PANCE Blueprint EENT (7%)

Oropharyngeal disorders (PEARLS)

Diseases of the teeth and gums (ReelDx)
Patient will present as → a 25-year-old HIV-positive male with pain associated with his gums. He has also noted bleeding of his gums when he brushes his teeth. On physical exam, you observe a bright erythematous line along the gingival margin. (gingivitis)

Gingivitis: the patient should be counseled about increased risk for cardiovascular events

Gingival Hyperplasia: Overgrowing of gums so that it blocks the teeth, commonly caused by medications. phenytoin, CCB's and cyclosporine

Vincent's Angina: “Trench Mouth” necrotizing gingivitis: characterized by the “punched-out” appearance of the gingival papillae

Dental abscess: Poor dental health is a risk factor for a dental abscess or facial cellulitis, treat with IM ceftriaxone and amoxicillin

Aphthous ulcers
Patient will present as → a 22-year-old complaining of a painful sore for 2 days.  He denies any alcohol or tobacco use and otherwise feels fine. The examination is significant for a 2-mm round ulceration with a yellow-gray center surrounded by a red halo on the left buccal mucosa

Single or multiple small, shallow ulcers with a yellow-gray fibrinoid center with red halos

DX: Diagnosis is made by history and clinical presentation

  • Biopsy should be considered for ulcers lasting more than 3 weeks
  • Rule out an oral manifestation of systemic disease: More likely if persists >3 wk or associated with constitutional symptoms.  Focus on symptoms of eyes, mouth, genitalia, skin, GI tract, allergy, diet history, and physical exam

TX: viscous lidocaine 2–5% applied to ulcer QID after meals until healed

Candidiasis
Patient will present as → a 3-week-old infant with decreased appetite and a rash in her mouth. On physical exam, you note white plaques on her tongue that scrape off with a tongue depressor and bleed slightly. Potassium hydroxide (KOH) preparation of the scrapings demonstrates budding yeasts with hyphae.

Immunocompromised, young patients

  • Painful, white fluffy patches that can be scraped off and may bleed when scraped (candidiasis can "come off") leaving an erythematous, friable base

DX: Potassium Hydroxide (KOH) prep for diagnosis

TX: Antifungals, which are available in several forms (i.e., ketoconazole or fluconazole orally, clotrimazole troches, nystatin liquid rinses)

Deep neck infection
Patient will present as → a 51-year-old male patient who underwent extraction of the mandibular right third molar. Seven days after the surgery, the patient developed facial edema, fever, intraoral purulent discharge, and extreme local pain.  Infectious cavities in the right and left submandibular, pterygomandibular, and pharyngeal regions were observed on computed tomography scans.

Deep neck space infections most commonly arise from a septic focus of the mandibular teeth, tonsils, parotid gland, deep cervical lymph nodes, middle ear, or sinuses

  • Classic manifestations of these infections include high fever, systemic toxicity, and local signs of erythema, edema, and fluctuance
  • The most common organisms isolated from deep neck space infections are viridans streptococci

DX: Computed tomography (CT) is the imaging modality of choice for the diagnosis of deep neck space infection

  • MRI is useful for assessing the extent of soft tissue involvement and for delineating vascular complications

TX: Antibiotics, aspiration or surgical drainage should be performed

Epiglottitis
Patient will present as → a 3-year-old who is brought into the emergency room by her parents. The child has had a high fever, sore throat, and stridor. She has a muffled voice and is sitting up on the stretcher drooling while leaning forward with her neck extended. The patient’s parents are adamantly against vaccinations, claiming that they are a “government conspiracy.” You order a lateral neck x-ray, which shows a swollen epiglottis. The patient recovered following treatment with prednisone and ceftriaxone.

