5 - Otolaryngology Flashcards
The 3 Pharynges
Nasopharynx
Oropharynx
Hypopharynx
Mouth disease list
Leukoplakia Erythoplakia Oral lichen planus Oral cancer Oral herpes Candidiasis Glossitis Intraoral lesions Disease of teeth/gums
Throat diseases list
Pharyngitis and tonsilitits
Peritonsillar abscess and cellulitis
Tonsillectomy
Diseases of the salivary glands list
Sialandenitis
Parotitis
Key to success for diagnosing oral lesions?
Form an appropriate differential diagnosis based on H/P
Even longer list of oral cavity lesions?
Slide 8
What is the problem with precancer and early oral cancer?
They are subtle and often asymptomatic
Presentation of early and precancer?
White/red patch
- Progresses to ulceration
- Becomes endophytic or exophytic mass (SCC)
Endophytic vs exophytic?
Endophytic - grows inward from superficial lesion
Exophytic - grows outward from the lesion
Best known precancerous oral lesion?
Leukoplakia - precancer
What is leukoplakia?
Precancer
white patches or plaques
- non-removal
Represents hyperplasia of the squamous epithelium
Transformation of leukoplakia?
Hyperplasia -> dysplasia -> carcinoma in situ -> invasive malignant tumor
Leukoplakia progression to cancer?
1-20% become cancer in 10 yrs
What (non-cancer) causes leukoplakia?
Inflammatory conditions
- hyperkeratosis from chronic irritation (dentures, tobacco etc)
What is erythroplakia?
Similar to leukoplakia except red (erythematous for your smart people)
Problem with erythroplakia?
More likely than leukoplakia to exhibit dysplasia or carcinoma microscopically
- 90% are dysplasia/SCC
Exam for leuko/erythroplakia?
Through oral exam
Palpation of neck for lymphadenopathy
Biopsy everything
When should you give an ENT referral for leuko/erythro?
Early
- precancer needs to be removed
- cryotherapy and lasers are used sometimes but not preferred
MC oral cancer?
Squamous cell carcinoma SCC
-90% of oral cancer
Describe SCC
Ulcers or masses that dont heal
Any persistent lesions in mouth need?
Biopsy and ENT referral
Risk factors for SCC?
Tobacco/ETOH
- accounts for 80%
Combine them and they are even more effective
Common locations of SCC?
Ventral surface of tongue
Hard palate
Tip of tongue
Mouth hole
5 yr survival SCC?
5 yr = 50-55%
ABCDE of melanoma?
A - assymetry B - Boarders (irregular) C - color (variable) D - Diameter (increased) E - elevation
DDX for melanoma?
Melanosis - symmetric spots on dark skin ppl
Oral melanotic macules - symmetric w sharp boarders
Amalgam tattoos - leeching of dental fillings
What are fordyce spots?
Benign neoplams of sebaceous gland etiology
- isolated/scattered
- white/yellow,
- 1-2mm discrete papules
Prominent on vermillion/buccal mucosal boarder
What are mucoceles?
Fluid filled caveties in mucous glands
- after mild oral trauma
Mucoceles MCC?
MCC - lower lip biting
Tx for mucoceles?
Symptomatic - cryotherpathy/excision
Aspiration may relieve symptoms but usually come back
Oral linchen planus are?
Chronic waxing and waning inflammatory condition
Maybe immune mediated
Usually pts >40yo
Forms of oral lichen planus?
2 clinical forms
Reticular
- white, lacy striations (wickham’s striae) or papules on buccal mucosa
- painless
Erosive
- zones of tender erythema and painful ulcers surrounded by white radiating straie
Thrush?
Oral candidiasis
What is candidiasis?
Fluctuating mouth or throat discomfort caused by fungus
- seen in young and AIDS
Describe thrush
Erythema of oral cavity
Creamy-white curd-like patches
Angular chelitis
Resolves rapidly w tx
Causes of etiology?
MC - candida albicans
Less common
- C glabrata
- C. Krusei
- C. Tropicalis
Forms of oral candidiasis?
Pseudomembranous form: MC
- overall-white plaques on buccal mucosa, palate, tongue or oropharynx
Atrophic form (denture stomatitis):
- MC in older adults
- erythema w/o plaques
Diagnosis of candidiasis?
