Throat/Mouth Flashcards
What is the health status of the oral cavity linked to?
Cardiovascular disease
Diabetes
Systemic Illnesses
What should you assume head and neck infections or swelling to?
Odontogenic in origin
What is a dental carie?
Infection that is bacterial in origin and causes demineralization and destruction of the hard tissues of the teeth
What can cause a dental carie?
A dry mouth
What mouth disease remains one of the most common diseases throughout the world?
Dental carie
What are risk factors for dental infection?
Low socioeconomic status/ poor access to care Poor oral hygiene Poor nutrition Inadequate fluoride Decreased saliva flow Use of anticholinergic medications
How do we prevent dental problems?
Flossing Brushing with fluoride toothpaste Biannual cleaning Avoid smoking Good control of systemic diseases
What pathogen causes dental infections?
Streptococcus mutants
What dental diseases are common in pregnant women?
Pregnancy gingivitis caused by hormonal changes which promote pathogen growth
Pyogenic granuloma
What disease is a systemic risk factor for periodontal disease?
Diabetes
What are the two main clinical presentations of periodontal disease?
Sensitivity to hot or cold stimuli
Pain on biting
If a child < 4 comes in with a stiff neck, sore throat, and dysphagia, what should they be worked up for?
Retropharyngeal abscess secondary to molar infection
What labs might you obtain if a patient has periodontal disease and when is the only time you would obtain these?
If the patient looks extremely ill —>
CBC with differential
Culture and sensitivity to test for aerobic and anaerobic pathogens
What might you use a CT scan for with periodontal disease?
TO determine the extent and density of swelling, as well as, the location of an abscess within soft tissue or bone
What differential diagnoses might you consider with periodontal disease?
Sinusitis
Jaw pain is an angina equivalent in postmenopausal women or long-term diabetic patients
What is the first line treatment for dental infection?
Penicillin VK
Loading dose of 1000mg followed by 500mg QID for 7-10 days
IN kids its 40-60 mg/kg/day divided four times a day
What is the second line treatment for dental infection and when should you use it?
If there is a longstanding infection or previously treated infection that does not respond to first line; or PCN allergy
Oral Clindamycin 300mg TID for 7-10 days
If a patient has a severe dental infection, what should the treatment be?
Loading dose of CLINDAMYCIN 600mg or 900mg IV, then 300mg every 6 hours
COnsider double coverage with metronidazole
What must be obtained before a patient with a dental infection can be released from the hospital?
Dental consult and follow up dental care appointment scheduled
What anti inflammatory agents should be used in dental infection?
Aspirin or NSAIDS
Careful with opioids
What is the criteria for admission to the hospital for patient with dental infection?
Swelling involving deep spaces (pre-fascial planes) of neck Unstable vital signs Fever Chills Confusion or delirium Evidence of invasvie infection
If a patient has an I&D for their dental infection, what is the treatment?
Warm salt water rinses several times a day to encourage drainage
Chlorhexidine gluconate twice a day
When can you discharge a patient from the hospital after they are admitted for a dental infection?
If airway is not compromised
If abscess and sepsis are eliminated
If the patient is able to take PO and ambulate
What should be avoided in young children in order to prevent dental caries?
Sleeping with a bottle
What are potential complications of dental infections?
Ludwig angina
Vincent’s angina
Retropharyngeal abscess/infection
Mediastinal infection
What is ludwig angina?
sublingual cellulitis with or without tracking abscess inferiorly
What is Vincent’s angina?
trench mouth
acute necrotizing ulcerative gingivitis
What are the two clinical pearls of dental infections?
Do not ignore toothache pain
Treat patients with facial swelling aggressively, as infections can quickly spread
What is tonsillitis?
inflammation of palatine tonsil glands
What is pharyngitis?
Inflammation of any structure of the pharynx, including adenoids and lingual tonsils
When is tonsillitis and pharyngitis usually seen?
winter and early spring
What virus typically causes tonsillitis or pharyngitis?
Rhinovirus
What bacteria typically causes tonsillitis or pharyngitis?
GABHS:
Strep pyogenes or GAS
What are the clinical manifestations of viral tonsillitis/pharyngitis?
