Mouth and throat Flashcards
2 types of HSV
HSV1
HSV2
Which type of HSV does not cause oral lesions? What lesion does it cause instead?
HSV2
It causes genital lesions
What is the hallmark feature of all herpes viruses
They can establish latent infections that can be reactivated and persist for the life of the individual
Primary HSV presentation
Primary gingivostomatis - painful ulcers on lips, hard palate, buccal mucosa (inner lining of cheeks)
Fever
Local lymphadenopathy
Where does HSV1 establish a latent infection
Trigeminal ganglia
What triggers the reactivation of latent HSV1 in trigeminal ganglia
Stress
Trauma
Febrile illnesses
UV radiation
Presentation of latent HSV
Herpes labials - cold sores
What is herpetic whitlow
HSV infection of the finger
How to prevent herpetic whitlow from spreading
Use of gloves
What is herpes simplex encephalitis
Inflammation of the brain due to HSV1
Symptoms of herpes simplex encephalitis
Fever
Headache
Seizures
Impaired consciousness
Sudden behavioural change
Investigations for HSV
Swab of lesion
Management for HSV
Aciclovir
HSV can cause which condition in a patient with atopic dermatitis
Eczema herpeticum
Management of eczema herpeticum
IV acyclovir
What is hand, foot and mouth disease
Oral enanthum + macular/vesicular/maculopapular rash of the hands and feet
Most common cause of hand, foot and mouth disease in children
Coxsackie virus A16
Hand, foot and mouth disease is usually preceded by
One day history of fever and lethargy
Management of hand, foot and mouth disease
Self-limiting - usually resolves within 10 days
Does not need to be isolated
Is hand, foot and mouth disease contagious
yes, most contagious in the first 5 days
Avoid sharing towels / items
Keep off school until the child is feeling better, no need to wait for the blisters to heal
What is aphthous ulcer
Recurrent ulcer in the mouth such as inside the lips / underneath the tongue / inside cheeks
Difference between aphthous ulcer and cold sores
Aphthous ulcers are not contagious
Aphthous ulcers do not occur on surface of lips
Aphthous ulcers are not caused by viruses
Management of aphthous ulcer
Self-limiting - resolves in less than 3 weeks
What is the causative pathogen of oral candidiasis
Candida albicans - fungus
Risk factors of oral candidiasis
Post antibiotics
Immunosuppresed
Smokers
Inhaled steroids
Management of oral candidiasis
Nystatin
Fluconazole
What is Behçet’s disease
Multi-organ disease caused by systemic vasculitis
What is the most common symptom presented in Behçet’s disease
Recurrent oral ulcers
Symptoms of Behçet’s disease
Recurrent oral ulcers
Recurrent genital ulcers
Uveitis
Erythema nodosum
Behect’s disease is common in which part of the world
Middle East
Asia
Which GI disease can cause recurrent aphthous ulcers
Coeliac
IBD
Which skin conditions can cause oral ulcers
Pemphigus vulgaris (almost always causes oral ulcers)
Lichen planus
Which age groups do squamous cell papilloma of the mouth affect
<5 years old
20-40 years old
Which disease is squamous cell papilloma of the mouth related to
HPV
Presentation of squamous cell papilloma of the mouth
Painless lesion in mouth
Where does squamous cell papilloma of the mouth usually affect
Soft palate
Hard palate
Tongue
Lips
Tonsils
Oesophagus
Management of squamous cell papilloma of the mouth
most do not need treatment
cryotherapy
Topical salicylic acid
Surgical excision
Which salivary gland is the most common site for tumours
Parotid gland
Are most of the parotid gland tumours malignant
No - 60% are benign
Tumours at smaller salivary glands are more likely to be malignant
What are the types of benign tumours of the salivary gland
Pleomorphic adenoma
Warthin’s tumour
What is the most common benign salivary gland tumour
Pleomorphic adenoma
