Head and Neck

Hyperthyroidism Hypothyroidism Menieres Vertigo/dizziness Migraines/Headaches Artery Occulsion/stenosis Stroke Nasal Septal Defect Cleft Palate TMJ Bells Palsy

Tympanic membrane rupture/holes/defects Ear Infections Tinnitus Rhinitis Torticollis Tonsillitis Sinusitis Lymph Node Enlargement Glucoma, macular degneration Conjuctivitis

Hyperthyroidism
Hyperthyroidism is a condition in which the thyroid gland makes too much thyroid hormone.

Hyperthryoidism
The thyroid gland is an important organ of the endocrine system Located just below the larynx it produces the hormones thyroxine (T4) and Triiodothryonine (T3) The pituitary controls how well the thyroid works. Located at the base of the brain and produces TSH which stimulates the thyroid. The thyroid gland removes iodine from the blood (which comes mostly from a diet of foods such as seafood, bread, and salt) and uses it to produce thyroid hormones These hormones control the way every cell in the body uses energy. (metabolism ).

Causes
Graves disease is the most common cause of hyperthyroidism. An autoimmune response creating a hormone imbalance. Graves' disease is hereditary and is up to five times more common among women than men. Thyroid nodules Taking too much medication too treat other conditions Thyroiditis inflammation due to virus

Symptoms
Muscle weakness Trembling hands Rapid heart rate Fatigue Weight loss Heat intolerance, increased sweating Irritability ,anxiety Vision problems Menstrual irregularities Infertility Increased bowel movements

Treatment
Antithyroid drug (methimazole, propylithiouracil) Beta blockers (atenolol) to control the symptoms of this hormone imbalance Radioactive iodine permanently destroying the thyroid Surgery usually when a large goiter is present making breathing difficult

Hypothyroidism
Hypothyroidism is a condition characterized by abnormally low thyroid hormone production. Hypothyroidism is a very common condition. It is estimated that 3% to 5% of the population has some form of hypothyroidism. The condition is more common in women than in men, and its incidence increases with age.

Symptoms
Fatigue Mental depression Sluggishness Feeling cold Weight gain Dry skin , hair Constipation Menstrual irregularities

Symptoms
In its most profound form, severe hypothyroidism may lead to a life-threatening coma (myxedema coma). In a severely hypothyroid individual, this condition tends to be triggered by severe illness, surgery , stress or trauma

Causes
Hashimotos Disease is the most common cause of hypothyroidism. An autoimmune response the attacks the thyroid creating a chronic inflammation that damages the gland. Swelling of the thyroid gland (due to the inflammation), leading to a feeling of tightness or fullness in the throat A lump in the front of the neck, (the enlarged thyroid gland) called a goiter

Causes
Postpartum thyroiditis Often starts as hyperthyroidism As stored hormones leaks out of the gland and raises hormone levels in the blood. Eventually resulting in temporary or hypothyroidism Drugs used to treat heart rhythm abnormalities, affect the thyroid function (amiodarone) A pituitary gland that does not make enough TSH Treatment for hyperthyroidism with radioactive iodine /surgery

Treatment
Drug replacement oral tablet (T4 levothyroxine)

Goiter aka enlargement on the thyroid

Definition Usually non-cancerous enlargement of the thyroid gland. Initial diagnosis via palpation, further diagnosed by ultrasound, needle aspiration, CT, MRI.
Classified based on the presence or absence of nodules; Uninodular, Multinodular, or Diffuse (global enlargement). Also classified on size; Class I, II, III. Nodule types; Fluid filled cyst, adenoma (benign tumor), or malignant (5-10%). Nodules will at times produce excess thyroid hormone leading to hyperthryoidism, these are called 'toxic nodes'>

Causes Most commonly iodine deficiency in diet. Consider GI absorption efficiency. Other cases of Goiter are considered to be caused by hypo/hyperthyroidism, though the diagnosed hypo/hyperthyoid is idiopathic itself. Hashimoto's thyroiditis; Hypothryroidism from autoimmune attack. Pituitary relation through TSH. TSH encourages size growth of gland, however low TSH is often found in goiter. In some cases the thyroid functions completely normally even with the goiter.

S and S Goiter may be symptomless a long time before and after detection. Hypo and Hyperthyroidism are associated results but have not been conclusively linked at this time. Hypothyroidism;
Weight gain and water retention, Bradycardia, Fatigue, Muscle cramps and joint pain, Dry, itchy skin, Brittle fingernails, Depression, Poor muscle ton, Female infertility, Elevated serum cholesterol.

Hyperthyroidism;
Reverse of above, bulging eyes.

Allopathic treatments Symptom based around hypo/hyperthyroidism. Asymptomatic goiter is monitored without intervention. Destruction of thyroid via radioactive iodine Surgical Removal

References; CAO manuals Low thyrotropin (TSH) levels in goiter. Relationship with scintigraphic findings and other biological parameters. Thyroidology. 1989 Apr;1(1):39-44.

