Clin Med Disorders of Oropharynx

odontogenic infection

bacterial infections that originate from teeth or supporting structures-may result in local or systemic complications

dental caries

destruction of tooth enamel caused by acid produced by bacteria

gingivitis

inflammation of the gums caused by plaque and tartar buildup, secondary to bacterial infection

periodontitis

chronic inflammatory condition that causes damage to the tissue and bone that support teeth

odontogenic infection clinical presentation

1-2 w of worsening dental pain, facial or neck swelling/pain, fever, malaise, decreased oral intake, odynophagia, trismus, hx of poor hygiene, facial paresthesias, ocular pain, diplopia, dyspnea, sialorrhea, purulent oral secretions

odontogenic infection- physical exam

erythema, edema, induration, tenderness, acute and tender cervical LAD, abscess

odontogenic infection- POCUS

abscess appears anechoic, occasionally loculated mass along bone cortex

odontogenic infection- CT w/ contrast

differentiates cellulitis from abscess

complex abscess formation or spread to deep neck spaces

when POCUS is suboptimal

odontogenic infection- flexible laryngoscopy

impending obstruction or edema necessitating need for urgent airway intervention

dental caries pathogen

strep mutans

dental caries clinical presentation

white spot, rough texture, cavitation, gingival bleeding

dental caries treatment/management

fillings, root canal for pulpitis, preventative care

gingivitis pathogens

strep, fusobacterium, actinomyces, veillonella, treponema

drug-induced gingivitis

phenytoin, CCBs, anticoags, fibrinolytics, OPCs, protease inhibitors, Vit A analogs

gingivitis treatment

good oral hygiene, mechanical debridement, chlorhexidine 0.12% oral rinse, augmentin +/- metronidazole, dietary supplements

if drug induced- stop/change offended med

periodontitis

progression of gingivitis, shift to gram - bacteria

periodontitis clinical presentation

gingival inflammation with bleeding, loss of gingival attachment, painless

periodontitis diagnostic workup

dental eval with periapical, bitewing, and/or panoramic xrays

treatment for severe periodontitis

amoxicillin or augmentin + metronidazole x14 days

PCN allergy: cephalosporin + metronidazole

or azithro, clarithro, or doxy if unable to take cephalosporin

mechanical debridgement

treatment for nonsevere periodontitis

topical abx formulation- 2% minocycline hcl microspheres, 10% doxy hyclate ER liquid, 0.5% clarithro gel, or chlorhexidine periodontal chips

scaling and root planing

cellulitis treatment

augmentin- 1st choice

pcn allergy- clindamycin

dental extraction of necrotic tooth

abscess treatment

needle aspiration, I&D, temp drain placement, culture

tooth extraction

abx- ampicillin-sulbactam (preferred), Pen G + metronidazole

PCN allergy- 2nd/3rd gen cephalosporin, levofloxacin, doxy, meropenem

IV therapy until improvement then change to oral

Ludwig angina

life-threatening cellulitis of the soft tissue of the floor of the mouth and neck

rapidly progressive and may lead to airway obstruction

Ludwig angina cause

dental infection in 2nd/3rd molars sublingual, submental, and submandibular compartments.

polymicrobial + and - (staph, strep, peptostrep, fusobacterium, bacteroides, actinomyces)

Ludwig angina risk fx

diabetes, oral malignancy, poor oral hygiene, dental caries, recent dental tx, malnutrition, alcoholism, immunocompromised

Ludwig angina S&S

recent dental pain, mouth pain, fever, fatigue, chills, weakness, trismus

tripod position, drooling, dysphagia, "hot potato voice", tongue swelling, bull neck, firm & swollen floor of mouth, restricted tongue mobility, restricted mouth opening

Ludwig angina diagnosis

clinical diagnosis, neck CT with contrast

Ludwig angina treatment

secure airway (flexible nasotracheal intubation preferred)

broad spectrum IV antibiotics- ampicillin-sulbactam or clindamycin

IV corticosteroids and nebulized epi

surgical drainage

aphthous ulcers

canker sores/ulcerative stomatitis

painful, round/oval, shallow sore that develops on the inside of the mouth

very common

aphthous ulcer subtypes

minor (1cm, heal in 10-14 days)

major (>1cm, may be disabling)

herpetiform

aphthous ulcer cause

unknown - possible link to herpes virus 6

triggered by stress, trauma, nutritional deficiences

aphthous ulcer S&S

single or multiple well-circumscribed, annular lesion

yellow-gray centers with red halos on buccal or labial mucosa

painful

spares hard palate and gingiva (differs from HSV)

aphthous ulcers treatment

usually resolve on their own

avoid irritants, topical steroid paste (triamcinolone 0.1% paste), oral steroid (prednisone), H2 blocker (cimetidine), "magic mouthwash"

