Oropharynx Disorders Evaluation & Management PDF

Part 9 Evaluation and Management of Oropharynx Disorders  Dental Abscess (Chapter 79, Slide 1 of 2) Abscess found in the tissues around the tooth, result of infection by normal oral flora in a carious tooth or as a result of traumatized gingival mucosa Causative organisms Fac...

Part 9 Evaluation and Management of Oropharynx Disorders  Dental Abscess (Chapter 79, Slide 1 of 2) Abscess found in the tissues around the tooth, result of infection by normal oral flora in a carious tooth or as a result of traumatized gingival mucosa Causative organisms Facultative anaerobes: Streptococcus anginosus and viridans groups Prevotella and Fusobacterium Presenting symptoms Localized pain, edema, erythema, and purulent discharge from the affected site Abscess region Heat sensitive and friable The tooth may be partially elevated out of the socket. The pain responds poorly to analgesic agents. Advanced infection Fever and lymphadenitis  Dental Abscess (Chapter 79, Slide 2 of 2) Exam and diagnostics A detailed history of pain, symptoms, and previous dental care Thorough oral exam Inspection of teeth, gingiva, sinuses, and facial sinuses Diagnostics are based on oral exam and may include CBC and/or X-ray (not reliable). Management I&D of periapical abscess Referral to dentist Extraction or root canal Antibiotics American Dental Association recommends against antibiotic use for immunocompetent adults with localized infection and without significant risk for spread Penicillin/clindamycin are first line Macrolide antibiotics (alternative) If known resistance in the area, then choose amoxicillin/clavulanate.  Discussion Question 1 Discuss management of dental abscesses. When are antibiotics indicated?  Diseases of the Salivary Glands (Chapter 80, Slide 1 of 3) Noninfectious salivary gland disorders Recurrent parotitis, sialolithiasis (salivary gland stones), branchial cleft anomalies, Sjögren syndrome (SS), xerostomia, ptyalism (hypersalivation), sialosis, and benign lymphoepithelial lesion of Godwin Radiotherapy (RT) and drug therapy—Xerostomia (dry mouth) Drug treatments (atropine)—Ptyalism (excess saliva) Alcoholism, metabolic disorders such as diabetes and various vitamin deficiencies, obesity, and malnutrition also can initiate enlargement of the salivary glands Phenothiazines, heavy metals, thiourea, and iodide-containing substances can cause salivary gland enlargement. Infectious Mumps parotitis, other viral infections, syphilis, HIV infection, and granulomatous diseases including tuberculosis, sarcoidosis, cat-scratch disease, uveoparotid fever (Heerfordt syndrome), and actinomycosis Benign tumors Malignant tumors  Diseases of the Salivary Glands (Chapter 80, Slide 2 of 3) Presenting symptoms depend on cause. Noninfectious entities Painless salivary gland swelling Exception: Sialolithiasis, painful edema of the affected gland and increased symptoms with meals Sjögren’s syndrome Commonly seen in women 40 to 60 years of age, associated with connective tissue diseases such as rheumatoid arthritis, polyarteritis nodosa, and systemic lupus erythematosus Benign or malignant mass Usually painless, slow-growing, and unilateral  Diseases of the Salivary Glands (Chapter 80, Slide 3 of 3) Exam Thorough history and physical exam HEENT exam Visual inspection of head, mouth, and neck Note gland edema (bilateral/unilateral) Facial paralysis (malignant sign) Intraoral inspection of duct orifices for obstruction Diagnostics X-ray MRI Ultrasound fine-needle aspiration or core Bx Cultures, viral titers (mumps), autoimmune studies: RF, ANA, SSA, SSB Management Conservative approach Pain management Hydration Surgery (recurrent parotitis) Sialolithiasis (warm compresses, analgesics, and sialagogues—e.g., lemon ball candies) Referral Recurrent or chronic symptoms, suspected neoplasm or salivary stone, infection or swelling that is unresponsive to treatment and complications from infection  Epiglottitis (Chapter 81, Slide 1 of 3) Epiglottitis (supraglottitis) Acute inflammation of the supraglottic region of the oropharynx characterized by inflammation and edema of the epiglottis, vallecular, arytenoids, and aryepiglottic folds A rare but serious life-threatening condition due to the potential for laryngospasm and irrevocable loss of the airway Infectious causes Most common cause of bacterial epiglottitis is group AB-hemolytic Streptococci (previously Haemophilus which is now decreased due to vaccinations). Other causes: H. influenzae type A, groups A and C streptococci; Streptococcus pneumoniae; Klebsiella pneumoniae; Candida albicans; Staphylococcus aureus; Haemophilus parainfluenzae; Neisseria meningitidis; varicella-zoster virus; and various other viral pathogens and possibly COVID-19  Epiglottitis (Chapter 81, Slide 2 of 3) Noninfectious causes Inflammation due to thermal injury (crack cocaine and marijuana smoking) Ingestion of caustic substances (automatic dishwashing detergent) Systemic disease (diabetes mellitus, hypertension, obstructive pulmonary disease, seizure disorder, alcohol and drug abuse, tobacco smoking) Chemotherapy for head and neck cancer Trauma by foreign objects Burns associated with bottle-fed infant formula Clinical presentation Severe odynophagia, shortness of breath with sitting up and leaning forward in an effort to enhance air flow, inability to swallow one’s secretions, stridor are common signs of epiglottitis in children, odynophagia, dysphagia, and voice change are common presenting symptoms in adults, cough, drooling, stridor, respiratory distress, hoarseness, dyspnea , neck tenderness, lymphadenopathy, dysphagia, and fever.  