Pharyngeal, larygneal and neck disorders Flashcards
lifespan of taste receptor cells? How do we interpret flavor?
most impt factor in flavor?
- 10 days
- flavor: combo of smell, taste, irritaion, texture and tempurature
- smell or aroma of food most impt factor in flavor!
What is hypogeusia?
- diminished taste to 1 or more tastants
Ageusea?
- absent taste fxn
Dysgeusia?
- persistent sweet, sour, salty, bitter, or metallic taste
What is allegeusia?
- unpleasant taste of food or drink that is usually pleasant
What is phantogeusia?
- unpleasant taste produced indigenously due to gustatory hallucination
Etiology of taste disorders?
- aging
- infections
- gastric reflux
- drugs
- xerostomia: diseases, radiation, infections, drugs (anticholinergics), toxins
Eval of pt with taste disorder?
- mouth exam
- can do whole mouth taste testing or referral for spatial testing
- smell pts breath 5-10 cm from their mouth, rate on scale from 0-5, 5 being unbearably strong
- next check air from nasal passages and score
- eval tongue odor, use spoon to scrap off exudate
- labs: ANA (autoimmune)
Tx of dysgeusia?
- diffiuclt to tx
- tx underlying problem when possible
- clonazepam (klonopin)
tx of burning mouth?
- TCAs (make mouth dry)
- clonazepam
What questions should you ask pt presenting with halitosis?
- good oral hygiene?
- dentures?
- mouth breather or snores?
- excess nasal d/c or nasal obstruction?
- underlying medical problems? diabetes, immunosuppressed
- halitophobics - constantly afraid of having bad breath even though they don’t
Etiology of halitosis?
oral cavity: 85-90%
- breakdown of aas producing sulfur and other gases
- poor oral hygiene
- accumulation and putrefaction of post nasal drip on back of tongue
- other: dental abscesses, gingivitis, unclean dentures (take dentures out to do thorough mouth exam)
nasal passages: 5-8%, from nasal infections, polyps
- in children with fbs in the nose
tonsils: 3%
tonsilloliths form from bacteria in tonsillar crypts and can be foul smelling
Tx of halitosis?
- specific dx tx appropriately
- may need referral to dentist
- oral source:
proper dental care and hygiene, cleaning of post. tongue, rinsing and deep gargling with mouthwash, brief gum chewing, sufficient water intake
59 YO Female pt presents with mouth being sore for 4-5 days especially when eating, it feels dry and she has pain at corners of mouth
- she is type II DM, HTN
dx?
tx?
- oral candidiasis
- susceptible to this because she is a diabetic
- tx: diflucan (one pill), or liquid nystatin
What are some oral infections (stomatitis)?
- candida
- HSV
- VZV
- HIV
- recurrent aphthous stomatitis (RAS) - most common cause of mouth ulcers in north america
- always rule out cancer for persistent or unusual lesions, esp if smokers, drink excessively, just older
Tx of aphthous ulcers?
- sx relief:
triamcinolone acetonide in orabase gel
topical analgesics (OTC):
oragel, anbesol - chemical cautery with silver nitrate or sulfuric acid
- severe: intralesional or oral cortisone
VZV presentation in oral cavity?
HSV?
- grouped vesicles or erosions unilaterally on hard palate, can include buccal mucosa, tongue and gingiva
- wouldn’t be limited to one side of mouth like VZV, could be vesicles on both sides
HIV infection in mouth?
- painful mucocutaneous ulceration one of most distinctive manifestations of primary HIV-1
- shallow, sharply demarcated ulcers can be found on oral mucosa
- there are many opportunistic infection that also cause oral lesions
Geographic tongue?
- harmless
- loss of lingual papillae, can migrate over time over tongue
Complications of xerostomia?
etiolgies of xerostomia?
Tx?
- dental caries - severe
- gum disease
- halitosis
- salivary gland calculi
- dysphagia
etiologies:
autoimmune, radiation, med side effects
tx: artificial saliva (use 6x a day with meals)
Ddx of odynophagia?
- severe stomatitis
- candida involving the esophagus
- GERD
- other causes of stomatitis usually seein in immunosuppressed pts
- tx underlying cause
Indications for indirect laryngoscopy?
CIs?
- hoarseness for longer than 2 weeks
- odynophagia
- voice change
- dysphagia
- hemoptysis
- fb sensation
CIs:
- uncoop pt, or one with strong gag reflex
- compromised airway (croup or epiglottitis)
What do you need for indirect laryngoscopy?
