the
tongue in AIDS. (Reproduced with permission from
Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux
EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed.
McGraw-Hill, 2013.)
Hairy leukoplakia occurs on the lateral border of the
Oral cavity squamous cell carcinoma can be hard to
Oropharyngeal squamous cell carcinoma generally
▲
Figure 8–7. Squamous cell carcinoma of the palate.
(Used, with permission, from Frank Miller, MD, in Usatine
RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of
Family Medicine, 2nd ed. McGraw-Hill, 2013.)