Mouth, throat, head and neck Flashcards
aphthous stomatitis
- aka cancer sore
- most common acute oral lesion
- often recurrent
classification of aphthous stomatitis
- simple- 1 to several episodes lasting 14 days in oral mucosa
- complex-oral and genital lesions, more numerous and last 4-6 weeks
risk factors for aphthous stomatitis
- smoking
- genetics
- trauma
- hormones
- stress
- food/ drug hypersensitivity
- immunodeficiency or other GI disorders
- vit b12, folic acid, or Fe deficiency
clinical presentation of aphthous stomatitis
- round, oval, clearly defined ulcers
- erythematous rim with yellow center
- usually small
- painful
management of aphthous stomatitis
- oral hygiene
- no alcohol mouthwash, soft tooth brush
- pain control- viscous lidocaine
- swish and spit steroids
- for complex cases can have intralesional steroids, colchisine, dapsone, immunomodulators
oral leukoplakia
- benign
- white gray lesions that cant be scraped off
- clinical significance depends on degree/presence of dysplasia
- associated with HPV
- common in smokeless tobacco users and pure inflammatory conditions
clinical manifestations of oral leukoplakia
- white gray lesions
- in trauma prone regions
- thin areas show more dysplasia
- not painful
- flat and not well defined
diagnosis of oral leukoplakia
- history and PE
- if indurated should be biopsied
management of oral leukoplakia
- doesnt require tx
- can surgically remove
- cryoprobe
- chemoprevention
- oral retinoids
Herpes
- more common in women
- usually transmitted by people who dont know they have it
- recurrent infection common
Herpes primary infection
- highly variable
- usually severe with systemic sx
- Fever, LAD, drooling, decreased PO intake
Herpes recurrent infections
- usually less severe
- more localized
clinical manifestations of herpes
- affects gingiva
- multiple oral vesicular lesions on erythematous base
- herpetic gingivastomatitis most common
- prodrome of burning, tingling, pain
management of herpes
- systemic antivirals
- swish and spit miracle mouthwash
- supportive
- popsicles
oral candida
- aka thrush
- involves mucous membranes- oropharyngeal and esophageal
what is the most common cause of oral candida
- candida albicans
what are the types of oral candida
- pseudomembranous- most common, forms white plaques
- atrophic- aka denture stomatitis, erythema without plaques
epidemiology of oral candida
- young infants
- older adults who wear dentures
- abx or chemo
- radiation to head and neck
- immunodeficiency
- inhaled steroids
- xerostomia
clinical manifestations of oral candida
- dry mouth, loss of taste
- white plaques
- erythema without plaques if denture wearer
- pain with swallowing or eating if esophageal
- beefy red tongue with dentures
- painful fissuring on sides of mouth
diagnosis of oral candida
- clinical
- white plaques removable
- KOH
- if refractory test for HIV
management of oral candida in health patients
- local therapy
- nystatin swish and swallow
- clomitrazole troches
- miconazole buccal tabs
- PO diflucan
what type of cancer is mainly found in the head and neck?
- squamous cell carcinomas
- arise from mucosal surfaces
- generally have good prognosis if detected early
what type of head and neck cancers respond best to treatment
- HPV associated cancer
- HPV cancers usually seen in younger patients
categories of oropharynx cancer
- carcinoma of oral cavity proper
- carcinoma of oropharynx
- carcinoma of lip vermillion
risk factors for oropharyngeal cancers
- smoking**
- alcohol abuse **
- HPV infection**
- EBV
- diet
- immune status
- environmental/ occupational pollutants
- genetics
anterior oral cavity cancers
- SCC
- ulcerative
- painful later in disease
- may be mass with raised, rolled boarder
- tongue is common site
- often see lesions on floor of mouth as well
what is the biggest risk factor for anterior oral cancers
- alcohol abuse
- tobacco abuse
posterior oral cancers
- SCC
- mostly associated with erythema rather than lesions
- pt presents with neck mass, sore throat, dysphagia
what is the biggest risk factor for posterior oropharyngeal cancers
- HPV (16 and 18)
clinical presentation of oropharyngeal cancers
- leukoplakia or erythroplakia*
- speckled erythroplakia
- dentures that no longer fit properly*
- most DONT have hx of premalignant lesions
- pain
- possible airway obstruction
- loosening of teeth
- LAD
what is the best imaging to dx oropharyngeal cancers?
