Block 1- Mouth and Throat Disorders Flashcards
cold sores are caused by
HSV-1
Can HSV-1 have asymptomatic viral shedding?
yes, pt won’t know when they are passing it on
Epidemiology
of HSV-1
worldwide.
By age 30, 50% of individuals in a high socioeconomic status and 80% in a lower socioeconomic status are seropositive
etiology of hsv
HSV-1 or HSV-2, trigeminal ganglia most often affected by HSV-1 , reactivation more common on mouth area
Risk Factors for hepres simplex
- sun exposure, surgery, stress, fever and viral infection, transmitted by close personal contact “kissing disease”
inoculation of virus is through susceptible mucosal surfaces such as?
- oropharynx, cervix, conjunctiva, small cracks in skin
Primary Infection symptoms of HSV
o Systemic symptoms: Fever, malaise, headache
o Acute herpetic gingivostomatitis lasts 5-7 days
o Maximum viral shedding is in the first 24 hours of the acute illness but may last 5 days
o Viral shedding from saliva (asymptomatic shedding) can last 3 weeks
Recurrent Infection symptoms – once HSV infection has occurred
o Prodromal symptoms
Pain, burning, tingling, pruritus 6 to 53 hours prior to appearance of vesicles
Reactivation by immunodeficiency or stress
Rarely associated with systemic symptoms, doesn’t last as long
what will you find on the physical exam for pts with herpes simplex?
Multiple painful vesicular lesions superimposed upon an inflammatory, erythematous base. They can rupture and cause ulcers.
- Most commonly on vermilion border of the lips
- Local LAD
- Can be associated with Bell’s palsy
Lab and Diagnostic Tests for herpes simplex?
o Viral tissue culture – most definitive (gold standard) – can take fluid out of vesicles for this culture
o Tzanck smear – multinucleated giant cells, not sensitive
o PCR for CSF
o Serologic tests for HSV-IgG- can’t readily distinguish antibody between HSV 1 and 2
Treatment
for herpes simplex
- Medications - No cure, but when started at FIRST onset, may decrease duration of symptoms
o Antivirals: Valacyclovir $ /Famciclovir $»_space; acyclovir most convenient for patients
o For recurrent can prescribe topical creams:
Penciclovir Cream / Acyclovir cream / Abbreva
Valacyclovir or Famciclovir x1day (at prodrome) - Avoid kissing, sharing beverages and food from the same container/utensils, or toothbrushes
What are Apthous Ulcers
- Self-limited painful ulcerations
- Also called “Canker sore” or Aphthous stomatitis
Epidemiology of Apthous Ulcers
slight female predominance, up to 66% pop, all races, typically starting in childhood
History of Apthous Ulcers
- Possible risk factors o Heredity o Oral local trauma o Stress o Vitamin, iron, or folic acid deficiency o Immunodeficiency o Toothpastes containing sodium lauryl sulfate (tartar-control toothpaste) o Tobacco use o Celiac Disease, Behcets, Crohn’s, HIV - Painful recurrent oral ulcers (RAS) MOST common mouth ulcers - They heal in 7-10 days. - They recur at intervals of 1-4 months
what will you find on the Physical exam of Apthous Ulcers
Circular, clearly defined, shallow ulcers covered by gray membrane surrounded by raised border of inflammation
name disorder:
Circular, clearly defined, shallow ulcers covered by gray membrane surrounded by raised border of inflammation
Apthous Ulcers
name disorder:
Multiple painful vesicular lesions superimposed upon an inflammatory, erythematous base. They can rupture and cause ulcers.
Herpes Simplex
treatment of Apthous Ulcers
- Eliminate predisposing factors- avoid spicy, tomato based foods
- Analgesia (many different) , Topical OTC preparations :
Orajel-Ultra Mouth Sore Medicine (benzocaine and menthol)
Magic Mouthwash, “Duke’s Magic Mouthwash” , viscous lidocaine - Promote ulcer healing/prevent recurrence (1st line)
o Triamcinolone 0.1% in Orabase: Apply to ulcer 2–4× daily until healed.
o Amiexanox 5% paste: 0.5 cm applied to ulcer q.i.d. after meals
o Clobetasol 0.05%: 0.5 cm applied to ulcer 2× daily
o Fluocinonide 0.05% gel: 0.5 cm applied to ulcer up to 5× daily - Systemic Therapy
o Prednisone
o Thalidomide
when to refer for Apthous Ulcers?
