HEENT Week 2 Flashcards
General Findings: Breath Odor
- Halitosis - systemic or local disease (gingiva, smoking, diabetic ketoacidosis–sweet, liver failure—faintly sulfurous, renal failure—ammonia); alcohol on breath
- Fetor oris - originates in the mouth, can be associated with appendicitis (add’l sx)
What is a common cause of dryness of the mouth (xerostomia)?
anti-cholinergic medicines is a common cause
• mouth breathing, dehydration, diuretics, salivary disease, sialoliths
What are some common symptoms of Gingiva? What is the normal appearance?
• darkening/dark line: heavy metal poisoning?
• Painful swelling in gum: possible tooth abscess
(Normally smooth, firm and contoured around the teeth)
What are a couple general findings in the teeth?
- Bruxism (erosion): clenching and grinding teeth wears down dental crowns, loosens teeth
- Decay, Tooth loss
General findings of the palate (hard palate, soft palate and uvula)?
- Hard palate: Lesions, petechiae (broken capillary blood vessels) (seen in Strep infx, suction)
- Soft palate: should elevate symmetrically when patient phonates “ahh” (CN IX, X – glossopharyngeal and vagus)
- Uvula: check for inflammation, ulnar deviation (while palate rises assymetrically)
General findings of the tongue and floor of the mouth:
oral cancers under the tongue
tongue movements (CN XII nerve, hypoglossal)
enlarged tongue: dentures, inflammation, myxedema etc.
papillae: enlarged or atrophied
Recurrent Herpes Labialis (herpes simplex HSV)
- what is the most common cause?
- what is different about the 1st and recurring oubreaks?
- triggers?
- concerns?
“cold sore” “fever blister”
• HSV-1 most common, high incidence; very contagious
o 1st outbreak is usually most intense
• Recurrence often has a Prodrome (itching, burning, tingling) lasts approximately 12 to 36 hours, followed by eruption of clustered vesicles (raised bumps, fluid filled) along the vermilion border. Subsequent rupture, ulceratation, and crusting
• Reactivation triggers: UV light, trauma, fatigue, stress, menstruation
• Concern re auto-innoculation to eye, skin (other parts of body)
Carcinoma of the lips:
- etiologies
- most common type
Etiologies: tobacco, alcohol, sunlight, poor oral hygiene or poorly fitting dentures.
Often: Squamous cell cancer (SCC)
Squamous cell cancer (SCC): lips
- lesion
- location
- risk
- Dx
- Lesion: painless, sharply demarcated (borders), elevated, indurated border with ulcerated base may be verrucous (cauliflower) or plaque (raised, but flat) like, hard at border
- Location: Usually found on the mucocutaneous junction of the lips;
- Slow- growing, fails to heal, can bleed. High risk of metastasis → these specific characteristics need biopsy
- Diagnosis: biopsy
Mucocele
- description
- location
- etiology
- Signs & Sx
• Soft cyst, mucin-filled cavity with mucous glands lining the epithelium
• Common on lips, under tongue (called a “Ranula” from latin rana—frog’s belly)
Etiology: minor injury to ductal system of minor labial or sublingual salivary gland, by trauma
Signs & Sxs:
• Thick, mucus-type saliva produced by the damaged gland creates a clear or bluish bubble of various size (1-2cm), movable, cystic, may rupture. Bleeding may occur with further damage, lesion may then look red or purple
• History of enlargement, breaking, and shrinkage is fairly common. Can persist, rarely goes away on its own (dentist can surgically remove)
• Usually benign, but can affect Pt speech/chewing
Cheilitis
- description
- etiology
- Erythema and scaling of the lips “chapped lips”
- Etiology: Use of retinoids (isotretinoin, acitretin), wind-burn, allergies, chronic lip licking (saliva causing irritant dermatitis)
- May become secondarily infected
E. Angular cheilitis (aka Perlèche, Cheilosis, Angular Stomatitis)
- Signs & Sx
- Etiology
- Lab
Signs & Sxs:
• Local! Deep cracks at labial commisure, if severe can split or bleed, form shallow ulcers. May become infected by Candida albicans; Staph aureus Often bilateral
Etiology:
• Elderly: ill-fitting dentures, loss of teeth changing bite, sicca (dry mouth)
• Poor oral hygiene
• Nutritional deficiencies, esp. vitamin B (Riboflavin B2, Cyanocobalamin B12) and iron deficiency anemia (due to poor diet, malabsorption).