HIV patients- thalidomide

magic mouthwash

contains anesthetic, antihistamine, antacid

may contain antibiotic, antifungal, steroid

herpes stomatitis

contagious viral infection of the mouth caused by HSV-1

spread from direct contact, droplets, lesions

children 6mo-5yrs MC affected

herpes stomatitis S&S

fever, sore throat, malaise, anorexia, pharyngeal erythema and edema

painful vesicular/ulcerative lesions on gingiva, palate, buccal, and labia mucosa that appear flat, yellowish, 2-5mm

heal within 2-3 weeks w/o scarring

herpes stomatitis treatment

topical acyclovir cream or oral acyclovir suspension

oral must start w/in 72hrs of onset

herpes labialis

cold sores

grouped vesicles w/erythematous base caused by secondary recurrent HSV-1

usually reoccur at the same site, mucocutaneous junction of lip MC

may follow stress, illness, sun exposure

herpes labialis treatment

valacyclovir 2000mg PO q12hr x1 day, acyclovir 200mg PO 5xday for 7-10 days ~within 24-48hr onset

suppressive therapy for frequent outbreaks- valacyclovir 500mg (1g if >10 outbreaks/year)

lysine

sunscreen

oral candidiasis

overgrowth on candida from oral flora

thrush

oral candidiasis risk factors

denture use, poor oral hygiene, dry mouth, DM, anemia, chemo, inhaled corticosteroids, abx use, immunocompromised, nursing babies

pseudomembranous oral candidiasis S&S

asymptomatic

if symptomatic- burning, bleeding, altered taste perception

white curd-like plaques that can be rubbed off leaving erythematous or bleeding base

tongue, labial and buccal mucosa, gingiva, palate, oropharynx

angular chelitis

painful, erythematous, fissured patches of commissures of the mouth; usually bilateral

usually candida overgrowth, can also be caused by s. aureus or strep

angular chelitis treatment

nystatin suspension 100,000 units/ml - 5mL PO four times a day

clotrimazole lozenge

fluconazole (avoid in 1st trimester of pregnancy)

2% miconazole cream for breastfeeding mothers

angular chelitis pt education

keep mouth angles dry, clean dentures with chlorhexidine, boil pacifiers and bottle nipples, rinse mouth after using inhaled corticosteroids

deep neck infection

local extension of infections in tonsils, pharynx, parotid glands, cervical lymph nodes, or odontogenic structures. Affects neck cervical spaces

life threatening

polymicrobial

deep neck infection S&S

may appear toxic

fever, neck pain, respiratory distress, neck swelling, dysphagia, dysphonia, trismus

divisions of cervical fascia

superficial- SQ neck tissue and platysma that envelops head and neck

deep- divided into superficial, middle, and deep layers

deep cervical fascia- superficial layer

submaxillary and parotid glands, trapezius, SCM, strap muscles

odontogenic and submandibular infections

deep cervical fascia- middle layer

pharynx, larynx, trachea, upper esophagus, thyroid, parathyroid glands

pharyngeal, tonsillar, laryngeal, and odontogenic (2nd/3rd molars) infection

deep cervical fascia- deep layer

"danger space"

covers vertebral column and muscles of the spine, continuity with the mediastinum

upper aerodigestive infections, retropharyngeal, vertebral, and prevertebral abscesses due to IV drug use

pharyngitis

inflammation of the mucus membranes of the oropharynx

MC in children <5yo

pharyngitis causes

viral (MC)

can also be bacterial, candida, environmental allergies, chemical exposures

acute viral pharyngitis

sore throat + other URI symptoms (cough, rhinorrhea, conjunctivitis, headache, rash)

treat with supportive therapy

acute streptococcal pharyngitis (GAS)

strep throat

caused by strep pyogenes (group A beta-hemolytic strep- GABHS)

accounts for 1 in 4 children w/acute pharyngitis

strep throat S&S

acute onset without signs of viral URI

sore throat, ear pain, temp >100.4, scarlatiniform rash, pharyngeal erythema, palatal petechiae, uvulitis, tonsillar exudates, cervical adenopathy

strep throat workup

RADT, throat culture (gold standard), modified centor scor

modified centor score

strep throat treatment

PCN V PO, PCN G IM (pcn is treatment of choice) or amoxicillin

PCN allergy: cephalosporins, macrolides, clindamycin

complications of untreated GABHS

scarlet fever, acute rheumatic fever, post-streptococcal glomerulonephritis

chronic carriers of GABHS

persistent presence w/o active infection

little risk for complications or transmission

indications for tonsillectomy in children

>/= 7 GAS infections in a year, >/= 5 episodes annually x2 years, >/=3 episodes annually x3 years

hx of peritonsillar abscess or multiple throat infections with multiple drug allergies

