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Name the nodes

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Name the nodes

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Name the nodes

• Size
• Mobility
• Discrete or matted
• Consistency
• Tenderness

• Small, mobile, discrete, rubbery, non-tender = normal
• Tender = inflammation
• Hard or fixed = malignancy
• Fluctuant nodes = pus
• Doughy (compressible) = caseation (TB)

• Syphillis, gonorrhea, chancroid, lymphogranuloma venereum
• Tuberculosis
• Penile cancer

• Strep infection, syphillis, TB, sporotrichosis, anthrax, etc.
• Primary neoplasm

• Male
• Age ~2 yrs
• Attends daycare
• Disease manifests in Fall/Winter
• Exposed to cigarette smoke
• Note: breast-feeding is believed to offer protection

• Most common are bulging tymanic membrane (LR = 51) with cloudy color (LR = 34) and impaired mobility (LR = 31)
• Despite what's taught, distinctly red coloration is only somewhat indicative of AOM (LR = 8.4)
• Non-specific symptoms (ear pulling, irritability, cough, rhinitis, fever) occur in ~70% of children WITHOUT AOM

• Deviate TOWARDS the side with volume loss
• Deviate AWAY from sides with effusion or pneumothorax

• Tuning fork is held to center of forehead
• Sound lateralizes TOWARDS ear with conductive hearing loss
• Sound lateralizes AWAY from ear with sensorineural hearing loss

• Pitchfork is struck and placed on mastoid process. Patient indicates when sound has stopped, at which point pitchfork is held to ear.
• In normal conditions, air conduction is greater than bone (patient can hear pitchfork when held to ear)
• In conductive hearing loss, bone conduction is greater than air (patient cannot hear pitchfork when held to ear)

• Serous otitis media
• Cerumen impaction
• Cholesteatoma (marginal TM rupture)
• Ostosclerosis
• Foreign body

• Congenital
• Bacterial meningitis
• Otic syphilis
• Collagen-vascular disease
• Loud noise
• Ototoxic drugs (e.g. aminoglycosides)
• Age (i.e. presbycusis)
• W/ balance disturbance
  • Viral labyrinthitis
  • Meniere's disease

Acute otitis media – Look for outward bulging of white opaque tympanic membrane.  also associated with rhinitis, ear pain, cough, irritability and fever

Bulous myringitis

• Localized type of Otitis Externa
  
• Associated with acute viral URI.
  
• Bullous, hemorrhagic lesions on skin in deep inner ear/surface of the tympanic membrane.  
• Bloody discharge.  
• Self-limited     

The Rinne to be neg on the left, and the Weber to lateralize to the left ear.

• Either a dark/sticky or yellow/crumbly waxy build-up in the ear
• Leads to conductive hearing loss
• No fever or pain
• Feeling of fullness or tinnitus
• Risk factors = use of Q-tip to clean ear canal, use of stethoscope, hearing aid or ear bud

Healthy tympanic membrane. Note pearly gray color and translucence.

1. Short process of malleus
   
2. Cone of light
   
3. Handle of the malleus
4. Short process of malleus 
   
5. “Chorda tympani”
   
6. The incus 
   
7. The round window niche;
   
8. The promontory,
   
9. eustachian tube orifice
   

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Pharyngitis (tonsilitis?)

Note the contrast between the pink color of the soft palate and the “beefy red” color of the tonsils and uvula. You can see the anterior tonsillar pillars, continuous with the uvula. The posterior tonsilar pillars are visible behind the tonsils. Note the patchy white exudate coating the tonsils, which is suggestive of group A beta-hemolytic strep or EBV infection.

Peritonsillar abscess in an adolescent. Note the edema above the tonsil on the right, and the displacement of the uvula to the left. The patient had severe pain on swallowing, and “trismus”—inability to fully open the mouth—because of spasm of the pterygoid muscle which is contiguous to the abscess.