Unvaccinated patient leaning forward, drooling, stridor and distress (tripod position and muffled voice)

  • H. influenza type B (Hib)

DX: Lateral radiograph: Thumbprint sign

TX: Secure airway, admit, IV Ceftriaxone, and IV fluids

Oral herpes simplex
Patient will present as → a 17-year-old female complaining of a painful rash on her cheek. She says that it has come and gone a few times before and that she usually can feel itching and a tingling discomfort before a break out of the lesions. On physical exam, you observe clusters of small, tense vesicles on an erythematous base.

HSV type 1, vesicular lesions all in the same stage of development, a prodromal period of tingling discomfort or itching

DX: Diagnosis is clinical; laboratory confirmation by culture, PCR, direct immunofluorescence, or serologic testing can be done

TX: Symptomatic treatment with antipyretics and analgesia is recommended. IV hydration is sometimes needed in cases of decreased oral intake

  • Oral acyclovir (15 mg/kg/dose five times per day for 7–10 days; max 200 mg per dose) may decrease the duration of illness if started within 72 hours at the onset of symptoms

Laryngitis
Patient will present as → a 27-year-old mezzo-soprano who states that she developed acute hoarseness 2 days ago. Prior to that, she had a cold, the symptoms of which are improving. There is no history of smoking or other tobacco use. She is very worried as she has an upcoming performance 3 days from now.

Almost always viral, hoarseness following a URI

  • Consider squamous cell carcinoma if hoarseness persists > 2 weeks, history of ETOH and or smoking

DX: clinical diagnosis ⇒ laryngoscopy is required for symptoms persisting > 3 wk

TX: Relax voice, supportive

  • Oral or IM corticosteroids may also hasten recovery for performers but requires vocal fold evaluation before starting therapy
Peritonsillar abscess
Patient will present as → a 19-year-old male who you are seeing for follow-up from the urgent care where he was seen 2 days earlier with a sore throat. The patient is febrile (102°F)has a muffled (hot potato) voice, and extreme difficulty opening his mouth (trismus). He opens it just far enough for you to note uvular deviation.

Presents with a severe sore throat, lateral uvula displacement, bulging tonsillar pillar

  • Hot potato (muffled) voice and deviation of the uvula to one side
  • + Streptococcus pyogenes

DX: Xray, CT, or ultrasound of the neck if the diagnosis is in doubt, particularly when the condition must be differentiated from a parapharyngeal infection or other deep neck infection

  • All such patients require needle aspiration of the tonsillar mass and cultures. Aspiration of pus differentiates abscess from cellulitis

TX: Aspiration, incision and drainage, and/or antibiotics

  • Parenteral amoxicillin, amoxicillin-sulbactam, and clindamycin
  • In less severe cases, oral antibiotics can be used for 7 to 10 days (i.e., amoxicillin, amoxicillin-clavulanate, clindamycin)
  • Tonsillectomy may also be considered in about 10% of patients

Pharyngitis
Patient will present as → a 7-year-old boy is brought to his pediatrician for evaluation of a sore throat. The sore throat began 4 days ago and has progressively worsened. Associated symptoms include subjective fever, pain with swallowing, and fatigue. The patient denies cough or rhinorrhea. Vital signs are as follows: T 101.4 F, HR 88, BP 115/67, RR 14, and SpO2 99%. Physical examination is significant for purulent tonsillar exudate; no cervical lymphadenopathy is noted.

Usually viral - adenovirus most common

  • Mononucleosis: Epstein Barr virus, fever, sore throat, lymphadenopathy, splenomegaly, atypical lymphocytes, + heterophile agglutination test (monospot)
  • Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis
  • Fungal in patients using inhaled steroids
  • Group A Streptococcal pharyngitis: S. pyogenes

DX: Centor Score for Strep Pharyngitis (MDcalc): 1. Absence of a cough, 2. exudates, 3. fever (> 100.4 F), 4. cervical lymphadenopathy

  • If  3 out of 4 Centor criteria are met get a rapid streptococcal test (sensitivity > 90%)
  • If negative → throat culture is the gold standard
  • Not suggestive of strep - coryza, hoarseness, and cough