Exophthalmic Goiter

Menieres Dx & Vertigo/dizziness

Lily Luu

Meniere's disease
Meniere's disease (MD) is an inner ear disorder that affects balance & hearing Inner ear contains fluid-filled semicircular canals. Canals + CNVIII help interpret body position & maintain balance Exact cause unknown. May occur when pressure of fluid in part of inner ear gets too high MD may be related to: Head injury, middle/inner ear infections Risk factors incl: Allergies, alcohol use, fatigue, family history, recent viral illness, respiratory infection, smoking, stress, use of certain meds 50,000-100,000 ppl/yr develop MD

Menieres disease
S&S: Attacks/episodes of MD often start w/o warning. May occur daily, or rarely (once a year). Severity of episode varies 4 main symptoms: 1. Dcr/loss in hearing, usually only in one ear, but it may affect both 2. Pressure in ear 3. Ringing/roaring in affected ear 4. Vertigo- Severe vertigo or dizziness is most problematic symptom Others: Severe nausea, vomiting, sweating often occur Dizziness & feeling off-balance will last 20 mins- few hours Symptoms worsen w/ sudden mvmt. Person will need to lie down. Low frequency hearing is lost first Hearing tends to recover b/n attacks but gets worse over time

Menieres disease
Tests: Neurological exam- may show problems w/ hearing, balance, eye mvmt Hearing test/Audiogram- will show hearing loss that occurs w/ Menieres Caloric stimulation- procedure used to diagnose damage to ear or brainstem. Tests eye reflexes by warming & cooling inner ear w/ water. Abnormal results can be a sign of MD Tests to distinguish causes of MD from causes of vertigo: Electrocochleography (ECOG) Electronystagmography (ENG)- uses electrodes placed around eyes to detect movements & computer records results Head MRI scan Allopathic Tx: No known cure Lifestyle changes can often help relieve symptoms Diuretics may help relieve fluid pressure in inner ear Low-salt diet may also help dcr amount of water/fluid in body which often helps control symptoms

Vertigo/dizziness
Vertigo- a subtype of dizziness accompanied by feelings of motion when stationary Assoc w/ nausea, vomiting, balance disorder/unsteadiness causing difficulty standing or walking & excessive perspiration. Recurrent episodes common & freq impair quality of life Symptoms are d/t an asymmetric dysfunc of vestibular sys in inner ear Dizziness & vertigo rank among most common complaints in medicine. Affects approx 20%-30% of general pop. Present in all ages but becomes more prevalent w/ incr age 3 types: 1. Objective- pt feels like objects in their enviro are moving 2. Subjective- pt feels as if he/she is moving 3. Pseudovertigo- pt feels intensive sensation of rotation inside pts head Classified as peripheral or central, depending on loc of dysfunc of vestibular pathway

Vertigo/dizziness
Peripheral- caused by dysfunc of inner ear or vestibular sys (semicircular canals, otolith- utricle & saccule) & CNVIII) called "peripheral", "otologic, "vestibular vertigo Common causes: benign paroxysmal positional vertigo (BPPV)- brief periods of vertigo (< 1 min) which occur w/ change in position. 32% of all peripheral vertigo Other causes: MD (12%), labyrinthitis, vestibular neuritis, visual vertigo, excess intake of ethanol (alcohol). Any cause of inflamm ie. common cold, influenza, bacterial infections may cause transient vertigo (if inner ear involved), chemical/physical trauma (ie. Concussion, skull fractures) S&S: mild-mod imbalance, nausea, vomiting, hearing loss, tinnitus, pain in ear Central- caused by injury to balance centers of CNS, often brainstem or cerebellum Less prominent mvmt illusion & nausea than of peripheral origin Improves slower than peripheral vertigo or may not improve at all S&S: neurologic deficits (ie slurred speech, dble vision), pathologic nystagmus (pure vertical/torsional), disequilibrium/feeling off-balance (often so severe many pts unable to stand/walk) CNS conditions that may lead to vertigo incl: lesions caused by infarctions or hemorrhage, tumor, epilepsy, cervical spine disorders, degeneration, migraine headaches, MS

Vertigo/dizziness
Allopathic Tx: Definitive tx depends on underlying cause of vertigo BPPV is treated w/ repositioning maneuvers designed to move the otoconia (crystals) back into place in utricle. Most common maneuver is Epley maneuver (performed by a doctor, audiologist, physical therapist, or w/ BPPV maneuver @ home) MD pts often prescribed a low dose of benzodiazepine (ie. Diazepam) to reduce vertigo by sedating vestibular sys Anticholinergics Antihistamines

Migraines
- recurrent moderate to severe headaches, often accompanied by ANS symptoms such as nausea, vomiting and sensitivity to light or sound. - Typically pulsing, unilateral, last 2-72 hours and aggravated by physical activity. Up to one third of sufferers may experience an aura which means a transient visual, sensory, language, or motor disturbance which signals that the headache will soon occur.

-mechanisms of migraines are not completely known, however, the pain is believed to be caused by vasodilation of the extra-cranial arteries, which is instigated by either sensory nerves of the blood vessels or diencephalon activity (the thalamus, the subthalamus, the hypothalamus and the epithalamus).

There is a strong genetic component to migraine susceptibility and often triggers are involved, including: stress hunger and fatigue, menstruation, other hormonal influences, dietary triggers and environmental triggers such as indoor air quality, lights and weather changes.

Treatment
Prevention -Trigger avoidance -Some medications reduce severity and frequency by %50. -Magnesium, CoQ10, riboflavin, fever-few and butter-bur. -Manual therapies, relaxation, biofeedback. -Surgery to decompress nerves in head and neck. Acute Management -Pain and anti-inflammatory medication.

Factoids
-9000 years ago Trepanation deliberate drilling of holes in the skull to let bad spirits escape. Also used for seizures, as emergency treatment for head wounds and for other mental disorders. In modern medicine this is still used for sub-dural hematomas.
- Migraines have been estimated to be the most costly neurological disorder in the developed countries, costing $20-30 billion per year in medications and missed work.

Trepanation

Headaches - Pain in your head or neck.

