Pharyngeal, Laryngeal, & Neck Disorders Flashcards
What does flavor consist of?
5
- smell,
- taste,
- irritation,
- texture and
- temperature
Define the following terms:
- Hypogeusia?
- Ageusea?
- Dysgeusia?
- Allegeusia?
- Phantogeusia?
- diminished taste to 1 or more tastants*
- absent taste function
- persistent sweet, sour, salty, bitter or metallic taste
- unpleasant taste of food or drink that is usually pleasant
- unpleasant taste produced indigenously due to gustatory hallucination
Etiology of Taste Disorders
4
- Aging
- Infections
- Gastric reflux
- Drugs
Etiology of Xerostomia?
5
- Diseases
- Radiation
- Infections
- Drugs
- Toxins
What labs to do for mouth taste disorders?
ANA maybe
Dysgeusia:
- What is it?
- How can we treat? 2
- a sweet, salty, rancid, or metallic taste sensation will persist in the mouth
- Treat underlying problem when possible
- Clonazepam (Klonopin)
Treatment for burning mouth?
2
- Tricyclic antidepressants
2. Clonazepam
WHat history questions should we ask for history in halitosis?
6
- Good oral hygiene?
- Dentures?
- Mouth breather or snores?
- Excess nasal discharge or nasal obstruction?
- Underlying medical problems?
- “Halitophobics”
PE for halitosis?
3
- Smell the patient’s breath 5-10cm from the patient’s mouth—rate on a scale from 0-5
- -5 being unbearably strong foul odor - Next check air from nasal passages & score
- Evaluating tongue odor—using a spoon
Oral Cavity Etiology of halitosis?
4
- Breakdown of amino acids producing sulfur and other gases
- Poor oral hygiene
- Accumulation & putrefaction of postnasal drip on back of tongue
- Other: dental abscesses, gingivitis, unclean dentures
Nasal passage etiology of halitosis? 2
Tonsil etiology of halitosis? 1
- From nasal infection, polyps
- In children foreign bodies in the nose (whole body will smell because of this infection)
- “Tonsilloliths” form from bacteria in the tonsillar crypts & can be foul smelling
Tonsoliths are what?
tonsil stones or tonsillar calculi (singular: calculus), are clusters of calcified material that form in the crevices of the tonsils
Tonsolith: Treatment for an oral source?
5
- Proper dental care & hygiene
- Cleaning of the posterior tongue
- Rinsing & deep gargling w/ mouthwash
- Brief gum chewing
- Sufficient water intake
Stomatitis
A condition that causes painful swelling and sores inside the mouth.
What bacteria/virus can cause stomatitis?
6
- Candida
- HSV
- VZV
- HIV infection**
- Recurrent aphthous stomatitis (RAS)–most common cause of mouth ulcers in North America
- ALWAYS rule out cancer for persistent or unusual lesions!!!
Aphthous Ulcers are what?
A small, shallow sore inside the mouth or at the base of the gums.
Aphthous Ulcers–Treatment 2
Symptomatic treatment? 2
- Chemical cautery w/ silver nitrate or sulfuric acid
- Severe: intralesional or oral cortisone
Symptomatic relief:
- Triamcinolone acetonide in Orabase gel
- Topical analgesics (OTC)
- Oragel
- Anbesol
- What is Varicella-zoster Virus?
2. Where is it found? 4
- Grouped vesicles or erosions unilaterally on the
- hard palate
- buccal mucosa
- tongue
- gingiva
Describe HIV oral infections
Painful mucocutaneous ulceration one of the most distinctive manifestations of primary HIV-1
Shallow, sharply demarcated ulcers can be found on the oral mucosa
Complications of dry mouth/Xerostomia?
5
Etiologies of dry mouth? 3
Treatment?
- Dental caries–severe
- Gum disease
- Halitosis
- Salivary gland calculi
- Dysphagia
- autoimmune dz,
- radiation tx,
- medication side
- Artificial saliva
- Odynophagia
- Differential diagnosis? 4
- Treatment?
- is painful swallowing, in the mouth
- Severe stomatitis
- Candida involving the esophagus
- Gastroesophageal reflux disease (GERD)
- Other causes of stomatitis usually seen in immunosuppressed patients
- Treat the underlying cause
Indications for Indirect Laryngoscopy? 6
Contraindications? 2
- Hoarseness > 2 weeks
- Odynophagia
- Voice change
- Dysphagia
- Hemoptysis
- Foreign body sensation
- Uncooperative patient, or one w/ a strong gag reflex
- Compromised airway (croup or epiglottitis)
What is replacing indirect laryngoscopy and becoming the procedure of choice?
