Lecture 6 Oct 4th

LECTURE 6: OCTOBER 4TH, 2006 **RE: EXAM** EXAM WILL BE ALL MULTIPLE-CHOICE QUESTIONS. SOME WILL BE CASEBASED. DISORDERS OF THE MIDDLE EAR (PG 4) LABYRINTHITIS: • Complete hearing loss and facial paralysis occur on one side. • “+/-“ means “may or may not” • Invasion of bacteria into inner ear • Severe vertigo/dizziness • “Nystagmus” : when eyes flutter back and forth quickly as they are tyring to focus. Test for this by doing the “H-Test”: draw the letter H with finger in air in front of patient. As patient looks up/down, side to side, their eyes will jump from place to place as they try to focus on the moving finger (positive sign). Nystagmus is usually related to a lesion in the brain but in this case, it is related to lack of feeling of balance. VESTIBULAR NERONITIS: • Patient has symptoms continuously, then it comes and goes. • Complete recovery in 3-4 weeks MENIERE’S DISEASE: • The lower frequencies are affected. • Patient will experience rotational vertigo: they will feel like they are turning. Homepathic remedies are very good for treating vertigo, but you need a complete description of the TYPE of vertigo. BENIGN PAROXYSMAL POSITIONAL VERTIGO • Due to calcium deposits causing vertigo. • Pathophysiology: Degeneration. Could also come on abruptly due to stress. • Very subtle movement of the head can provoke spinning. Consider this when treating patient. Lying down (eg. For acupuncture) might be uncomfortable for them. DISORDERS OF THE NOSE (PG 5) RHINITIS: • Difficulty breathing during prodromal phase • Erythema and edema inside nose, mucus develops ATROPHIC RHINITIS:

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Also called “oznea” “Patency” is the amount of air passing through turbinates of the nose. “Anosmia”: patient can’t smell. Their sense of smell is impaired (nerve), but they may be able to describe “smell” because they can taste it. Idiopathic Tissue inside nose is rotting: foul odour. Green/yellow crusts may be visible on turbinates. Patient can “smell” the odour themselves (really tasting, not smelling)

VASOMOTOR RHINITIS: • Spasm of nerve • Clear, watery mucus ALLERGIC RHINITIS: • Related to allergies, predisposes patient to polyps. • Symptoms are typical allergic symptoms. • Nasal mucous membrane may have pale bluish/greyish colour. SINUSITIS: • Pale colour, whitish discolouration of mucus membranes. • Watery discharge • Can be due to bacterial/viral/allergic cause • PAIN: head is very sensitive to movement, pressure • Feeling of wanting to blow nose, but can’t due to swelling. • Wet sock treatment will help to move lymph: will give relief from pressure. • Teeth will ache (maxillary sinus is close to roots of teeth) • Acute maxillary sinusitis (seen in slide): see purulent discharge, looks full of pressure. • Look for structural abnormality if patency remains abnormal after resolution of infection. Deviated septum? • Many migraine sufferers have deviated septa (clinical observation) NASAL POLYPS (not in nose: slide was shown) • Looks like a peeled grape • Lesion is solid tissue, not fluid-filled. CARCINOMA OF NASOPHARYNX: (discussed: no notes) • We won’t see these in practice: they will be too deep to observe, but they are VERY red. DISORDERS OF THE MOUTH AND THROAT (PG 6) ANGULAR CHEILITIS:

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At edges (corners) of mouth If person drools in sleep, the constant dampness may irritate their skin Dermatitis on edge of mouth. BEEFY RED TONGUE. Look for fissures

LEUKOPLAKIA: • Can become cancerous • DDX: Herpes? Herpes has vesicles Canker sores? Canker sores present as discreet circles Oral thrush? Can scrape oral thrush off mucous membrane. • Painless: typically smooth lesions, except on tongue where you may observe some texture. GINGIVITIS: • May be due to nutritional deficiencies. Check levels for iron, zinc, Vitamin A, especially if they have good oral hygiene and still have gingivitis. • Edematous and erythematous gums • Usually painless, but tenderness after brushing/flossing. DENTURE GRANULOMA • Hard groth: related to rubbing/friction of dentures on oral mucosa. AMALGAM TATTOO: (not in notes) • Discolouration of gingival due to mercury fillings. Can be confused with carcinoma. • If removing fillings, should stage removal over time. Don’t do them all at once: toxicity. • Use caution if patient’s vitality is low. • Debate: is it more dangerous to remove fillings and release mercury, or to leave them in and have small amounts of mercury released over the long term? ERYTHROPLAKIA: • Carcinomal of oral mucosa • Refer: many people don’t go to the dentist regularly. Refer to oncologist: may work with dental surgeon. KAPOSI’S SARCOMA OF THE MOUTH: (not in notes) • Saw this on skin: purple, flat macules • May be ulcerated in mouth: greyish, bluish, whitish lesion. BLACK HAIRY TONGUE: (not in notes) • Papilla on tongue elongate and turn black. • Western medicine: no explanation for black colour. In TCM: heat and fire cause black colour • Observed in a patient with myacemia gravis: had been on prednosone.

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Have to ask if patients scrape their tongues: may confuse diagnosis. DISORDERS OF THE OROPHARYNX (PG 7)

PHARYNGITIS: • “injected tonsils” means “bloodshot”. Will seem this term referred to in other sections, eg. To do with the sclera of the eye. • More systemic symptoms than with tonsillitis. TONSILLITIS: • DDX: Vincent’s angina is more ulcerated than tonsillitis • Some people naturally have very large tonsils! • Use grading system for inflamed tonsils: +1 -> +4. Allows for monitoring of size. ACUTE TONSILLITIS (aka Strep throat) • Caused by strep infection. • Very swollen tonsils (+3 or +4) • May see tonsillar crypts: pus coming out of them. (Tonsils are lymphatic tissue) • Pain! Can’t swallow! • Treatment: antibiotics, salt-water gargle, homeopathic, aloe vera (drink) • Homeopathic: Hepar-sulph, especially when pain refers to ears (sharp pain!) INFECTIOUS MONONUCLEOSIS: • EBV=Epstein-Barr Virus • Symptoms may include: o High fevers o Fatigue o Enlarged spleen: can burst if active o May be asymptomatic: variation in presentation • Often affects teenagers 15-19 • Swelling in face may present • When you are older, symptoms take more time to clear up • Petechia: dots of blood on back of throat. DISORDERS OF THE LARYNX (PG 8) LARYNGITIS • May or may not accompany strep. • Have to rule out cancer of the throat (also involves hoarseness) NODULES AND POLYPS: • Nodules form on the edges of vocal folds. Edges may look irregular.

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We won’t see this without scope to look down thrat, but it is good for us to know about it. Patient may tell us that they have it. Whispering is hard on the vocal cords! Constant clearing of throat will irritate vocal cords as well.

ACUTE EPIGLOTTITIS (LARYNGOTRACHEITIS) • Airway becomes very restricted due to edema. Accessory muscles are used for breathing • Have to refer! Life threatening situation. Have to intubate patient to breathe. • Particular concern with babies. Have to be careful. Look for distress, signs that they can’t breathe. Talk to parents who may be able to help diagnose stress. CROUP (LARYNGOTRACHEOBRONCHITIS) • “Barking” cough: homeopathic remedy is Spongia. • More rales and wheezing • “Wheeze”: high pitched sound • “Rales” lower pitched sound. (“Rhonchi” is also a lower sound) • Hear wheezing in trachea? May be obstruction. LARYNGEAL CARCINOMA: • Hoarseness: if it doesn’t resolve in 2 weeks, refer to GP • History of smoking? May predispose to cancer.