Chronic sore throat and symptoms of common cold
Coryza Cough Malaise Fatigue Hoarseness
What symptoms are associated with viral tonsillitis/pharyngitis caused by mono?
Viral symptoms
Posterior LAD
Kissing tonsils
Hepatosplenomegaly
What are the clinical manifestations of Bacterial tonsillits/pharyngitis?
Lack of cough, coryza, or other URI symptoms
Sudden onset of sore throat
Anterior LAD
Fever
Petechiae of soft palate
What can bacterial tonsillits/pharyngitis lead to in children?
Scarlett fever (GABHS Pharyngitis)
What are the clinical manifestations of Scarlett fever?
strawberry tongue
Sandpaper rash on trunk and armpits
What are the general symptoms of Tonsillitis/pharyngitis?
Dysphagia Odynophagia Sore throat Fever LAD Exudate Headache N/V Abdominal pain
What do we use to diagnose GABHS pharyngitis/tonsillitis?
Centor Criteria
What is the centor criteria?
Fever
Anterior LAD
Tonsillar exudate
Absence of cough
1 symptom = likelihood low for strep
2-3 symptoms = confirm via rapid strep test
4 symptoms = treat for strep pharyngitis
What do we treat Adult bacterial pharyngitis with?
Pen VK 500MG twice a day for 10 days
What do we treat child bacterial pharyngitis with?
Amoxicillin 50mg/kg PO every day for 10 days
or
24 mg/kg PO twice a day for 10 days
What is the secondline treatment for bacterial pharyngitis if the patient has a penicillin allergy?
Cephalexin or Macrolide
What is the treatment for viral pharyngitis?
Gargle with warm water Antipyretics Analgesis for bad cases of mono Rest Decadron single dose if tonsils are really enlarged IVF if dehydrated
What are the complications of strep pharyngitis/tonsillitis?
Peritonsilar abscess
Rheumatic fever
Glomerulonephritis
What is the most common complication seen with strep pharyngitis/tonsillitis?
Peritonsilar abscess
What is a peritonsilar abscess?
Collection of pus located between the capsule of palatine tonsil and pharyngeal muscles
What are the causative steps of peritonsilar abscess?
Tonsillitis/pharyngitis –> cellulitis –> abscess
What is considered the most common deep space infection of the head and neck?
peritonsilar abscess
What is a peritonsilar abscess caused by?
GABHS
Others:
S. aureus
Neisseria
Corynebacterium
What are the clinical manifestations of peritonsilar abscess?
Severe sore throat that is unilateral
Muffled/”hot potato voice”
What are other symptoms of peritonsilar abscess?
Fever Ipsilateral ear pain Fatigue Irritability Decreased PO intake Trismus Neck pain with movement Unilateral, swollen, and fluctuant tonsil with contralateral deviation of uvula Pooling of saliva/drooling Neck swelling Rancid or fetor breath Erythema or exudate of the tonsil
What are differential diagnoses of peritonsilar abscess?
Retropharyngeal abscess Ludwig angina Dental infection Peritonsilar cellulitis Infectious mononucleosis
What typically occurs after patient has had viral pharyngitis?
peritonsilar cellulitis
What is the diagnostic tool used to diagnose a peritonsilar abscess?
CT neck with IV contrast
If you get an xray of the neck and see a positive thumb sign, what is diseased?
epiglottis
When would you get imaging for a peritonsilar abscess?
If you are uncertain about your diagnosis
How is a peritonsilar abscess treated?
Drainage
Empiric antibiotics –> Augmentin 875 mg twice a day for 14 days or Unasyn IV or clindamycin IV
Antipyretics
Analgesia
What is rheumatic fever?
Delayed, non-suppurative sequelae of GABHS pharyngitis involving lesions of joints, heart, subcutaneous tissue, and CNS
What is the concern with rheumatic fever?
lifelong complications and damage to cardiac valves
What are the clinical manifestations of rheumatic fever?
Carditis/Valvulitis Migratory arthritis Erythema marginatum Sydenhaum chorea Subcutaneous nodules
What symptoms are assocaited with carditis/valvulitis in rheumatic fever?
