Mouth/Throat disorders Flashcards
Glossodynia
General
Burning and pain of the tongue
Benign
Sometimes happens with glossitis
Associated with DM, certain drugs, tobacco, candida infection (thrush)
Sometimes called “burning mouth syndrome” if there are no other symptoms
No known risk factors but most common in postmenopausal females
Glossodynia
Tx
Treatments
If with glossitis: stop smoking/ using tobacco, change medication, work on glucose level, treat candida infection
Burning mouth: alpha-lipoic acid and clonazepam (rapid dissolving)
Glossitis
general
Tongue inflammation that causes loss of texture (filiform papillae)
Red, smooth tongue
Sometimes painful but that is when it is associated with glossodynia
Often due to nutritional deficiencies (niacin, iron, vitE), drug reactions, dehydration, food reactions, autoimmune reactions, psoriasis
Need to find cause to treat
Dysgeusia & Ageusia
general
Dysgeusia: distorted sense of taste; everything tastes bitter, sour, metallic, or sweet
Ageusia: complete loss of sense of taste
Etiology/ causes: smoking, pregnancy, aging, infections, nerve damage, neurological d/o (MS, Parkinson’s and Alzheimer’s, SEVERAL medications, chemo and radiation (especially radiation of the head and neck), metabolic deficiencies (vitB, zinc), dentures, DM, thyroid disease, kidney disease…basically EVERYTHING
How do you figure out what is causing it? GET A GOOD HISTORY. If history doesn’t reveal most likely culprit, CBC and CMP.
Dysgeusia & Ageusia
Tx
Treatment: fix underlying cause, no specific treatment for dysgeusia
Viral pharyngitis
S/Sx
Exam
Pharyngeal erythema
(look at tonsils and soft palate)
Lymphadenopathy
Fever
Exudate is possible!!!
Symptoms: think cold with sore throat
Sore throat
Fever (low grade if adeno, higher if flu)
Malaise/ body aches
Poor appetite
Conjunctivitis
Coryza
cough
Hoarseness
Small ulcers in the mouth
Viral pharyngitis
Dx
Diagnostic Studies
Rapid strep test
Rapid monospot test
Viral pharyngitis
Tx
Palliative/ symptomatic care
Ie Tylenol, NSAIDs, chicken noodle soup
Reassurance
Viral pharyngitis
general
Number one cause
Adenovirus is most common cause
Can be caused by influenza and mononucleosis (see later slides)
Misc
Viral causes are more common than bacterial
Most common cause of lost workdays
Bacterial pharyngitis
etiology
Etiology
Group A Strep (GAS)
one of the most common bacterial infections of childhood, accounting for 20–40% of all cases of exudative pharyngitis in children over age 3
Infection is acquired through contact with another individual carrying the organism. Respiratory droplets are the usual mechanism of spread.
The incubation period is 1–4 days.
Bacterial pharyngitis
Sx and exam
Symptoms
sore throat
fever and chills
Malaise
sometimes abdominal complaints and vomiting, particularly in children- more often than you think!!
Exam
Erythematous pharynx (remember to look at all surfaces inside the mouth)
Lymphadenopathy (anterior cervical)
Fever
Exudate on tonsils is probable but NOT GUARANTEED
IT SMELLS!
Bacterial pharyngitis
Tx
Treatment
Typically will resolve on its own in 3-5 days but antibiotics need to be used to prevent complications
10 days of oral penicillin treatmentis first line OR a single intramuscular injection of benzathine penicillin or procaine penicillin (1.2 million units is an effective antibiotic treatment, but the injection is painful)
A first-generation cephalosporin, such as cephalexin orcefadroxil, may be substituted for penicillin in cases of penicillin allergy if the nature of the allergy is not an immediate hypersensitivity reaction (anaphylaxis or urticaria) or another potentially life-threatening manifestation (e.g., severe rash and fever)
Alternative agents: erythromycinandazithromycin
Bacterial pharyngitis
carriers
Misc
What do you do with carriers?