What other tools do we need for this procedure? 4
Fiber optic nasopharyngoscopy
- Light source
- Warmed mirror
- Gauze to wrap patient’s tongue
- Topical anesthetic can be used to prevent gagging
What history questions should we ask for hoarseness?
8
- Duration and onset
- Triggering factors
- What makes it better and/or worse
- Other head and neck sx or past surgery involving the neck
- Hx of smoking or alcohol abuse
- Hx of reflux or sinonasal disease
- History of trauma or endotracheal intubation
- Occupation, hobbies and habits impacting voice use
What has caused the vocal cord polyp?
Treatment?
GERD
- dont eat large meals before bed
- raise head 30 degrees while sleeping
- Antacids
- no alcohol
- Remove polyp
Etiologies of Hoarseness?
7
- Acute laryngitis—URI or voice misuse
- Chronic laryngitis
- Benign vocal fold lesions
- Malignancy involving the larynx
- Neurologic dysfunction
- Non-organic (“functional”) issues
- Systemic conditions and rare causes
Etiologies & Treatments: Acute laryngitis 1. duration? 2. prognosis? 3. Secondary to what? 4. Treatment? 2
- less then 3 wks duration
- Self-limited condition
- Secondary to URI or acute vocal strain
- Voice rest,
- fluids
- What is Chronic Laryngitis?
- What can cause this? 7
- Treatment?
- Chronic irritants that over time result in injury
- Toxins,
- GERD,
- chronic sinusitis,
- postnasal drip,
- chronic alcohol use,
- chronic vocal strain,
- tobacco smoke
- Treat underlying etiology
- What is Muscle tension dysphonia (this causes laryngitis)?
- What population is it often seen in?
- Imbalance of tension in muscles involved in voice production
- Seen in aging with atrophy of some of the supporting structures of the vocal cords
Benign Vocal Cord Lesions? 2
polyps
nodules
Benign Vocal Cord Lesions:
Polyps
1. Result from what?
2. Etiologies include? 5
Nodules
- Present how?
- Often seen in who?
- More common in what populations? 2
- Result from chronic vocal cord irritation
- Etiologies include
- smoking,
- reflux,
- muscle tension dysphonia
Some are traumatic from
- coughing or
- vocal abuse
- Bilaterally, symmetric
- “singer’s” or “screamer’s” nodes
- More common in women and children
Laryngeal Cancer Primarily squamous cell: 1. Arises from where? 2. Metastasizes where? 3. Major risk factors? 2 4. Early lesions look like what? 5. 5 year cure rate? 6. If its metastsized to the lymph nodes what is the cure rate?
- Arises from the mucosal surface of the larynx
- Metastasizes to regional lymph nodes
- Major risk factors smoking and alcohol abuse
- Early lesions can appear initially as white (Leukoplakic) plaques
- 5-year cure rate 90% for small, early stage lesions,
- cure rates halved if metastasized to lymph nodes
Physiology of Swallowing
What are the three phases?
- Oral preparatory phase (CN V, VII, XII)
- Pharyngeal phase (CN V, X, XI, XII)
- Esophageal phase
Describe each phase in the process of swallowing:
- Oral preparatory phase (CN V, VII, XII) 2
- Pharyngeal phase (CN V, X, XI, XII) 2
- Esophageal phase 2
- –Bolus processed by mastication
–Tongue important to direct bolus to upper pharynx - –Bolus advances into esophagus by pharyngeal peristalsis
–Cricopharyngeus muscle relaxes (makes up most of the upper esophageal sphincter UES)
3.
–Peristaltic contractions in the body of the esophagus propel the bolus down
–Relaxation of the LES allows the bolus to enter the stomach
Disorders of the Oral Preparatory Phase
4
- Inadequate mastication
- Xerostomia
3 .Neurologic disorders
- Disruption of the oropharyngeal mucosa
Disorders of the Pharyngeal Phase
3
- Neuromuscular discordination
- Obstructions within the oropharynx
- Poor compliance of the upper esophageal sphincter (UES)
Oropharyngeal Dysphagia
history questions?
6
- Symptoms occur immediately after swallowing
- Point to the cervical region as to where food “sticks”
- Complain of coughing, choking, drooling, odynophagia, changes in speech
- History of neurologic symptoms
- Complain of weight loss, aspiration
- Dry mouth or eyes
Oropharyngeal Dysphagia
PE
- Thorough HEENT exam
2. Thorough neurologic exam
What would we do on the neuro exam for Oropharyngeal Dysphagia 4
- Cranial nerves
- Checking for muscle weakness
- Ptosis
- Signs of Parkinson disease
Oropharyngeal Dysphagia
diagnostic tests
4
- Barium studies (Give specific reason to radiologist)
- Fiberoptic endoscopic evaluation of swallowing
- Nasopharyngeal laryngoscopy
- Manometry (gives info mainly about UES [upper esophageal sphincter])
Acute Pharyngitis in Adults
etiologies?