Epiglottitis (Chapter 81, Slide 3 of 3) Physical exam Adults: Anterior neck tenderness with severe sore throat Signs of respiratory distress May not have fever and a toxic appearance. Direct visualization via laryngoscopy with a flexible fiberoptic scope or a laryngeal mirror Indirect laryngoscopy Erythematous, edematous epiglottis with a narrow glottic opening Substernal and supraclavicular retractions, tachycardia, tachypnea, and inspiratory stridor are common Diagnostics Ultrasound Lateral neck X-ray (useful; not diagnostic) CBC, blood cultures Management Hospitalization in the intensive care unit for aggressive airway monitoring IV antibiotics, short course of steroids Urgent otolaryngology consult Surgery if abscess is present Isolation is sometimes recommended for the first 24 hours after the initiation of antibiotic therapy. Influenza vaccination for prevention  Discussion Question 2 Discuss the causes and management of epiglottitis. When is an urgent otolaryngology referral indicated?  Oral Infections (Chapter 82, Slide 1 of 3) The most common oral infections Candidiasis, herpes labialis, and recurrent aphthous stomatitis Sources of infection Herpes labialis: HSV1 Gingivitis (most commonly associated with bacterial overgrowth) Candidiasis: Fungal C. albicans Aphthous ulcers: Autoimmune, physical, chemical, or local agents Emotional stress Vitamin B12, folic acid, or iron deficiencies Familial or genetic predisposition Microbial agents Hypersensitivity states such as gluten-sensitive enteropathy  Oral Infections (Chapter 82, Slide 2 of 3) Herpes simplex—Prodromal set of symptoms that include fever and headache, localized pain, tingling, and burning with erythema. HPV infections manifest as white, verrucous lesions individually or in clusters. The lesions can be found on the lips, hard palate, or gingiva. The candidal infection, thrush, usually appears as white, cottage cheese-like lesions that are easily removed with a swab and are most commonly found on the palate, tongue, oral mucosa, or oropharynx. Gingivitis manifests as an inflammation of the gingiva, possibly with areas of ulceration with or without purulent discharge from the affected areas. Patients typically report bleeding with eating (hard food such as chips and crusty breads) or tooth care. Aphthous ulcers are painful, shallow ulcerations of the nonkeratinized oral mucosa and occur as solitary or multiple lesions. A prodrome of burning or pricking of the oral mucosa has been reported.  Oral Infections (Chapter 82, Slide 3 of 3) Diagnostics Herpes simplex Physical exam findings; excisional biopsy and pathologic evaluation provide definitive diagnosis Tzanck smear Serum antibody titers Candidal infections Physical exam findings and appearance Microscopic exam of oral scrapings will reveal the classic findings of hyphae. Gingivitis Based on physical exam findings and presentation Aphthous ulcer Based on physical exam and presentation and other labs, including CBC and Tzanck smear Management HSV—Oral and/or topical (immunocompromised patients) valacyclovir, hydration, analgesia, antipyretic and nutrition Oral papillomas—Excision Candidal Infection—Antifungals (nystatin) Gingivitis—Oral hygiene Aphthous stomatitis—Topical steroids (triamincolone in Orabase)  Parotitis (Chapter 83, Slide 1 of 2) Parotitis: An inflammatory reaction of the parotid gland that may be caused by bacterial, viral, fungal, or mycobacterial invasion. Clinical presentation Localized pain, edema, induration of the infected gland, fever, chills, anorexia, malaise Intraorally, pus can be visualized with manual pressure on the parotid duct orifice. Inflammatory conditions caused by tuberculosis appear like a malignant neoplasm.  Parotitis (Chapter 83, Slide 2 of 2) Physical exam Bimanual palpation of the gland with attention to the Stensen duct Palpation of the gland elicits a suppurative discharge from the Stensen duct. Bilateral edema suggested viral infection. Suppurative discharge should be cultured. Diagnostics CBC with differential, culture and sensitivity X-ray studies, CT scan with contrast, ultrasound, MRI Management Parenteral antibiotics Antibiotic choices Amoxicillin/clavulanate Dicloxacillin Clindamycin Cephalosporin w/metronidazole Possible hospitalization Surgical drainage Poor prognosis with postoperative patients  Pharyngitis and Tonsillitis (Chapter 84, Slide 1 of 3) Pharyngitis Encompasses noninfectious or infectious inflammation of the pharynx from either infection or irritation Tonsillitis An acute or chronic inflammation of the tonsils and usually results from GAS infection. Clinical presentation Symptoms vary according to the offending agent. Bacterial: Sore throat and dryness; if environmental allergens are the cause, symptoms often include rhinorrhea, watery eyes, and postnasal drip. Viral: Sudden onset of a sore throat, fever, malaise, cough, headache, myalgias, and fatigue; tender/painful lymphadenopathy usually not present. GAS: More acute symptoms with lymphadenopathy and exudates Immediate emergency department referral or physician consultation is indicated for pharyngeal abscess.  