Follow up with Otolaryngologist or Rheumatologist if lesions have not resolved within 2 weeks
One non healing lesion of Apthous Ulcers are more concerning for ____, multiple recurrent lesions more concerning for rheumatologic or autoimmune disorder
SCC
“thrush” is what disease?
Oral candidiasis
Etiology of Oral candidiasis
Candida albicans
Epidemiology of Oral candidiasis
up to 37% infants
worldwide
M=F
History of Oral candidiasis
- Can be asymptomatic or painful during eating/swallowing Soreness in the mouth and pharynx
o Pain when swallowing: odynophagia
o Difficulty swallowinf: dysphagia - Difficultly swallowing Altered taste
- “cottony” feeling in mouth
- Risk factors: Infants immunodeficiency (HIV/AIDS) Denture use (Denture Stomatitis) Debilitated or have poor oral hygiene History of diabetes undergoing chemotherapy or local irradiation
- Taking corticosteroids (inhaled) or broad-spectrum antibiotics
what would you fond on the Physical Exam of Oral candidiasis
- Erythema of the oral cavity or oropharynx with fluffy, white patches
- White plaques on the buccal mucosa, palate, tongue, or oropharynx
- “creamy-white patches overlying erythematous mucosa”
- Easily rubbed off !!! - reveals red base, pinpoint bleeding
Labs/ diagnostic tests of Oral candidiasis
- Diagnosis is usually made clinically
- Gram stain or KOH wet prep of scrapings
Budding yeast with or without pseudohyphae
Treatment of Oral candidiasis
- Infection Antifungal therapy – “azole”
Ð Fluconazole 100mg PO daily x 7 days
Ð Ketoconazole 200-400mg with breakfast for 7-14 days
Ð Clotrimazole troches 10mg dissolved orally five times daily
Ð Nystatin swish and spit (also good for HIV/AIDS pts because thrush may be in throat, pts can swish and swallow) - Pain
Ð 0.12% chlorhexidine or half-strength hydrogen peroxide mouth rinses
Ð Mike’s Magic Mouthwash containing Nystatin - Cause
Ð Denture use Nystatin powder applied to dentures 3-4x daily for several weeks or swish and spit
Ð Underlying immunosuppression
PEARLS: ______ is often the 1st manifestation of HIV infection
Candidiasis
name disease:
Lesion that presents as white patches or plaques of the oral mucosa that do NOT scrape off
Oral Leukoplakia
name disease:
Erythema of the oral cavity or oropharynx
with fluffy, white patches , White plaques on the buccal mucosa, palate, tongue, or oropharynx- Easily rubbed off
Oral candidiasis
Epidemiology of Oral Leukoplakia
<1% population
M:F 2:1,
~80% of patients are older than 40 years
pt History of Oral Leukoplakia
- Painless white area on tongue, inside cheek, lower lip, or floor of mouth
Common among smokeless tobacco users
- Risk Factors: Ð Tobacco abuse Ð Alcohol abuse Ð Repeated trauma (dentures or cheek biting) Ð History of diabetes or HIV positive*
what would you find on Physical Exam of Oral Leukoplakia
- CANNOT be wiped or scraped off
- Varies from homogeneous, nonpalable, faintly translucent white areas to thick, fissured, papillomatous, indurated plaques
- Five criteria for risk of malignancy: o Verrucous o Erosion or ulceration o presence of a nodule o hard in its periphery o Lesion on anterior floor of the mouth or undersurface of the tongue
Labs/Diagnostic Tests of Oral Leukoplakia
- Any area should be biopsied by an Otolaryngologist or oral/maxillofacial surgeon
- Should be followed q3-6 months because of risk of malignant transformation
- Re-biopsy when lesions grow or change
Treatment of Oral Leukoplakia
- Surgical removal of the lesion
- Systemic retinoids (high induction followed by low systemic does), beta-carotene for sustained remissions
- Stop predisposing habits (alcohol and tobacco)
- Long-term observation
name disease
¥ Painless, white, nonremovable, plaque-like lesion typically on lateral aspect of tongue
¥ Associated with Epstein-Barr virus in HIV-infected patients
¥ Non-malignant
Oral Hairy Leukoplakia
HOW DOES Oral Hairy Leukoplakia
present?
