Clin Med - Oropharynx Flashcards
stomatitis
inflammation / infection of the mouth
sx of stomatitis
- pain
- salivation
- halitosis
- anorexia
Causes of stomatitis
- viruses
- chemicals
- acids
- trauma
Stomatitis can be associated with what other conditions?
stomatitis plus thrush
stomatitis w/ dentures
Tx of stomatitis
supportive measures
- pain relief
- benadryl/maalox (1:1 5mL swish/swallow TID prn)
- “magic mouthwash” - benadryl/decradron/lidocaine
- avoid spicy/acidic/rough foods
- maintain hydration
gingivostomatitis etiology
- primary herpes simplex virus infection
- if recurs, “cold sore” or “fever blister”
S/S of gingivostomatitis
- can be asymptomatic
- small vesicles on gingiva, tongue, buccal mucosa, lips
- vesicles break and leave a ulcer w/ erythematous base and yellow crust
- can occur on genitalia
- headache
- fever
- lymphadenopathy
- malaise
- irritability
When is gingivostomatitis often seen?
in children < 3 who have not been previously exposed to the virus
outcome of gingivostomatitis
- resolves in 10-14 days
- virus becomes latent in sensory ganglia (trigeminal)
- can reoccur
Tx of gingivostomatitis
- symptomatic tx: analgesics, barrier cream/gel on lips
- avoid steroids - can spread/worsen
- oral antiviral (acyclovir)
- magic mouthwash
Tx of gingivostomatitis w/ acyclovir in children
susp X 7 days if child presents w/i 72 hrs of onset, unable to eat, in significant pain, etc
aphthous ulcers
common condition that causes single or multiple painful ulcers in the oral cavity (1-6 lesions); tend to be episodic (1-6 months)
etiology of aphthous ulcers
unknown; not infectious, contagious, or sexually transmitted.
-stress, certain foods, or illness may precipitate lesions
sx of aphthous ulcers
– Painful sores in mouth
– Anorexia (not common)
-few (if any) constitutional symptoms
Signs of aphthous ulcers
– White, round or oval ulcerative patch (2-4mm)
– Erythematous halo
– Mild edema
– Ulcers may remain for 2 weeks
– Leave little or no evidence of scarring
aphthous ulcers found mainly on what mucosa?
– Lips
– Cheeks
– Floor of the mouth
– Tongue
Tx of aphthous ulcers
-topical corticosteroids: (reduces painful symptoms)
-kenalog/orabase paste
-oralone paste
-dexamethosone elixir 5mg/5ml
-topical anesthetics:
topical viscous lidocaine 1% swish and spit 5 ml q 3 hrs or apply w/ qtip to ulcer
Thrush is typically limited to what patients?
-infants/neonates: vaginal births and breastfed infants
-denture wearers
-diabetics
-patients on prior abx or steroids
-immunodeficient patients
(could be first sign of HIV infection)
Sx of thrush
- white coating in mouth w/ erythematous base
- pain/difficulty feeding in severe cases
- anorexia
- medical hx: recent abx/steroid; inhaled steroid; DM
- maternal hx: vaginal candidiasis
Signs of thrush
- white patches on oral mucosa: doesn’t scrape off easily and/or leaves inflammed base that may bleed
- candidal infection in diaper area can accompany it
- differentiate thrush from a coated tongue (milk tongue)
importance of physical exam in thrush
it is critical; especially for patients w/ recurrent thrush infections and for older children and adults (immunodeficiency)
Tx of thrush
- antifungal therapy:
- Gentian violet (OTC) solution
- oral nystatin susp
- Diflucan 100 mg QD 7-10 days
Gentian violet tx
- “paint mouth” QD X 3-7 days
- should not be swallowed
oral nystatin susp tx
- older children and adults: swish 5cc in oral cavity and swallow
- younger patients: 1 mL of solution inside of each cheek; may also be applied w/ qtip
- administer b/w meals to increase contact time
Alternative tx of thrush
- drink buttermilk
- new toothbrush daily
- treat/soak dentures w/ Nystatin
- sterilize bottles, nipples, pacifiers
- tx breasts w/ gentian violet
gingivitis
inflammation of the gingiva; causes bleeding, redness, change in normal conture and occasionally discomfort
causes of gingivitis
- plaque induced (main cause)
- non-plaque induced
S/S of gingivitis
Deepening of the sulcus between the tooth and gingiva, followed by a band of red, inflamed gingiva along one or more teeth, with swelling of the interdental papillae and easily induced bleeding. Pain is usually absent.
