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Oropharyngeal Infections/Inflammatory disorders

Aphthous ulcers (Canker sore)

• Round ulcer on oral mucosa
• Unknown etiology

Clinical Presentation

• Small open sore in the mouth
• The sore is yellow or white

Labs, Studies and Physical Exam Findings

• Clinical diagnosis

Treatment

• Self limiting
• ½ hydrogen peroxide or chlorhexidine mouthwash
• Corticosteroids

Oral candidiasis (Thrush)

• Yeast infection of the mouth
• 50% of humans have candida in the oral cavity

Risk Factors

• Newborns
• Uncontrolled Diabetes
• HIV/AIDS
• Chemotherapy
• Side effect of inhaled steroids
• Side effect of antibiotics
• Dentures or poor hygiene

Clinical Presentation

• White fluffy patches on the tongue or in the mouth
• Varying degrees of discomfort
• Painful eating or swallowing

Labs, Studies and Physical Exam Findings

• Lesions can be scraped off and may bleed
• Potassium hydroxide wet mount of scrapings show pseudohyphae

Treatment

• Address underlying cause
• Antifungal topical agents
  • Clotrimazole
  • Miconazole
  • Nystatin
• Oral antifungals
• Fluconazole 100mg x 7 days for non-immunocompromised patients

Oral leukoplakia

White patches which cannot be diagnosed as anything else

Cause

• Often associated with tobacco use
• Alcohol and smoking
• HPV

Clinical Presentation

• White plaque on the oral mucosa
• Often found on routine exam

Labs, Studies and Physical Exam Findings

• White adherent plaque
• Biopsy

Treatment

• Remove offending agents
• Monitor closely as this is a premalignant condition

Epiglottitis

• An inflammation of the epiglottis
• Epiglottis is the tissue that prevents food from entering trachea
• May become a life threatening emergency secondary to obstruction

Cause

• Viral infection
• Bacterial infection
  • Haemophilus influenzae – significantly less common likely due to vaccination

Clinical Presentation

• High fever
• Sore throat
• Difficulty moving air
• Difficulty swallowing
• Drooling
• Patient prefers tripod position

Labs, Studies and Physical Exam Findings

• Stridor – a high pitched breath sounds usually heard with inspiration
• Cyanosis
• Direct visualization with laryngoscopy in OR as it may cause spasms
• Throat culture
• X-ray – Thumbprint sign on c spine film
• CT

Treatment

• Be prepared for intubation
• Keep patient calm and breathing easily
• Antibiotics may be necessary
  • Ceftriaxone

Herpes Simplex (Cold Sores)

• Herpes simplex virus type 1 and type 2 are the main culprits here. It is often said that type 1 is oral herpes and type 2 is genital, but they overlap to a significant degree.
• Transmitted through close contact with a person who is shedding the virus
• Shedding may occur even if lesions are not visible
• Once infected the virus remains in the nerve cells and cycles through active and dormant phases

Risk factors for reactivation

• Sunlight
• Fever
• Stress
• Immunosuppression

Clinical Presentation

• Recurrence may be preceded by neuralgic symptoms including burning and itching
• Small groups of painful vesicles
• Typically found at the vermilion border (cold sore) or gential area
• Variations and Complications
  • Herpetic Whitlow – infection of the fingers
  • Herpes keratitis – eye infection
  • Herpes encephalitis – CNS infection
  • Neonatal infection – Active herpes infection in the mother is an indication for a c-section

Labs and Studies

• Generally a clinical diagnosis
• Stains of vesicles will show multinucleated giant cells
• Antibody test is available

Treatment

• No true cure
• Typically self limiting
• Topical antiviral 5% acyclovir
• Oral antiviral
  • acyclovir
  • valacyclovir
• Tylenol and ibuprofen

Laryngitis

An inflammation of the larynx or vocal chords

Cause

• Often an infectious cause (think upper respiratory infection)
• Viral
  • Rhinovirus
  • Adenovirus
  • etc.
• Bacterial
  • Group A Strep
• Noninfectious causes
  • Over use
  • Acid reflux
  • Allergies
  • Trauma including smoking etc.

Clinical Presentation

• Hoarseness
• Fever
• Swollen glands
• Cough
• Cold and flu symptoms

Labs, Studies and Physical Exam Findings

• Usually clinical diagnosis
• Laryngoscopy may be helpful in chronic patients

Treatment

• Resting the voice
• Humidifying the air
• Fluids
• Treat for GERD if appropriate
• Antibiotics if appropriate

Acute pharyngitis

• Diagnosis of acute pharyngitis is a straightforward diagnosis. The difficulty comes in determining the causative agent.

Causes

• Viral infection
  • Epstein barr – mononucleosis
  • Herpes
  • Cold viruses
    • Adenovirus
    • Rhinovirus
    • RSV
• Bacterial infection
  • Strep pneumonia
    • The most common bacterial cause of acute pharyngitis however this only accounts for between 15 and 30% of sore throats
  • Neisseria gonorrhoeae
  • Mycoplasma
  • Chlamydia

Clinical Presentation

• Sudden onset
• Fever/chills
• Difficulty swallowing
• Tender, swollen throat
• No cough
• Typically younger than 15 years old for group B strep.

Labs, Studies and Physical Exam Findings

• Tender anterior cervical adenopathy for group B strep
• Tender posterior cervical or generalized adenopathy for mononucleosis
• Purulent exudate in pharynx
• Shaggy white tonsillar exudate think mono
• Throat culture – 90-95% sensitive for Stre
• Rapid antigen test is 90-99% effective for strep

Treatment

• Symptomatic treatment
• NSAIDS or tylenol
• Fluids
• Appropriate antibiotic treatment
• Strep –
  • Penicillin BID
  • Amoxicillin TID

Peritonsillar abscess

An abscess near the tonsils

Cause

• Most commonly secondary to tonsillitis (think pharyngitis)

Clinical Presentation

• Severe, one sided sore throat
• Odynophagia – difficulty swallowing – drooling
• Hot potato voice
• Fever
• Tender glands – pain in head and neck
• Trismus – difficulty opening the mouth

Labs, Studies and Physical Exam Findings

• Erythematous pharynx
• Uvula displaced towards unaffected side
• Ultrasound
• CT with contrast

Treatment

• Needle aspiration
• Incision and drainage
• Tonsillectomy
• Antibiotic therapy
  • Clindamycin