¥ Painless, white, nonremovable, plaque-like lesion typically on lateral aspect of tongue
is Oral Hairy Leukoplakia malignant?
no
name disease
¥ Similar to leukoplakia, but has a erythematous component
¥ More likely to be malignant
Erythroplakia
Erythroplakia is Similar to leukoplakia, but has a _______.
erythematous component
is oral hairy leukoplakia or erythroplakia more likely to be malignant
erythroplakia
typically in oral cancer, early lesions appear as ___?
leukoplakia or erythroplakia
PEARL or oral cancer
Any persistent papules, plaques, erosions, or ulcers in the mouth should be biopsied
what is sialolithiasis?
- Formation and deposition of calculi within the ductal system of the gland
Mechanism of stone formation in sialolithiasis is unclear, but it appears to be related to the following conditions:
Salivary stagnation
Epithelial injury along the duct resulting in sialolith formation
Precipitation of calcium salts
Patients with sialolithiasis most often present with ________.
a colicky postprandial swelling of the gland.
Acute sialadenitis is an acute inflammation of a ______.
salivary gland
Etiology of sialadenitis
- Staphylococcus aureus , Streptococcus viridans , Haemophilus influenzae, Streptococcus pyogenes, Escherichia coli
- Dehydration with overgrowth of the oral flora
- Postoperative dehydration, radiation therapy, and immunosuppression
- Mumps virus
- Other viruses: HIV, coxsackievirus, parainfluenza types I and II, influenza A, and herpes
Epidemiology of sialadenitis
- Submandibular Sialadenitis not as frequent as sialadenitis of the parotid gland
- Sialadenitis as a whole tends to occur in the older, debilitated, or dehydrated patient
History
of sialadenitis
- Non-specific prodrome of low-grade fever, malaise, headache, myalgias, anorexia
- Followed within 48 hours of pain and swelling of the parotid glands
- Ask about vaccinations
- 3rd world setting
name disease:
- Acute painful swelling of salivary glands with fever, pain exacerbated by meals and salivation
Acute Suppurative Sialadenitis
Risk factors of Sialadenitis
¥ Caffeine ¥ Smokers ¥ Chronic medical conditions ¥ Medications – reduce salivary secretion ¥ Dehydration ¥ Immunosuppression
infectious cause of parotitis
mumps
bacterial cause of parotitis
Ð Blockage of salivary duct from stone
Ð Poor oral hygiene
Ð Dehydrated
Ð Post-surgical
Epidemiology of parotitis
- Race equal frequency in all races
- Sex: equal gender frequency
- Age: Viral parotitis occurs most frequently in children
Death from parotitis is usual or unusual?
unusual
what type of parotitis?
The patient reports progressive painful swelling of the gland and fever; chewing aggravates the pain
- Acute bacterial parotitis
what type of parotitis?
Pain and swelling of the gland last 5-9 days. Moderate malaise, anorexia, and fever occur. Bilateral involvement is present in most instances
- Acute viral parotitis (mumps)
Physical Exam of Sialadenitis/Parotitis
- Edema and tenderness over affected gland (can be exquisitely tender)
- Viral: Bilateral swelling
- Bacterial:
o May appear toxic, with high fever
o Area of induration, erythema, edema, heat in overlying skin
o Purulent discharge may be present, purulent saliva is expressed with bacterial parotitis
o Decreased skin turgor (dehydration)
Labs/Diagnostic Tests for Sialadenitis/Parotitis
- Diagnosis based on clinical presentation and physical exam
- Plain Film XR for calculi
- Viral cause
o Usually made clinically
o Atypical presentation – serology, viral cultures - Bacterial cause
o CBC
o Needle aspiration and culture if purulent drainage or abscess present
o CT or ultrasound to help differentiate between duct obstruction by a stone, abscess collection, or tumor
Treatment of Sialadenitis/Parotitis
- Viral cause :
o Self-limiting, provide symptomatic pain relief
o Prevention with vaccine
- Bacterial cause o Antibiotic therapy, steroids o Surgical drainage if medical therapy failure o Treat underlying medical condition o Hydration o Pain relief - VERY PAINFUL o Simulate salivary flow: Warm compresses, mouth irrigations, citrus lozenges or beverages, massage of gland o Improve oral hygiene
- Salivary calculi
o Medical management - Hydration, compression and massage, antibiotics for the infected gland
o Surgical management - Duct cannulation with stone removal, gland excision in recurrent case
Sialadenitis/Parotitis Prognosis?
Sialolithiases require definitive surgical treatment in most cases, has excellent prognosis.
Acute sialadenitis is very good. Most cases easily treated with conservative medical management, and admission is the exception, not the rule.
inflammation of pharynx or palatine tonsils is what disease?
Acute Pharyngitis/Tonsillitis