Types -Tension: Muscular Tension caused by stress, hunger, posture, eyestrain, sleep deprivation. This type accounts for %90 of headache cases. - Migraines -Cluster: More severe pain, unilateral, occur in bouts lasting up to a few hours, several times per day for 1-48 hours.

-Trigeminal Neuralgia: CN5 nerve entrapment OR an enlarged blood vessel (possibly the superior cerebellar artery) compressing the trigeminal nerve near its connection with the pons injuring the nerve's protective myelin sheath and causing erratic and facilitated functioning of the nerve.

Headache Treatment
Prevention Keep a headache diary to discern triggers. Pain / Symptom management medication, relaxation, OMT, acupuncture . . .

Factoids
-of headaches seen in the ER %1 have a serious underlying problem.

Superior Cerebellar Artery

Artery Occlusion/Stenosis

Matthew Lubbock

Definition
Artery occlusion is a partial or complete obstruction of peripheral arteries Stenosis is a narrowing or constriction of the lumen of an artery Arterial stenosis or occlusion is commonly caused by atherosclerosis, but can occur acutely as a result of emboli or trauma. Stenosis or occlusion produces symptoms related to the organ which is supplied by the artery

Signs and Symptoms

Depends on the site of occlusion/stenosis Intermittent claudication, rest pain, coldness, numbness, paraesthesia, cyanosis, blanching, ulceration, gangrene, decrease pulse, arterial bruits (turbulence),

Treatment
Lifestyle changes: smoking, blood pressure, cholesterol, diabetes, heart disease, limit alcohol, exercise, decrease salt Meds: anticoagulants, NSAIDs Surgery: carotid endarterectomy removes fatty plaque from carotid arteries

Diagnosis
Electrocardiography (helps determine if surgery is necessary) Echocardiography (assessing left ventricular funciton) Doppler Ultrasound blood flow detection (wave used to determine moving RBC) Duplex Imaging (B-mode ultrasound to provide image of vessels)

Stroke

 A stroke is a medical emergency and can cause permanent neurological damage and death.

Definition
A stroke, or cerebrovascular accident (CVA), is the rapid loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage like a thrombosis or arterial embolism, or a hemorrhage. The affected area of the brain cannot function, which can result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.

Risk Factors
Risk factors for stroke include old age, high blood pressure, previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, tobacco smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke. It is the second leading cause of death worldwide.

Types
Strokes can be classified into two major categories Ischemic and hemorrhagic. Ischemic strokes are those that are caused by interruption of the blood supply Hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). It is unknown how many hemorrhages actually start as ischemic stroke.

Ischemic

In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: 1. Obstruction of a blood vessel by a blood clot forming locally (Thrombosis) 2. Obstruction due to an embolus from elsewhere in the body. (Embolism) 3. General decrease in blood supply (Systemic hypoperfusion e.g., in shock) 4. Venous thrombosis.

 Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes 30-40% of all ischemic strokes. There are various classification systems for acute ischemic stroke. The Oxford Community Stroke Project classification OCSP, (Aka Bamford or Oxford classification) Relies primarily on the initial symptoms; based on the extent of the symptoms. The stroke episode is classified as; Total anterior circulation infarct (TACI). Partial anterior circulation infarct (PACI). Lacunar infarct (LACI). Posterior circulation infarct (POCI). These four entities predict the extent of the stroke, the area of the brain affected, the underlying cause, and the prognosis.

 The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of further investigations; on this basis, a stroke is classified as being due to 1) thrombosis or embolism due to atherosclerosis of a large artery 2) embolism of cardiac origin 3) occlusion of a small blood vessel 4) other determined cause 5) undetermined cause (two possible causes, no cause identified, or incomplete investigation).

Hemorrhagic
Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. Intra-axial hemorrhage (blood inside the brain) Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system). Extra-axial hemorrhage (blood inside the skull but outside the brain). The main types of extra-axial hemorrhage are epidural hematoma, subdural hematoma and subarachnoid hemorrhage. Most of the hemorrhagic stroke syndromes have specific symptoms (e.g., headache, previous head injury).

Signs and Symptoms

Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intra-cerebral hemorrhage.

How to Recognize a Stroke

Various systems have been proposed to increase recognition of stroke. Sudden-onset face weakness, arm drift and abnormal speech are the findings most likely to lead to the correct identification of a case of stroke. Similarly, when all three of these are absent, the likelihood of stroke is significantly decreased. While these findings are not perfect for diagnosing stroke, the fact that they can be evaluated relatively rapidly and easily make them very valuable in the acute setting. To test patient is asked to raise both arms, involuntarily lets one arm drift downward Proposed systems include FAST (stroke) (face, arm, speech, and time), the Los Angeles Prehospital Stroke Screen (LAPSS) and the Cincinnati Prehospital Stroke Scale (CPSS). Use of these scales is recommended by professional guidelines. For people referred to the emergency room, early recognition of stroke is deemed important as this can expedite diagnostic tests and treatments. A scoring system called ROSIER (recognition of stroke in the emergency room) is recommended for this purpose; it is based on features from the medical history and physical examination.

Surgical Treatments
Carotid endarterectomy is a procedure used to remove plaque and clots from the carotid arteries, located in the neck. These arteries supply the brain with blood from the heart. Endarterectomy may help prevent a stroke from occurring. Carotid stenting a large metal coil (stent) is placed in the carotid artery much like a stent is placed in a coronary artery. The femoral artery is used as the site for passage of a special hollow tube to the area of blockage in the carotid artery. This procedure is often done in radiology labs, but may be performed in the cath lab. A craniotomy is a type of surgery in the brain itself to remove blood clots or repair bleeding in the brain. surgery to repair aneurysms and arteriovenous malformations (AVMs) An aneurysm is a weakened, ballooned area on an artery wall that has a risk for rupturing and bleeding into the brain. An AVM is a congenital (present at birth) or acquired disorder that consists of a disorderly, tangled web of arteries and veins. An AVM also has a risk for rupturing and bleeding into the brain. Surgery may be helpful, in this case, to help prevent a stroke from occurring.

