CMS I: EXAM #1 (ORAL CAVITY & PHARYNX DISEASES)

What has periodontal disease been linked to? (Maternal and nonmaternal)

Maternal=preterm delivery and low birth wt infants due to strep mutans transmission

Generally associated with coronary heart dz in study of veterans

Describe odontogenic infections

Dental caries and periodontal dz (gingivitis and periodontitis)-50/50 reason why people lose their teeth

Describe what systemic diseases periodontal infection can be associated with

Fever of unknown origin, bacteremic seeding of heart valves and prosthetic devices, preterm birth of low weight children, increase risk of coronary heart dz and cerebrovascular events, may be associated with increases in coronary and cerebrovascular dz

Describe the association with diabetes and periodontal dz

Pts with type 1 and 2 have increased risk for periodontal dz

Probably due to impaired immune function; the dz worsens glucose control

Describe the etiology of oral leukoplakia

Usually chronic irritation (hyperkeratosis/dyskeratosis)

Male more than female

Some either dysplasia or early SCC

2-6% malignant transformation in older pts

EtOH, tobacco-risk factors for SCC as well as HPV, syphilis, EBV, immunocompromised pts

What can you clinically see with oral leukoplakia

White lesion 50% on tongue but can be buccal mucosa

CANNOT BE SCRAPED OFF

Usually small but can reach several cm

Whats the difference physically with oral leukoplakia and oral candidiasis

Oral leukoplakia cannot be scraped off but oral candidiasis can

A pt comes in with white lesions on their tongue. They are small but cannot be scraped off. What diagnostic should you do, what should you diagnose, and how do you treat

If abnormal and growing-biopsy/cytologic exam

Oral leukoplakia

Refer to ENT, benign/minimally dysplastic (close follow up or elective excision), premalignant or moderate dysplasia=excision

If multiple or large lesions, consider cryotherapy or laser

Meds=carotenoids, vit A, C, K but are ineffective for malignancy

What is the medical term for losing all your teeth

Edentulous

If a pt has moderate dysplasia oral leukoplakia, how do you treat

Excision

If multiple or large, consider cryotherapy and laser

If pt comes in with benign oral leukoplakia, how should you treat

Refer

Close follow up or elective excision

Give carotenoids, vit a, c, k

What is erythroplakia

Vascularized leukoplakia that is highly suggestive of squamous cell dysplasia; more of a concern than leukoplakia

EtOH and tobacco in ages >45 greatest risk factors

A pt comes in with a red plaque that won't scrape off their tongue. They are an alcoholic as well. What can you assume about this most likely

It is erythroplakia and most likely dysplasia or carcinoma

Describe oral lichen planus

T-cell mediated autoimmune dz where autocytotoxic CD8 T cells trigger apoptosis of oral epithelial cells

Who does oral lichen planus effect and how does it present

Typically seen in adults >40; presents as lacey leukoplakia, reticular pattern; painful, may be erosive (be suspicious of SCC0

A 50 yo pt comes in with an unusual painful lesion on their tongue. It has a reticular pattern and is slightly erosive. What should you do and how do you diagnose

Biopsy for definitive diagnosis

Oral lichen planus

Corticosteroids -both topical and oral in some cases

How do early oral cancer lesions present

As leukoplakia or erythroplakia

What are a lot of oral cancers now linked to

HPV 16

How large does a lesion have to be to most likely consider for metastasization

>4 cm (less than don't usually

You find a tumor in a pt's oropharynx. You confirm that it is squamous cell carcinoma, how do you treat

Complete resection

Lymph node bx prn

Large tumors=combination resection, neck dissection, irridation

What are the risk factors and in what type of pts is oral candidiasis seen in

Risks=DM, AIDS/HIV, inhaled steroids, Abx use, immunocompromised

Commonly seen in pts with denturs, debilitated, anemia, chemotherapy, corticosteroid or broad spectrum use

What is a common first sign of HIV or DM in the oral cavity

Oral candidiasis

A pt comes into the ER and has painful, creamy-white, curd-like plaques. You find they can easily be scraped off but due cause a bit of bleeding. What is it and what should you do

Oral candidiasis

Wet prep with KOH will reveal spores

RX=nystatin oral suspension 100,000 units 5 mL PO QID x 7-14 days

OR

Clotrimazole troches "lozenges"

