6.3 Nose, Sinus, Oropharyngeal & Oral Cavity Disorders

Nose, Sinus, Oropharyngeal & Oral Cavity Disorders

Upper respiratory complaints generate more primary care visits than any other category, and they generate more inappropriate antibiotic prescriptions than any other category. The AGPCNP examination tests whether you can apply explicit diagnostic criteria rather than treat symptoms, and whether you recognize the small set of upper aerodigestive findings that signal malignancy.

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1. Rhinosinusitis: The Temporal Criteria

More than 98 percent of acute rhinosinusitis is viral. The distinction from bacterial disease is made by the pattern over time, not by the color of the discharge - purulent green or yellow mucus is produced by neutrophil myeloperoxidase and occurs in ordinary viral illness.

+---------------------------------------------------------------------------------------------------+
|                  ACUTE BACTERIAL RHINOSINUSITIS: ANY ONE OF THREE PATTERNS                        |
|                                                                                                   |
|   1. PERSISTENT ..... Symptoms lasting >= 10 DAYS with NO improvement                             |
|                                                                                                   |
|   2. SEVERE ......... Fever >= 39 degrees C (102.2 F) PLUS purulent nasal discharge or facial     |
|                       pain for at least 3 to 4 CONSECUTIVE days at the START of illness           |
|                                                                                                   |
|   3. WORSENING ...... "DOUBLE WORSENING" or "double sickening": new fever, headache or increased  |
|                       nasal discharge AFTER a typical viral URI that had begun to improve,        |
|                       usually on day 5 to 6                                                       |
|                                                                                                   |
|   ACUTE = < 4 weeks | SUBACUTE = 4 to 12 weeks | CHRONIC = >= 12 weeks with objective             |
|   inflammation on endoscopy or CT (and chronic disease requires imaging or endoscopy, not just    |
|   symptom duration)                                                                               |
+---------------------------------------------------------------------------------------------------+

Treatment. For acute bacterial rhinosinusitis in adults, amoxicillin-clavulanate is first-line, typically 500/125 mg three times daily or 875/125 mg twice daily for 5 to 7 days. Watchful waiting with symptomatic care for up to 7 days is an acceptable alternative in reliable, non-toxic patients with adequate follow-up. For a documented type I penicillin allergy, use doxycycline or a respiratory fluoroquinolone (levofloxacin or moxifloxacin), reserving fluoroquinolones because of their tendon, neuropathy, aortic and central nervous system warnings. Macrolides and trimethoprim-sulfamethoxazole are no longer recommended because of high rates of pneumococcal resistance. Adjuncts: intranasal saline irrigation, intranasal corticosteroids (particularly with an allergic background), and analgesia. Oral decongestants raise blood pressure and are on the Beers list of drugs to avoid or use with caution in older adults; topical oxymetazoline must be limited to 3 days to avoid rhinitis medicamentosa.

Red flags demanding urgent imaging and referral: periorbital swelling or erythema, proptosis, ophthalmoplegia or vision change (orbital cellulitis), altered mental status or meningismus, severe unilateral headache, or forehead swelling (Pott puffy tumor). Immunocompromised or poorly controlled diabetic patients with black nasal eschar and facial numbness require emergency evaluation for invasive fungal sinusitis (mucormycosis).

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2. Allergic Rhinitis

Sneezing, clear rhinorrhea, nasal itching and congestion with pale boggy turbinates, allergic shiners and a transverse nasal crease. It coexists with asthma in a majority of asthmatic patients ("one airway, one disease"), and uncontrolled rhinitis worsens asthma control.

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3. Pharyngitis

The purpose of evaluating a sore throat is to identify the roughly 5 to 15 percent of adult cases caused by group A Streptococcus, in order to prevent acute rheumatic fever and suppurative complications.