Pharmaceutical treatments
Medications that help to prevent additional blood clots from forming are called anticoagulants, as they prevent the coagulation of the blood. Medications of this type include, for example, heparin and warfarin (Coumadin) and enoxaparin (Lovenox). medications that reduce the chance of blood clots by preventing platelets (a type of blood cell) from sticking together Examples of this type of medication include aspirin, clopidogrel (Plavix) or dipyridamole (Aggrenox). medications to treat existing medical conditions such as diabetes, heart, or blood pressure problems

-NASAL SEPTAL DEFECTSNasal septum: The dividing wall that runs down the middle of the nose, separating the two nasal cavities, each of which ends in a nostril. The nasal septum is composed of bone, cartilage, and membranes.

Made up of 3 parts: 1) Ethmoid bone- (perpendicular plate) forms upper part of nasal septum 2) Vomer- thin trapezoidal bone of the skull forms the posterior/inferior nasal septum 3) Cartilage of Septum-

-NASAL SEPTAL DEFECTSPOSSIBLE DEFECTS definitions:

DEVIATION: The nasal septum is a thin structure, separating the two sides of the nose. If it is not in the middle of the nose, then it is deviated. PERFORATION: The nasal septum, the cartilaginous membrane dividing the nostrils, develops a hole or fissure. HEMATOMA: A mass of extravasated blood that is confined within the nasal septum. Extravasated: Let or force out (a fluid, esp. blood) from the vessel that naturally contains it into the surrounding area. POLYPS: Nasal polyps are common, noncancerous, teardrop shaped growths that form in the nose, usually around the area where the sinuses open into the nasal cavity. Mature nasal polyps look like seedless, peeled grapes.

-NASAL SEPTAL DEFECTSSIGNS & SYMPTOMS

DEVIATION The most common symptom is difficulty breathing/snoring at night Depending on the severity of the obstruction; chronic nasal congestion, sinusitis, repeated ear infections, headache, or nosebleeds Scuba divers with a deviated septum may have difficulty equalizing the pressure in their ears when they dive PERFORATION A sensation of nasal obstruction (as a result of turbulent air flow) Dry, irritated nasal mucosa (a result of reduction of nasal temperature and humidity) Increased mucous production (a.k.a secondary rhinorrhea) New intranasal crusting Low grade bleeding in cases where the mucosa fails to heal completely Pain (as the result of a low grade infection of underlying structures) A whistling sound during nasal breathing Collapse of the support structures (resulting in saddle nose deformity) HEMATOMA A hematoma puts ongoing pressure on the cartilage of the septum that can lead to its destruction Usually associated with blunt trauma to face/nose Septum enlarged/swelling, tender and may appear discolored or bruised May be associated bruising/swelling about the eyes The septum will appear enlarged, bulging into the airway (can interfere with breathing) POLYP Nasal polyps are soft and lack sensation not aware of them Multiple growths or a large polyp may block your nasal passages and sinuses A runny nose, persistent stuffiness, postnasal drip, decreased/absent sense of smell, loss of taste, facial pain/headache, pain in upper teeth, snoring, itching around your eyes

-NASAL SEPTAL DEFECTSCOMMON CAUSES/RISK FACTORS

DEVIATION Present at birth - occurring during fetal development OR due to injury during childbirth After birth - most commonly caused by an injury that knocks your nasal septum out of place Risk factors include: Playing contact sports / Not wearing your seat belt while riding in a motorized vehicle Normal aging may cause nasal tip cartilage to deteriorate - aggravating a deviated septum over time PERFORATION Damage reduces blood supply in the septum, the cartilage begins to die, and a hole develops Iatrogenic: resulting from previous nasal septal surgery (most common cause) Trauma: causes nasal septal fracture & septal hematomas Inflammation: These cases occur in patients with systemic inflammatory of auto-antibody conditions such as: Lupus, Crohns disease, polyarteritis nodosa, antiphospholipid antibody syndrome, rheumatoid arthritis, sarcoidosis, Wegeners granulomatosis, leprosy and tuberculosis. Infection: occur less frequently as a result of infection with Syphilis, HIV, fungus or varicella Neoplastic (abnormal mass of tissue): also rare; causes include carcinoma, T-cell lymphoma Nasal drug use: Cocaine abuse is the worst and most common offender. However, overuse of over-the-counter nasal sprays like oxymetazoline, phenylephrine and menthol inhalers also implicated HEMATOMA Collagen vascular diseases (ie. lupus/rheumatoid arthritis), are disorders that cause weak arteries and thus easy bleeding Excessive nose picking / Harsh nose blowing Medications that are used as anticoagulants, making blood less likely to clot History of drug use where the drug is "snorted" through the nose Tumors POLYP Inflammation causes an accumulation of fluid in the cells of the nose and sinuses - eventually, gravity pulls these heavy cells down, resulting in polyps Individuals with asthma, Churg-Strauss syndrome, frequent sinus infections/allergies (rhinitis), and some children with cystic fibrosis, are more likely to develop nasal polyps Cystic fibrosis: disrupts the body's salt balance, leaving too little salt and water on the outside of cells and causing the thin layer of mucus that usually keeps the lungs free of germs to become thick and sticky Churg-Strauss syndrome : a disease that results in the inflammation of blood vessels People with an allergic response to aspirin or other NSAIDs(non-steroidal anti-inflammatory drugs) more likely to develop polyps More common among adults aged 40+ years If your parents have/had nasal polyps your risk of developing them yourself is greater, compared to other people (Genetics)