Occurs mostly in kids and lasts long-term
30-60% of patients get this on first occurence
Effects pericardium, epicardium, myocardium, and valves
MITRAL VALVE IS MOST AFFECTED
Pericardial friction rub
New murmur
CHF symptoms
What are the symptoms associated with migratory arthritis?
Lasts 4 weeks Seen in older teens/adults 75% will get on first occurence Asymmetric pattern Large joints effected Edema Swollen joints
What are the symptoms associated with erythema marginatum?
lasts weeks to months
Seen in kids and rarely adults
10% will get on first attack
Non-pruritic, serpinginous erythematous eruption on the trunk
Effects trunk more than proximal extremities
Non-pruritic rash
What are the symptoms associated with sydenhaum chorea?
Lasts 2-3 years Seen in children and rarely in adults Females are most likely to get this 25% will get on first occurence Neurological and pyschological components Abrupt rhythmic, purpseless movement Emotionally labile
What are the symptoms associated with Subcutaneou nodules?
Rare and assocaited with carditis Persists for 1-2 weeks Rare to get Painless nodules over tendon sheaths Occurs on elbows, wrist, ankles, and achilles
How do we diagnose Rheumatic fever?
Jones criteria
What is the Jones criteria?
Evidence of recent strep infection +
2 major
Or
1 major and 2 minor
Or
3 minor if recurrent
What are the major symptoms associated with Jones’ criteria?
Migratory arthritis Carditis/valvulitis Sydenhaum chorea Erythema marginatum Subcutaneous nodules
What are the minor symptoms associated with Jones’ criteria?
Arthralgia
Fever
Elevated ESR or CRP
Prolonged PR interval
How are adults with rheumatic fever treated?
Pen VK 500mg twice a day for 10 days
Bed rest until fever is gone and labs/EKG normalize
How are children with rheumatic fever treated?
Pen VK 250 mg twice a day for 10 days
Bed rest until fever is gone and labs/EKG normalize
What is the secondary prophylaxis treatment for rheumatic fever?
PCN Benzathine G 1.2 million units IM every 4 weeks for
5 years without carditis or 10 years with carditis
What is post-streptococcal glomerulonephritis?
Kidney injury caused by a strep infection from impetigo or sore throat that can cause nephritis
What is nephritis syndrome?
inflammation of glomerulus
Where is post-strep glomerulonephritis most common?
in developing countries
What are the clinical manifestations of post-strep glomerulonephritis?
Edema Hematuria Hypertension Oliguria Proteinuria
What are some nonspecific symptoms associated with post-strep glomerulonephritis?
General malaise
Weakness
Anorexia
N/V
How do we diagnose post-strep glomerulonephritis?
Urine dip and microscopy to test for hematuria/proteinuria and RBC casts
Streptozyme test
Rapid strep/strep culture
Renal function for increased BUN/Creatinine which would signify AKI
What antigens does the streptozyme test test for?
Anti-Dnase B Antinicotinamide-adenine dinucleotiase (Anti-NAD) Antistreptokinase (ASKase) Antihyaluronidase (Ahase) Antistreptolysin (ASO)
How would we treat post-strep glomerulonephritis?
Treat the underlying condition Symptomatic/supportive care: Restrict water and salt intake \+/- diuretics for edema HTN control with diuretics, CCB, and ACE's Limit activity \+/- dialysis if needed
What is laryngitis?
inflammation of vocal fold mucosa and larynx
What is the funciton of the larynx?
Voice
Prevent aspiration of food
What is acute laryngitis caused by?
VIRUS bacteria GERD Environmental Vocal trauma
How long is acute laryngitis?
Resolves in 7-10 days
How long is chronic laryngitis?
> 3 weeks
What are the clinical manifestations of laryngitis?
Hoarseness (dysphonia)
Preceding or concurrent URI symptoms like cough and rhinitis
Odynophonia
Odynophagia
What is the treatment for laryngitis?
VOICE REST
inhaled humidifier
What is the most common virus that causes Non-suppurative sialadenitis?
MUMPS
What bacteria typically causes suppurative sialadenitis?
Staph aureus
Which salivary duct most commonly is inflammed?
parotid duct
What are the clinical manifestations of bacterial suppurative sialadenitis?
