Oral/Pharyngeal/Laryngeal Disorders Flashcards
What type of pharyngitis is the most common type? Which type of bacteria is associated with it and which population does it mostly affect?
Viral
Group A beta hemolytic strep (strep pyogenes)
children
What are the causes of viral pharyngitis?
rhinovirus, coxsackie virus, HSV-1 and 2, EBV (mono), CMV
A patient presents to the office with a sore throat, odynophagia and rhinitis. What would you expect to find when doing the PE?
(viral pharyngitis)
Pe: erythema of the tonsils and posterior oropharynx WITHOUT exudate, +/-fever, +/-adenopathy
A patient presents with viral pharyngitis. You decide that you want to order a rapid strep screen or a throat culture. Why?
because you want to rule out strep
What is the clinical presentation of a patient with GABHS Strep pharyngotonsilitis?
fever, oropharyngeal exudate, anterior cervical adenopathy, absence of common cold sx/cough
What types of diagnostic tests and antibiotics may you want to give to a patient with GABHS strep?
rapid strep screen, culture and sensitivity
Pen VK
Alt: erythromycin and cephalosporins
What is the etiology of pharyngitis?
infections, immune, xerostomia, dehydration, GERD, degenerative, trauma, congenital, vitamin, neoplastic
A 13 year old patient presents to the office with tonsillar exudates and a fever. They do not have a cough or tender anterior cervical adenopathy. Based on the centor criteria, what is their score and what does it mean?
Their score is a 2. Based on the centor criteria. a score of 2-3 means supportive care, rapid test, tx abx if positive, if negative do culture and tx oral if culture is positive
What is the centor criteria?
absence of cough
tonsilar exudates
history of fever
tender anterior cervical adenopathy
age under 15 you add 1 point
age over 44 subtract 1 point
What does a score of 0-1 on the centor criteria indicate?
GAS unlikely, suppostive care
What does a score of 2-3 on the centor criteria indicate?
supportive care, rapid test, tx abx if positive, if negative do culture and tx oral if culture is positive
What does a score of 4 or more indicate on the centor criteria?
(risk is about 50%): empiric abx, rapid test, culture, supportive care
(should treat)
A 20 year old patient presents to the office with posterior triangle neck lymph node enlargement. Upon doing the PE, you noted that the pt has hepatosplenomegaly. Which blood test do you want to order? When running labs on this patient what will the results show?
monospot heterophile blood test (may be delayed)
the results will show lymphocytosis on WBC differential, esp increase in monocytes and atypical lymphocytes
What virus is infectious mononucleosis associated with?
epstein-barr virus
For infectious mononucleosis, what does a heterophile IgM increase indicate?
acute disease
For infectious mononucleosis, what does a heterophile IgG increase indicate?
prior disease
What is the treatment plan for a patient with infectious mononucleosis?
supportive, hydration
avoid contact sports for 6 weeks
check liver and spleen for hypertrophy
steroids
consider antibiotics for secondary bacterial infection- avoid amoxicillin and ampicillin
How is gonococcal pharyngitis usually aquired?
by oral sex exposure
The majority of oropharyngeal infections with ________________ are asymptomatic. Although in some cases they can have symptoms such as what?
N gonorrhoeae
sore throat, pharyngeal exudates, and or cervical lymphadenitis are present in some cases
What is the preferred diagnostic test for gonococcal pharyngitis?
NAAT (nucleic acid amplification testing) of a pharyngeal swab and if unavailable a culture can be done. NAAT offers rapid results and enhanced sensitivity
What is the treatment for pts with gonoccal pharyngitis?
IM dose of ceftriaxone, supposrtive care such as fluids, lozenges, analgesics
What are the complications associated with gonnocal pharyngitis?
retropharyngeal abcess
rheumatic fever
post strep acute glomerular nephritis
peritonsilar abscess
ludwig’s angina
What is peritonsilar cellulitis?
inflammatory reaction of the tissue between the capsule of the palatine tonsil and the pharyngeal muscles that is caused by infection but not associated with a discrete collection of pus. an alternative term for cellulitis is phlegmon
What is peritonsilar abscess?
collection of pus located between the capsule of the palatine tonsil and the pharyngeal muscles.