HOW IS IT DIAGNOSED

-NASAL SEPTAL DEFECTS-

DEVIATION Complete medical history and physical examination Imaging scans may be ordered including computed tomography (CT) scans Use of an endoscope, a small telescope rod with a lighted end, to examine the insides of nose (determine the extent of the deviation or turbinate hypertrophy) PERFORATION Medical history & physical examination (sometimes using nasal endoscopy extent & location) Laboratory evaluation for anemia and toxicology may be indicated. Typical tests include: urinalysis (drug screening to rule out cocaine use), complete blood count (CBC), erythrocyte sedimentation rate (ESR), evaluation for syphilis etc. A CT may be used to examine the sinuses if granulomatous disease is suspected (Granulomatous = special type of inflammation/macrophages) Cultures and biopsy of the septal tissue may be helpful in identifying fungal or bacterial infections HEMATOMA A healthcare provider can diagnose hematomas by looking at the nose Sometimes x-rays are done to view the nasal bones and facial structures to make sure there are no fractures (Cranial CT/MRI scans can detect more serious injuries. If a person is on medication, blood tests will be done to check the ability of the blood to clot. A complete blood cell count, or CBC, will often be ordered to check for anemia, or a low red blood cell count. POLYP Drs generally diagnose based on symptoms, carrying out a general examination, and examining the patient's nose (polyps often visible with light instrument) The doctor may also order the following tests: Nasal endoscopy - an endoscope - a narrow tube with a small camera inserted into the patients nose CT (computerized tomography) scan - enables the doctor to locate nasal polyps as well as other abnormalities linked to chronic inflammation Skin prick allergy test - small drops known to cause allergies in some people are pricked into the skin Cystic fibrosis - if young pt - measures the amount of sodium and chloride in the child's sweat

-NASAL SEPTAL DEFECTSCOMMON ALLOPATHIC TREATMENTS

DEVIATION Mild forms require no medical intervention other than treatment of occasional nasal congestion, sinusitis, or allergy symptoms (treated with decongestants, antibiotics, or antihistamines and nasal inhaled steroids) When the deviation is more severe and obstructs breathing, surgical intervention is necessary Septoplastyis - is performed under local or general anesthesia. (realigns and/or removes the deviated portions of the septal bone and cartilage) A submucous resection (SMR) - (more extensive) resection of cartilage and bone, removing part of flat bone from the inside/back of the nasal septum (vomer) and the ethmoid bone that defines the sinus above the septum, as well as correcting the deviated septum itself (Watson) PERFORATION Majority can be managed without surgery - hole will never close but if edge of perforation can heal vast majority of symptoms resolve The open irritated and raw surface must be continuously covered with a cream using a cotton applicator Will prevent this area from drying out, cracking, bleeding, forming a scab and crusting up - A few months of successful application allows it to heal A silicone button prosthesis may relieve symptoms of whistling sound/nasal obstruction etc. (placed with the help of a local anesthetic) In a small percentage of patients surgery is necessary to alleviate symptoms HEMATOMA Monitoring the hematoma and use of ice packs and nonsteroidal anti-inflammatory drugs (NSAIDs) A change in medication may be necessary to prevent or decrease the likelihood of bleeding Some people require surgery to remove the hematoma and repair any damage to the nasal septum POLYP Steroids - spray or nose drops - shrinks the polyps and reduces inflammation (this tx more common for patients with one or more small polyps) Side effects include: sore throat / headache / nosebleeds Steroid tablets larger polyps/more severe inflammation, may be taken along with a nasal spray Very effective at shrinking polyps BUT more serious side effects (ex. weight gain), should be taken for a few weeks at the most Other medications - treat conditions which may be making the inflammation worse (ex. antihistamines for allergies, antibiotics for infections etc.) Surgery - surgery is only used if the polyps are very large / patient has not responded well to other treatments Approximately 75% of patients polyps grow back about 4 years after they have been surgically removed Polypectomy - Through nostrils - sometimes may remove small pieces of bone from the nose to reduce the risk of recurrence Endoscopic sinus surgery - if the polyps are particularly large, in clusters, or are seriously blocking the sinuses (more invasive) After surgery - most likely be prescribed a corticosteroid nasal spray to help prevent recurrence

CT SCAN CT scan of a deviated septum OF A DEVIATED SEPTUM

Steps involved in a Septoplasty

-CLEFT PALATEDEFINITION
An opening in the roof of the mouth due to a failure of the palatal shelves to come fully together from either side of the mouth and fuse during the first months of development as an embryo The opening in the palate permits communication between the nasal passages and the mouth Surgery is needed to close the palate Cleft palate can occur alone or in association with cleft lip

-CLEFT PALATESIGNS & SYMPTOMS

Eating problems
Food and liquids can pass from the mouth back through the nose Fortunately, specially designed baby bottles and nipples that help keep fluids flowing downward toward the stomach are available May need to wear a man-made palate to help them eat properly (ensure that they are receiving adequate nutrition) until surgical treatment is provided

Ear infections/hearing loss

At increased risk of ear infections - prone to fluid build-up in the middle ear If infection left untreated can cause hearing loss Usually need special tubes placed in the eardrums to aid fluid drainage to prevent this

Speech problems
Voice often doesn't carry well/nasal sound/speech difficult to understand Surgery or a speech pathologist, can resolve speech difficulties

Dental Problems
Prone to a larger than average number of cavities and often have missing, extra, malformed, or displaced teeth requiring dental and orthodontic treatments In addition, children with cleft palate often have an alveolar ridge defect The alveolus is the bony upper gum that contains teeth. A defect in the alveolus can (1) displace, tip, or rotate permanent teeth, (2) prevent permanent teeth from appearing, and (3) prevent the alveolar ridge from forming. These problems can usually be repaired through oral surgery.

