Mouth and Thoat Flashcards
1
Q
Acute pharyngitis (sore throat)
- Sxs
- PEx
- Evaluation goals
- Dx
- Tx
A
Acute pharyngitis (sore throat)
- 5-15% cases are caused by Group A strep
- It is uncommon to need abx for pharyngitis, but if you do the most common reason is because it is for strep
- However, abx are rx for pharyngitis 60% of the time
- Other causes besides strep: viral, allergies, irritants
Symptoms
- Sore throat
- Fever
- Headache
- Malaise
- “swollen glands”
- URI symptoms
PEx
- Pharyngeal erythema
- Tonsillar hypertrophy
- Purulent exudate
- Tender and/or enlarged anterior cervical lymph nodes
- Palatal petechiae
Evaluation goals
- Identify GABHS pharyngitis (strep)
- Make sure it is not:
- Epiglottitis
- Peritonsillar abscess
- Submandibular space infections (Ludwig’s angina)
- Retropharyngeal space infections
- Primary HIV (this is when they are most infectious)
Dx
- Exclude GABHS pharyngitis
Tx
- Supportive tx
- Reassess in 5-7 days
2
Q
GABHS (Group A beta hemolytic streptococcal tonsillopharyngitis)
- Clinical presentation
- Centor criteria
- Ddx
- Diagnostics
- Tx
- Complication
- ENT referral
A
GABHS (Group A beta hemolytic streptococcal tonsillopharyngitis)
4 things for clinical presentation
- Sudden onset sore throat
- Tonsillar exudate
- Tender cervical adenitis
- Fever
Other things for clinical presentation
- Rhinorrhea
- No cough
Centor criteria
- Less than 2 = lower likelihood
- Greater than 3 = higher likelihood
Ddx
- Other causes of acute pharyngitis
- Acute epiglottitis
- Group A strep carrier state
Diagnostics
- Rapid antigen detection test (RADT)
- If negative, confirm with culture
- Sensitivity for GABHS ranges from 70-90%; specificity 90-100%
- Results in 15 minutes
- Rapid strep is helful if centor criteria is 2-3 because you’re not sure if it is or isn’t (as compared to a 1 or 4)
-
Throat culture is gold standard / definitive test
- Sensitivity for GABHS is 90-95%; specificity 95-99%
Tx
- Penicillin V 500 mg po bid to tid x 10 days
- Amoxicillin 500 mg bid x 10 days
- Penicillin G benzathine 1.2 million units IM
- Cephalexin 500 mg po bid x 10 days
- PCN allergy: macrolides (erythromycin, clarithromycin, azitheromycin)
Complications
- Acute rheumatic fever
- Acute glomerulonephritis
- Scarlet fever
- Peritonsillar abscess
- Otitis media
- Mastoiditis
- Sinusitis
- Bacteremia
- Pneumonia
ENT referral
- If recurrent, child may benefit for tonsillectomy (7 episodes in a year)
3
Q
Peritonsillar abscess
- Sxs
- PEx
- Diagnostics
- Tx
A
Peritonsillar abscess
- MC deep neck infection in children
- Occurs more frequently in adolescents and young adults
Sxs
- Severe sore throat
- Fever
- Hot potato / muffled voice
- Drooling (can’t swallow)
- Trismus (can’t open jaw)
- Neck swelling and pain
- Ipsilateral ear pain
- Fatigue, irritability, decrease po intake
PEx
- Swollen, fluctuant tonsil with deviation of uvula to the opposite side
- Fullness or bulging of posterior soft palate
- Cervical lymphadenopathy
Ddx
- Infectious mono
- Lymphoma
- Peritonsillar cellulitis
- Retropharyngeal abscess
- Retromolar abscess
- Ludwig’s angina
Diagnostics
- Dx by PEx
- Do diagnostics if severe, in hospital, immunocompromised, can’t take in fluids
- Labs
- CBC
- Electrolytes
- Throat culture
- Culture of abscess fluid
- Imaging
- CT with IV contrast (if concerned about things on ddx to r/o)
Tx
- Monitor for airway obstruction