Diagnosis og gingivitis
clinical eval: erythematous, friable tissue at the gum lines
Tx of gingivitis
- regular oral hygiene and professional cleaning
- antibacterial mouth rinse
herpes labialis
-Recurrent herpes lesions are commonly referred to as “cold
sores”
-infected in childhood, lives in nerve, trigger causes reactivation
-usually 1-3 recurrences per year but can be monthly
-contagious thru saliva, can be up to 5 days
Possible triggers of herpes labialis
– Sunlight exposure – Physical stress – Emotional stress – Systemic illness – Trauma – Wind – Menstruation – Heavy alcohol use
Sx of herpes labialis
– Prodrome of pain, burning or itching often precedes vesicle
formation.
– Blisters on lips or mucosa
oral antiviral tx of herpes labialis
• Acyclovir 400mg PO TID X 7 days (also famciclovir,
valacyclovir 1200 mg BID x 2 days)
• May shorten duration and lesson symptoms
• Take within 24 hrs of onset, begin ASAP when pt feels tingling of the lip.
topical antiviral tx of herpes labialis
- abreva
- Help if applied early
- Lysine tablets
- Camphophenique OTC
herpetic whitlow
an intense painful infection of the hand involving one or more fingers that typically affects the terminal phalanx
How is herpetic whitlow initiated?
-by viral inoculation of the host through
exposure to infected body fluids via a break in the skin, most commonly a torn cuticle
common cause of herpetic whitlow
autoinoculation from primary oropharyngeal lesions as a result of finger-sucking or thumb-sucking behavior in
children with herpetic gingivostomatitis.
• Involved finger is often exquisitely tender and quite edematous
angular cheilitis
inflammation and fissuring from the
commissures (angles) of the lips
causes of angular cheilitis
– Nutritional deficiencies (B2 deficiency)
– Candida albicans (yeast) infection
– Excess saliva accumulation in angles of lips due to overclosure of the mouth
– Dentures
S/S of angular cheilitis
– Usually painful fissures in corners of mouth
Tx of cheilitis
– Correct underlying cause, Take B complex vitamins
– Symptomatic treatment, tx w/ Nystatin
Glossitis
- Inflammation of the tongue
- Tongue is painful, saliva thick and viscid
- Swallowing can be painful
- Generalized malaise
- +/- fever
causes of glossitis
– Certain foods – Medications – Stress – Vitamin deficiency – Fe deficiency
smooth, red tongue (atrophy of the tongue)
• A smooth, red tongue with a slick appearance • May indicate niacin or vitamin B12 deficiency • Due to atrophy of papillae
Black Hairy Tongue
- Temporary, harmless oral condition that gives the tongue a dark, furry appearance.
