Mouth & Throat (Exam 2)

Basic Tooth Anatomy

-Enamel

-Crown

-Dentin

-Pulp

-Root

-Periodontium

-Gingiva

Most common childhood disease and cause

-Dental Caries

-S. Mutans

Gingivitis

-Reversible inflammation of gingiva due to plaque & can progress

Periodontitis

-Caused by chronic inflammation of gingiva & support tissue by Gram (-) bacteria

-If present in pediatrics, consider systemic disease such as DM, Down syndrome, leukemia, histocytosis

-Presents as interdental papillae edema, erythema and bleeding; tartar build up

-Education on prevention is key!

Treatment of Periodontitis

-Chlorhexidine mouthwash

-Professional dental care

-Periodontal surgery

Oral Pain

-Majority is related to inflamed or injured tooth pulp or periodontal disease

Non-dental oral pain

-Myofascial pain

-Bruxism (grinding of teeth)

-Temperomandibular joint disorder

-Osteoarthritis

-RA

-Trigeminal neuralgia

-Glossopharyngeal neuralgia

-Bell's palsy

-Herpes Zoster

-Maxillary sinusitis

Treatment of Dental/Oral Pain

-NSAIDs

-Consider Narcotics sparingly

When are ABX indicated for an Oral infection?

-When fever, lymphadenopathy, progressing disease, or IC

What ABX are indicated for Oral pain?

Amoxicillin, Augmentin, Clindamycin, doxycyline

Leukoplakia

-Caused by Hyperkeratosis related to chronic irritation

-Small % are dysplastic or early SCC

-MC in middle aged & older men

-CX: White lesion on mucosa; can NOT be rubbed off; can be small

-DX: Punch biopsy

-TX: excision

Hairy Leukoplakia

-Most prevalent in HIV pts; ALSO s/p organ transplant

-Associated with EBV & long term corticosteroid use

-Slightly raised areas develop rapidly on lateral border of tongue with "Hairy" surface

-Waxes and wanes, moderately irritative

-Acylovir/Valacyclovir for temp relief

Treatment of Hairy Leukoplakia

-Acyclovir or Valcyclovir

Erythroplakia

-Related to hyperkeratosis related to chronic irritation

-Most often associated with tobacco & alcohol use

-90% transform into malignancy

-MC in older pts

-CX: "Fiery" red, well demarcated lesions of mucosa; may be flat/depressed; smooth or granular

-DX: Biopsy

-TX: excision with clear margins

Oral Lichen Planus

-Uncommon autoimmune condition related to chronic inflammation

-Occurs in middle-aged and elderly women

-Associated with Hep C

-CX: Reticular, atrophic, bullous; MC on buccal mucosa, tongue, and gingiva, occurs bilaterally; Whickam striae, painful/burning; associated with dermal form

-Dx: punch biopsy, direct immunoflouresence

-Tx: clobetasol daily (or cyclosporines, retinoids, or tacromilus)

Diagnosis of Oral Lichen Planus

-Punch biopsy or direct immunofluorescence

Treatment of Oral Lichen Planus

-Topical mid/high potency corticosteroids (Clobetsol); Cyclosporins; Retinoids; Tacrolimus

Oral Cancer

-Epidemiology: 2-3% of all cancers in US

-Etiology: SCC; HPV accounts for 26-70% of cases; tobacco and ETOH use. MC in younger white men.

-CX: MC on tongue, lips, floor of mouth; most are advanced as diagnosis

-DX: biopsy non-healing white or red lesions. CT/MRI to see extent of disease

-TX: chemo, surgery, radiation

Diagnosis of Oral Cancer

-Biopsy any non-healing white or red lesions present >2weeks

-CT or MRI for extent

Treatment of Oral Cancer

-Chemotherapy, surgery

-Radiation based on severity/extent

Oral Cavity Squamous Cell Carcinoma

-High suspicion for raised, firm, white lesions with ulceration

-Lesions <4mm are unlikely to metastasize

-TX: Lesions <2cm in Diameter tx with local resection; large= resection, neck dissection, and external beam radiation; radiation indicated for (+) margins or metastatic disease

Oropharyngeal SCC

-Presents later, lesions are deep in lymphoid tissue or tonsils

-Associated with tobacco, alcohol, and HPV

-Worse prognosis if tobacco/alcohol related

-Unilateral odynophagia, weight loss

-PE: may reveal ipsilateral lymphadenopathy

Necrotizing Ulcerating Gingivitis

-"Trench Mouth"