Sudden onset of pain, fever, and chills
Unilateral
Firm and tender
Expression of pus
How do we diagnose sialadenitis?
Physical exam
MUMPS titer -RT PCR or serology if indicated
HIV RNA if indicated
If unclear or unimproved:
Ultrasound
CT face/neck
Sialadenoscopy
How do we treat bacterial sialadenitis?
Paraenteral or oral antibiotics --> nafcillin, dicloxacillin, Augmentin Massage of duct Warm compresses Sialagogues Surgical drainage if abscess develops
What is chronic or recurrent sialadenitis?
Caused by obstruction (stone or stricture of duct)
Repeated episodes of pain, swelling, and recurrent infections
Swollen or firm gland; imaging revels calculus of dilated ducts
Treat with hydration, gland massage, sialedonscopy, or surgery and antibiotic
What is neoplasm sialadenitis?
Benign or malignant
Painless, firm, slow growing
Imaging; CT or MRI; FNA
Surgical removal of gland
What is autoimmune sialadenitis?
Caused by Sjogren’s
Gradual onset swelling bilateral parotid or submandibular
Lab work specific to Sjogren’s
Supportive treatment
What is parotitis?
Acute-onset of parotid swelling lasting about 2 days
Parmyxoviral disease spread by respiratory routes like saliva, droplets, and fomites
What is parotitis caused by?
exposure to MUMPS about 2-3 weeks before symptom onset
Who are most effeced by parotitis?
Children but college students are now being seen with it due to waning immunity to vaccines
What are the clinical manifestations of parotitis?
Bilateral parotid gland edema
Flu like prodrome 48 hours before
Unilateral testicular swelling and tenderness
What are the complications of parotitis?
Deafness
Orchitis
Meningitis
Fetal congenital abnormalities
How do we treat parotitis?
Supprtive care: Bed rest Hydration Sialagogues Analgesia warm or cold compresses on parotid Testicular pain is treated with scrotal sling
What are cancers of the oral cavity associated with?
Ulcers or masses that DO NOT HEAL
What accounts for 80% of Squamous cell carcinoma of the head and neck?
Tobacco and Alcohol use
What is aphthous stomatitis?
Canker sore
Painful oral lesion that often reoccurs
What is the most common acute oral lesion?
Aphthous Stomatitis
When do aphthous stomatitis usually develop?
First during adolescence and will wane with increasing age
Where does aphthous stomatitis usually occur?
in middle east and south asia
What type of aphthous stomatitis is most commoN?
simple aphthous
What is simple aphthous (Mikulicz)?
Several episodes a year
May be 1 sore to several at a time
They can last up to 14 days
Limited only to oral mucosa
What is a complex aphthous?
Can be oral or genital More numerous lesions will occur Lesions are > 1 cm Takes 4-6 weeks to resolve So frequent that patients almost always have them
What are aphthous stomatitis caused by?
Multifactorial causes that are often unknown
Immune dysregulation
Exaggerated proinflammatory process
Weak anti-inflammatory response
Possibel genetic predisposition
Certain foods can exacerbate them
May be seen in celiac disease, IBD, or Crohn’s
Conditions that cause decrease in mucosal thickening
Use of antimetabolites such as methotrexate for RA
Vitamin B12, folic acid, or iron deficiency
Neutropenia of any cause
What are the risk factors of aphthous stomatitis?
Smoking cessation Familial tendency Trauma like dental cleaning Hormonal factors like progestin falling in luteal phase of menstrual cycle Emotional stres Food or drug hypersensitivity Immunodeficiency
What are the clinical manifestations of Aphthous stomatitis?
1-5 can occur at one time Round to oval shape Clearly defined ulcers Erythematous rim Yellowish/whitish central space Small, usually 1-3 cm Painful
How do we treat aphthous stomatitis?
Oral hygiene with non-alcohol mouthwash and soft toothbrush
Pain control–>
viscous lidocaine 2% applied directly or swish and spit
Diphenhydramine liquid swish and spit
Dyclonine lozenges
Topical steroids–>
Dexamethasone elixir swish and spit
Clobetasol gel
Triamcinolone paste
How do we treat complex aphthous stomatitis?