2nd line=oral fluconazole

What is the tx for oral candidiasis

RX=nystatin oral suspension 100,000 units 5 mL PO QID x 7-14 days

OR

Clotrimazole troches "lozenges"

2nd line=oral fluconazole

Describe angular cheilitis

An inflammatory reaction, this type is characterized by soreness, erythema, and fissuring at the corners of the mouth

Can be manifestation of candidiasis; seen in nutritional deficiencies like vit B; seen in immunocompromised pts

Describe glossitis and what its associated with

Burning mouth syndrome-inflammation of the tongue due to loss of papillae

Associated with nutritional deficiencies (niacin, riboflavin, iron, vit e), drug rxns, dehydration, irritants, autoimmune rxns, foods, liquids

A pt comes in with a red, smooth tongue. What is it and how do you treat

Glossitis

Treat underlying cause

Describe torus palatinus

Common abnormality of oral cavity (up to 20% of pop)

Benign bony exostosis (can be palatinus or mandibularis-roof or floor of mouth)

Problematic with dentures

A pt comes in with a benign bone spur on their hard palate. What is it and what should you do

Torus palatinus

r/o tumor and cyst

Surgically remove only if problematic

A pt comes in with a localized pus swelling in their gums above the 6th tooth. They have much pain and it is painful to bite. What is it and how do you treat

Dental abscess

Dental or surgical intervention I&D

Treat with PCN V K 250-500 mg PO 6h

Clindamycin 150-540 mg PO q6h

Erythromycin 250-500 mg po q6-8h

Duration=7-10 days

2nd=augmentin

What are the complications of dental abscess

Osteomyelitis

Cellulitis

Ludwig's angina

Sinus infection

What can you treat for a dental abscess

Dental or surgical intervention I&D

Treat with PCN V K 250-500 mg PO 6h

Clindamycin 150-540 mg PO q6h (

Be careful because causes cdiff and is expensive)

Erythromycin 250-500 mg po q6-8h

Duration=7-10 days

2nd=augmentin

Describe the etiology of necrotizing ulcerative gingivitis

Trench mouth caused by infection of spirochetes & prevotella intermedia

Common in young adults in periods of stress

A 22 yo PA student comes in very stressed. They have painful inflamed gums that are slightly grayish. They are bleeding and they have a fever. What is it and what do you treat

Necrotizing ulcerative gingivitis

PCN, warm H2o2 rinses, viscous lidocaine, pain meds

Abx if fever or immunosuppressed

What is the tx for ANUG

PCN, warm H2o2 rinses, viscous lidocaine, pain meds

Abx if fever or immunosuppressed

A pt comes what is the etiology of aphthous ulcer

Canker sore

Very common; possibly human herpes virus 6

A pt comes in with a white ulcer on the mucosa surrounding the oral orifice. It is fairly painful and is small. This pt has gotten these before. What is it and how do you treat

Aphthous ulcer

Biopsy if looks a bit abnormal

Can use topical or oral corticosteroids for symptomatic help; avoid acidic food; use a straw; will resolve in 1-3 wks

Describe herpetic stomatitis

Cold sores

Can form from HSV1 (most common-congenital) or HSV2 (less common-acquired by sexual contact)

Recurrent (last about 7-10 days) and occur after trauma, minor infections, stress, and sun exposure

A pt comes in with a burning stinging small group of lesions on their lip. What is it and what should you do for it

Herpetic stomatitis

Pts w/ 72-96 hrs of onset and unable to drink or significant pain; can use systemic agents such as the cyclovirs

Topical antivirals are not helpful

Can give pain relief

DO NOT USE MAGIC MOUTHWASH (can cause seizures, increase risk of choking because many pts with it are unable to swish and spit)

Describe the tx for a cold sore

Pts w/ 72-96 hrs of onset and unable to drink or significant pain; can use systemic agents such as the cyclovirs

Topical antivirals are not helpful

Can give pain relief

DO NOT USE MAGIC MOUTHWASH (can cause seizures, increase risk of choking because many pts with it are unable to swish and spit)

Describe the grading of tonsils

0=surgically removed tonsils

1=tonsils hidden within tonsil pillars

2=tonsils extending to the pillars

3=tonsils are beyond the pillars

4=kissing tonsils

What are the etiologies for acute pharyngitis and tonsillitis

Viral (most common)