How is a peritonsilar abcess differentiated from peritonsilar cellulitis?
by needle aspiration and or neck CT
A patient presents with a history of a sore throat. When doing the PE you recognize that the patient has a hot potato voice, displaced uvula and fluctuance. You inform the patient that since they have this, it is very likely that they will develop it again in the future. What is the diagnosis and what are the options to manage it?
peritonsilar abscess. Manage it with clindamycin, oral steroids, incision and drainage, referral for tonsillectomy
What is the most common neck space infection
ludwig’s angina
A patient presents with edema and erythema of the neck and floor of the mouth. You tell the patient that they have ludwig’s angina. The patient is curious as to what this is, how it occurred and what other symptoms/complications the condition may cause. What do you tell them?
I would tell them that it is a bacterial infection of the sublingual and submaxillary spaces. It usually occurs from dental infections. It may also cause dysphagia, odonophagia, pain, and airway compromise.
What are the treatment options for a patient with ludwig’s angina?
IV antibiotics, I and D, protect airway (tracheostomy possible)
What are the sources of infection for deep neck space infections in the pediatric population?
tonsil, sinus, otitis
What are the sources of infection for deep neck space infections in the adult population?
teeth, salivary, gland, skin
What are the signs and symptoms of deep neck space infections
fever, pain, swelling (>90%)
dysphagia, trismus (18%)
fluctuance- uncommon (27%)
What are the most common bacteria that causes deep neck infections?
strep and staph
What are the options to manage a deep neck space infection?
secure airways as needed
CT scan with contrast (cellulitis vs ascess) (identifies neck space involved)
Cultures- blood and needle aspirate
IV antibiotics
Incision and drainage
Explain how retropharyngeal space infections spread
They spread from:
lateral pharyngeal space infection
lymphatic spread from posterior sinuses,adenoids, nasopharynx
Retropharyngeal abscess most common under the age of _________
5
What are the causes of retropharyngeal infection/abscess
trauma (endoscopy or foreign body) in adults
trauma (lollipop-stick perforation) or URI in children
A patient presents to the office with a fever, dysphagia, dyspnea, hot-potato voice, and torticollis. When taking the history, the patient stated that they recently had an endoscopy. Upon doing the PE you recognize that the patient has posterior wall swelling. What is the dx, what imaging would you send this patient for and what are options to manage this diagnosis?
retropharyngeal infection/abscess
lateral neck x-ray- screening
CT WITH contrast- definitive
IV antibiotics (strep, staph, anaerobes)
incision and drainage
This condition mostly affects women of childbearing age. The common symptoms include jaw pain or dysfunction, earache, HA, and facial pain.
TMJ dysfunction
What are the treatment options for TMJ dysfunction?
most pts improve with noninvasive therapies such as pt education, self care, congnitive behavioral therapy,pharmacotherpy, PT.
NSAIDs and muscle relaxants are recommended initially. benzodiazepines or antidepressants may be added in chronic cases
Explain what apthous ulcers are and what is their treatment
they are also known as “canker sores”, ulcerative stomatitis. They are caused from human herpes virus 6 and found on buccal and labial mucosa. They are recurrent, painful round shallow ulcers with red halos.
For the symptomatic treatment, lidocaine, topical steroid in orabase
A patient presents with fluid filled blisters on the lip which they describe as painful. When taking the history, the patient states that they have been experiencing a lot of stress lately due to school. What is the dx and how would you explain what it is to the patient.
the dx is oral herpes simplex virus “fever blisters” or “cold sores”. The blisters rupture within hours then crust over. They last about 7-10 days. It is a result from herpes simplex virus that becomes active from stress, fever, trauma, hormonal changes or sunlight. It is contagious even when the lesions are not present
What is the treatment for oral herpes simplex virus
topical or oral antivirals
____________________ is a manifestation of herpes simplex virus type I (HSV-I)
herpetic gingivostomatitis
What is oral herpetic gingivostomatitis characterized by? Which population does it mostly affect?
characterized by high grade fever and multiple painful oral lesions. It most often occurs in young children and is usually the first exposure that a child has to the herpes virus
What are the risk factors for oral candidiasis (thrush)
dentures, diabetes, anemia, recent chemo/radiation, recent steroids/antibiotics, immunocompromised
T/F patients with oral candidiasis (thrush) do not experience burning pain in the tounge, inside the cheek, or in the throat
false, they do
What is oral candidiasis and what is the treatment?
creamy curd like patches that when scraped off is overlying erythematous, raw, and friable mucosa. the treatment is antifungals
What is oral leukoplakia?