-
Drainage
- Needle aspiration
- I & D
- Tonsillectomy
- Drain, then give abx
- Parenteral: ampicillin-subactam or clindamycin (if concerned for MRSA, use vancomycin)
- Oral: amoxillicin-clavulanate or clindamycin x 14 days
- Supportive care
- Possible hospitalization
4
Q
Acute laryngitis
- Causes
- Clinical presentation
- Ddx
- Tx
- When to refer
A
Acute laryngitis
Infecious causes
- Respiratory virus (almost always)
- Bacterial causes
Non-infectious causes
- Vocal abuse
- Intubation / trauma
- Toxic exposure
- GERD
- Vocal cord nodules or laryngeal polyps
- Vocal cord paralysis
- Carcinoma of vocal cords
Clinical presentation
- Hoarseness (primary symptom)
- If viral, will also have URI symptoms
Ddx
- Irritant exposure
- Croup
- Acute epiglottitis
- Chronic causes
- Head/neck cancer
- GERD
- Vocal nodule
- Tuberculosis
Tx
- Treat the underlying cause
- Humidification
- Voice rest (Important! Do not even whisper)
- Hydration
- Avoid smoking
Resolves in 1-3 weeks, if longer 3 weeks then refer to ENT
5
Q
Epiglottis
- Causes
- Risk factors
- Clinical presentation
- Be careful with what during exam
- Diagnostics
- Tx
A
Epiglottis
Emergency! Airway can be blocked.
Causes
- Viral or bacterial
- Haemophilus influenzae type B (HiB)
- Streptococci
- S. aureus
Risk factors
- Incomplete or non-vaccination
- Immunodeficiency
Clinical presentation (the 3 D’s)
- Respiratory Distress
- Drooling
- Dysphagia / odynophagia (pain with swallowing)
- Fever
- Anxiety
- “Tripod” position
- Pain out of proportion
- Muffled speech
- Stridor
Exam
- Be careful with visualization b/c this can increase anxiety and lead to hyperventilation and more obstruction
- Do not use tongue depressor
Diagnostics
- Labs (but not until airway is secured)
- CBC, blood culture, epiglottal culture (if intubated)
- Imaging
- Lateral plain XR
- Shows “thumb sign”
- Direct laryngoscopy
- Fiberoptic nasolaryngoscopy
Tx
- Medical emergency
- Airway protection
- Hospitalization
- IV antibiotics
- 3rd generation cephalosporin & antistaphylococcal (vancomycin)
- Possible dexamethasone
- Prevention – IMMUNIZATION!
6
Q
Oral HSV (cold sores)
- Cause
- Clinical presentation
- Triggers
- Dx
- Tx
A
Oral HSV (cold sores)
- Cause: HSV 1
Clinical presentation
- Sudden onset of multiple painful vesicular lesions on inflamed, erythematous base
- 10-14 days for initial
- 5 days for recurrent
Triggering factors
- Sunlight
- Fever
- Menstruation
- Stress
- Trauma
Dx
- Clinical impression
- But you can do viral culture, serology, microscopy
Tx
- Antiviral (can prevent outbreak if given early, otherwise will help shorten course)
- Analgesics
- Fluid management (if infection is so severe they do not want to drink)
Herpetic gingivostomatitis (more severe infection)
- Primary HSV infection
- Ulcerative lesions of gingiva and mucus membranes of mouth often with perioral vesicular lesions
7
Q
Coxsackie virus (hand foot mouth)
- Clinical presentation
- Dx
- Tx
A
Coxsackie virus (hand foot mouth)
- MC in children
- Coxsackie 16
Clinical presentation
- Prodrome: low-grade fever, malaise, abdominal pain, URI symptoms
- Painful oral lesions - PAPULES on erythematous base (vs HSV which are not papules)
- Lesions on hand, feet, mouth and buttocks
Dx
- Clinical impression
Tx
- Supportive
- Resolves in 2-3 days
8
Q
Hand foot mouth vs Herpangina
A
Hand foot mouth vs Herpangina
Hand foot mouth
- Lower grade fever