Is there a risk of malignant transformation for pleomorphic adenoma
Yes, if the tumour has been there for a long time
Pleomorphic adenoma most commonly occurs in
Females
30-60 years old
Histological appearance for pleomorphic adenoma
Epithelial + myoepithelial cells
Chondromyxoid stroma
With an outer fibrous capsule
Warthin’s tumour is most commonly seen in
Males
Over 50
Smokers - strongly associated with smoking
What are the malignant tumours of salivary gland
Mucoepidermoid carcinoma
Adenoid cyst carcinoma
Who should you suspect to have malignant tumour of salivary gland
Young patients
w Painful mass
Most common type of malignant salivary gland tumour worldwide
Mucoepidermoid carcinoma
most common type of malignant salivary gland in UK
Adenoid cystic carcinoma
Adenoid cystic carcinoma usually affects
Those over 40
Which structures can adenoid cystic carcinoma affect
Parotid gland
Palate
Malignant tumours of the salivary gland usually causes
Facial nerve palsy
Management of tumours of salivary glands
Resection of tumours - no matter benign or malignant
What structures may be damaged in parotidectomy
Facial nerve
External carotid artery
Retromandibular vein
Acute tonsillitis often occurs with
Pharyngitis
Most common cause of acute tonsillitis
Viral tonsillitis
What are the viral causes of acute tonsillitis
EBV
Rhinovirus
Influenza
Parainfluenza
Enterovirus
Adenovirus
What are the bacterial causes of acute tonsillitis
Strep pyogenes
Strep pneumoniae
H. influenza
Pharyngitis can be due to non-infectious causes as well. What are the non-infectious causes of pharyngitis
GORD
Chronic irritation from smoking
Symptoms of viral tonsillitis
Malaise
Sore throat
Cough
Able to undertake normal activity
Mild fever
Symptoms of bacterial tonsillitis
Fever >38
Odynophagia
Halitosis
Unable to work / school
Lymphadenopathy
How long does viral tonsillitis usually last
3-4 days
How long does bacterial tonsillitis usually last
1 week
How to differentiate between viral and bacterial tonsillitis
Bacterial
- NO COUGH
- Higher fever
- Tonsillar exudate
- presence of lymphadenopathy
Which criteria are used for tonsillitis that suggests a bacterial cause
CENTOR criteria
FeverPAIN
What are the factors in CENTOR criteria that suggests bacterial tonsillitis
- Tonsillar exudate
- Tender cervical lymphadenopathy
- Fever >38
- No cough
A score of 3-4 in CENTOR criteria suggests
32-56% likelihood of strep causing tonsillitis
What are the factors of FeverPAIN criteria that suggests bacterial tonsillitis
Fever
Purulence
Attend rapidly within 3 days (onset)
very Inflamed tonsils
No cough
Investigations for acute tonsillitis
History and clinical examination
CENTOR and FeverPAIN criteria
What are the scoring criteria used for in acute tonsillitis
To see who is more likely to benefit from antibiotics
What CENTOR score would indicate prescribing antibiotics
3/4
What FeverPAIN score would indicate prescribing antibiotics
4/5
2-3 suggests moderate association w strep hence consider delayed prescription for antibiotics
Management of acute tonsillitis
Eat and drink
Rest
Regular analgesia
Lozenges
Antibiotics if indicated by scoring system
Antibiotics used for acute tonsillitis
Penicillin or clarithromycin if allergic
When should you admit a patient with acute tonsillitis
If present with
- stridor
- breathing difficulty
- dehydration
- persistent sore throat that lasts for 3-4 weeks
- persistent sore throat with neck mass
- persistent lesions in oral / pharyngeal mucosa
Management of tonsillitis in hospital
IV fluids
IV antibiotics
Tonsillectomy for recurrent tonsillitis in adults
Complications of tonsillitis
Otitis media
Quincy - peritonsillar abscess
Parapharyngeal abscess
Rheumatic fever
Glomerulonephritis
Symptoms of rheumatic fever
