Mouth/Throat Flashcards
Recurrent Herpes Labialis (HSV-1 - “cold sore” “fever blister”)
high incidence; contagious
Prodrome (itching, burning, tingling) lasts approximately 12 to 36 hours, followed by eruption of clustered vesicles along the vermilion border. Subsequent rupture, ulceratation, and crusting
Reactivation triggers: UV light, trauma, fatigue, stress, menstruation – can re auto-innoculate in eye, skin
Carcinoma of the lips (often SCC)
Painless lesion with sharply demarcated, elevated, indurated border and ulcerated base; may be verrucous (wart-like) or plaque like. Usually found on the mucocutaneous junction of the lips. Slow- growing, fails to heal, can bleed. High risk of metastasis
Etiologies: tobacco, alcohol, sunlight, poor oral hygiene or poorly fitting dentures.
Dx: biopsy
Mucocele
Soft cyst, mucin-filled cavity with mucous glands lining the epithelium. Common on lips, under tongue (“Ranula”). History of enlargement, breaking, and shrinkage is fairly common. Can persist, rarely goes away on its own (dentist can surgically remove)
Etiology: minor injury to ductal system of minor labial or sublingual salivary gland, by trauma – biting lip
SSx: 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
Cheilitis
Erythema and scaling of the lips “chapped lips” - May become secondarily infected
Etiology: Use of retinoids (isotretinoin, acitretin), wind-burn, allergies, chronic lip licking (saliva causing irritant dermatitis)
Angular cheilitis (perlèche, cheilosis, angular stomatitis)
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: Ill-fitting dentures, loss of teeth changing bite, sicca (dry mouth), Poor oral hygiene, nutritional deficiencies (Riboflavin B2, Cyanocobalamin B12, and iron deficiency anemia
Irritant or allergic reaction to oral hygiene or denture material
Lab: KOH prep to assess for Candida infx
*Note: May also be part of a group of symptoms in Plummer-Vinson syndrome (upper esophageal web, iron deficiency anemia, glossitis, and cheilosis)
Oral Lichen planus
Non-erosive lesion. Usually 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.
Leukoplakia
White patches or plaque on the oral mucosa that cannot be rubbed off.
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
Also seen in inflammatory conditions not associated with malignancy
~ 90% of lesions in those > 40 yrs, M > F
Etiology: trauma from habitual biting, dentures, tobacco use (oral tobacco, esp), oral sepsis, local irritation, alcoholism, syphilis, vitamin deficiency, endocrine disturbances, dental galvanism, AIDS
SSx: Located on tongue, mandibular alveolar ridge and buccal mucosa in ~50%. Also–palate, maxillary alveolar ridge, floor of mouth, retromolar regions.
Forms vary - nonpalpable, faintly translucent white areas to thick, fissured, papillomatous, indurated lesions.
Surface is often shriveled in appearance and may feel rough on palpation.
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, may indicate malignant changes
Diagnosis: Biopsy to obtain a definitive diagnosis, multiple samples if large lesions
DDX: Candidiasis and aspirin burn (can be wiped away with a gauze)
“Other” white oral lesions that cannot be wiped off: traumatic or frictional keratosis, lichen planus, leukoedema, SLE, galvanic keratosis, white sponge nevus, verrucous carcinoma, SCC
Erythroplakia
Red macule or plaque with well-demarcated edges with soft texture; Often on floor of mouth, tongue, palate
Seen in smokers and drinkers
Etiology: Unknown - considered a type of epithelial dysplasia, thus pre-cancerous (Cancer found in 40% of cases) Biopsy!
Oral Squamous Cell Carcinoma (SCC)
~ 30,000 in US each year; 90% are smokers, alcohol is also a risk factor.
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
SSx: May appear as area of erythroplakia or leukoplakia
Exophytic or ulcerated - both variants are indurated with a rolled border
Early lesion may be asymptomatic; ulcerated lesions are often painful
May be difficulty in speaking if lesion is large
Metastatic mass (non-tender) in the neck may be the first symptom.
***Biopsy any persistent papules, plaques, erosions or ulcers!
Melanoma
Pigmented lesions with concerning signs: asymmetry, irregular borders, variable coloration, increasing diameter; lesion will not blanch
Often diagnosed at later stages
DDX: 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
Benign neoplasms from sebaceous glands (sebaceous choristomas)
Most common 20 -30 years; M = F
SSx: Asymptomatic, multiple, white to yellow, 1-2 mm papules, often occurring confluent cluster
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
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”)
Common oral fungal (yeast) infection by Candida albicans, C glabrata, C tropicalis
Risk factors: denture-wearers, diabetics, use of antibiotics, exposure to chemotherapy or radiation, HIV/AIDS, use of inhaled glucocorticoids (eg asthmatics); common in infants
SSx: Lesion: slightly raised soft white plaques (look like milk curds) that are easily wiped away, causing bleeding
May have burning sensation
Mouth appears dry (xerostomia)
Dx: confirmed with KOH prep
**Recurrent, persistent, extensive disease warrants immune status evaluation
Pseudomembranous stomatitis
Inflammatory reaction that produces a membrane-like exudate
Etiology: by chemical irritants or bacterial infections
SSx: Fever, malaise, and LA may result or it may be localized to the mouth
Recurrent Aphthous Stomatitis (”canker sores”)
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.