- Papules on tongue and hard palate (hands and feet too)
Herpangina
- Higher fever
- Lesions more posterior (soft palate)
9
Q
Aphthous ulcer (canker sore)
- Causes
- Clinical presentation
- Tx
A
Aphthous ulcer (canker sore)
Causes
- Uncertain, but associated with HHV-6
- Also seen in with celiac dz, IBD (inflammatory bowel dz), HIV
- Triggered by stress
Clinical presentation
- Found on gums, tongue, lips, palate, buccal mucosa
- Single or multiple
- Recurrent
- Painful small, shallow, round ulcers with gray base surrounded by red halo
Tx
- Topical corticosteroids in adhesive base
- Topical analgesics
10
Q
Bechet’s
- What is it
- Clinical presentation
- Dx
- Tx
A
Bechet’s
- Inflammatory disorder
Clinical presentation
- Recurrent oral and genital ulcers
- Lesions may occur at multiple sites
Dx
- Recurrent oral ulcers more than 3x a year plus 2 other clinical findings (e.g. recurrent genital ulcers, eye lesions, or skin lesions)
Tx
- Refer to rheumatologist
11
Q
Oral candidiasis (thrush)
- Risk factors
- Clinical presentation
- Dx
- Tx
A
Oral candidiasis (thrush)
- Candida albicans
- Infants and older adults with dentures
Risk factors
- Denture use
- Poor oral hygiene
- Diabetes mellitus
- Anemia
- Chemotherapy or local radiation
- Corticosteroid use
- Antibiotic use
- HIV
Clinical presentation
- Painful, creamy-white, curd-like patches over erythematous mucosa (or may present as angular cheilitis)
- May not always see this white plaque because it brushes off so easily
- Easily scraped off (“thrush will brush”)
- Cotton mouth
- Loss of taste
- Pain with eating or swallowing
Dx
- Clinical impression
- KOH wet prep (budding yeasts or without pseudohyphae)
- Culture
- Biopsy
- Other labs: HIV, glucose
Tx
- Antifungals
- Clotrimazole troches
- Nystatin mouth rinses
- Fluconazole
- Ketoconazole
12
Q
Oral lichen planus
- What is it
- Clinical presentation
- Diagnostics
- Dx
- Tx
A
Oral lichen planus
- Chronic, inflammatory autoimmune dz
- Difficult to dx because of wide range of presentation
Clinical presentation
- reticular white plaques (like thrush)
- or mucosal erythema
- or erosions/ulcerations
- or hyperkeratotic plaques
- painless or painful
Dx
- Exfoliative cytology
- Biopsy
Tx
- Manage pain/discomfort
- Corticosteroids (since it is autoimmune)
- Managed by rheumatology
- Need frequent follow ups because this is a risk factor for oral cancer
13
Q
Oral leukoplakia
- What is it
- Irritants
- Clinical presention
- Tx
A
Oral leukoplakia
- Hyperplasia of squamous epithelium
- Precancer
- Cause: chronic irritation
- Can be associated with HPV
Irritants
- Dentures
- Tobacco
- Lichen planus
Clinical presentation
- White plaque
- Can NOT be removed by scraping
Tx
- Consider biopsy or exfoliative cytologic exan
- Can be dysplasic or early invasive squamous cell carcinoma
- Consider referral to ENT, surgeon, rad/onc
14
Q
Erythroplakia
- What is it
- Dx
- Tx
A
Erythroplakia
- Almost always cancer
- 90% represent a malignant change
- Red, velverty plaque lesion
- Common in tobacco and etoh
Dx
- Clinical impression + biopsy
- ALL must be biopsied
Tx
- Refer to ENT
15
Q
Hairy leukoplakia
- What is it
- Clinical presentation
- Tx
A
Hairy leukoplakia
- Epstein Barr virus
- Almost exclusively seen with HIV
- Not precancerous
Clinical presentation
- Lateral tongue
- White, painless plaque that can NOT be scraped
Tx
- Can tx with antiviral but not necessary