Intralesional or oral glucocorticoids for recalcitrant lesions or severe disease:
Colchicine
Dapsone
Pentoxifylline as bronchodilator and immunomodulator
Thalidomide in HIV infected patients
What is oral leukoplakia?
Benign reactive process
Clinical significance depends on degree of and presence of dysplasia
What is the change that oral leukoplakia will progress to carcinoma in 10 years?
1-20%
Who most commonly gets oral leukoplakia?
Men more than women
Those with HPV
Smokeless tobacco users
What are the clinical manifestations of oral leukoplakia?
Leukplakic lesions that show up in trauma prone regions like the cheek and dorsum of tongue where mucosa is normally thicker
Thin areas of mucosa like ventral tongue or retromolar triangle show more dysplasia
Not painful
Whitish grey lesions
Flat
Not well defined
Can’t scrape off easily
How do we treat oral leukoplakia?
Most won’t need treatment but if they do, surgery, cryoprobe, or chemoprevention
What is oral hairy leukoplakia?
NOT premalignant
EBV associated
Occurs almost entirely in HIV affected patients
Who is Herpes simplex virus (HSV-1) most common in?
women
What are the characteristics of primary HSV-1 infection?
HIghly variable and usually severe and systemic
What are the characteristics of recurrent HSV-1 infection?
Common but typically less severe and more local
What are the clinical manifestations of HSV-1?
Herpetic gingivostomatitis
Multiple oral vesicular lesions and erosions surrounded by erythematous base
Painful
Prodromal of signs and burning, tingling, and pain will occur 24 hours prior to outbreak
Where do recurrent outbreaks of HSV-1 usually occur?
on lip borders
What are the symptoms that young children infected with HSV-1 will have?
Fever
LAD
Drooling
Decreased oral intake
Where will sores be located in primary herpetic gingivostomatitis?
Inside of mouth
Where will sores be located in recurrent herpetic gingivostomatitis?
On outside of mouth
What are the risk factors for HSV-1?
Sunlight exposure
Stress
Trauma
What labs could you get to confirm HSV-1?
Tzanck smear, immunofluorescent smear or viral culture
How do we treat HSV-1?
Systemic antiviral –> Acyclovir, valacyclovir, or Famciclovir
Swish and spit miracle mouthwash
Supportive care
Popsicles for kids
What is oral candida?
Common local infection involving oropharyngeal and esophageal mucous membranes
Who most commonly gets oral candida?
Young infants Older adults who wear dentures Those on antibiotics Those on chemotherapy Those on radiation of head and neck Those that are immunodeficient Those that have inhaled corticosteroids Those with xerostomia
What is oral candida caused by?
Candida albicans
What is pseudomembranous oral candida?
White plaques on buccal mucosa, palate, tongue, and oropharynx
What is atrophic oral candida?
Found around upper dentures and appear as erythema without papules
What are the clinical manifestations of oral candida?
Asymptomatic Dry mouth Loss of taste Pain with swallowing or eating White plaques on buccal mucosa, palate, or tongue Erythema without placques in denture wearers Painful swallowing if esophageal Beefy, red tongue with denture wearers Angula chelitis Painful fissuring
How do we treat oral candida in healthy patients?
Local therapy
Nystatin suspension swish and swallow
Clotimazole troches
Miconazole buccal tabs
How do we treat oral candida in immunocompromised patients?
Diflucan PO
What structures are in the oropharynx?
Posterior 1/3rd of tongue
Soft palate
Lateral and posterior walls of throat
Tonsils
What are the regions of the throat?
Nasopharynx
Oral cavity
Oropharynx
Larynx
What are malignant neoplasms of head and neck?
Epithelial carcinomas of head and neck that arise from mucosal surfaces and are overwhelmingly Squamous cell carcinomca
What are anterior cancers of head and neck caused by?
Tobacco and alcohol
What are posterior cancers of head and neck caused by?
HPV 16 and 18
What are anterior cancers of head and neck associated with?
nonhealing ulcers or masses
Dental changes or poorly fitting dentures
WHo have a 3-8X greater risk of developing oral cancer?
moderate to heavy drinkers
Who has a 30X greater risk for oral cancers?
extremely heavy drinkers
Who has a 100X greater risk for oral cancers?
