Chapter 7: Eye, Ear, Nose, and Throat 65
asmeclizine,duringtheacutephaseandvestibularreha-
bilitationwithphysicaltherapyforchronicvertigo.
12
Lifestyle Changes: Practical Tips for Your
Patients
Patientswithvertigoneedtoensurethattheirhomes
arefreeoftriphazards,suchasthrowrugsandother
itemsontheoor.Theyalsoneedambientlightingat
night, and some patients may need assistive devices,
suchaswalkersorcanes,untilthevertigoisresolved.
Mouth and Throat Disorders
Aphthous Ulcers
General Characteristics
Problems involving the mouth and throat account for
approximately 20 percent of all clinic visits to primary
careproviders(Figure 7–3).
3
Aphthousulcersarecommon
andaresmall,round,erythematousshallowerosionswith
awhitecenterontheoralmucosa.Theyareoftencalled
canker sores. It has been theorized thatthese ulcersare
caused by viruses, specically human herpesvirus 6, as
wellashormoneandnutritionalimbalances;however,the
etiologyremainsunknown.
9,36
The ulcersarethoughtto
be inammatory in nature.
3
Risk factors include stress,
hormonal uctuations, inammatory bowel disease, and
chemotherapy.
3
Theulcersresolveslowlyin7to10days
withouttreatment,withtherstfewdaysbeingthemost
painful.Recurrenceratesvarypertheindividual.
Signs, Symptoms, and Diagnosis
Symptomsincludepaininthemouthwitheatingorswal-
lowing.Theinitialcomplaintisaburningsensation,with
development of an ulcer in the following hours to days.
Symptomsgraduallyresolveoveraweekto10days.The
ulcers are bright red in appearance with a white center.
Theymaybesolitaryorhavemultipleulcerations.Mostare
smallinsizeandarelocatedontheoralpharyngealmucosa.
Theulcersareverypainfulandmayinterferewitheating
and swallowing. Obtaining a thorough patient history is
importanttoruleoutothercausesofulcers.Thisincludes
secondaryherpeticlesions,Vincentstomatitis(trenchmouth),
allergicstomatitis,nicotinicstomatitis,candidiasis,parasitic
stomatitis,andpseudomembranousstomatitis.
3
Larynx
Trachea
Tongue
Hard palate
Epiglottis
Nasal cavity
Middle nasal concha
Inferior nasal concha
Pharynx
Vocal cords
Esophagus
Nasopharynx
Oropharynx
Laryngopharynx
Figure 7–3 Anatomy of the mouth and throat.
66 PART II: PRIMARY CARE DISORDERS
Management
Expectantmanagementwithsymptomcontrolistheusual
therapy.Becausethepainismostintensewitheatingand
swallowing,therapyisdirectedatmakingtheseactivities
morecomfortable.Ahomeremedyistohavethepatient
mixequalpartsdiphenhydramine(Benadryl)liquidwith
anantacid, suchas simethicone(Maalox), (total 10 ml)
andswishanddiscardthreetofourtimesdailyasneeded
to coat the ulcers, which provides some pain relief and
comfortforeating.
3
Topicalsteroidssuchastriamcinolone
acetonide(Kenalog)inOrabaseGel(benzocaine)maybe
helpful.
36
Oralsteroidsmaybeindicatedinseverecases.
3
Lifestyle Changes: Practical Tips for Your
Patients
Dailyvitaminsmay be helpfulifthe ulcersarethe
resultofavitamindeciency.Acidicfruits,suchas
tomatoes, may precipitate ulcers and should be
avoidedbypatientswithsevere,recurrentepisodes
ofaphthousulcers.All patients with mouthulcers
needtobeeducatedongoodoralhygiene,including
twicedailytoothbrushingwithasoft-bristledbrush
anddailyossing.
3
Laryngitis
General Characteristics
Laryngitisisaninammationofthevoicebox,thelarynx.
9
Thelarynxitselfisnotinfected;ratheritisinamed.This
inammation can be caused by upper respiratory infec-
tion,esophagealreux,tumor,orvocalabuse.
9
The sever-
ityoflaryngitiscanvaryfrommildhoarsenesstocomplete
voiceloss.Laryngitiscanbeacuteorchronic.