these are benign, pre-cancerous, or invasive painless white areas on the tongue, inside the cheek, on the lower lip or on the floor of the mouth. They usually occur in response to irritation such as chewing tobacco, smokers, ETOH abuse, dentures and they cannot be scraped off. Must biopsy to rule out malignancy. Refer to ENT
What is sialadenitis/parotitis caused by and what are the risk factors associated with it?
bacterial infection (usually staph) and or ductal obstruction. risk factors are dehydration, chronic illness (Sjogren’s)
What is sialadenitis/Parotitis?
inflammation of the salivary gland, mostly the parotid gland. There is pain and swelling that is worst with eating or chewing gum, erythema of the duct opening and pressure on the gland may express pus/stone.
What is the treatment of sialadenitis/parotitis?
conservative: hydration,warm compresses, local massages, sialogogues (lemon candy), anti-staph antibiotic
T/F recurrent sialadenitis is common in sialolithiasis
true
What is sialolithiasis?
salivary stone. It is more common in wharton’s duct (drain submandibular glands) vs stenson’s duct (drain parotid gland) there is post prandial pain and swelling
What is epiglottitis and what is it most commonly caused by?
it is a life threatning infection of the epiglottis that can lead to airway obstruction. most commonly caused by Haemophilus influenza type B. It was more common in children prior to vaccine but now more common in adults
What are the clinical features of a patient with epiglottitis?
abrupt onset, high fever, difficulty swallowing, sore throat, drooling, tripod/sniffing position in kids
How is epiglottitis managed?
lateral soft tissue neck XR- thumb sign
intubation
IV fluids and antibiotics then oral antibiotics
uninmmunized contacts should be given prophylaxis with rifampin
What is hoarseness and what are the 7 different types?
symptom of laryngeal disease, change in vocal quality.
- breathy- vocal cords do not approximate completely (nodules, lesion, polyps)
- raspy- thickened vocal cord from edema or inflammation
- shaky- decreased respiratory force (elderly)
- muffled- airway obstruction (PTA, epiglottitis)
- harsh- laryngitis
- stridor- narrowing above vocal cords, high pitched
- Presbyphonia- aging voice
What conditions are considered to be acute hoarseness?
- laryngitis- viral, allergy, vocal abuse
- laryngeal edema- trauma/infection, toxic inhalation, cough/choking, angioedema, allergy, hereditary angioneurotic edema (c1 esterase inhibitor deficiency)
- Epiglottitis
Laryngitis is typically _________ and follows _________
viral, URI
What is the treatment for laryngitis?
conservative treatment: hydration, no yelling/whispering voice, quit smoking, avoid spicy/acidic foods
treat underlying issue: rhinitis, reflux, neurologic issues
refer for laryngoscopy or videostroboscopy
What causes chronic hoarseness?
tobacco, allergy, vocal abuse, GERD/LPR, vocal cord polyps/nodules, chronic environmental irritant exposure, MS, etc
What are associated symptoms for hoarseness?
sore throat, globus sensation, dysphagia, mucus, cough
What is the workup for hoarseness?
labs: CBC, ESR, TFIs
chest XR or chest CT
neck CT/MRI
videostroboscopy
barium swallow
What is the management for hoarseness?
treating the underlying cause: PPI, steroids, allergy management, sx, injectables, voice therapy
voice rest, hydration, smoking cessation
What is GERD/laryngeopharyngeal reflux?
reflux of stomach contents into esophagus and into larynx
(extremely common)
A patient presents with hoarseness, cough, mucus in throat, globus, dysphagia, sore throat and halitosis. They complain of also having associated heart burn. What tests do you want to do to diagnose this pt? What is the dx and what are the options to treat it?
Diagnosis:
HEENT exam
NPL
H pylori test
Barum swallow
Transnasal esophagoscopy (TNE)
Upper endoscopy
Treatment: dietary lifestyle modifications, PPI’s, H2 blockers
What are examples of vocal cord abnormalities and how are they treated?
- Polyps/Nodules: microdirect laryngoscopy (MDL) with biopsy, SPEECH THERAPY, SMOKING CESSATION
- Leukoplakia/Erythoplakia/Lesion- MDL with Bx
- Vocal cord paralysis- diagnose the etiology
-R/O neoplastic process
-thyroplasty with vocal cord medalization or injectables (radiesse)
-video swallow to rule out aspiration
-tracheostomy with bilateral vocal cord paralysis
-speech therapy