- fiber optic nasopharyngoscopy becoming procedure of choice!
- need: light source warmed mirror gauze to wrap pts tongue topical anesthetic can be used to prevent gagging
Pt comes in complaining about voice being scratchy and coughing, has hoarse voice. Has nonproductive cough especially at night for past couple of weeks. No hemoptysis or night sweats or odynophagia, non-smoker, does take occasional tums for heart burn after he eats, has 3-5 drinks/week
- nothing is remarkable on exam - you want to see down the throat - larynx - get?
- then you see polyp on right vocal cord, what was most likely cause of this polyp?
- pt education?
- indirect laryngoscopy
- most likely has GERD
- acid is refluxing over vocal cords - forming polyps
- educate pt: tell him not to eat large meals within 3 hrs of betime, elevate head of bed, don’t add pillows, no ETOH before bed, no acidic foods, use PPI
What history ?s should you ask about if a pt presents with hoarseness?
- duration and onset
- triggering factors
- what makes it better and or worse?
- other head and neck sxs or past surgery involving neck
- hx of smoking or ETOH abuse
- hx of reflux or sinonasal disease
- h/o trauma or endotracheal intubation
- occupation, hobbies and habits impacting voice use
(sing frequently?)
Etiologies of hoarseness?
- acute laryngitis (URI or voice misuse)
- chronic laryngitis
- benign vocal fold lesions
- malignancy involving larynx
- neuro dysfxn (ALS, MS)
- non-organic (fxnl) issues: aging
- systemic conditions and rare causes
Tx of acute laryngitis?
- less then 3 weeks duration
- self-limited condition
- secondary to URI or acute vocal strain
cause and Tx of chronic laryngitis?
- chronic irritants that over time result in injury
- toxins, GERD, chronic sinusitis, postnasal drip, chronic ETOH use, chronic vocal strain, tobacco smoke
- tx underlying etiology like GERD - PPI, lifestyle changes
What is muscle tension dysphonia?
- not neuro or psychological
- imbalance of tension in muscles involved in voice production
- seen in aging with atrophy of some of the supporting structures of the vocal cords
Polyps etiologies?
- benign vocal cord lesions
- result from chronic vocal cord irritation
- etiologies: smoking, reflux, muscle tension dysphonia, some are traumatic from coughing or vocal abuse
Nodules most commonly seen in what pts?
- bilaterally, symmetric
- singers or screamers nodes
- more common in women and children
Laryngeal cancer -
- primarily squamous cell
- arises from mucosal surface of larynx
- mets to regional lymph nodes
- major risk factors: smoking and ETOH abuse
- early lesions can appear initially as white (leukoplakic) plaques
- 5 yr cure rate 90% for small, early stage lesions, cure rates halved if mets to lymph nodes
Physiology of swallowing?
- oral prepatory phase (CN 5, 7, 12): bolus processed by mastication, tongue impt to direct bolus to upper pharynx
- pharyngeal phase (CN 5, 10, 11, 12): bolus advances into esophagus by pharyngeal peristalsis, cricopharyngeus muscle relaxes (makes up most of upper esophageal sphincter UES)
- esophageal phase: peristaltic contractions in the body of the esophagus propel the bolus down, relaxation of LES allows the bolus to enter the stomach
Disorders of the oral prepatory phase?
- inadequate mastication
- xerostomia
- neuro disorders
- disruption of oropharyngeal mucosa
Disorders of the pharyngeal phase?
- neuromuscular discoordination
- obstructions within oropharynx
- poor compliance of UES
Hx ?s to ask if pt presenting with oropharyngeal dysphagia?
- sxs occur immediately after swallowing?
- pt to cervical region as to where food sticks
- complain of coughing, choking, drooling, odynophagia, changes in speech
- hx of neuro sxs
- complain of wt loss, aspiration
- dry mouth or eyes
PE of pt with oropharyngeal dysphagia?
- thorough HEENT exam
- thorough neuro exam:
CNs
checking for muscle weakness
ptosis (myasthenia gravis)
signs of parkinsons (cogwheeling, shuffling)
Dx tests for oropharyngeal dysphagia?
- barium studies (give specific reason to radiologist)
- fiberoptic endoscopic eval of swallowing
- nasopharyngeal laryngoscopy
- manometry: gives info mainly about UES
35 yo male c/o of severe sore throat for 2 days, hurts to swallow and talk, he has some fever with one temp being 101.4. he denies congestion, cough, sneezing, or myalgias. He has been around his 4 yo nephew who goes to daycare. Non-smoker, healthy?