- Buildup of dead skin cells on the papillae on the tongue
precipitating factors for hair tongue include:
–Poor oral hygiene: •Lack of tooth brushing, •Broad-spectrum abx •Radiation of the head and neck •Excessive use of mouthwash
contributory factors for black hairy tongue include
– Tobacco use
– Coffee
– Tea drinking
Tx of black hairy tongue
– Brushing the tongue with a toothbrush or tongue scraper to remove elongated filiform papillae and retard the growth of additional ones
– Treat with antifungals
keratosis pharyngeus / tonsilliths
-Small, white “stones” that form when food
particles get caught in crypts in the tonsils and pack in to hard stones; common
-pts complain of halitosis, frequent sore throat
-they contain anaerobic bacteria that can lead to tonsillitis
Tx of tonsilliths
frequent gargling/rinsing after eating; water pick; possibly tonsillectomy
pharyngitis
-Inflammation of the pharynx, including the tonsils and adenoids
-aka tonsillitis, pharyngotonsillitis and
adenotonsillitis
Viral vs. bacterial pharyngitis
VIRAL: note presence of rhinorrhea, cough, hoarseness, and diarrhea. -coxsackievirus -epstein-barr -adenovirus BACTERIAL: group A strep most common
viral pharyngitis
-inflammation of the pharynx d/t viral infection
-cough, hoarseness, PND, runny
nose, sore throat
mononucleosis
• Acute viral illness due to Epstein-Barr Virus
(predominantly a disease of teens and young adults)
• Transmitted by saliva, incubation period is 5-15 days
S/S of mono
– Pharyngitis with/without exudates (prominent during 1st week)
– Striking malaise
– Fever
– Lymphadenopathy (especially occipital and posterior cervical)
– Splenomegaly
– Hepatomegaly
Labs in mono
– Positive Mono-spot test (heterophil agglutination test)
– Can take up to 4 weeks to convert. May remain positive for up to one year after resolution of infection.
– Blood count - atypical lymphocytes*
Rare complications w/ mono
– Splenic rupture – Hepatitis – Myocarditis – Thrombocytopenia – Encephalitis
Tx of mono
– Symptomatic treatment (Magic Mouthwash, Ibuprofen, Tylenol, fluids) – Symptoms may continue for 1 week to several months (especially fatigue, lymphadenopathy & splenomegaly)
– Maculopapular rash occurs with ampicilllin (and possibly other antibiotics)
– No contact sports/activities if splenomegaly
Strep pharyngitis etiology
– Group A beta-hemolytic Streptococcus pyogens
S/S of strep pharyngitis
– Triad of strep pharyngitis: • Fever • Tonsillar erythema and exudates • Anterior cervical lymphadenopathy – Pharynx • Erythematous and edematous • Ulcerations • Exudate • Palatal petechiae –Dysphagia/odynophagia – “Strep breath” – Malaise – Nausea – Headache – Abdominal pain
labs in strep pharyngitis
– Positive rapid strep test and/or strep culture: Rapid strep test >95% specific, sensitivity varies (60-100%)
– Strep culture
– +/- Complete blood count (CBC
Tx goals in strep pharyngitis
– Shorten duration/severity of symptoms
– Soft diet, fluids, analgesics and antipyretics
– Prevention of rheumatic fever, requires compliance of medications
meds listed for strep pharyngitis
-amoxicillin most common • Pen VK 1 po QID x 10d • Ceftin 500 mg BID • Augmentin 875 mg BID x 10 days • Azithromycin x 5d days(zpak) • Clarithromycin x 10days • Clindamycin 300 mg TID-QID x 10 days
scarlet fever
More severe manifestation of strep throat
S/S of scarlet fever
– Same as strep pharyngitis plus
– Strawberry tongue
– Scarlatina rash:
Red, “sandpaper” rash appears 12-48 hours after fever; Papular with petechiae
Tx of scarlet fever
same as strep
rheumatic fever
Inflammatory disease that can develop as a complication of inadequately treated strep throat or scarlet fever. Chronic progressive damage to the heart and its valves. .
S/S rheumatic fever
– Sudden onset of fever and joint pain 2-6 weeks following strep throat
– Fatigue
– Heart murmur
– Rheumatic heart disease (shortness of breath, chest pain)
– Younger children tend to develop carditis first, while older patients tend to develop arthritis first.
-rare in US
lab test for rheumatic fever
– No specific confirmatory laboratory tests exist. – Streptococcal antibody tests – Strep throat culture • Imaging Studies: Echocardiogram
Tx of rheumatic fever
– Prevention by treatment of strep throat is key
– Preventable if abx are initiated within 9 days of the onset of infxn
• In children and adolescents, a negative rapid antigen test (strep
screen) result should be followed by culture
– Steroids and NSAIDs are useful in the control of pain and inflammation.