Asymptomatic carriers: only treat if they are spreading the infxn
Bacterial pharyngitis
if mono is suspected
Ampicillin should routinely be avoided if mononucleosis is suspected because it induces a rash that might be misinterpreted by the patient as a penicillin allergy.
Group A Strep
complications
Mononucleosis
Sx and exam
Symptoms
Malaise, fever, and (exudative) sore throat
They are exhausted
Exam
Palatal petechiae, splenomegaly, and, occasionally, a maculopapular rash
Posterior cervical chain lymphadenopathy
transient bilateral upper lid edema and splenomegaly
Almost definite rash if given ampicillin by mistake
Mononucleosis
Etiology
Epstein-Barr Virus (1), cytomegalovirus (2)
EBV is largely transmitted by saliva but can also be recovered from genital secretions. Saliva may remain infectious during convalescence, for 6 months or longer after symptom onset. The incubation period lasts several weeks (30–50 days).
Mono
Dx
Diagnostic Studies
heterophile agglutination test (Monospot) sometimes negative in early disease
Atypical large lymphocytes in blood smear
Mono
Tx
Treatment
In uncomplicated cases, fever disappears in 10 days and lymphadenopathy and splenomegaly in 4 weeks. The debility sometimes lingers for 2–3 months. Don’t treat simple cases
Rupture of the spleen requires splenectomy and is most often caused by deep palpation of the spleen or vigorous activity. Patients should avoid contact or collision sports for at least 4 weeks to decrease the risk of splenic rupture
Mono
complications
Misc
Complications:hepatitis, myocarditis, neuropathy, encephalitis, airway obstruction from adenitis, hemolytic anemia, thrombocytopenia, splenic rupture because of splenomegaly
Peritonsillar abscess
general
infection penetrates the tonsillar capsule and involves the surrounding tissues
Misc
May develop deep neck infection or aspirate pus into lungs if not resolved/ treated properly
Peritonsillar abscess
S/Sx (6)
Symptoms
severe sore throat
Odynophagia (pain swallowing)
trismus (lock jaw)
medial deviation of the soft palate and peritonsillar fold
abnormal muffled (“hot potato”) voice
Peritonsillar abscess
Dx
Diagnostic studies
Ultrasound may be a useful adjunct to clinical suspicion, but imaging is not required for the diagnosis
The existence of an abscess may be confirmed by aspirating pus from the peritonsillar fold just superior and medial to the upper pole of the tonsil
Peritonsillar abscess
Tx
Treatment
parenteral amoxicillin (1 g), amoxicillin-sulbactam (3 g), orclindamycin(600–900 mg)
Less severe cases and patients who are able to tolerate oral intake may be treated for 7–10 days with oral antibiotics, including amoxicillin, 500 mg three times a day; amoxicillin-clavulanate, 875 mg twice a day; orclindamycin, 300 mg four times daily
needle aspiration, incision and drainage, and tonsillectomy
Sialadentis:
general
Salivary Gland Disorder
Sialadentis:
Salivary gland infection
Swelling and tenderness that increase with eating/ anything that causes salivation
Erythema of the duct opening
Often happens after dehydration, with chronic illness, with Sjogren’s syndrome
Usually S. aureus
Sialadentis:
Tx
Tx: IV abx (nafcillin), resolve dehydration, give lemon drops/ lemonheads, warm compresses
When ready to send home, continue oral antibiotics for 10-day total of treatment
Will occasionally not drain and will require surgical I&D
Sialolithiasis
general and Tx
Sialolithiasis:
Stone that blocks drainage of salivary gland
Usually, Wharton duct in submandibular glands and Stensen duct in parotids
Pain and swelling that increases with salivation, no erythema or “illness” like with infection
If stone is small- treat with lemon candy
If stone is large- refer for surgical removal which can be difficult
If recurrent and frequent, sometimes the gland is just removed
Salivary Gland tumor
General and Dx
80% are in parotids and 80% OF THESE are benign
Tend to have more malignancies in submandibular tumors