6
- Majority caused by viruses including influenza
- 10% due to Group A strep (GAS)
Others: - HSV
- EBV
- HIV (primary)
- Diphtheria
- What is the Centor Criteria?
- What does the criteria consist of? 4
- WHo should not recieve antibiotics?
- Who should recieve antibiotics without a throat culture?
- Who should be tested with a throat culture?
- Used to identify patients at high risk for having Group A Streptococcus (GAS) pharyngitis
- Tonsillar exudates
- Tender anterior cervical adenopathy
- Fever by history
- Absence of cough
- Patients with less then 3 centor criteria should NOT receive either antibiotics or diagnostic testing
- If an adult patient has 3 or more criteria than testing with a rapid antigen detection test without backup throat culture for a negative test
- Throat culture reserved for patients w/ neg RADT higher risk for more severe infections or when transmission of GAS is important**
Acute Pharyngitis Management
Testing?
5
- Obtaining throat and nasopharyngeal specimens
- Rapid streptococcal antigen test/throat culture**
- Monospot—blood test: rapid antigen test
- Influenza test
- History of HIV risk factors consider primary HIV and test appropriately
GAS Treatment 1. first line 2. For pen allergies? 3. What is GAS resistant to? 4. Should improve in how many days? If not? 5.
- Penicillin/amoxacillin—first line:
- -Can give penicillin IM injection - If allergic cephalosporin or macrolide
- Resistant clindamycin
- Should improve within 2-3 days, if not then follow-up is needed
What antobiotics should be used because of high rates of resistance?
3
- Sulfonamides,
- fluoroquinolones
- tetracyclines
should NOT be used because of high rates of resistance
Symptomatic treatment for GAS:
Systemic pain relief? 3
Topical pain relief? 3
- Acetaminophen
- NSAIDS
- Aspirin in adults (Why not in children- Reyes syndrome)
- Lozenges
- Sprays
- fluids
- Within 24 hrs of antibiotic therapy infectivity decreases by how much
- Should be improved in terms of decreased pain and fever in how much time?
- If not improving or worsening need to do what?
Remind good hand washing to prevent spread of viruses and bacteria and not to share water bottles, utensils or glasses
- 80%
- 48hrs
- return to clinic
- Tonsillopharyngitis is usually caused by what? 2
- Presents how? 3
- Signs? 2
- GAS (other EBV)
- Presentation:
- More severe sore throat
- Sometimes difficulty swallowing
- Fever - Signs:
- Enlarged, erythematous tonsils with exudate
- Lymphadenopathy
Treatment goals when Tonsillopharyngitis
is GAS:
3
- Reduce duration and severity of symptoms
- Reduce nonsuppurative complications:
- Reduce transmission to close contacts
Complications with Tonsillopharyngitis thats GAS caused
4
- Abscess
- Otitis media
- Sinusitis
- meningitis
Reduce nonsuppurative complications of Tonsillopharyngitis. What are these? 3
- Acute rheumatic fever
- Glomerulernephritis
- Pediatric autoimmune neuropychiatric disorder (PANDAS) syndrome
Peritonsillar Abscess
- Is a complication of what?
- Can be primary or secondary to what?
- Presentation? 6
- A complication of tonsillitis
- Can present primarily or patient may be under tx for tonsillitis
- Presentation:
- Sore throat
- Odynophagia
- Fever
- Trismus
- Can develop dysphagia and drooling and voice changes*
- Ipsilateral ear pain
Pertonsillar Abscess
PE? 3
DDx? 4
PE:
- Can be difficult to examine because of trismus
- Inferior and medial displacement of the tonsil & uvula
- Helpful to examine digitally to differentiate from cellulitis
Differential Dx:
- Unilateral tonsillitis
- Peritonsilar cellulitis
- Mono
- Neoplasm
Peritonsillar Abscess
1. Diagnosis? 2
Treatment options? 3
- Needle aspiration diagnostic if purulent material obtained, but if not—cannot rule out
-Sometimes need to confirm diagnosis and location—CT scan
- Treatment options:
- Incision and drainage by ENT then
- start on antibiotics—sometimes IV
- Occasionally these patients need immediate tonsillectomy
Diphtheria
- Causitive agents?
- Spread how? 2
- Pharyngeal finding?
- Dx? 2
- Treatment? 3
- Causative agent: Corynbacterium diphtheriae
- Spread by
- respiratory droplets
- cutaneously - Pharyngeal finding: grayish or white exudate and 1/3 cases pseudomembrane
Dx:
- culture*,
- test for toxin
Treatment:
- erythromycin
- PCN,
- antitoxin