Signs, Symptoms, and Diagnosis
Laryngitis frequently accompanies an upper respiratory
infectionandmaybeginasascratchythroatandprogress
tovaryingdegreesofvoiceloss.Painmaybeassociated;
however, there should be no complaints of shortness of
breath.Thisisbecausethehoarsevoiceiscausedbythe
vocalcordsnotbeingabletoapproximate;therefore,there
isadequatespaceforairpassage.
9
Diagnosisismadefrom
a history and physical examination that is suggestive of
laryngitis.Thetwomethodstovisualizethelarynxareto
usean angled heatedmirrorora nasopharyngealscope,
whichistypicallyperformedbyaspecialist.Therefore,in
primary carethe physical examination does not include
directvisualizationofthelarynx.
Management
Acutelaryngitisusuallyresolvesin2weekswithoutinter-
vention. Management of laryngitis includes voice rest,
which means not speaking unless necessary. Gargling
with salt water may provide some relief. Treatment of
underlyingesophagealreuxwillbeimportantinprevent-
inganacutelaryngitisfromdevelopingintochroniclar-
yngitis.
9
Treatmentoflaryngitiswithsteroidsmayactually
makeitworseandisnotrecommended.
9
If the hoarseness is caused by an upper respiratory
infection,adecongestantmaybe helpful; antihistamines
shouldbeavoidedbecausetheyaredryingandresultin
thicker mucus, therebycausing dryness of the laryngeal
folds.
9
Antibiotics are necessary only if the underlying
causeisbacterial,suchasfromacutesinusitis.
Ifthehoarsenessiscausedbygastroesophagealreux,
therapyshouldincludestomachacidsuppressants.First-
linemanagementincludesanH2blocker,suchasraniti-
dine (Zantac), and dietary modication.
9
An alternative
wouldbeprotonpumpinhibitortherapy.
Therearesomerarecircumstancesthatrequireimme-
diatereferraltoaspecialist.Theseincludesuddenhoarse-
ness during extreme vocal stress, such as shouting, or
liftingheavyobjectsthatmayresultinhemorrhageofthe
vocalfold.Traumatotheexternalneckmayfracturethe
larynx. Severe hoarseness after endotracheal intubation
requiresimmediateconsultationbyanotolaryngologist.
9
Lifestyle Changes: Practical Tips for Your
Patients
Recommend avoidance of repetitive throat clearing
because this is an irritant to the vocal cords. Vocal
hygiene, such as refraining from shouting, talking
loudly or frequently on the telephone, or trying to
speakoverloudnoise,will helptospeedhealing.If
esophageal reux is a concern, education regarding
dietarychangesmaybehelpful.
Sialadenitis
General Characteristics
Virusesorbacteriacancauseinammationorinfectionof
thesalivaryglands,whichisknownassialadenitis.This
inammationcausesthesalivaryglandtoswell,resulting
in pain and edema. Saliva assists in mouth hygiene by
cleansing away bacteria and keeping the mouth clean.
Whensalivaisdecreased,thereisincreasedriskforinfec-
tion of the salivary glands.
9
The parotid gland is most
commonlyaffected.
Riskfactorsfordecreasedsalivaoutputleadingtosali-
varyglandinfectionincludedehydration,debilitation,and
salivaryductobstructionbyastone,stricture,ortrauma.
Anyconditionthatcausesstasisofsalivaryow,suchas
thepostoperativestateandnottakinginoralfoodoru-
ids, is also a risk factor for salivary gland infection.
9,37
Common causative organisms include Staphylococcus
aureus, Streptococcus pneumoniae, Haemophilus influenzae,
and Escherichia coli.
37
Hospitalized patients may have
otheradditionalbacteria,suchasKlebsiella, Enterobacter,
Pseudomonas, or Candida.
37
Signs, Symptoms, and Diagnosis
Symptomsincludepainfulswellingoftheaffectedsalivary
gland,metallictasteinthemouth,andpainwitheating.
9,37
Fevermayalsobepresent.Onexamination,theaffectedgland
isvisiblyswollen, warm to the touch, and erythematous.

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