+-----------------------------------------------------------------------------+
|             CENTOR CRITERIA (McIsaac modification adds age)                  |
|                                                                             |
|   +1  Tonsillar exudate or swelling                                         |
|   +1  Tender ANTERIOR cervical lymphadenopathy                              |
|   +1  Fever by history (> 38 degrees C)                                     |
|   +1  ABSENCE of cough                                                      |
|   -----------------------------------------------------------------------   |
|   McIsaac age modifier:  +1 if age 3-14 | 0 if age 15-44 | -1 if age >= 45  |
|                                                                             |
|   SCORE 0 to 1 ...... No testing, no antibiotic. Symptomatic care.          |
|   SCORE 2 to 3 ...... Rapid antigen detection test (RADT); treat if positive |
|   SCORE 4 to 5 ...... RADT; many still test rather than treat empirically    |
+-----------------------------------------------------------------------------+

Testing rule for adults. Per IDSA guidance, a negative RADT in an adult does not require a back-up throat culture, because the incidence of group A streptococcal pharyngitis and the risk of acute rheumatic fever are both low in adults. Children and adolescents do need a confirmatory culture after a negative RADT.

Treatment of confirmed group A streptococcal pharyngitis: penicillin V 500 mg two to three times daily, or amoxicillin 500 mg twice daily, for a full 10 days (a single dose of intramuscular benzathine penicillin G is an alternative). For non-anaphylactic penicillin allergy use a first-generation cephalosporin such as cephalexin; for anaphylactic allergy use clindamycin or azithromycin. Group A Streptococcus has never developed penicillin resistance, so a broad-spectrum agent is never required.

Do not miss:

• Peritonsillar abscess: unilateral severe pain, trismus, a "hot potato" muffled voice, uvular deviation away from the swollen tonsil. Needs urgent otolaryngology or emergency evaluation for drainage.
• Epiglottitis in an adult: rapid onset of severe odynophagia, drooling, muffled voice and stridor with an unimpressive oropharyngeal examination. Do not depress the tongue. Emergency airway management.
• Infectious mononucleosis: posterior cervical adenopathy, marked fatigue, splenomegaly, atypical lymphocytosis and positive heterophile antibody. Avoid amoxicillin (morbilliform rash) and avoid contact sports for at least 3 to 4 weeks because of splenic rupture risk.
• Acute HIV (retroviral) syndrome: fever, non-exudative pharyngitis, diffuse adenopathy, rash and mucocutaneous ulcers. Order an HIV RNA test, because antibody assays may still be negative.
• Gonococcal pharyngitis: consider with a compatible sexual history; it is frequently asymptomatic.

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4. Epistaxis

About 90 percent of bleeding is anterior, from Kiesselbach plexus on the anterior nasal septum.

Initial management: have the patient sit upright and lean forward (to avoid swallowing blood), blow out clots, apply oxymetazoline spray, and pinch the soft cartilaginous part of the nose - not the bony bridge - continuously for 10 to 15 minutes without releasing to check. If bleeding stops, apply petroleum-based ointment and humidification. If it persists, proceed to silver nitrate cautery of a visualized anterior bleeding point (never cauterize both sides of the septum at the same visit, which risks septal perforation) or anterior packing.

Posterior bleeding - profuse bleeding, blood in the posterior pharynx, failure to control with anterior measures - requires emergency referral. Reassess anticoagulants and antiplatelets, control hypertension, and consider hereditary hemorrhagic telangiectasia in recurrent cases with mucocutaneous telangiectasias and a family history.

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5. Oral Cavity and Laryngeal Findings

Hoarseness (dysphonia). Most acute hoarseness is viral laryngitis; voice rest and hydration suffice. Hoarseness persisting more than 3 weeks requires laryngoscopy, and the threshold should be lower still with tobacco or alcohol use, a neck mass, dysphagia, odynophagia, stridor, hemoptysis, or a history of head and neck radiation. Chronic hoarseness also results from laryngopharyngeal reflux, inhaled corticosteroids without spacer use and rinsing, vocal cord nodules, hypothyroidism, and vocal cord paralysis from mediastinal, thyroid or intracranial pathology.

Screening note. The USPSTF concluded that evidence is insufficient (Grade I) to assess screening for oral cancer in asymptomatic adults. That is not a reason to skip oral inspection in a patient who uses tobacco or alcohol heavily; it means population screening lacks trial evidence.