-CLEFT PALATECOMMON CAUSES/RISK FACTORS

In most cases, cause UNKNOWN Most scientists believe its a combination of genetic/environmental factors
If a sibling, parent, or relative has had the problem; there is a greater chance of cleft palate in a newborn

Medication a mother may have taken during her pregnancy

Drugs that may cause cleft lip/palate include:
anti-seizure/anticonvulsant drugs, Acne drugs containing Accutane Methotrexate a drug commonly used for treating cancer/arthritis/psoriasis

As a result of exposure to viruses or chemicals while fetus is developing in womb

-CLEFT PALATEHOW IT IS DIAGNOSED Causes very obvious physical changes easy to diagnose Prenatal ultrasound can sometimes determine if a cleft exists in an unborn child
MRI is used increasingly for evaluation of fetal abnormalities that are difficult to identify on sonography alone Fetal MRI is less dependent than sonography on optimal amniotic fluid volume, fetal position, and maternal body habitus (womans disposition)

If not detected prior to the baby's birth, a physical exam of the mouth, nose, and palate confirms the presence of cleft lip/palate after a child's birth Sometimes diagnostic testing conducted to determine/rule out presence of other abnormalities
Intra-uterine magnetic resonance imaging scan (sagittal view) demonstrating: normal a and cleft b palates The absent palatal stripe (red arrow) in b is indicative of cleft palate

COMMON ALLOPATHIC TREATMENT

-CLEFT PALATE-

Treatment involves surgery to repair the defect & therapies to improve related conditions GOAL: ensure the child's ability to eat, speak, hear and breathe and to achieve a normal facial appearance Surgery : Based on child's particular situation - following initial cleft repair, the doctor may recommend follow-up surgeries to improve speech or improve the appearance of the lip and nose Surgeries typically are performed in this order:
Cleft lip repair between 1 and 4 months of age Cleft palate repair between 5 and 15 months of age Follow-up surgeries between age 2 and late teen years
Ear tube surgery May be placed during the first surgery to reduce the risk of frequent ear infections, which can lead to hearing loss - involves placing tiny cylinders in the eardrum to prevent fluid buildup Surgery to improve cosmetic appearance Additional surgeries may be needed to improve the appearance of the mouth, lip and nose Treatment for complications of cleft lip and cleft palate Additional treatment for complications caused by cleft lip and cleft palate may include: Hearing aids or other assistive devices for a child with hearing loss Speech therapy to correct difficulty with speaking Therapy with a psychologist to help a child cope with the stress of repeated medical procedures

TEMPOROMANDIBULAR JOINT DYSFUNCTION

 Any disturbance to the normal functioning of the TMJ The term is used to describe a group of problems involving the TMJs and the muscles, tendons, ligaments, blood vessels, and other tissues associated with them

CAUSES
Direct trauma Malocclusion of the joints (a bad bite) Orthodontic treatment (braces, headgear) Degeneration of the disc or cartilage of the joint Stress/anxiety, may lead to clenching or grinding of teeth

SIGNS AND SYMPTOMS

Limited movement or locking of the jaw Pain in the jaw and in the muscles that move the jaw Ache around the ear Clicking, popping, or grating sounds when opening and closing the mouth Headaches Change in bite Occasionally earaches, dizziness, or hearing problems

COMMON TREATMENTS
Treatment is aimed at correcting the problem. Bite plates if bite is out of alignment Night guards for grinding Massage Hydrotherapy Stress management NSAIDs, muscle relaxants, corticosteroid injections if severe. Surgery to remove fluid with in the joint or to remove the disc completely

BELLS PALSY

Disruption of the facial nerve (CN VII) function Most often unilateral Very rarely it may be bilateral Mostly believed to be caused by viral infections Disproportionately attacks people who have diabetes or upper respiratory ailments

SIGNS AND SYMPTOMS

Vary greatly from person to person due to the many functions of the facial nerve Range in severity from mild weakness to total paralysis Symptoms usually peak within 48 hours and often resolve in 3-6 months

Innervations of CN VII
The nasopharynx and taste buds of the palate The anterior two thirds of the tongue Submandibular and sublingual salivary glands The lacrimal glands The mucous membranes of the nose and roof of the mouth Muscles of facial expression Muscles of the stapes

SIGNS AND SYMPTOMS

Twitching, weakness, or paralysis of the muscles of facial expression Drooping of the eyelid and corner of the mouth Drooling Dryness of the eye or mouth Impairment of taste Excessive tearing in one eye Ringing in the ear Dizziness Impaired speech Hypersensitivity to sound

COMMON TREATMENTS
Treatment depends on severity and cause of condition Mild cases may resolve with no treatment within two weeks Prednisone to reduce inflammation and swelling Anti-viral drugs (acyclovir) if cause is viral Analgesics for pain relief Keeping the eye moist and protected Physical therapy to stimulate the facial nerve and help maintain muscle tone Rarely, surgical decompression of the nerve