- CT
- need chest CT if there is distant metastasis
- f/u with MRI or PET scan
treatment and prognosis of localized oropharyngeal cancers
- curative intent
- surgery for smaller lesions
- radiation preferred in laryngeal lesions
- survival is good
- if recurrence usually happens if first two years
treatment and prognosis of advanced oropharyngeal cancers
- curative intent
- combo of surgery, radiation, and chemo
- can do chemo and radiation at the same time
treatment and prognosis of recurrent/ metastatic oropharyngeal cancers
- usually palliative intent
- poor prognosis
- poor response to chemo
what is the most common cause of viral tonsillitis/ pharyngitis
- rhinovirus
clinical manifestations of viral tonsillitis/ pharyngitis
- sore throat
- coryza*
- cough*
- N/V/ abdominal pain
- malaise/ fever/ hoarseness
- more erythematous
clinical manifestations of mono
- may appear similar to viral tonsillitis
- inclused posterior LAD
- kissing tonsils
- hepatosplenomegaly
diagnosis of viral tonsillitis/ pharyngitis
- no tests
- rapid flu and rapid mono testing
treatment of viral tonsillitis/ pharyngitis
- supportive
- warm water gargle
- antipyretics and analgesia
- +/- single dose steroids
- +/- IV fluids
- if mono- no contact sports
- if flu- tamiflu
what is the most common cause of bacterial tonsillitis/ pharyngitis
- s. pyogenes
clinical manifestations of bacterial tonsillitis/ pharyngitis
- LACK of coryza, cough, or other URI sx
- sudden onset sore throat*
- anterior LAD
- petechiae on soft palate
- n/v/ abdominal pain
- malaise, fever, hoarseness
what is the centor criteria used to diagnose
- strep throat
what are the components of the centor criteria
- fever
- anterior LAD
- tonsillar exudate
- absence of cough
scores of centor criteria
- 0-1= likely not strep, no testing
- 2-3= confirm with rapid strep test
- 4= treat for strep
diagnosis of strep
- use centor criteria
- rapid antigen detection testing
- culture
- may also want to r/o pharyngitis caused by diptheria, gonorrhea, and chlamydia
treatment of bacterial tonsillitis/ pharyngitis
- Pen VK 500 mg BID X 10 days
- if PCN allergy use cephalexin or macrolide
classic symptoms of scarlet fever
- strawberry tongue
- sandpaper like rash on trunk or armpits
peritonsillar abscess
- collection of pus between palatine tonsils and pharyngeal muscles
- pharyngitis -> cellulitis -> abscess
- usually unilateral
what is the most common cause of peritonsillar abscesses?
- s. pyogenes
clinical manifestations of peritonsillar abscesses
- severe unilateral sore throat*
- ipsilateral ear pain*
- muffled/ “hot potato voice” *
- contralateral uvula deviation
- trismus and decreased PO intake
- neck pain with movement
- drooling and blocked airway if severe
- fowl breath
- erythema/ exudate on tonsil
differential dx for peritonsillar abscess
- retropharyngeal abscess
- ludwig angina
- dental infection
- peritonsillar cellulitis
- mono
diagnosis of peritonsillar abscess
- almost always just clinical dx
- can get CT or ENT consult if uncertain
- intra-oral US
- lateral soft tissue xray to r/u epiglottitis
treatment of peritonsillar abscess
- secure airway
- drain via needle aspiration or I&D
- empiric abx- augmentin
- antipyretics
- analgesia
- +/- steroid
complications of peritonsillar abscess
- airway obstruction
- internal jugular seeding of infection
- septicemia
rheumatic fever
- sequelae of s. pyogenes pharyngitis
- spreads to heart, joints, subq tissue
- cardiac complications may be permanent
cardiac involvement in rheumatic fever
- more often in kids
- mitral valve affected
- can see new murmur, CHF sx, pericardial friction rub
migratory arthritis in rheumatic fever
- usually in teens/ adults
- asymmetric involvement of knees, elbows, wrists
erythema marginatum in rheumatic fever
- usually in kids
- non-pruritic erythematous eruption on trunk
Jones criteria
- used to dx rheumatic fever in addition to evidence of recent strep infection
- need 2 major sx OR
- 1 major and 2 minor sx OR
- 3 minor sx
- also get rapid strep or throat culture if needed
- imaging- EKG, chest XR, echo
major sx of jones criteria
- migratory arthritis
- carditis/ valvitis
- sydenham chorea
- erythema marginatum
- subq nodules
minor sx of jones criteria
- arthralgia
- fever
- elevated ESR or CRP