KOB - budding yeast
Aids test
Candidiasis tx in infants
Topical antifungal
- nystatin suspension x 2 weeks
- gentian violet/oral fluconazol if refractory
Sterilizing bottles/nipples
Candidiasis tx in older kids?
Mild: topical nystatin or clotrimazol
Severe:
- fluconazole 6mg/kg once
- followed by 3mg/kg q day x 7-14 days
Adult candidiasis tx?
Fluconazole 100mg po x 7 days
Ketoconazole 200-400mg po x 7-14 days
Nystatin mouth rinse
HIV needs longer tx
Cancer sore is aka?
Appthous ulcer
Describe aphthous ulcer
Painful oral lesion
Small round ulcerations
Yellow-gray base w red halo
MCC form of oral lesions?
RAS - recurrent aphtosus stomatitis
Risk factors for RAS?
Stress Hormones Food sensitivitis celiac disease IBD Vitamin deficienes (B 1,2,6,12)(iron)(folate) (zinc)
Presentation/course of RAS?>
Round clearly defined small painful ulcer
- heals in 10-14 days
- larger lesion (>1cm) last 6 weeks
2-4 times/yr or more
Usually resolves by age 30
Tx fo RAS?
Usually nonsystemic
- septra/fluocinonide (orobase)
- diclofinac in hyaluronan
- amlexanox (aphthasol) paste
Systemic
- Oral prednisone 1 wk taper (40-60mg q day)
Herpetic gingivostomatitis is aka?
Herpes labialis
HSV 1
S/s of herpetic gingivostomatitis?
You should know these by now but slide 41 has them
Picture dew drops on a rose petal but the rose is your mouth
Dx for herpetic gingivostomatitis?
Multinucleated giant cells on tzank smear
Comes from a scraping
Tx for herpetic gingivostomatitis?
Acyclovir PO 5per day x 7-14 days
Valcyclovier 1000mg PO BID
Tx for herpes only works if?
You take it prophylacticl
or
W/in 24-48 hrs of prodromal symptoms
Varicella-zoster virus
Yep it can be in the mouth
- so run the autism risk and get the vaccine
Atrophic glossitis is?
Inflammatory d/o of tongue that leads to atrophy of papillae
Causes of atrophic glossitis
Nutritional deficiencies Chronic dry mouth Oral candidiasis Protein-calorie malnutrition Celiac disease
Sx of atrophic glossitis?
Burning sensation
Increases sensitivity to eating acidic or salty foods
Tx of atrophic glossitis
Directed at cause
Describe fissured tongue?
Deep grooves over tongue surface
Generally asymptomatic
Permanent
Fissured tongue is associated w?
Downs - T21
Black tongue
Hyperpigmentation common in dark-skinned individuals
Less common cause of black tongue?
Tetracyclines Bismuth subsalicylate Antidepressants PPI Interferon
Tx for black tongue?
None unless med induced then stop the meds
Geographic tongue?
Local loss of filiform papillae leads to ulcer-like lesions
Lesions cause change location, pattern and size w/in min/hours
Tonsil size?
0 - surgically removed 1 - tonsils hidden w/in pillars 2 - tonsils extending to pillars 3 - tonsils are beyond pillars 4 - tonsils extend to midline
Slide 54 pic
Essentials of diagnosis
Strep
Sore throat
Fever
Anterior cervical adenopathy
Tonsillar exudate
Focus to tx group A b-hemolytic strep
All sore throats are not strep throat but?
If its GAS you must treat w abx
Centor criteria?
Suggest GAS
3/4 present 90% GAS
FACE F - Fever (>100.4) A - Anterior cervical LAD C - Con-cough E - exudate
RADT?
Rapid antigen detection test
Rapid strep
Can also do culture
Other pharygitis and tonsillitis that looks like strep?
Mononucleosis (petichia) - shaggy white-purple exudate Diphtheria - gray tonsillar pseudomembrane Virals agents (dont forget a z-pack) - cough, rhinorrhea, no exudate Neisseria, chlamydia - culture/history
Tx for GAS?