Tympanic membrane rupture/holes/defects

By Genevieve Zizzo-Borys

Tympanic membrane rupture/holes/defects

Definition : a perforation/rupture/ defect occuring within or around the tympanic membrane directly influencing the conduction of sound waves into the inner ear Etiology:
Trauma (noise, pressure, injury, foreign objects) Congenital (vascular defects, tegmental defects, congenital rubella, cholestatoma and perilymph fistula) Infections Surgical (tubes in ears)

Tympanic membrane rupture/holes/defects

Signs and symptoms
Pain and extreme discomfort (trauma/pressure changes, infection) A popping sound Sensitivity to hearing/hearing loss Vertigo/dizziness Tinnitus Drainage/discharge pus, blood, clear

Tympanic membrane rupture/holes/defects

Treatment
Trauma/rupture may repair on own
Cotton balls or ear plugs used to keep ears dry

Antibiotics (oral /eardrops)

May not be effective as many ear infections that cause tympanic membrane ruptures are viral in nature)

Surgery (tympanoplasty/myringoplasty)

Ear infections Ext/Mid/Deep

Otitis is a general term for inflammation or infection of the ear It is subdivided into the following Otitis externa, external otitis, or "swimmer's ear" involves the outer ear and ear canal. In external otitis, the ear hurts when touched or pulled. Otitis media or middle ear infection involves the middle ear. In otitis media, the ear is infected or clogged with fluid behind the ear drum, in the normally air-filled middle-ear space. This very common childhood infection sometimes requires a surgical procedure called "myringotomy and tube insertion". Otitis interna or labyrinthitis involves the inner ear. The inner ear includes sensory organs for balance and hearing. When the inner ear is inflamed, vertigo is a common symptom.

otitis externa
Signs & Symptoms: pain, and worsens if touched or pulled at tragus,pinna, lobe. may experience discharge and itchiness. This discharge can lead to blockage and hearing loss. Causes: swimming, also, a combination of germs and skin trauma Diagnosis: canal is red and swollen, maybe difficult to inspect the tympanic membrane using an otoscope. Lymph nodes may be noticeable just below the ear. Lack of cerumen in early cases Tx: refrain from immerging head in water. The use of acidifying and drying agents. Burows solutin is very effective . As well as other topical solutions. A physician may need to insert an ear wick to soften the debris. Eardrops containing antibiotics to fight infection and corticosteroids to reduce inflammation and itchiness

Otitis media
S&S: intense pain due to pressure build up behind tympanic membrane. This can lead to an inflamed or blistered membrane. This membrane may rupture producing instant relief. Also, may lead to chronic irritation and infection of inner ear. This may lead to Eustachain tube dysfunction. (effusion), slimmer tube Causes: viral, bacterial and fungal. Children under 5-7 due to horizontal Eustachian tube Diagnosis: visual inspection of tympanic membrane via otoscope Tx: oral agents NSAIDS, antihistamines, ear drops (benaocaine), antibiotics/amoxicillin

Otitis interna or labyrinthitis

S&S: severe vertigo, nausea and vomiting. Hearing loss Severe S&S: convulsions, double vision, fainting, fever, persistent vomiting Cause: viral inflammation of the vestibular labyrinth, caused by otitis media or an upper respiratory tract infection. Smoking, stress Diagnosis: EEG, Head CT, MRI, hearing test Tx: vestibular suppressants diazepam/meclozine to tolerate vertigo Antibiotics to prevent bacterial spread from mid-ear to inner ear. Antihistamines Prognosis: within a week up to 2-3 months

Tinnitus
Tinnitus is abnormal ear noise, and come arise from any of the four sections of the ear. S&S: sensor-neural hearing loss, noise induced hearing loss o Causes: neurological damage (MS), ear infection, stress, nasal allergies-fluild build up, wax, loud noise, ear buds, withdrawal from benzodiazepines Hyperactive dorsal cochlear nucleus (DCN) Diagnosis: the brain tendency is to select out the loudest sound Tx: gamma knife radiosurgery, Teflon implant shielding of coclea, cleaning of ear canal Meds: melatonin, lidocaine (injection into inner ear 20 relief, White noise maker

Rhinitis
Robyn Kirkpatrick

Definition
Inflammation of the inner lining of the nose

Signs & Symptoms

May be characterized by the presense of one or more of the following
Runny nose Nasal itching Nasal congestion Sneezing

Causes & Types

Allergic Rhinitis Seasonal Allergic Rhinitis (hay fever) Perennial Allergic Rhinitis Non-allergic Rhinitis Occupational Rhinitis Viral Rhinitis Other Causes May be associated with other medical conditions

Treatment
Avoidance of allergens Steroid nasal sprays- potent anti-inflammatory and anti-allergic agents Oral Steroids highly effective in allergic patients, short term Antihistamines Decongestant sprays quickly reduce swelling of nasal tissue by shrinking blood vessels Oral decongestants Cromolyn Sodium (Nasalcrom) spray helps stabilize allergy cells by preventing release of allergy mediators Montelukast (Singulair) similar to antihistamine Ipratropium (Atrovent nasal ) helps control nasal drainage through neural pathways, not allergies Mucus Thinning agents Allergy shots (immunotherapy) interfere with allergic response Combinations made up of one or more anti-allergy medications

Torticollis
Robyn Kirkpatrick

Definition & Causes

The neck tends to twist to one side due to over contracted musculature causing head tilt Family history (spasmodic torticollis), Trauma (acute torticollis), Infection of head or neck or Medications

Signs & Symptoms

Spasmodic Torticollis = abnormal contraction of the muscle on one side of the neck Neck muscles and those between the neck and shoulder will be tense and tender Acute Torticollis = unwilling to turn their head to one side, or may have their head turned slightly away from the side of discomfort Shoulder pain, back pain, headache, neck cramps, muscle tightness, or burning sensation

Treatment
Targeted to relax the contracted neck muscles involved Treatments include:
Medications Physical devices Botulinum toxin blocks the release of ACh Physical therapy Stretching exercises Surgery

Tonsillitis
an infection and swelling of the tonsils (oval-shaped masses of lymph gland tissue located inside the oropharynx palatine tonsils)
3 sets of tonsils:
Palatine Pharyngeal (Adenoids) Lingual

most commonly affected are the palatine tonsils Function of palatine tonsils is thought to be associated with preventing infection in the respiratory and digestive tracts by producing antibodies that help kill infective agents.

