mouth/throat Flashcards
types of oral lesions
squamous cell carcinoma oral leukoplakia candidiasis herpes simplex virus aphthous ulcers
causes of squamous cell carcinoma
dental changes/ ill fitting dentures
tongue/lip cancers- painful exophylic or ulcerative lesions
persistant papules, plaques, erosions, ulcers
smoking/alcohol
hpv infx
path SCC
leukoplakia, erythroplakia, leukoerythroplakia all progress to invasive cancer
pt presents w nonhealing mucosal ulcers, sore throat, referred otalgia, hoarseness, dysphagia, chronic cough, and neck mass
SCC
precancerous lesion presents as white patches/plaques of oral mucosa (cheek/tongue) that doesn’t scrape off
oral leukoplakia- progress to become SCC
white plaques that can be scraped off
pseudomembranous form oral candidiasis
erythema without plaques
atrophic form oral candidiasis
beefy red tongue w soreness
candidiasis
local infx seen in infants, denture wearers, diabetics, tx w abx/chemo,radiation, and immunocomp
oral candidiasis
tx candidiasis
nystatin suspension/ troche
clotrimazole troche
mc manifestation of primary herpes simplex infx in childhood caused by herpes simplex virus type 1
herpetic gingivostomatitis
multiple intraoral vesicular lesions and erosions bordered by inflam, eryth base
herpes simplex virus
what is herpes simplex virus brought on by
sunlight
trauma
emotional/physiologic stress
young kid with fever, lymphadenopathy, drooling, and dec po intake
herpes
where can a ruptured vesicle leave area of ulceration or erosion with herpes
bone bearing tissues or keratinized mucosa
palate, attached gingival, dorsal surface tongue
dx herpes
multi nucleated giant cells on tzanck smear
direct immunofluorescence smear
viral culture
tx herpes
acyclovir
fluids
ice/popsicles/oral sinuses
magic mouthwash, diphenhydramine, carafate, viscous lidocaine
painful oral lesions that appear as localized, shallow, round to oval ulcers w grayish base
aphthous ulcer- canker sore
presents round, clearly defined, small, painful ulcers that heal within 10-14d no scarring
aphthous ulcer
where does aphthous ulcers occur
soft, movable tissues that are non keratinized
labial/buccal mucosa, ventral surface tongue, floor mouth
tx aphthous ulcer
topical anesthetics- or abase w triamcinolone
magic mouthwash
silver nitrate/cautery
viral causes pharyngitis
influenza parainfluenza adenovirus enterovirus rsv hsv ebv cmv hiv
bacterial causes pharyngitis
group a strep- incubate 2-4d, resolves 3-4d
mycoplasma
noninfectious causes pharyngitis
allergies
post nasal drip
group a strep (GAS) pharyngitis complications
acute rheumatic fever/scarlet fever
glomerulonephritis
peritonsillar abscess
toxic shock syndrome
pt sore throat worse when swallows, fever, ha, malaise, lymphadenopathy, uri
pharyngitis
what will see physical exam pharyngitis
doesn’t dist viral from bacterial
pharyngeal erythema
tonsillar swelling/exudates= kissing tonsils
lymphadenopathy
centor criteria for clinical indications for potential GAS
tonsillar exudates tender anterior cervical adenopathy fever absence of cough (
dx GAS
rapid antigen detection test “rapid strep”- specific
throat cx is GS
tx viral pharyngitis
fever control
fluids
magic mouthwash or topical spray (chloraseptic )
cough drops/ lozenges
tx GAS
penicillin VK- 1st line amoxicillin, ampicillin
- (po amoxil tastes better)
- cephalosporins, macrolides, clinda
penicillin G im injection
tx kissing tonsils
steroids
when can someone return school
after abx therapy, fever free 24h
infection between the capsule of the palatine tonsil and the pharyngeal muscles
peritonsillar cellulitis
collection of pus located between the capsule of the palatine tonsil and the pharyngeal muscles
peritonsillar abscess
deep cervical tissue infection
retropharyngeal cellulitis/abscess
path of peritonsillar abscess
peritonsillar infx- preceded by tonsillitis or pharyngitis and progresses from cellulitis to phlegm on to abscess
where does peritonsillar abscess occur
superior pole of tonsil
bacterial causes peritonsillar abscess
GAS, staph aureous, respiratory anaerobes
severe sore throat, fever, “hot potato”/muffled voice and may have drooling, trismus, ear pain
peritonsillar abscess
extremely swollen tonsil, uvula deviated to opposite side, building of posterior soft palate, fever, exudates
peritonsillar abscess
dx peritonsillar abscess
labs for baseline- cbc, bmp, throat cx/rapid strep, aso titer
imaging for extent- ct w contrast
tx peritonsillar abscess
consult ent
abscess- needle aspiration, iv clinda or ampicillin-sulbactam
cellulitis- 24h iv abx and reeval
what must you match sure you do with peritonsillar abscess