-Destruction of periodontium

-Associated with poor dental hygiene, emotional stress, tobacco use, IC state

-Caused by Fusobacterium & Spirochetes

-Pt presentation: Fever, malaise, lymphadenopathy; foul breath; metallic taste

-CX: Painful, edematous papillae; Ulcers with overlying pseudomembrane; gingiva is inflamed, friable, and necrotic

Treatment of Ulcerating Gingivitis

-Warm peroxide or chlorhexidine rinses

-Topical & oral analgesia

-PCN TID x 10 days

Aphthous Ulcer

-HHV6; associated with stress

-Occur on buccal mucosa

-Can be single or multiple, recurrent

-CX: Small, round ulceration with yellow/gray fibrous center; surrounded by red halo; Painful

Treatment of Aphthous Ulcers

-Diclofenac 3%

-Cimetidine for recurrent

-Prednisone taper x 1week

Herpes Stomatitis

-Common and mild in IC; NO TX needed

-Burning, small vesicles that rupture and scab

-Found on lips, tongue, buccal mucosa, soft palate

-Presentation: Painful ulceration, fever, lymphadenopathy

Treatment of Herpes Stomatitis

-Acyclovir 5x daily x 7-10 days

-Valcylovir BID x 7-10 days

Viral Pharyngitis

-MC is Rhinovirus; also coronavirus, adenovirus, HSV, Parainfluenza

-CX: Sore throat; Cough; Rhinorrhea

-CX findings: Vesicular or petechial patterns of soft palate; cervical lymphadenopathy

Diagnosis of Viral Pharyngitis

-No testing required except in Influenza, mono, or acute retrovrial syndrome are suspected

Treatment of Viral Pharyngitis

-Symptomatic

-NSAIDs, rest

-IV fluids if too dehydrated

Bacterial Pharyngitis

-Associated with Group-A Beta Hemolytic Strep (GAHBS), Neisseira Gonorrhea, Mycoplasma, Chlamydia Trachomatis

-Presentation: CENTOR criteria; Cervical adenopathy, Exudates, NO cough, Temperature, Age

-DX: Rapid Antigen; Throat culture

Streptococcal Bacterial Pharyngitis Tx

-TX: 1st line is PenVK 500 mg BID x 10 days

-Cephalexin; Azithromycin

-Supportive: Analgesics; Fluids

Scarlet Fever

-Complication of strep pharyngitis

-Caused by pyogenic streptococcal exotoxins

-Scarletina erythematous rash with fine red papules "Sandpaper" rash

-Starts on trunk, spreads to extremities; Spares palms and soles

-Most severe in groin

-Blanches with pressure

-Circumoral pallor

-Fades in 2-5 days

-"Strawberry tongue"

-TX: Supportive, PCN

Post-Streptococcal Glomerulonephritis

-Complication of Strep Pharyngitis

-Caused by nephritogenic strains of GABHS, immune-mediated process

-Onset 1-3 weeks after pharyngitis

-More common in children/elderly

-Presentation: Hematuria, Dysuria, Edema, HTN, Renal failure, HA, Malaise, Anorexia, Flank pain

-DX: ASO titers; Anti-DNAse; Anti-hyaluronidase Ab; Biopsy

-TX: Supportive; Control HTN, edema; Hemodialysis prn; ABX (PCN)

Rheumatic Fever

-Complication of Strep Pharyngitis

-Systemic immune response to beta-hemolytic strep

-Possibly due to similar surface antigens between strep and human proteins

-Onset: 2-3 weeks after pharyngitis

-MC in children 5-15 yrs old

-Most often affects Mitral Valve (75-80%), less often aortic valve (25%)

-CX: Carditis, Arthritis, Chorea, Subcutaneous modules, Erythema marginatum

-DX: Jones Criteria (2 major OR 1 major + 2 minor)

Treatment of Rheumatic Fever

1.2 million units of IM PCN once

-Bed rest, NSAIDs; PCN or Erythromycin if PCN allergic

-Corticosteroids for joint pain if not responsive to salicylates (prednisone)

-Prevention: Early tx of strep pharyngitis; prophylaxis is PCN G

Gonococcal Pharyngitis

-Neisseria gonorrhea infection transmitted via oral sex & occurs simultaneously with genital gonorrhea