Heavy smokers and heavy drinkers
Who has a 5-9X greater risk for oral cancers?
Smokers
Who has a 17X greater risk for oral cancers?
heavy smokers
What are the risk factors for oral cancers?
Smoking
Alcohol abuse
HPV infection
EBV infection
Who most commonly get oral cancers?
males
Who do HPV related oral cancers occur in?
younger patients usually in their 40s
What are the clinical manifestations of posterior tongue cancers?
HPV 16
Does not produce visible lesions/discolorations
There are no warning signs
There will be erythema but no ulcers
What are the clinical manifestations of Oral cavity cancers?
Lesions present as exophytic, ulcerative, and often painful
What do 2/3rds of patients with primary tongue lesions also have?
nodal disease
What is oral cavity squamous cell carcinoma usually proceeded by?
Leukplakia
Erythroplakia
Speckled Erythroplakia
What is erythroplakia?
Red patch similar to leukoplakia except that is has erythematous components
What is speckled erythroplakia?
Combination of red and white freatures
Fiery red patch taht cannot be identified clinically/pathologically as any other definable disease
Will show evidence of high grade dysplasia, carcinoma in situ, or invasive SCC
Lesions appear as red, velvety patho that is often demarcated
Some lesions may have rough, granular surface
What are the clinical manifestations of oral cavity squamous cell carcinoma?
Painless
can appear as ulcer without adjacent mucosal change
Continued growth can result in a mass with raised, rolled borders
Pain/tenderness often will develop but later in the disease
What is the most common site of oral squamous cell carcinoma?
Tongue
What is the second most common site of oral cavity squamous cell carcinoma?
Floor of mouth
Where do the vast majority of tongue lesions in OC-SCC occur?
lateral and ventrolateral aspects
Where does oralpharyngeal squamous cell carcinoma develop?
Tonsillar region and base of tongue
What are the clinical manifestations of oropharyngeal squamous cell carcinoma?
Appear as ulcerated mass, fullness, or irregular erythematous mucosal changes
Presents at more advanced stage as it grows undetected and has higher propensity for metastasis
Presene of neck mass
Sore throat
Dysphagia
What are the clinical manifestations of SCC with leukoplakia?
Rough, papillary patch of leukoplakia seen in retromolar trigone and soft palate
Large size and nonhemogenous nature of lesions worrisome for malignancy
Biopsy shows invasive SCC
What are symptoms of oral cavity cancers?
pain that will occur in stage 3 or 4 Otalgia Dysphagia Odynophagia Airway obstruction Neuropathies
What are the signs of oral cavity cancers?
Cervical LAD Cranial neuropathies Decreased tongue mobility Fistulas Skin involvement
Where can oral cancer occur in oral cavity?
lips tongue floor of mouth Maxillary alveolar ridge/hard palate Mandibular alveolar ridge Buccal vestibules
Where can oral cancer occur in oropharynx?
Tongue base
Soft palate
Palatine tonsils
Posterior wall of pharynx
Where can oral cancer occur in hypopharynx?
Piriform sinuses and postcricoid area leading into esophagus below
Where can oral cancer occur in larynx?
Supraglottis (epiglottis and false vocal cords)
Cancers here will spread to lymph nodes early
Where can oral cancer occur in glottis?
true vocal cords
Presents with hoarseness
What are some later symptoms of oral cancer?
Bleeding Loosening of teeth Difficult wearing dentures Dysphagia Dysarthria Hoarseness Development of a neck mass
How do we figure the extent of oral cancers?
Contrast or noncontrast CT scan of neck and head
What are the three clinical groups for treatment of oral cancers?
Localized disease
Locally or regionally advanced disease
Recurrent and/or metastatic disease
How do we treat localized oral cancers?
Curative intent by either surgery or radiation
How do we treat locally or regionally advanced disease?
Curative intent but with combined modality therapy using:
Surgery
Radiation therapy
chemotherapy
How do we treat recurrent and/or metastatic oral cancer?
Treated with palliative care
THis can’t be cured so radiation and chemo just extend the patients life for a few months and relieve the pain
Which oral cancer has the best overall 3 year survival rate?
Those caused by HPV