- Mouth exam and you see erythmatous tonsils
what next?
tx?
- rapid strep and culture (if rapid strep negative and you think it is strep)
- tx: amoxicillin or PCN
Differential and abx use of acute pharyngitis?
- over tx of acute pharyngitis represents one of major causes of abx abuse
- diff:
majority caused by viruses including influenza
10% due to GAS
others:
HSV
EBV (run monospot if rapid strep negative)
HIV (primary)
diptheria
Centor criteria for IDing pts at high risk for having GAS?
criteria:
- tonsillar exudates
- tender anterior cervical adenopathy
- fever by hx
- absence of cough
- pts with less than 3 centor criteria shouldn’t recieve either abx or dx testing
- if adult has 3 or more of criteria then testing with rapid antigen detection test w/o backup throat culture for negative test
- throat culture reserved for pts with neg RADT higher risk for more severe infections or when transmission of GAS is impt
Testing - for acute pharyngitis?
- obtain throat and nasopharyngeal specimens
- RADT/ throat culture
- monospot - rapid antigen test
- influenza test
- hx of HIV rfs consider primary HIV and test appropriately
GAS tx?
- PCN/amoxacillin: first line
- can give PCN IM injection
- if allergic cephalosporin or macrolide, if resistant: clindamycin
- sulfonamides, fluoroquinolones, and tetracyclines shouldn’t be used b/c of high rates of resistance
- should improve 2-3 days, if not f/u needed
- some pts are pharyngeal carriers and there is usually another etiology for their condition
sx tx:
analgesics - NSAIDs, acetaminophen aspirin in adults (not in children)
-topical analgesics:
lozenges, sprays, fluids
abx response - GAS?
- w/in 24 hrs of abx therapy infectivity decreases by 80%
- should be improved in terms of decreased pain and fever in 48 hrs
- if not improving or worsening need to return to clinic
- remind good hand washing to prevent spread of viruses and bacteria and not to share water bottles, utensils, or glasses
Cause, presentation and signs of tonsillopharyngitis?
- usually caused by GAS (other - EBV)
- presentation:
more severe sore throat, sometimes difficulty swallowing, fever - signs:
enlarged, erythematous tonsils with exudate
lymphadenopathy - hot potato voice: abscess
Tests and tx goals for GAS tonsillopharyngitis?
- same exam and tests as for pharyngitis - RADT, monospot, influenza swab, throat and nasopharngeal specimen
- tx goals when GAS:
reduce duration and severity of sxs - abscess, otitis media, sinusitis and meningitis - reduce nonsuppurative complications - acute rheumatic fever, glomerulonephritis (PSGN), ped autoimmune neuropsychiatric disorder (PANDAS) syndrome
- reduce transmission to close contacts
What is a peritonsillar abscess a complication of?
Presentation?
- complication of tonsilitis
- can present primarily or pt may be under tx for tonsilitis
- presentation:
sore throat
odynophagia
fever
trismus
can develop dysphagia and drooling and hot potato voice
ipsilateral ear pain
What will you see on PE of peritonsillar abscess?
DDx?
- can be difficult to examine b/c of trismus
- inferior and medial displacement of tonsil and uvula
- helpful to examine digitally to diff from cellulitis (hard if cellulitis)
DDx: unilateral tonsilitis peritonsilar cellulitis mono neoplasm
Tests and tx options for peritonsillar abscess?
- needle aspiration dx if purulent dc obtained, but if not -can’t rule it out
- sometimes need to confirm dx and location - CT
-tx options:
IND by ENT then start abx - sometimes IV
- occasionally these pts need immediate tonsillectomy
Cause and spread of diphtheria?
- findings?
- Dx?
- tx?
- causative agent: corynbacterium diptheriae
- spread by respiratory droplets or cutaneously
- pharnygeal findings: grayish or white exudate and 1/3 cases pseudomembrane
- dx: culture, test for toxin (hard to culture)
- tx: erythromycin or PCN, antitoxin, other
- stay away from unimmunized contacts (can infect them for up to 6 weeks)
- complications: can interfere with breathing
technique you would use to eval hoarseness?
nasal laryngoscope
What should you think about when you have a pt with persistent ear pain with a normal ear exam?
- peritonsillar abscess