Pharyngitis and Tonsillitis (Chapter 84, Slide 2 of 3) Physical exam Fever, cough, nasal symptoms, mild erythema Painful or tender lymphadenopathy is not typically present. GAS symptoms Marked erythema of the throat and tonsils; patchy, discrete, white or yellowish exudate; pharyngeal petechiae; and tender anterior cervical adenopathy Diagnostics GAS screening Throat culture, a rapid antigen detection test (RADT), and sometimes an antistreptolysin O (ASO) titer CBC Monospot  Pharyngitis and Tonsillitis (Chapter 84, Slide 3 of 3) Management Viral Rest, fluids, humidification, voice rest, and warm saline gargles to ease discomfort Acetaminophen or ibuprofen Bacterial Antibiotic therapy Penicillin V, 500 mg two to three times daily for 10 days or amoxicillin If PCN allergy, first- or second-generation cephalosporin, clarithromycin, azithromycin, and clindamycin  Discussion Question 3 Discuss management of pharyngitis. When is an immediate referral indicated?  Peritonsillar Abscess (Chapter 85, Slide 1 of 2) A peritonsillar abscess (PTA) is an accumulation of pus within the peritonsillar tissues between the tonsil and the pharyngeal constrictor muscle. Common deep infection of the head and neck. Frequently occurs in patients with a history of recurrent, chronic, or improperly treated tonsillitis. Common occurrences in the middle teenage years through age 40, higher occurrence in those who smoke Specialist referral is recommended. Clinical presentation Fever, and chills, fatigue, malaise, foul breath, dysphagia, severe sore throat and otalgia, drooling, “hot potato” (harsh voice) Often reports pain radiating to the ear of the affected side May appear acutely ill Trismus often present Spasms of the masticator muscles  Peritonsillar Abscess (Chapter 85, Slide 2 of 2) Physical exam Marked edema and erythema of the peritonsillar tissue and soft palate; tissue is often fluctuant and covered with exudate. Almost always unilateral Uvula edematous Diagnostics CT scan with contrast will confirm abscess formation and the presence of gas. Ultrasound either oral or cutaneous CBC Monospot/heterophil antibody test Aspiration of the abscess for culture and sensitivity Management Emergent ED referral Surgical intervention is required with needle aspiration, incision and drainage, or tonsillectomy. Antibiotics Pain medication Maintenance of hydration Part 9: Evaluation and Management of Oropharynx Disorders Case Study 1 Mary, a 39-year-old female, presents with complaints of oral pain. She states that she has been having symptoms for quite a while, but her symptoms have become worse, prompting her to present for evaluation. She states that she has pain in her gums and has noted bleeding when she eats and brushes her teeth. She states that she also has noted bad breath even after brushing her teeth.  Case Study 1 Discussion Question 1 You examine Mary and note inflammation of the gingiva, with areas of ulceration with purulent discharge from the affected areas. What diagnosis do you provide Mary based on symptoms and examination? A. Oral abscess B. Gingivitis C. Candidal infection D. Herpes virus  Case Study 1 Discussion Question 2 Mary asks what is the cause of her symptoms. You tell her, A. This is caused by a fungal infection. B. Gingivitis is typically caused by bacterial overgrowth. C. This is a viral infection, typically a herpes virus. D. This is an autoimmune disorder.  Case Study 1 Discussion Question 3 What will be the recommended treatment? A. Oral hygiene including brushing/flossing, chlorhexidine mouth rinse, and dental referral B. Nystatin swish and swallow C. Acyclovir D. Lidocaine mouth rinse to help with pain Part 9: Evaluation and Management of Oropharynx Disorders Case Study 2 Marcus, a 7-year-old boy, presents with his parents with complaints of a sore throat. He tells you that it hurts to swallow. His mother tells you that symptoms started the previous night. His father states that several children in Marcus’s class have been out sick recently.  Case Study 2 Discussion Question 1 When you examine Marcus, you note erythema of the throat and tonsils; patchy, discrete, yellowish exudate; pharyngeal petechiae; and tender anterior cervical adenopathy. What is the most likely cause of pharyngitis? A. Viral B. Allergen C. Bacterial D. Fungal  Case Study 2 Discussion Question 2 What is the most likely causative agent? A. Group A Streptococcus B. Epstein Barr virus C. Herpes virus D. Candida  Case Study 2 Discussion Question 3 What is the recommended first line treatment? A. Self-limiting. Supportive care and OTC analgesics. B. Amoxicillin. May use OTC acetaminophen or NSAIDs along with throat sprays and lozenges to help with pain. C. Nystatin D. Antihistamines and Tylenol or NSAIDs as needed