monitor airway
complications of peritonsillar abscess
airway compromise
sepsis
necrotizing fasciitis
complication of GAS pharyngitis may be life threatening
retropharyngeal infx
when to worry w retropharyngeal infx
torticollis/pain neck movement difficulty swallowing, drooling changes in voice neck swelling trismus
what should you do for retropharyngeal infx
airway protection
ct/ soft tissue X-ray of neck
tx retropharyngeal infx
admit/stat ent consult
may need intubation/surgical airway
may need surgical evacuation of abscess
iv abx- clinda or ampicillin-sulbactam
Inflammation of the epiglottis and adjacent supraglottic structures
epiglottitis
life threatening infx- airway obstruction
Kids: Trouble breathing, fever, toxic appearing, Tripod position, neck extended / chin thrust forward, drooling, stridor
epiglottitis
Adults: Sore throat, fever, muffled voice / hoarseness, stridor, trouble breathing, drooling
epiglottitis
path of epiglottitis
Cellulitis of epiglottis and adjacent tissue
Posterior nasopharynx is the primary source of pathogens in epiglottitis
Once infection begins, swelling rapidly progresses to involve the entire supraglottic larynx
bacterial causes epiglottitis in kids
Haemophilus influenzae type b (Hib) – most common! Also see H. flu (other types), Strep, Staph
bacterial causes epiglottitis in adults
Hib is most common. Can be caused by viruses, bacteria, and fungal pathogens as well
bacterial causes epiglottitis immunocomp
Pseudomonas and Candida
what dec incidents of epiglottitits
hib vaccine
rf epiglottitis kids
incomplete/lack immunizations, immune def
rf epiglottitis adutls
htn, diabetes, substance abuse, immune def
3 d’s in kids for epiglottitis and other symp
dysphagia, drooling, distress
fever, sore throat, toxic appearing, choking sensation, stridor, muffled voice, tripod position, neck extension/jaw forward
adult presentation epiglottitis
sore throat, fever, muffled voice, drooling, stridor, respiratory distress
what will see on imaging for epiglottitis
later soft tissue film of necks shows enlarged protruding epiglottis
“thumb sign”
tx epiglottitis
Mild - treat and watch
Signs of distress / compromise - Prophylactic Intubation or Surgical Tracheostomy
ICU Admission
IV Antibiotics:
3rd Gen Cephalosporin (Cefriaxone or Cefotaxime) AND antistaph agent that covers MRSA (Vancomycin or Clindamycin)
Usually a 7-10 day course
IV Glucocorticoids - controversial - not recommended until days later
“Hoarseness” - often used to describe any change invoice quality
laryngitis
causes of hoarseness in laryngitis
acute, chronic, benign vocal fold lesions, malignancy, neurologic dysfunction, non organic (functional) issues
common, self limited inflammation resulting in hoarseness that lasts
acute laryngitis
bacteria that causes laryngitis
m cat, h flu, strep pneumo
pt presents with runny nose, cough, and sore throat from screaming
acute laryngitis
hoarseness as result of irritants that leads to persistent inflam
chronic laryngitis
ex of causes of chronic laryngitis
inhaled fumes, gerd, chronic post nasal drip, etoh use, chronic vocal strain, smoking
gastric contents come to larynx and cause laryngitis
laryngopharyngeal reflux
psychological/neurologic disorder - excessive muscle tension - stain on vocal cords
muscle tension dysphonia
Viscous material accumulates on true vocal cords - results from irritants like smoking
Vocal cords appear swollen/floppy - seen in women in 50s - husky, low-pitched voice. “Sound like a man”
polypoid corditis
“reinke’s edema”
results from chronic irritation- smoking, reflux, muscle tension
polyps/nodules
form following trauma, vocal abuse, coughing, and tend to be unilateral
polyps
form in singer/screamers b/l from overuse and abuse, mc w/k
nodules
what is most laryngeal cancer caused by
squamous cell carcinoma
what do early lesions of laryngeal cancer look like
white plaques
what do late lesions of laryngeal cancer look like
large, exophytic or deep ulcers
unilater or b/l cord paralysis of neuro dysfuntion laryngitis causes
trauma, iatrogenic, neuro ds parkinsons motor neuron ds tremors myasthenia gravis
impairment of voice production without an identifiable organic cause
functional dysphonia
impairment of voice related to a psychiatric condition
laryngeal conversion disorder
mistaken for asthma - cords move to close with inspiration (rather than open)
paradoxical vocal cord motion
tx acute laryngitis
should resolve on own
Hydration, humification, vocal rest
Antibiotics not indicated - unless there is strong evidence of a bacterial infection