• Irritant or allergic reaction to oral hygiene or denture material
Lab: KOH prep to assess for Candida infx
• Dx: usually from observation, but KOH lab can confirm
Mouth
Lesions may occur anywhere on mouth structures; includes ulcerations, cysts, firm nodules (raised, bigger than papule), hemorrhagic lesions, papules (raised, firm), vesicles (fluid), bullae (bigger fluid), and erythematous lesions (solid/fluid filled, size, raised/flat).
• Vary in symptoms from asymptomatic to very painful.
• Typical etiologies: trauma, infection, systemic disease, drug use, or radiation therapy.
• Multiple causes/conditions. Need complete history, FHx, allergy history. PE: check whole body for lesions that may explain the oral ones. Direct smears, stains and cultures sometimes helpful.
*A solitary lesion that lasts >2 weeks should be biopsied for malignancy.
Oral Lichen planus:
- Non-erosive lesion: usu painless, vary from lace-like white patches/papules/streaks (Wickham striae) on buccal mucosa to erosions on gingival margin. If painful can interfere with eating. Not contagious.
- Etiology: unknown. Possible drug reaction, Hep C, worse with stress
- An erosive form can erupt into violet papules with white lines or spots, usually on the genitalia, lower back, ankles, and anterior lower legs; pruritus;
- If chronic, can increase risk for oral cancer.
Mucosal Lesions
Oral Lichen Planus
Leukoplakia
Leukoplakia
- age and gender
- etiology
- Signs & Sx
- PE
- Dx
White patches or plaque on the oral mucosa that cannot be rubbed off.
a. Precancerous hyperplasia of the squamous epithelium (thought to be early step in transformation of clonally independent cells) Up to 20% of lesions will progress to CA in 10yr
b. Also seen in inflammatory conditions not associated with malignancy
~ 90% of lesions in those > 40 yrs, M > F
Etiology: presumptive factors include:
• trauma from habitual biting, dentures, tobacco use (oral tobacco, esp)
• oral sepsis
• local irritation
• alcoholism
• syphilis
• vitamin deficiency
• endocrine disturbances
• dental galvanism
• AIDS
Signs & Sxs:
• Located on tongue, mandibular alveolar ridge and buccal mucosa in ~50%.
Also–palate, maxillary alveolar ridge, floor of mouth, retromolar regions
• Forms vary: nonpalpable (patch), faintly translucent white areas to thick, fissured, papillomatous (has a base and is out on a stock), indurated lesions.
• Surface is often shriveled in appearance and may feel rough on palpation.
o Can look like “flaking white paint”, may have red specks
• Color variants: white, gray, yellowish-white, brownish-gray (patients with heavy tobacco use.)
PE: lesion cannot be wiped away with gauze
• Check for cervical LA (lymph adenopathy), may indicate malignant changes
Diagnosis: Biopsy to obtain a definitive diagnosis, multiple samples if large lesions
DDX for Leukoplakia and
“Other” White Oral Lesions That Cannot Be Wiped Off with Gauze
DDX: Candidiasis and aspirin burn (can be wiped away with a gauze → potential pin point bleeding)
“Other” White Oral Lesions That Cannot Be Wiped Off with Gauze • traumatic or frictional keratosis • lichen planus • leukoedema • Systemic lupus erythematous SLE • galvanic keratosis • white sponge nevus • verrucous carcinoma • squamous cell carcinoma SCC
Erythroplakia
- description
- etiology
- why biopsy?
- risk factors
- Red macule (flat, colored lesion) or plaque (slightly raised) with well-demarcated edges with soft texture; Often on floor of mouth, tongue, palate
- Unknown etiology, but considered a type of epithelial dysplasia, thus pre-cancerous
- Cancer found in 40% of cases. Biopsy!
- Risk factors: smoking, alcohol
Oral Squamous Cell Carcinoma (SCC)
- most common location
- S&S
- DDX
- ~ 30,000 in US each year; 90% are smokers, alcohol is also a risk factor (we don’t know if
- Subset of SCC associated with HPV-16 infection
- Most on floor of mouth or on the lateral and ventral surfaces of tongue. Also lip, palate.