Physical trauma - toothbrush abrasions, laceration by sharp foods/objects, biting, dental braces
Chemical irritants
Thermal injury (coffee, tea)
Sodium lauryl sulfate (Foaming agent in toothpaste)
Food allergies - citric acid, artificial sugars, gluten
Deficiencies in vitamin B12, iron, and folic acid
Stress, illness, fatigue
Immunodeficiency (eg HIV)
Neutropenia– history of taking antimetabolites (eg methotrexate)
Hormonal changes, menstruation
Associated with celiac disease and inflammatory bowel disease (eg Crohn’s dz)
SSx: Painful lesions, occasionally have prodromal burning or tingling
Ulcers are shallow, round to oval with a grayish base, with a red border
Occur on non-keratinized, moveable mucosa: buccal and labial mucosa, buccal and lingual sulci, ventral tongue, soft palate and floor of mouth.
Some individuals have 2-4 outbreaks a year, while others can have continuous eruptions
DDX: Secondary herpetic ulceration - history of vesicles preceding the ulcers, a location on periosteum-bound mucosa (gingival, hard palate) and crops of lesions.
Trauma, pemphigus vulgaris and cicatricial pemphigoid.
Systemic disorders: Crohn’s disease, neutropenia and sprue.
Herpetic Gingivostomatitis (HSV-1 infection - “cold sore”)
Painful eruptions of the unmovable oral mucosa and vermilion border - common in children
Triggers: trauma, emotional stress
SSx: Often a prodrome of pain, burning, tingling; also fever, malaise, LA, painful eating
Eruption of multiple interoral vesicular lesions and erosions, erythematous base, crusting
Self limited in 1-2 wks in most cases
Kids: fever, LA, drooling, decreased oral intake due to pain (watch for dehydration)
Recurrence is common
Lab: Tzank smear, direct immunofluorescence smear, or viral culture
DDX: aphthous stomatitis, erythema multiforme, drug eruptions, pemphigus
Oral Erythema Multiforme
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
Bullae rupture leaving raw, painful, friable surfaces, then form crusts
May be Prodrome: sinusitis, rhinitis
May see a high fever for 4-5 days, and severe systemic symptoms
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
DDX: aphthous stomatitis, allergic stomatitis, pemphigus, herpes
Chancre
Painless ulcerating lesion formed during the primary stage of syphilis, ~21 days after the initial exposure to Treponema pallidum lasting 2 wks to 3 mos without treatment
SSX: Painless single ulcerated lesion, indurated border, no central necrotic tissue
Ulcers usually form on or around the lips, tongue, also anus, penis, and vagina.
Tender cervical LA
PE: be sure to look for genital lesions as well
Lab: PCR serology
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)
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
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
Most common benign oral soft tissue neoplasm forming in buccal mucosa, lateral border of the tongue and the lower lip (area of trauma)
Lesion is painless, sessile or occasionally pedunculated swelling that can be firm and resilient or soft and spongy in consistency; typically ≤ 1cm
Color is slightly lighter than the surrounding mucosa from relative lack of vascular channels
May become irritated or ulcerated
Most often 20 - 49 years; M = F
DDX: based mainly on the location
Tongue - neurofibroma, neurilemmoma or granular cell tumor
Lower lip or buccal mucosa - lipoma, mucocele or salivary gland tumor.
Angioedema (Quincke’s edema)
Acute edema 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: Allergens (most common - not IgE mediated) to 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
Can also be caused by infection, illness, autoimmune disorders, leukemia
SSx: Painless, non-pruritic (if non-allergic), nonpitting, and well-circumscribed areas of edema from increased vascular permeability.
May progress to complete airway obstruction and death caused by laryngeal edema.
May be chronic when lasting more than 3 weeks
Hereditary angioedema
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
SSx: 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.
Palatal or Mandibular Torus
Non-neoplastic, slowly growing nodular protuberance of bone. Of little clinical significance, except with interference with denture construction and placement. Likely hereditary
Incidence F > M (2:1). Peak incidence occurs shortly before age 30
Hemangioma
Proliferation of blood vessels, often congenital.
F>M : 2:1
SSx: Lesions are flat or raised, with a deep red or bluish-red color
Most common sites: lips, tongue, buccal mucosa and palate. Because of location, frequently traumatized and can undergo ulceration and secondary infection.
DDX: Arteriovenous fistula: more likely if history of trauma to the area of the lesion
Varicosities
Dilated, tortuous veins in the oral cavity are attributed to increased hydrostatic pressure and poor support by surrounding tissues
Commonly located on ventral aspect of the tongue, but may also be found on upper and lower lips, buccal mucosa and buccal commissure
SSx: Blue, blanch when compressed
Papilloma
Etiology: Some oral papillomas are associated with the same human papillomavirus (HPV) subtype that causes cutaneous warts
SSx: Asymptomatic, well-circumscribed, usually pedunculated benign growths with numerous, small finger-like projections (papillary or verrucal)
Generally < 1 cm in diameter, most often solitary
Locations: any intraoral mucosal site and vermillion border of the lips, most common on soft palate or hard palate, uvula, tongue
DDX: Verruciform xanthomas - distinct predilection for the gingiva and alveolar ridge
Warty dyskeratoma - tends to occur as multiple lesions
Condylomata acuminate - usually larger and multifocal, with a broader base