Steroids - should be reserved for those who need used of their voice (i.e. professional speaking engagement / vocal performance)
tx chronic laryngitis
Remove irritant and treat underling cause
Ex: GERD, smoking cessation
Muscle tension dysphonia - voice therapy is helpful
Education of vocal hygiene - stop screaming
Most recover well with removal of irritant
tx benign vocal cord lesions (corditis, polyps, nodes)
Polypod corditis - smoking cessation, reflux management, and voice therapy
Polyps - surgey
Nodes - correcting vocal strain and poor vocal habits - voice therapy
tx laryngeal cancer
refer ent
5y cure rate >90%, 25% if metastasis
tx vocal cord paralysis
Damage to recurrent laryngeal nerve - likely is permanent - vocal therapy to help regain some speech
Unilateral - surgical procedures are available
Bilateral - various surgical procedures available - airway maintenance is a concern
Spasmotic dysphonia - voice therapy is not effective - botox injections have been helpful
acute inflam/infx of parotid glads usually in elders postoperative due to dehydration/intubation
parotitis
path parotitis
These glands are located on side of face anterior to the external auditory canals, superior to angle of mandible, and inferior to zygomatic arch
Acute bacterial suppurative parotitis can occur when salivary status permits retrograde seeing of bacteria through Stensen’s duct - mixed oral flora
Ductal obstruction by calculi (sialolithiasis) can predispose to infection
rf parotitis
recent intensive teeth cleaning, use of anticholinergic drugs or other meds that reduce salivary flow, malnutrition, salivary duct obstruction, and neoplasm of oral cavity
bacterial causes parotitis
Variable - mixed oral flora
Staph aureus - most common, anaerobes are common, Gram-negatives are seen in hospitalized patients
Strep pneumo, Moraxella, Pseudomonas, Mycobacterium - all rare causes
viruses that can cause parotitis
mumps, influenza, coxsackievirus, ebv, parainfluenza, hsv, cmv
why get imaging for parotitis
Can be helpful in determining inflammation or duct obstruction from stone
Differentiate suppurative parotitis versus large abscess collection versus tumor
Ultrasound will show abscess and duct obstruction
CT is the most sensitive test for assessing suppurative infection vs. large abscess
tx parotitis
This can spread and become a life-threatening infection
Admission - IV fluids / IV antibiotics
Antibiotics: Total course is 10-14 days (IV and Oral)
Immunocompetent: Nafcillin or Ancef + Mentronidazole or Clindamycin
Immunocompromised: Vancomycin +
Cefepime / metronidazole, or Imipenem, or Meropenem, or Piperacillin-tazobactam
complications of parotitis
Progression of infection can lead to:
Massive neck swelling, airway compromise, sepsis, and osteomyelitis
Other complications: facial nerve palsy, fistula development, parapharyngeal space infection
stones (calculi) in salivary gland/duct in men 30-60
sialolithiasis
path of sialolithiasis
Believed to be secondary to stagnation of saliva - rich in calcium - in the setting of a particle obstruction
Stones composed primarily of calcium - also has magnesium, potassium, and ammonium
Inflammation of the gland (sialadenitis) can occur
rf for sialolithiasis
dehydration, diuretics, anticholinergic meds, trauma, gout, smoking
pt presents w pain/swelling that is made worse w eating
sialolithiasis
typically presents with pain, swelling, and erythema in the area of the gland - purulent drainage can be noted from the duct, +/- fever/chills
sialadenitis
tx sialadenitis
abx for 7-10d (oral/outpt)
imaging for sialolithiasis
CT Scan - High resolution CT is the test of choice for salivary stones - typically do not need contrast
Plain films - good at detecting stones
Ultrasound - >90% effective at seeing stones > 2 mm
Sialography - cannulated duct and injected dye - this was replaced by CT scan
MRI - standard MRI cannot see stones
conservative tx sialolithiases
Keep well hydrated, warm compresses to area, massage the gland, and “milk” the duct
Sour candy - increases saliva production and flow
Discontinue any anticholinergic meds - if possible
Pain meds - NSAIDS - might needs opiates
tx for sialolithiases w infx
cephalexin or dicloxacillin
ent tx sialolithiases
lithotripsy, wire basket retrieval, sialoendoscopy, surgical intervention for excision of stone
complications of sialolithiases
Can lead to secondary infections - usually minor - can spread in to larger infections involving the surrounding tissues / structures
Could lead to airway compromise
Chronic obstruction - leads to dysfunctional gland - leads to drop in salivary flow rates
Increased risk of dental problems, eating issues, loss of taste