fever
arthritis
pancarditis
3 weeks post strep pyogene infection
What is quinsy
When abscess forms between one of the tonsils and wall of throat due to spread of infection
When does quinsy usually occur
3-7 days after onset of tonsillitis
Presentation of quinsy
Displacement of tonsil and uvula
Loss of concavity of palate
Management of quinsy
Aspiration
IV antibiotics
What is considered as chronic tonsillitis
Infection of the tonsils that persist beyond 2 weeks
Presentation of chronic tonsillitis
Chronic sore throat
Very unpleasant breath
Tonsil stones
Persistent cervical lymphadenopathy
Management of chronic tonsillitis
Dental mouthwash
Neutropenia can be caused by
Severe sepsis
Bone marrow failure due to malignancy
Drugs
Felty’s syndrome
Hypersplenism
Which drugs are associated as cause of neutropenia
Carbamazepine
Carbimazole / propythiouracil
Clozapine
DMARD - methotrexate, azathioprine, sulfasalazine, hydroxychloroquine
Diphtheria is caused by
Corynebacterium diphtheria
Presentation of diphtheria
Severe sore throat
Grey-white coating over pharynx / nose / tonsils (pseudomembrane)
What can happen to pseudomembrane in diphtheria if left untreated
Becomes very large and obstruct airway
Management of diphtheria
Penicillin or erythromycin
Diphtheria antitoxin if severe
What is glandular fever (infectious mononucleosis)
infection caused by EBV
Glandular fever most commonly affects which age group
young adults
Primary glandular fever present in different ages has different severity. At which age does glandular fever cause more severe infection
Teenagers > 10 years old
How does glandular fever spread
By saliva
What is the classic triad of glandular fever
Fever
Pharyngitis
Lymphadenopathy
Symptoms of glandular fever
Fever
Pharyngitis / sore throat / tonsillitis
Malaise
Signs of glandular fever
Tonsillar enlargement with membranous exudates
Cervical lymphadenopathy
Palatal petechial haemorrhage
Hepatomegaly
Splenomegaly
Jaundice
Rash
What are palatal petechial haemorrhage
Pinpoint red macule in oral cavity
Investigations for glandular fever
Bloods - low CRP
EBV serology
Deranged liver function tests
Management for glandular fever
Self limiting - paracetamol
Systemic steroids if severe
Avoid sports for 6 weeks
Complications of glandular fever
Anaemia
Thrombocytopenia
Splenic rupture
Upper airway obstruction
Increased risk of lymphoma
Cause of Acute epiglottitis
H influenza B (not common anymore due to vaccines)
Strep pneumoniae
Strep pyogenes
S aureus
Children can still present with acute epiglottitis if
Missed the vaccination
Born overseas with poor immunisation coverage
Symptoms of acute epiglottitis
Severe sore throat - cannot speak or swallow
Drooling saliva
High fever
Stridor
Breathing difficulty
Child sits immobile / upright with open mouth
What are the 4Ds that suggest acute epiglottitis
Dysphagia
Dysphonia
Drooling
Distress
Acute epiglottitis most commonly affects which age group
1-6 years olds
Investigations for acute epiglottitis
DO NOT EXAMINE the child without seniors / sufficient staff
Urgent referral to ENT
Why shouldn’t you examine a child with acute epiglottitis without seniors around
High risk of laryngeal spasm causing total airway obstruction
Management of mild acute epiglottitis
Supportive
Oral antibiotics
Nebulisers
Management of severe acute epiglottitis
Secure airway via intubation
Take cultures and examine the throat
IV cefuroxime
What is Reinke’s oedema
Swelling of vocal cords due to fluid collected in Reinke’s space
Where is Reinke’s space
The space right below the squamous epithelium of vocal cord
Most common cause of Reinke’s oedema
Smoking
Symptoms of Reinke’s oedema
Hoarse voice
Dysphonia
Throat discomfort
Management of Reinke’s oedema
Smoking cessation
Voice therapy
Surgery