Tonsillitis
Infection and inflammation can be caused by:
Debris lodging in pits of tissue Viruses Bacteria (streptococcus pyogenes)

Tonsillitis
Signs and Symptoms: Mild or severe sore throat Fever Chills Tiredness Muscle aches Earache Pain or discomfort when swallowing Swollen glands in the neck Tonsils may appear swollen and red (may have white or yellow spots)

Tonsillitis
Allopathic Treatment: If caused by virus:
Rest Gargling with warm salt water NSAIDs for fever

If caused by bacteria:
Antibiotics Symptoms usually resolve within 4-6 days.

Sinusitis
Definition
Inflammation of the mucus membrane lining Lining swells and fluids build up Can be acute or chronic Maxillary, frontal, ethmoid and sphenoid Pain & tenderness over affected sinus Headache Yellow/greenish discharge Stuffy nose Cough that produces mucus Fever Tooth pain & bad breath Reduced sense of taste or smell

Signs and symptoms

Sinusitis
Common causes
Primary viral/bacterial infection Allergies Mucus producing foods such as milk/cheese

Risk factors
Infections: recent cold or upper respiratory Pharmaceutical: overuse of decongestant sprays Mechanical: deviated septum Metaplasia: nasal polyps Irritants: smoking, air pollution, cold weather, swimming

Diagnosis
Medical history Physical exam

Sinusitis
Diagnostic imaging pictures
Common:
CT Scan Sinus X-Ray

Uncommon
ESM Needle Puncture MRI

Common allopathic treatments

Surgical: endoscopic or traditional Pharmaceutical: decongestants, corticosteroids, anti bacterial, analgesics, mucolytics Alternative: Salt rinse or diet change

Lymph Node Enlargement

Definition
Lymph nodes are part of immune system Contain white blood cells & some red blood cells Lymph contains a concentration of infectious and other foreign substances Enlargement is a sign of infection

Signs and symptoms

Depends on cause & location cervical Upper Respiratory infection (runny nose, sore throat, fever) Cervical pain or tenderness Redness or infection on skin over affected nodules

Lymph Node Enlargement

Common causes/risk factors
Infections: cold/flu, measles, rubella, mumps, chicken pox, HIV, mononucleosis Mechanical: Injury Systemic :Lupus, Rheumatoid Arthritis Metaplasia: Benign nodule growth Pharmaceutical: Side effect of other medications Neoplasia: Cancer

Diagnosis
Medical history Physical exam

Lymph Node Enlargement

Diagnostic imaging pictures

Blood Tests X-rays CT scan Biopsy may be requested for further investigation
OTC: ibuprofen / acetaminophen to help with pain & fever Antibiotics or Antiviral Mechanical drainage through irrigation if localized abscess Surgery, radiation or chemotherapy if malignancy Pharmaceutical: if immune disorder is suspected

Common allopathic treatments dependant on cause

Glaucoma, Macular Degeneration, Conjunctivitis

Glaucoma
loss of retinal ganglion cells (optic neuropathy) Most often associated with ocular hypertension (aqueous humor fails to drain due to
destruction/obstruction of trabecular meshwork)

2 types Open angle - silent thief of night

(gradual loss of vision over a long time, may not be noticed until advanced)

Closed angle sudden, often painful, halos around lights, red eye (acute is medical emergency)

Glaucoma treatment
eye drops (lower ocular pressure by increasing outflow
or decreasing fluid creation)

Beta-blockers (decrease fluid, can cause asthma) Prostaglandin analogs (relax interior eye muscles
allows better flow of fluids)

Alph-adrenergic agonists ( fluid production) Carbonic anhydrase inhibitors ( fluid production) Parasympathomimetics ( outflow) Epinephrine ( fluid production, outflow)

Macular degeneration
Damage to macula (central area of retina) commonly age related Retina can become detached 2 types cause unknown Dry atrophy of retinal pigment epithelial layer under
retina causes photoreceptor loss protein leakage leading to scarring & photoreceptor damage

Wet abnormal blood vessel growth = blood and

Macular degeneration
S&S drusen (cellular debris) accumulates btn
retina and choroid layer, pigment alteration, eye hemorrhages, atrophy, decrease of visual acuity Rx - degeneration is irreversible, rely more on peripheral vision (only affects macula [2.1% of retina but
50% of visual cortext devoted to it])

prevention of further deterioation with supplements (antioxidents & zinc), stop smoking, wear sunglasses Wet type: Rx destroys BVs laser, injections to close or slow growth of vessels

Conjunctivitis
Inflammation of membrane lining eyelids Causes: viral (pink eye), allergies, bacteria, certain
diseases, chemical exposure, chlamydia, fungi, parasites, contact lenses (extended wear) S&S: blurred vision, crusts that form on eyelids overnight, eye pain, gritty feeling in eyes, tearing, itching red eye, light sensitivity Rx: depends on cause antibiotics, allergy Rx, etc.

Eye compresses: viral (warm), allergic (cool)