- prolonged PR interval
treatment of rheumatic fever
- pen VK 500 mg BID X 10 days
- aspirin for joint pain
- +/- steroids
- bed rest until fever is gone, labs and EKG normalize
secondary prophylaxis for rheumatic fever
- PCN IM q4 weeks
- without carditis- for 5 years
- with carditis- for 10 years
sx of post-streptococcal glomerulonephritis
- edema
- hematuria
- HTN
- proteinuria
- majority of pts have at least two of the sx
- nonspecific malaise, weakness, anorexia, n/v
diagnosis of post-strep glomerulonephritis
- urine dip and microscopy*
- streptozyme test
- renal function tests*
- renal biopsy- last resort
treatment of post-strep glomerulonephritis
- treat underlying cause
- mostly supportive
- restrict salt and water intake
- +/- diuretics
- HTN control
- limited activity
- dialysis if severe
laryngitis
- inflammation of vocal cords
- typically resolves in 7-10 days
- mostly viral cause
chronic laryngitis
- > 3 weeks
clinical manifestations of laryngitis
- preceding or concurrent URI
- hoarseness
- odynophonia
- odynophagia
diagnosis of laryngitis
- clinical
- ENT may use fiber optic laryngoscope for chronic cases
treatment of laryngitis
- voice rest
- inhaled humidifier
sialadenitis
- usually viral- mumps
- may be related to HIV infection
- duration varies
parotitis
- secondary to mumps infection
- acute parotid swelling
- see more cases in college aged students d/t waning immunity to vaccine
clinical manifestations of mumps
- bilat parotid gland inflammation
- flu like prodrome
- unilateral testicular swelling and tenderness
complications of mumps
- deafness
- orchitis
- meningitis
- fetal congenital abnormalities
treatment of mumps
- supportive
- bed rest and hydration
- sialagogues
- scrotal sling for testicular pain
- warm or cold compress
- analgesia
- live MMR vacine +/- booster
diagnosis of sialadenitis
- PE
- mumps titer
- HIV RNA detection if indicated
- if unclear or unimproved get US, CT, or sialadenoscopy
other causes of sailadenitis
- stones
- elderly, malnourished, or post op (dehydration in all)
- s aureus
- usually more unilateral involvement
what causes dental caries
- strep mutants
- demineralization exceeds saliva and remineralization -> progressive breakdown
what are the top four complaints of drug seekers
- HA/migraine
- back pain
- tooth ache
- kidney stones
what should happen before you d/c a patient with an oral infection
- consult dentist
- definitive f/u care scheduled prior to d/c
risk factors for oral infectiosn
- low SES
- poor access to care
- poor oral hygiene and nutrition
- prior trauma or many dental procedures
- inadequate fluoride
- decreased salivary flow
- anticholinergic medications
how do you prevent oral infections
- prevent bacterial infection
- regular floss, brushing with fluoride tooth paste, biannual cleaning
- no smoking
- control systemic diseaseS
what causes most oral infections
- usually strep mutans
- often polymicrobial infections with anaerobes
- caregivers can vertically transmit infections
periodontal disease and DM
- severe periodontal disease and DM increases risk of worsening glycemic control
- DM is a risk factor for periodontal disease
pregnancy gingivitis
- d/t hormonal changes
- pyogenic granulomas can occur
si/sx of dental infections
- sensitivity to hot or cold stimuli*
- pain on biting*
- pain at site or refered to jaws, ears, cheeks, sinuses
- bleeding or purulent d/c
- if severe can have systemic sx
what should kids < 4 years old with stiff neck, sore throat, and dysphagia be worked up for
- retropharyngeal abscess
diagnosis of oral infections
- clinical
- no labs unless acutely ill
- can use xrays but not usually necessary
- CT to determine extend and density of swelling, location of abscess
treatment for oral infections
- anti-inflammatories for pain***
- nerve block for severe pain
- Pen VK (or amoxicillin) loading dose 1000 mg then 500 mg QID X 7-10 days
- use clindamycin or erythromycin for PCN allergy
- +/- IV fluids
- admit if necessary
- educate about good oral hygiene
- warm salt water rinses
ludwig’s angina
- sublingual cellulitis
- +/- tracking abscess
- potential for airway issue
- possible complication of oral infections
vincent’s angina
- acute necrotizing ulcerative gingivitis
- aka trench mouth
- possible complication of oral infections