-Asymptomatic or with sx: Sore throat, pharyngeal exudates, lymphadenopathy

-DX: Culture or NAAT

-TX: Single dose of Ceftriaxone 1g IM

Glossdynia

-Benign; Burning painful tongue

-With glossitis: DM, drugs, tobacco, candidiasis

-If no cx findings: "Burning mouth syndrome" tx with Alpha-lipoic acid or Clonazepam; behavioral therpay

Glossitis

-Absence of filiform papillae

-Smooth, red tongue

-Rarely painful

-Nutritional deficiencies, drug rxs, dehydration, irritants, foods/liquids, autoimmune

-TX: ID underlying cause; empiric nutritional replacement therapy

Oral Candidiasis

-Colonization of mucosal epithelium

-Occurs s/p ABX use, corticosteroid, head/neck radiation

-Common in very young, and IC, chronic irritation also

-CX: Erythematous mucosa; creamy white curd-like plaques; may have pain; easily rubbed off

-DX: Clinical

Treatment of Oral Candidiasis

-Oral: Fluconazole, clotrimazole, nystatin mouth rinse

-HIV pts- longer tx with variconazole

Peritonsillar abscess

-Spreading infection beyond tonsillar capsule

-Most often strep, may be multimicrobial w/anaerobes. can progress into quincy abcess.

-Presentation: Fever, Severe sore throat, Odynophagia, Trismus, Muffled "Hot potato" Voice

-CX: Erythema; medial deviation of soft palate; deviated uvula

-TX: Amoxicillin, augmentin, clindamycin. Supportive measures- Needle aspiration, I&D, tonsillectomy

Retropharyngeal Abscess

-Complication of peritonsillar abscess

-Preceeded by URI, tonsillitis, pharyngitis, otitis media, or wound

-Most common GAHBS, S. Aureus, MRSA, Hib, respiratory anaerobes

-CX: Fever, Sore throat, excessive drooling, voice change, neck stiffness

-CX findings: Midline edema of posterior pharynx; tender anterior cervical adenopathy; decreased cervical ROM

Diagnosis of Retropharyngeal Abscess

-Lateral neck x-ray will reveal edema

-CT with contrast is gold standard

Treatment of Retropharyngeal Abscess

-Assess airway!

-ASAP: Clindamycin or Ampicillin-sulbactam IV

-IV hydration

-Needle aspiration; ENT consult

Ludwig Angina

-Spreading cellulitis of submandibular and sublingual spaces from mandibular molars

-MC Strep, Staph, bacteroides

-MC in males, ages 20-60 yrs

-CX: Fever, odynophagia, dysphonia

-CX findings: Painful, brawny edema & induration of tissue Bilaterally; poor dental hygiene; trismus

Diagnosis of Ludwig Angina

-CT or MRI

Treatment of Ludwig Angina

-Airway mangement

-IV ABX x 2-3 weeks: Ampicillin-sulbactam or ceftriaxone; clindamycin with levoflaxacin (PCN allergic); add vanco or linezolid for MRSA

-Analgesia

-IND; ICU admission for airway surveillance

-Complications: Acute laryngospasm & airway compromise

Complications of Ludwig Angina

-Acute laryngospasm & airway compromise

Sialadenitis

-Caused by obstructed duct

-MC pathogen is S. Aureus

-MC affects parotid gland

-Often occurs in dehydration & chronic illness

-CX: Acute swelling; pain with eating; tender & erythematous duct opening

-CX Findings: Erythema of skin; pain; trismus; induration

Diagnosis of Sialadenitis

-Clinical

-CT or US if unresponsive to ABX

Treatment of Sialadenitis

-IV Nafcillin q4-6h x 48 hrs then po PCN x 10 days

-Hydration, warm compress

Complications of Sialadenitis

-Suppurative

-Present with fever

-Often don't respond to hydration & IV ABX

-Require operative IND

Sialolithiasis

-Stone formation in Wharton (Larger) or Stenson duct (smaller)

-Occur in dehydration, chronic disease

-CX: Postprandial pain; swelling of gland; gritty FB in mouth

-CX Findings: Induration of floor of mouth; may palpate stones near orifice

Diagnosis of Sialolithiasis

-Sialography, CT, US; endoscopy

Treatment of Sialolithiasis

-Intraoral extraction

-Surgical Excision

-Endoscopy

Dysphonia/Hoarseness

-Abnormal vibration of vocal chords

-Breathy: Unilateral paralysis

-Harsh: Laryngitis, malignancy

-Rough: edema of chords

-High pitched: Narrow airway above chord

-MC cause is Viral laryngitis

Diagnosis Dysphonia/Hoarseness

-History is central!