Preschoolers—aged 2-4—can get a “retropharyngeal” abscess, meaning an infection in the potential space between the posterior pharyngeal wall and the prevertebral fascia. They may present with inspiratory noise, high fever, drooling, and refusal to move the neck/head. Do not struggle to examine the throat of a child with such a presentation—get urgent ENT consultation for help in managing the airway.

Suggestive of GAS (Group A strep) pharyngitis- note petechiae on hard palate.

Diagnosis would be supported by headache, fever, or abdominal pain, as well as cervical LAD and odor of breath. Rhinorrhea, cough or hoarseness suggests viral process.

Aphthous ulcer

• Painful ulcer
• 20% of population
• Etiology – stress, fatigue, hormonal changes, biting, food allergies
• Treat with topical analgesic

A white halo surrounded by erythematous halo on unkeratinized mucosa.  Small, <5mm in anterior mouth and large >5mm in posterior mouth.  Painful.

Herpetic lip lesion

HSV-1 and HSV-2.  On keratinized epithelia only.  55% of adults

Tongue squamous cell carcinoma

• Most common site of malignant growth in head & neck
•  Risk factors - cigarette smoking, tobacco chewing, alcohol ingestion, betel nut chewing
•  Exophytic lesion or nonhealing ulcer often with submucosal extension
•  Diagnosed by tissue biopsy
•  Regional lymph node metastases often present
•  CT imaging & endoscopic examination under GA to stage lesion & r/o synchronous lesions
•  Rx is surgery, RT or both, chemo sometimes

Tongue squamous cell carcinoma

• Most common site of malignant growth in head & neck
•  Risk factors - cigarette smoking, tobacco chewing, alcohol ingestion, betel nut chewing
•  Exophytic lesion or nonhealing ulcer often with submucosal extension
•  Diagnosed by tissue biopsy
•  Regional lymph node metastases often present
•  CT imaging & endoscopic examination under GA to stage lesion & r/o synchronous lesions
•  Rx is surgery, RT or both, chemo sometimes

Candiadiasis (or thrush)

• Fungal 
• Predisposing factors-oral antibiotic use, pregnancy, immunodeficiency, HIV, nutritional deficits, systemic steroids
• Soft, white plaques that can be removed, leaving an erythematous suface
• Usually asymptomatic
• Rx: topical nystatin or systemic therapy for resistant cases

Leukoplakia

• White patch or plaque
• Related to tobacco use or trauma
• 25% chance of malignancy

Gingival enlargement

• Inflammation of gums
• Can be due to prolonged use of phenytoin, cyclosporin, calcium channel blockers, hemotologic malignancy
• Seen in patients with AIDs and diabetes (high blood glucose)
• Gums foggy and erythromatic

• Congenital hypothyroidism (cretinism)
• Lethargy, edema, persistently open fontanelles, course voice
• Considered emergency; early dx is essential since disease can be irreversible
• Treat with thyroxine

• High TSH, with low T3/T4 (hypothyroidism)
• Positive anti-TPO
• Slow speech, bradycardia, puffy facies, dry skin, delayed relaxation of deep tendon reflexes
• Also known as acquired hypothyroidism due to Chronic Lymphocytic Thyroiditis

• Low TSH, high T3/T4 (hyperthyroidism)
• Thyroid stimulating immunoglobulins
• Ultrasound: Increase blood flow, no focal nodularity
• Radioiodine Uptake: high radioiodine uptake
• Rapid speech, staring, thyroid uniformly firm and diffusely enlarged , proximal muscle weakness, hyper-reflexia

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• thyroid gland enlarged asymmetrically, hard consistency, fixed mass apparent with swallow
• TSH normal
• No anti-thyroid antibodies detected 
• Cold, non-functioning nodule when radioactive iodine scintigraphy is administered
• Bimodal age distribution (occurs in young and old, but not middle aged) in men

• Presents as hypothyroidism (high TSH, low T3/T4), without any anti-TPO or anti-TG
• Stunted growth/maturation
• Pale appearance, no thyroid enlargement, delayed reflex relaxation
• Typically seen in patients with family history of "thyroid problems"
• Failure of fourth pharyngeal arch to descend causes lingual growth