Signs & Sxs:
• May appear as area of erythroplakia (red) or leukoplakia (white);
• Exophytic (outward growth) or ulcerated (sunken in/erosion). Both variants are indurated with a rolled border.
• Early lesion may be asymptomatic, Ulcerated lesions are often painful
• May be difficulty in speaking/chewing if lesion is large
• Metastatic mass (non-tender) in the neck may be the first symptom. Firm, fixed mass.
***Biopsy any persistent papules, plaques, erosions or ulcers!
DDx – lipoma (fat-filled cyst),
Melanoma:
- what are the concerning factors
- DDx
Pigmented lesions with concerning signs:
• Asymmetry
• irregular borders
• variable coloration
• increasing diameter; lesion will not blanch
• (evolving)
*Often diagnosed at later stages
DDx: *Becomes more definitive upon biopsy (she doesn’t emphasize these DDxs on quizzes)
• Melanosis–symmetric lesions in individuals with dark skin
• Oral melanotic macules—symmetric, stable, sharply delimited dark macules on lips or oral mucosa
Fordyce’s Spots
- age and gender
- signs & sx
- DDx
Benign neoplasms from sebaceous glands (sebaceous choristomas)
•Most common 20 -30 years; M = F
Signs & Sxs:
•Asymptomatic, multiple, white to yellow, 1-2 mm papules, often occurring confluent cluster (central aggregation and thins out)
•Most common on the vermillion/buccal mucosal border. Also on the inner surface of the lips, the retromolar region, tongue, gingiva, frenulum linguae or palate
DDX: Candida albicans - candida lesions wipe off, but Fordyce’s granules do not wipe off
Description and etiology of STOMATITIS.
Inflammation of oral tissue from local or systemic conditions
Etiology:
•infection: strep, candida, Corynebacterium, syphilis, TB, measles, HIV, coxsackie virus, HSV, Varicella-zoster virus, fungus (Histoplasmosis, Mucor, Cryptococcus, Coccidiomycosis)
•deficiencies: vitamins B and C, iron
•leukemia
•mechanical trauma: poorly fitting dentures, improper nipples on bottles
•alcohol, tobacco, hot/spicy foods and drinks
•mouth breathing, cheek biting, irregular teeth, poor orthodontia
•chemicals eg, mercury poisoning (with marked salivation)
•allergy - intense shiny erythema with swelling, itching, dryness, burning
•drug hypersensitivity reaction
Oral Candidiasis (“Thrush” “moniliasis”)
- Description
- Risk Factors
- SSx
- Dx
Common oral fungal (yeast) infection by Candida albicans, C glabrata, C tropicalis
Risk factors: (common in individuals with other diagnoses) denture-wearers, diabetics, use of antibiotics, exposure to chemotherapy or radiation, HIV/AIDS, use of inhaled glucocorticoids (eg asthmatics); individual who has had a transplant and taking immunosuppressive drugs; common in infants
SSX: Lesion: slightly raised soft white plaques (look like milk curds) that are easily wiped away, causing bleeding
o May have burning sensation
o Mouth appears dry (xerostomia)
Dx confirmed with KOH prep
**Recurrent, persistent, extensive disease warrants immune status evaluation → not necessarily dangerous by itself, but may indicate a larger, deeper and undiscovered issue
Types of Stomatitis
Oral Candidiasis
Pseudomembranous stomatitis
Recurrent Aphthous Stomatitis: (aphthae=”canker sores”)
Herpetic Gingivostomatitis: HSV-1 infection “cold sore”
Oral Erythema Multiforme
Chancre
Pseudomembranous stomatitis
- etiliogy
- Sx
Inflammatory reaction that produces a membrane-like exudate
•Caused by chemical irritants or bacterial infections
•Fever, malaise, and LA may result or it may be localized to the mouth
Recurrent Aphthous Stomatitis: (aphthae=”canker sores”)
- etiology
- S & Sx
- DDx
Acute, painful, recurring, solitary or multiple necrotizing ulcerations of the oral mucosa. Possibly T-cell mediated localized destruction of oral mucosa
Etiology: Provocations (exact cause is unknown)
o Trauma is the most common trigger:
• Physical: toothbrush abrasions, laceration by sharp foods/objects, biting, dental braces
• Chemical irritants or thermal injury: (coffee, tea)
• Sodium lauryl sulfate: foaming agent in toothpaste
o Food allergies, citric acid, artificial sugars, gluten
o Deficiencies in vitamin B12, iron, and folic acid
o Stress, illness, fatigue
o Immunodeficiency (eg HIV)
o Neutropenia– history of taking antimetabolites (eg methotrexate) – fewer than normal WBCs
o Hormonal changes, menstruation
o Associated with celiac disease and inflammatory bowel disease (eg Crohn’s dz)
Signs & Sxs:
o Painful lesions, occasionally have prodromal burning or tingling
o Ulcers= shallow, round to oval with a grayish base, with a red border
o Occur on non-keratinized, moveable mucosa: buccal and labial mucosa, buccal and lingual sulci, ventral tongue, soft palate and floor of mouth.