obstructed sleep-disordered breathing

parent education for children s/p tonsillectomy

manage pain w/NSAIDs or acetaminophen

pain will improve after 3-5 days and recur when scabs fall off around day 7

peritonsillar abscess

pocket of infection in peritonsillar space

complication of bacterial pharyngeal/tonsillar infection

peritonsillar abscess S&S

typically unilateral, severe sore throat, odynophagia, "hot potato voice"

unilateral swelling of soft palate, tonsil is medially displaced, uvula shifted to opposite side

peritonsillar abscess treatment

referral to ENT for needle aspiration and I&D

laryngitis

inflammation of the larynx

laryngitis etiology

URI, overuse, GERD, irritants

chronic laryngitis- consider GERD, vocal nodules, polyps

laryngitis clinical presentation

hoarseness, loss of voice, sore throat

not contagious unless due to URI

laryngitis treatment

rest voice, humidified air, home remedies, treat underlying cause

ENT referral for laryngoscopy if no resolution

epiglottitis

inflammation of the epiglottis and nearby structures caused by h. flu type B

rare

medical emergency

epiglottitis risk factors

3x more common in adults, men>women, middle aged, high BMI, DM, pneumonia, Sjogren syndorme, epiglottic cyst

epiglottitis symptoms

sudden onset of fever, dysphagia, drooling, sore throat, thick-muffled voice, stridor

epiglottitis physical exam findings

tripoding, retractions, labored breathing, cyanosis may be present, significant pain w/external palpation of larynx

do not attempt an oral eval with direct visualization -can exacerbate

epiglottitis management

ICU admit, examination using nasal fiberoptic endoscope, thumb sign on xray, emergency airway/trach tray on standby

epiglottitis treatment

IV cefotaxamine 2g q 6h or ceftriaxone 1-2g/day

IV corticosteroids (debated)

close observation

acute bacterial sialadenitis

bacterial infection of the salivary gland, MC in parotid

S aureus MC

occurs w/stasis of salivary flow from dehydration or decreased oral intake

acute bacterial sialadenitis risk factors

DM, hypothyroidism, renal failure, Sjogren's syndrome, anticholinergic meds, stones or duct strictures

acute bacterial sialadenitis S&S

acute onset of pain and swelling of the affected gland

induration, edema and extreme localized tenderness, unilateral

diagnosis of acute bacterial sialadenitis

massage gland to express purulent drainage and culture

CT scan

acute bacterial sialadenitis treatment

warm compress, increased oral intake, sialagogues (lemon drops), gland massage

severe cases- IV nafcillin 1g

less severe cases- oral augmentin 875mg

resolution 2-3 weeks

I&D if abscess formation

acute non-suppurative sialadenitis

inflammation of the salivary glands not secondary to bacterial infection

MC cause is Mumps

85% cases are 15yo and younger

acute non-suppurative sialadenitis S&S

local pain, edema, otalgia, trismus, commonly bilateral

acute non-suppurative sialadenitis diagnosis and treatment

viral serology

supportive treatment

vaccine has reduced incidence by 99%

chronic sialadenitis

repeat episodes of pain and inflammation, MC in parotid gland

caused by decreased salivary flow or stasis from stone, stricture, scar tissue, tumor compression

chronic sialadenitis presentation and diagnosis

less severe than acute

CT scan to identify underlying cause

chronic sialadenitis treatment

treat underlying cause

if no cause found, treat with sialagogues, hydration, massage, NSAIDs

excision can be effective

sialolithiasis

formation of stone in the duct system, usually in submandibular gland (Wharton's duct)

sialolithiasis clinical presentation

postprandial salivary pain and swelling, may have hx of recurrent acute sialadenitis

sialolithiasis diagnosis

bimanual palpation along course of Wharton's duct may reveal stone

CT showing large radio-opaque stone

sialolithiasis treatment

sx removal of stone, lithotripsy, gland excision

oral leukoplakia

persistent, adherent white plaque of the oral mucosa that cannot be rubbed off; results from a disturbance of surface epithelium

most are idiopathic, 2-6% are early SCC

increases risk of esophageal SCC

oral leukoplakia risk factors

chewing tobacco, smoking, excessive alcohol, poorly-fitting dentures, trauma to cheeks

oral leukoplakia diagnosis

ENT eval with biopsy

must rule out other causes (fungal, neoplasm)

oral leukoplakia treatment

discontinue tobacco/alcohol, avoid triggers, close f/u on small lesions, sx excision, cryotherapy ablation or CO2 laser ablation

oropharyngeal trauma

wounds to hard and soft palate, tonsils, and posterior pharyngeal walls

commonly involves a young child falling with an object in the mouth

complications of oropharyngeal trauma

ICA injury- compresses ICA against lateral process of cervical vertebra causing intimal tear

deep neck space infection

GSW or air bag deployment with object in mouth may have

penetrating neck injuries

if you see focal neuro changes with oropharyngeal trauma think:

ICA injury

symptoms of deep neck infection 24hr after oropharyngeal trauma

fever, neck pain, torticollis, drooling