Bacterial (strep group a, s pneumo, c diphtheriae)

Fungal (candida a)

Tobacco smoke

Post nasal drip

Irritants

What is the most common pathogen for acute pharyngitis and tonsillitis

Viral

Describe the difference between viral and bacterial tonsillitis

Bacterial you see swollen uvula, white spots on tonsils, gray furry tongue

Viral you see red swollen tonsils and throat redness

What are 2 concerns for acute pharyngitis and tonsillitis

Antibiotic resistance (s pneumo)

Identifying those with group a strep (need to prevent rheumatic fever and glomerulonephritis)

A pt comes in with a fever of 40 degrees c, swollen red tonsils that appear to have white spots on them, and a swollen uvula. Upon inspection you find that they also have tender neck anteriorly, and they don't cough. Specifically, what is the diagnosis and how do you treat

Group a b hemolytic streptococcus (pharyngitis and tonsillitis)

Do rapid strep and throat culture

PCN IM x single dose or bicillin LA 1.2 million

Oral abx-PCN, amox, cephalexin

2nd=erythromycin/azithromycin/clindamycin

What is the treatment for GABHS

PCN IM x single dose or bicillin LA 1.2 million

Oral abx-PCN, amox, cephalexin

2nd=erythromycin/azithromycin/clindamycin

A pt comes in with swollen red tonsils, they have throat pain, and hoarseness. They also have a cough. The rapid strep is negative and you have not gotten the throat culture back. What can you assume the tonsillitis is and how can you treat

Viral pharyngitis

Give analgesics, anti-inflammatory agents (ASA and APAP), salt water gargles, anesthetic gargles/lozenges

What is the centor criteria for GABHS

Fever >38C

Tender anterior cervical adenopathy

Lack of couch

Pharyngotonsillar exudate

What should you do if you have a tx failure for acute pharyngitis and tonsillitis and what are the possible complications

Use augmentin or same drug again

Scarlet fever glomerulonephritis, rheumatic myocarditis, local abscess formation

How might you be able to differentiate between mono and strep

Strep has lack of cough, anterior cervical tenderness.

Mono is more of an all over problem as theres malaise, fatigue, swollen lymph nodes, organ megaly, etc

What should you be sure to do if you differentiate that a pt has mononucleosis

AVOID AMPICILLIN/PCN

What diagnostic studies should you do if you believe a pt has mono

Monospot test, heterophil agglutination test, EBV titer

A pt comes in with swollen red tonsils that have white exudates. They also have significant malaise, fever, splenomegaly, and a rash. What do you think it is and what should you do

Mononucleosis

Check monospot test, ebv titer, heterophil agglutination test

Do supportive care, hydration, antipyretics, analgesics, steroids (if significant pharyngeal erythema)

NO CONTACT SPORTS FOR 3 WKS

What is the tx for mononucleosis

Do supportive care, hydration, antipyretics, analgesics, steroids (if significant pharyngeal erythema)

NO CONTACT SPORTS FOR 3 WKS

Describe a peritonsillar abscess and the risk factors

Most frequently occurring deep space infection of head and neck

Infection penetrates tonsillar capsule (peritonsillar cellulitis)

Caused by mixed aerobic/anaerobic flora

Risks=chronic tonsillitis, multiple oral abx trials, previous episode

A pt comes in with a severe sore throat and pain while swallowing. They have a muffled voice, and there is a medial deviation of the soft palate. They also cannot open their mouth that much. What do you believe it could be and what do you do

Peritonsillar abscess

CT soft tissues of neck with contrast or ultrasound; do needle aspiration for culture

Treat with needle aspiration; I&D; tonsillectomy esp with recurrence

What is the tx for a peritonsillar abscess

Treat with needle aspiration; I&D; tonsillectomy esp with recurrence

Describe a retropharyngeal abscess

Typically follows a URI, infrequent occurrence, most often arises from infection of nasopharynx, paranasal sinuses or middle ear; infection the spreads to nodes

DM and other immunosuppressed state may predispose to infection

Has significant mortality risk due to airway obstruction

A pt comes in in a tripod position and drooling. They also have a sore throat, fever and neck stiffness. Upon exam you hear high pitch noises in their lungs and they have some tenderness around their hyoid bone. What should you do and what can you guess it might be