o Some individuals have 2-4 outbreaks a year, while others can have continuous eruptions
** Different from herpes: no vesicles, no crusting, not a viral infxn
DDX:
o Secondary herpetic ulceration - history of vesicles preceding the ulcers, a location on periosteum-bound mucosa (gingival, hard palate) and crops of lesions.
o Trauma, pemphigus vulgaris and cicatricial pemphigoid.
o Systemic disorders: Crohn’s disease, neutropenia and (tropical) sprue.
Three forms of aphthous ulcers (same disease spectrum, different by size, duration, location)
*Not going to be emphasized
- Minor form – Most common/least severe form
Develop in childhood and adolescence, and then sporadically throughout life; Usually solitary, shallow, oval yellow-gray ulcer with raised yellowish border surrounded by an erythematous halo, <1 cm diameter; Lasts 7 to 10 days; heals without scars - Major form - multifocal, ragged edges, may be up to 2 cm in diameter, may last up to 6 weeks and may be immediately followed by a recurrent ulcer; Heals with scarring and cause severe pain and discomfort; Typically develop after puberty with frequent recurrences. Occur on moveable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces
- Herpetiform ulcers - most severe form
Occurs more frequently in females, and onset is often in adulthood. Small, numerous, pinpoint lesions (1–3 mm) that form clusters, coalesce into ulcers. Typically heals in less than a month without scarring.
Herpetic Gingivostomatitis:
- Triggers
- S & Sx
- Lab
- DDx
HSV-1 infection “cold sore”; Painful eruptions of the unmovable oral mucosa and vermilion border; Primary infection of HSV-1, common in children
Triggers: trauma, emotional stress
Signs & Sxs:
o Often a prodrome of pain, burning, tingling; also fever, malaise, LA, painful eating
o Eruption of multiple interoral vesicular lesions and erosions, erythematous base, crusting
o Self limited in 1-2 wks in most cases
o Kids: fever, LA, drooling, decreased oral intake due to pain (watch for dehydration)
o Recurrence is common
Lab: Tzank smear, direct immunofluorescence smear, or viral culture
DDX: aphthous stomatitis, erythema multiforme, drug eruptions, pemphigus
Oral Erythema Multiforme:
- SSx
- DDx
Hypersensitivity reaction to HSV, other organisms (eg Mycoplasma pneumoniae), drugs or idiopathic with skin lesions and mucosal involvement
SSx: Painful stomatitis, sudden onset of diffuse hemorrhagic vesicles and bullae with erythematous base, on lips/mucosa
o Bullae rupture leaving raw, painful, friable (easily bleeds) surfaces, then form crusts
o May be Prodrome: sinusitis, rhinitis
o May see a high fever for 4-5 days, and severe systemic symptoms
o Other areas of body – maculopapular erythematous lesions (target lesions) form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia → shape of bulls eye
DDx: aphthous stomatitis, allergic stomatitis, pemphigus, herpes
Chancre
- SSX
- PE
- Lab
Lesion: painless ulceration formed during the primary stage of syphilis, ~21 days after the initial exposure to Treponema pallidum, these ulcers usually form on or around the lips, tongue, also anus, penis, and vagina. *Common to have lesions elsewhere when it forms in the mouth
SSX:
o Painless single ulcerated lesion, (firm) indurated border, no central necrotic tissue
o Tender cervical LA
o Chancres typically last 2 wks to 3 mos without treatment (but infxn can persist to tertiary/quaternary syphilis that damages the nervous system)
PE: be sure to look for genital lesions as well
Lab: PCR serology
Other causes of inflammation and irritation in the mouth
- Frictional hyperkeratosis
- Epulis Fissura (Denture hyperplasia)
- Denture sore spot
- Denture sore mouth (denture stomatitis)
- Irritation Fibroma
Frictional hyperkeratosis
caused by chronic friction against an oral mucosal surface, resulting in a hyperkeratotic white lesion (a protective response to low-grade, long-term trauma).