– May need tx for heart failure from RF.
glomerulonephritis
Acute glomerulonephritis: inflammation and proliferation of kidney tissue in response to an immune reaction
• Onset of nephritis is within 1-4 days of streptococcal infection (can occur up to 3 weeks post-infection)
S/S of glomerulonephritis
– Puffiness of the eyelids – Facial edema – Hematuria – Oliguria – Hypertension – Headache from hypertension – Weakness – Fever – Abdominal pain – Malaise
Tx of glomerulonephritis
– In most patients it’s not a life-threatening emergency as long as they’re stable
– Eradicate strep infection
– early abx therapy does not affect
development of poststreptococcal glomerulonephritis.
– Admit patients presenting with renal failure
peritonsillar abscess (Quinsy)
-Infection of the peritonsillar space located between the tonsil, soft palate, and the pharyngeal muscles
what leads to abscess formation in peritonsillar abscess?
An episode of acute exudative tonsillitis, inappropriately treated or not treated at all
causative organism of peritonsillar abscess
Group A Strep (Streptococcus pyogenes)
Sx of peritonsillar abscess
-begin about 2-8 days prior to abscess formation – Severe sore throat becoming more severe and unilateral –Dysphagia/odynophagia – Trismus (due to involvement of the internal pterygoid muscles) – Fever – Headache – Malaise – Neck Pain – Referred otalgia
Signs of peritonsillar abscess
– Drooling, salivation – Halitosis – Lymphadenopathy – Tachycardia – Dysphonia (“Hot potato” voice) – Anxiety, agitation, and potentially extreme distress may occur if the airway is compromised due to pharyngeal or laryngeal edema (rare finding).
Oropharyngeal examination signs in peritonsillar abscess
- Anterior deviation of the soft palate and tonsil
- Displacement of the uvula to the contralateral side of the pharynx
- Erythematous, enlarged, and/or exudate-covered tonsil
complications in peritonsillar abscess
– Aspiration pneumonia secondary to spontaneous rupture of abscess
– Airway obstruction
– Sepsis
Tx of peritonsillar abscess
– Make sure airway is secure
– Fine needle aspiration or I & D
– Antibiotics to treat strep infection
• IV antibiotics (possible hospital admit)
abx used in tx of peritonsillar abscess
- Ampicillin-sulbactam IV
- Clindamycin IV
- Can treat outpatient with Augmentin, Clindamycin if pt is stable.
- Parenteral ABX treatment until pt is afebrile, then switch to oral X 14 day Augmentin or Clindamycin
*clavulanic acid gives more coverage
absolute indications for tonsillectomy
– Obstructive sleep apnea
– Malignancy or suspected malignancy (tonsil Bx is tonsillectomy)
– Tonsillitis resulting in febrile convulsions
– Tonsillar hemorrhage
Relative indications for an elective tonsillectomy
– Recurrent acute pharyngitis: • 7 infections in one years • 5 infections/yr in last 2 consecutive yrs • 3 infections/yr for 3 consecutive yrs • >2 weeks missed form school or work in any 1 year – Peritonsillar abscess – Eating or swallowing disorders – Tonsillolithiasia
complications of tonsillectomy
(same as adenoidectomy)
– Hemorrhage (Intraoperative or delayed bleeding)
– Airway obstruction d/t swelling
– Dehydration
– Weight loss
– Severe post op sore throat (adults especially)
– Loss of taste-mechanical damage to glossopharyngeal nerve
epiglottitis
- RARE PEDIATRIC EMERGENCY!