Pen VK - DOC
Amoxicillin - better for kids (taste like bubble gum)
IM benzathine pen G (honestly why would you give anything else)
Ancillary tx for GABHS?
Aspirin/nsaid
Acetaminophen
Corticosteroids
Salt water gargle
Tx for MONO
Same except no abx (its viral)
With mono you need to watch for?
Splenomegaly
- no sports
- no bikes
- no skateboarding (this is a rule of life not just for mono)
Quinsy tonsil?
Peritonsillar cellulitis and abscess
Peritonsillar cellulitis and abscess is?
Infection penetrates the tonsilar capsule and involves the surrounding tissurs
Peritonsillar cellulitis and abscess sx?
Severe sore throat Odynophagia Trismus Medial deviation of soft palate/peritonsillar fold Hot potato voice
Dx for peritonsillar cellulitis and abscess?
US/CT Needle aspiration (pus)
Complications for peritonsillar cellulitis and abscess?
Extension to the retropharyngeal, deep neck, and posterior mediastinal space
Tx for peritonsillar cellulitis and abscess?
GET ENT INVOLVED
Cellulitis - good airway, no sepsis
- empiric IV abx (GABHS, S. Aureus, resp anaerobes)
- admit
PTA w good airway
- needle aspiration and admission
Tonsillectomy or I/D if they dont respond
Indications for tonsillectomy?
Obstructions or infections
- obstruction of naso or oropharyneal airway
- sleep disordered breathing (SBD)
Tonsillectomy in kids?
Kids w SDB might get better w/o tonsillectomy and s/e may be
- growth delay
- poor school performance
- bedwetting
- behavioral problems
Watchful waiting is best
When to do tonsillectomy in kids?
<7 episodes/yr - dont do
<5 a yr in past 2 yrs or <3 in past 3 yrs
But if needed can reduce req of sever throat infections
Concerns w tonsillectomy”
Bleeding - can lead to laryngospasm and airway obstruction
Pain - can be considerable
Protracted emesis/fever
Secondary bleeding 5-8 days later
Important salivary glands?
Stenson - on top
Wharton duct - on bottom
Drain pattern of salivary glands?
Parotid glands -> stenson duct
Submandibular -> wharton duct
Sublingual gland
What is sialadenitis?
Ductal obstruction from mucous plug - salivary stais from secondary infection with:
- staph Aureus MC
Parotid or submandibular gland and duct infection
Symptoms of sialadenitis?
Swelling of gland
Pain/swelling w meals
Tenderness/erythema of duct opening
Exudate w massage of duct
Tx for sialadenitis?
Mild - hydrate, warm compress of gland
Less sever - PO abx for s aureus
Severe - IV abx (nafcillan) followed by PO abx
Failed tx for sialadenitis?
Failed tx - consider abscess, stricture, tumor suppurative sialadenitis
What is suppurative sialadenitis
Sever/life threatening form
- Get US/CT
- will need I/D
What is suppurative parotitis?
Acute infection of parotid gland w bacteria or virus
- MC s. Aureus
Seen with dehydration or dirty mouth
Presentation of suppurative parotitis?
Sudden onset
- firm, Erythematous swelling of pre and postauricualr areas that extends to angle of mandible
TTP w trismus and dysphagia
Fever/chills
Purulent material (maybe)
Tx for parotitis?
Immediate referral
- may spread to deep neck spaces
Hydrate and IV abx
- nafcillin + metrinidazol or clinda
- vanc for aids pts
Prob needs an I/D
Sialolithiasis?
Stone in ductu
- usually wharton duct
- maybe stenson duct
Palpated manually
CT for sialolithiasis?
Wharton duct stones - large and radiopaque
Stensen duct - small and radiolucent
Tx for sialothiasis
< 2cm from duct opening- sialangouges, warm fluids, massage, dilation or I/D
> 2cm from duct opening - sialendoscopy
Chronic
- sialoendoscopy - management of choice
Salivary gland tumors a big deal?
80% are benign
- mostly asymptomatic
When to worry about malignancy for salivary gland tumors?
If CN VII affected
Tumors in paraphyngeal space cause by medial deviation of soft palage
Audience member:
“Why do you have such a small mouth?”
Comedian:
“To make dicks like yours seem big”