• Leads to white line called linea alba if caused by biting
• If cause is uncertain, the lesion should be considered idiopathic leukoplakia and be biopsied
Epulis Fissura (Denture hyperplasia) - SSx
Signs & Sxs:
• Painless folds of fibrous connective tissue, firm or spongy to palpation with the impression of denture edge (tissue reaction—maxillary mucosa—to chronically ill-fitting dentures)
• Usually not highly inflamed, but may be erythematous or even ulcerated in the base where the edge of the denture flange fits
**Ask Px with dentures to remove to ensure a good exam
Denture sore spot
small, painful ulcers, characterized by an overlying, grayish necrotic membrane and surrounded by an inflammatory halo. Usually heals quickly once denture removed
Denture sore mouth (denture stomatitis)
very common
• Mucosa beneath the denture becomes extremely red (sharply demarcated and localized) and swollen, with either a smooth or granular appearance.
• Severe burning sensation is common.
• May be caused by allergy to acrylic or by fungal infection
Irritation Fibroma
- SSx
- DDx
Most common benign oral soft tissue neoplasm; most often 20 - 49 years; M = F
Signs & Sxs:
o in buccal mucosa, lateral border of the tongue and the lower lip (area of trauma)
o Lesion: painless, sessile or occasionally pedunculated swelling that can be firm and resilient or soft and spongy in consistency; typically ≤ 1cm
o Color is slightly lighter than the surrounding mucosa from relative lack of vascular channels
o May become irritated or ulcerated
DDX: based mainly on the location
o Tongue - neurofibroma, neurilemmoma or granular cell tumor
o Lower lip or buccal mucosa - lipoma, mucocele or salivary gland tumor.
Oral Edema
- Angioedema
2. Hereditary angioedema
Angioedema: (Quincke’s edema)
- Etiology
- SSx
Acute edema (swelling) of the skin, mucosa (mouth, throat, tongue) and submucosal tissues,
• Rapid onset (over the period of minutes to several hours).
• Urticaria (itchy raised bumps) may develop if the angioedema is related to allergy.
• Hand swelling common
Etiology: contact with Ag that stimulates immune response
a. Allergic (most common,) not IgE mediated. Common allergens include:
- medications
- foods (such as berries, shellfish, fish, nuts, eggs, milk, wheat)
- pollen
- animal dander
- insect bites
- exposure to water, sunlight, cold or heat
- emotional stress
b. Infection or illness: autoimmune disorders, leukemia
Signs & Sxs:
o Painless, non-pruritic (if non-allergic), nonpitting, and well-circumscribed areas of edema from increased vascular permeability.
o May progress to complete airway obstruction and death caused by laryngeal edema.
o May be chronic when lasting more than 3 weeks
**Could very well be an emergency situation
Hereditary angioedema (hereditary angioneurotic edema) *not to be emphasized
Rare, autosomal-dominant inheritance, presenting as edema in the face, airway passages, hands and feet; 85% are deficiencies of C1 esterase inhibitor, see family history
Signs & Sxs:
• Edema is unifocal, indurated, painful rather than pruritic
• Usually no associated itch or urticaria (non-allergic)
• Precipitated by stress, infection, trauma, viral illness, though no cause may be apparent
• Patients can also have recurrent episodes (“attacks”) of abdominal pain, usually accompanied by intense vomiting, weakness, watery diarrhea, and flat, non-itchy splotchy/swirly rash.
Other Oral Findings
- Palatal or Mandibular Torus
- Hemangioma
- Varicosities
- Papilloma
- Lipoma