Retropharyngeal abscess

You can see it in an xray but do a CT with contrast

Medical emergency; emergent ENT consult, airway management, IV abx, surgical I&D

Describe sialaditis and what can cause it

Inflammation of the salivary gland (usually acute, pain and edema with meals)

Systemic issues can cause, metabolic causes, drugs, tumors

Where is sialadenitis more common and what bacteria can cause it

Whartons ducts

S aureus

Describe acute bacterial sialadenitis

Occurs with dehydration, chronic illness (sjorgens my be contributory)

Ductal obstruction leads to infection so you see pus from parotid or submandibular glands

Can be LIFE THREATENING

A pt comes in with inflammation under their tongue. There is pain and edema when they eat. They have DM. What can you guess it is and what do you do

Sialadenitis

Culture of drainage; ultrasound; CT head/neck

IV antibiotics, followed by po x10days

Increase salivary flow with hydration, warm compresses, sialagogues, massage of gland

What should you do for a pt with sialadenitis

If not bacterial, remove it

IV antibiotics, followed by po x10days

Increase salivary flow with hydration, warm compresses, sialagogues, massage of gland

Describe sialolithiasis

Calculus formation in salivary duct

Can manipulate if large enough

Describe the difference between whartons and stensens duct stones

Whartons are large and opaque

Stensen are small and radiolucent

A pt comes in saying they have oral pain after eating. They have swelling under their tongue and you can feel a little bump. What do you think it is and what should you do

Sialolithiasis

Duct dilation, sialoendoscopy (if chronic), lithotripsy

Describe hoarseness-the two different types

Abnormal vibration of the vocal folds

Breathy=too much air passes thru incompletely closed vocal cords

Harsh=stiff vocal cords vibrate irregularly

Describe strido

All cases need specialist eval

High pitched, inspiratory sound typically indicating an upper airway obstruction

Beyonce comes in with voice hoarseness. What can you assume she has and how can you help

Vocal cord nodules

Inhaled corticosteroid, change voice habits, occasionally surgery

What is the most common cause of hoarseness

Laryngitis

A pt comes in a wk after getting over a URI. They have voice hoarseness, difficulty talking, cough, and pain while swallowing. What should you do and what is it

Laryngitis

Tx=conservative; rest, fluids, abx if necessary; avoid singing and shouting

Erythromycin ethynyl suxinate may reduce hoarseness

A pt comes in in the tripod position, drooling, sore throat, pain while swallowing, dyspnea, fever, tachycardia, no cough, and can barely talk at all. What do you think it is and what do you do

Epiglottitis

Do lateral neck xray (see thumbprint), indirect laryngoscopy

Hospitalize for IV abx (ceftizoxime, cefuroxime), corticosteroids (dexamethasone), pulse oximetry, intubation if severe dyspnea

What is the most commonly encountered neck infection and what causes it

Ludwig angina

Strep, staph, bacteroides, fusobacterium

A pt comes in with ludwig angina, how do you treat

Secure airway, IV PCN, metronidazole, selective cephalosporins, CT with contrast, I&D via bilateral submental incissions

What are almost always the causes of laryngeal cancers

Tobacco and EtOH

A pt comes in complaining their voice has changed. They also have throat and ear pain, hemoptysis, dysphagia, weight loss and airway compromise. What should you do and what can you assume it is

Laryngeal cancer

Do CT or MRI PET for distant mets, laryngoscope by ENT, biopsy diagnostic (TMN staging)

Tx based on stage

How should you tx early glottic and supraglottic CA

Radiation

How should you tx advanced laryngeal cancer

Partial laryngectomy

How should you tx a very advanced tumor

Cisplatin-based chemoradiation tx

How should you tx a far advanced tumor of laryngeal cancer

Total laryngectomy, voice rehab, indwelling prosthesis, long term follow up

What are fun facts about parotid tumors

Generally the site of most salivary gland tumors and most are benign (if theres facial nerve involvement suspect malignancy)

Describe angioedema

Sudden swelling of face, palate, tongue, and airway

Other sxs include: Stridor, abdominal pain-bowel wall affected, lack of response to steroids

What are the two types of angioedema

Mast cell-mediated (allergic) and bradykinin-mediated (ACE inhibitor induced)