Parotids are usually slow growing but will eventually get large enough to push the soft palate medially
MRI and CT are used to diagnose
Salivary Gland tumor
Tx
Treatment: refer out for surgical excision, sometimes surgeon will do FNA biopsy first; radiation therapy for malignant tumors
Misc: facial nerve involvement has high correlation with malignancy
Laryngitis
etiology
any inflammatory process involving the larynx
Nearly all major respiratory viruses have been implicated in acute viral laryngitis, including rhinovirus, influenza virus, parainfluenza virus, adenovirus, coxsackievirus, coronavirus, and RSV
can also be associated with group AStreptococcusbut less likely
Laryngitis
S/Sx and exam
Symptoms
Hoarseness
other symptoms and signs of URI, including rhinorrhea, nasal congestion, cough, and sore throat
Exam
hoarseness
URI symptoms
Laryngitis
Dx
Diagnostic Studies
laryngoscopy often reveals diffuse laryngeal erythema and edema, along with vascular engorgement of the vocal folds
Laryngitis
Tx
humidification and voice rest
Antibiotics are not recommended except when group AStreptococcusis cultured, in which case penicillin is the drug of choice
laryngitis
complications
persistent use of voice while infected may lead to the formation of traumatic vocal fold hemorrhage, polyps, and cysts
Laryngopharyngeal Reflux
general
GERD acid will cause hoarseness after irritating the laryngeal tissue
Laryngopharyngeal Reflux
Dx and Tx
Testing and Treatment: patients with chronic hoarseness just need to be referred out for scope with ENT (otolaryngologist)
IF high suspicion for this, you can do a trial of GERD meds (PPI) for 3 months, but the tissue can take up to 6 months to improve
Respiratory Papillomatosis
general
Growths where the ciliated tissue and throat epithelial tissue meet
Usually caused by HPV (types 6 & 11)
Cause hoarseness since they are close to laryngeal tissue
Basically have to send to ENT to have laser or cryotherapy to excise them, over and over again
Misc: Can sometimes cause airway compromise BUT you should avoid tracheotomy because it can cause the problem to worsen
Laryngopharyngeal Reflux
S/Sx and exam
Symptoms:
Chronic hoarseness
Chronic cough or throat clearing
Esophageal spasm
Sometimes asthma symptoms
Usually have other GERD symptoms
PE: nothing exciting unless you can scope and see the tissue; basically, a normal exam
Vocal Fold Problems
general
Nodules/ polyps/ cysts can cause hoarseness
Usually from “vocal abuse”
Treat with modification of habits (AKA don’t talk), speech therapy and possibly even specialist for surgery if necessary
Misc: this is what you hear about with singers that have “vocal cord surgery”
Epiglottitis
general
Etiology
cellulitis of the epiglottis and adjacent structures that can cause potentially fatal airway obstruction
H. Influenza and group AStreptococcus
Misc
Security of the airway is always of primary concern
Disease is more severe/ acute in young children
Epiglottitis
S/Sx and exam
Symptoms
high fever
severe sore throat
drooling while sitting forward
Patients come in with a look of distress
Exam
high fever
severe sore throat
tachycardia
systemic toxicity
drooling while sitting forward
DO NOT USE TONGUE BLADE/DEPRESSOR
moderate or severe respiratory distress with inspiratory stridor and retractions of the chest wall. These findingsdiminishas the disease progresses and the patient tires
Epiglottitis
Dx
Diagnostic Studies
Neck radiographs typically reveal an enlarged edematous epiglottis (the “thumbprint sign”)
specimens of blood and epiglottis tissue should be obtained for culture AFTER securing airway
Laryngoscope but ONLY in the OR in case you need to do immediate procedure for airway (will have “cherry-red” epiglottis)
Epiglottitis
Rx
Treatment
IV antibiotics
cefotaxime, or ceftriaxone is given;clindamycin plus fluoroquinolone reserved for patients allergic to β-lactams.
Antibiotic therapy should be continued for 7–10 days
“Thumb Print” sign on lateral neck x-ray