* Life-threatening bacterial infection with edema of the epiglottis
etiology of epiglottitis in children
– Children (7 months to 10 years) • H. influenzae (rare due to vaccine) • S. pyogenes • S. pneumoniae • S. aureus
etiology of epiglottitis in adults
- Group A strep
* H. influenzae (rare due to vaccine)
what is the classic triad in the diagnosis of epigottitis
- Drooling
- Dysphagia
- Distress (respiratory)
other presentations in the diagnosis of epiglottitis
– Child is anxious and prefers to sit in tripod position (do not make
patient lie down)
• Older child may have neck extended and appear to be sniffing
due to air hunger
– Odynophagia
– Open mouth, drooling (cannot swallow)
– Muffled voice
– Febrile
– Cherry-red, swollen epiglottis on indirect laryngoscopy
– Hospitalize if epiglottitis is suspected
initial goal in tx of epiglottitis
to establish and maintain a good airway – a physician/PA skilled in airway management must accompany the patient at all times
tx of epiglottitis
– Humidified oxygen with no manipulation of oropharynx or epiglottis
– Airway observation in monitored setting
– Intubation w/ tracheostomy stand-by – Children usually need intubation
– Direct laryngoscopy in operating room
– Give a beta lactamase resistant abx- Ceftriaxone
imaging findings in epiglottitis
-not always necessary for diagnosis – Lateral radiograph should be taken in the erect position only b/c: • Supine position may close off airway – Enlargement of epiglottis: • “Larger than your thumb”
sialoadenitis
-Inflammation of salivary glands (parotid or submandibular)
etiology of sialoadenitis
– Viral • Mumps (rare) – Bacterial • Staph aureus • S. pneumonia • H. influenza
Stenson’s duct
parotid gland duct
Wharton’s duct
submandibular gland duct
predisposing conditions of sialoadenitis
– HIV – Diabetics – Sjogren’s syndrome – Cirrhosis – ETOH – Dehydration – Medications that increase stasis: Diruetics, anticholinergics, antibiotics
S/S of sialoadenitis
– Acute onset of pain and edema of parotid or
submanibular gland
– +/- fever
– +/- leukocytosis ( I don’t usually get a CBC) – +/- purulent drainage from gland (massage gland)
diagnosis/Tx of viral sialoadenitis
- Symptomatic treatment
* sialogogues, massage, hydration, heating pad
diagnosis/Tx of bacterial sialoadenitis
-Abx:
• Augmentin
• Clindamycin
sialolithiasis
-ductal stones leading to sialadenitis:
– Submandibular gland - 80%
– Parotid gland - 20%
risk factors for sialolithiasis
– Any condition/medication causing duct stenosis or a
change in salivary secretions
• Dehydration, diabetes, alcohol
S/S of sialolithiasis
– Pain, warmth, and tenderness over involved gland
– Intermittent swelling related to meals
– Palpable calculi
diagnosis and Tx of sialolithiasis
– May resolve spontaneously
– Massage gland
– Dilation of duct and possible excision of gland
– Increase fluids
– Antibiotics
– Suck on a lemon (“sialogouge”)
– If calculi cannot be dislodged, gland removal is indicated (cannot just remove stone because this will scar the duct)
functions of the larynx
– Protection of the lower airway
– Phonation
– Respiration
laryngitis
Inflammation of the larynx and vocal cord mucosa
acute laryngitis
– Abrupt onset – Self-limited (less than 3 weeks) – Etiology: • Vocal overuse • Exposure to chemical agents • Bacterial • Viral URI
chronic laryngitis
– Laryngitis for more than 3 weeks – Etiology: • Environmental factors - smoke • Irritation from asthma inhalers • Vocal misuse
S/S of laryngitis
– diagnosis may be made solely based on the hx and sx – Dysphonia (hoarse voice) - Breathiness and tension – Odynophonia - painful talking – Dysphagia/Odynophagia – Dyspnea – Rhinorrhea – Postnasal discharge – Sore throat – Congestion – Fatigue/malaise
Examination of the airway for laryngitis
- Indirect examination of the airway with a mirror
- direct examination w/ a flexible nasolaryngoscope reveals erythema and edema of the vocal folds, secretions, and irregularities of the surface contour of the vocal folds.
Tx of acute laryngitis
- symptoms usually last 7-10 days
- if longer than 3 weeks, w/u for chronic
- reassurance
- avoidance of vocal axcess and other irritants
- tx underlying cause
What meausures can help lessen intensity of laryngitis while waiting for it to resolve?
- Humidified air
- Complete voice rest
- No evidence for the use of antihistamines and corticosteroids
- Stop smoking