-Sx present for >2 weeks must be evaluated

-Tobacco use is concerning or lung cancer

-Other HEENT sx

Treatment of Dysphonia/Hoarseness

-REFER to ENT!

-Treat underlying disorder

-Voice rest

-Medication: ABX, Glucocorticoids, anatacids, NSAIDS

-Surgery

Laryngitis

-Acute is MC

-Chronic is rare and bacterial (TB, Candida, Crypto)

-Most often is Viral (M. Catarrhalis & Hib)

-Presents with hoarseness & URI sx

-CX: Diffuse laryngeal edema, vascular engorgement of vocal cords

Treatment of Laryngitis

-Voice rest

-Humidification

-ABX NOT indicated

Epiglottitis

-Medical Emergency!

-Caused by Hib, now GAHBS, S. Pneumo, H Parainfluenza, S. Aureus

-CX: Rapid sore throat; Odynophagia; high fever; tachycardia; drooling; stridor; "tripoding"

-CX Findings: Respiratory distress; signs of systemic toxicity; normal pharyngeal exam

Diagnosis of Epiglottitis

-Clinical findings

-Laryngoscopy in OR: cherry red epiglottis

-Lateral neck x-ray: enlarged "Thumbprint sign"

-Blood cultures

Treatment of Epiglottitis

-Secure Airway!

-IV ABX: Ampicillin-sulbactam, cefotaxime or ceftriaxone; vancomycin if MRSA; Clindamycin or bactrim for PCN allergy

-Admit to ICU

SCC of Larynx

-Epidemiology: MC malignancy of larynx; exclusive to tobacco users; common in men 50-70 yrs old

-CX: Hoarseness is MC; throat or ear pain; hemopytsis; dysphagia; weight loss; stridor

Diagnosis of SCC of Larynx

-Imaging: CT or MRI

-Biopsy via laryngoscopy

Treatment of SCC of Larynx

Radiation is standard

-Partial laryngectomy may be considered

-Chemotherapy with cisplastin and radiation for advanced stage

Neck masses

-DX depends on location; age; & associated disease

-CX: Tender with rapid growth; firm, painless, slow growth, malignant process

-If pts uses tobacco or alcohol, consider metastasis from oral/oropharyngeal/laryngeal CA

-Suspect lymphoma if <30 or >70

-Types: Congenital, inflammatory, tumor associated

Branchial Cleft Cyst

-Congenital neck mass

-Soft cyst along anterior border of SCM

-Common in 2nd-3rd decades

-May have abrupt edema and infection

-Tx: Excision

Thyroglossal duct cyst

-Midline mass, below hyoid bone, mobile with swallowing

-Common <20

-TX: excision

Reactive Cervical Lymphadenopathy

-Infectious/Inflammatory neck masses

-Persistent enlargement of LN s/p infection

-LN>1.5 cm (increased suspicion with tobacco/etoh use)

Granulomatous Mass

-Infectious & inflammatory mass

-Mycobacterium, sarcoides, cat-scratch disease

-Single or matted LN

-FNA bx with PCR or excisional Bx

Lyme Disease Mass

-Infectious & Inflammatory neck mass

-Often presents with cervical lymphadenopathy, HA, pain, facial paralysis

Malignancy Causing Neck masses

-Majority of fixed, firm, persistent, enlarging masses are metastatic in older patients

-Most often malignant SCC of head/neck that metastasize to cervical lymph nodes

-Lung, GI, and breast tumors metastasize to supraclavicular nodes

-DX: laryngoscopy, esophagoscopy, bronchoscopy, cytology if scopy fails

-10% present in neck: Rubbery nodes, MC in young or AIDS pts; bx required

Snoring

-Occurs in 60% people

-narrowing or upper airway

-Varies from simple without obstruction to severe obstructive apnea

-CX: Palate may be enlarged with excess mucosa hanging below soft palate

-DX: Recommend polysomnography to eval for OSA

-TX: Diet & Exercise; modification of position; CPAP; surgical correction