TX:

  • Viral: supportive
  • Mononucleosis: Symptomatic and avoid contact sports, antibiotics such as amoxicillin or ampicillin may cause a rash
  • Fungal: clotrimazole, miconazole, or nystatin
  • Group A Strep: Penicillin is first line, azithromycin if penicillin allergic
    • Complications: Rheumatic fever and post-strep glomerulonephritis
  • Gonorrhea pharyngitis: follows the same principles for the approach to therapy of uncomplicated urogenital gonococcal infections
    • Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
      • For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered.
Sialadenitis
Patient will present as → a 39-year-old female complaining of episodic left-sided jaw pain and swelling. The symptoms are typically aggravated by eating or by the anticipation of eating. Over the last 2-days, the patient has been experiencing worsening pain, redness, and fever. On physical exam, the left salivary gland is exquisitely tender. High-resolution noncontrast computed tomography (CT) scanning reveals a left-sided salivary gland stone.

Sialadenitis is a bacterial infection of a salivary gland usually caused by sialolithiasis which is an obstructing stone in the salivary gland

DX: Diagnose with CT, ultrasonography, or MRI

TX: Dicloxacillin, 1st gen cephalosporin, or clindamycin, symptomatic: hydration, sialogogues

Parotitis
Patient will present as → an 11-year-old boy with malaise and swelling of his face.  He has no significant past medical history, but it is documented in his chart that his mother declined the recommended standard immunizations for children because of personal beliefs. Vital signs are stable with the exception of a mild fever. In addition to the facial swelling, physical exam is also notable for swelling around the testes. There are no rashes.

Parotitis is an inflammation of one or both parotid glands, the major salivary glands located on either side of the face, in humans

  • Patients present with fever and chills, periauricular, mandibular pain, and swelling; trismus, dysphagia; purulent drainage
  • Viral ⇒ No discharge, prodrome followed by swelling lasting 5–10 days

Causes:

  • Bacterial: S. aureus, most common
  • Viral: mumps, influenza, coxsackie, Epstein–Barr virus (EBV)
  • Autoinflammatory: sarcoidosis as part of Mikulicz syndrome

Mumps parotitis

  • Mumps is caused by a paramyxovirus. Likely in a child without a complete vaccination series. Transmitted via airborne droplets
  • Typically, it begins with a few days of fever, headache, myalgia, fatigue, and anorexia, followed by parotitis
  • In adult males look for an associated orchitis

DX: often clinical

  • Sample purulent exudate, ultrasound-guided needle aspiration; culture, Gram stain
  • Ultrasound ⇒ increased blood flow through gland, enlargement, nodules
  • CT scan ⇒ extension of inflammation to surrounding tissue
  • Complete blood count (CBC)
  • Serum and urinary amylase rise during the first week of parotitis without underlying pancreatitis
  • Viral shows leukocytosis, increased IgM against mumps

TX: Self-limiting treat with hydration and rest

  • Vaccination is effective for prevention
  • Contagious for 9 days after onset of parotid swelling

Leukoplakia
Patient will present as → a 42-year-old male with symptoms of the flu. On social history, the patient describes drinking 2-3 beers per day as well as smoking 1 pack of cigarettes per day. He is noted on physical exam to have a white plaque-like lesion on the side of the tongue which could not be scraped off with a tongue depressor.

Oral leukoplakia is an oral potentially malignant disorder that presents as white patches of the oral mucosa that cannot be wiped off with a gauze

  • Tobacco use (smoked and especially smokeless), alcohol abuse, HPV infections
  • Leukoplakia is in itself a benign and asymptomatic condition. However, some patients will eventually develop squamous cell carcinoma (SCC)

DX: The diagnosis of leukoplakia is suspected in patients presenting with a white lesion of the oral mucosa that cannot be wiped off with gauze and that persists after eliminating potential etiologic factors, such as mechanical friction, for a six-week period

  • Excisional biopsy is indicated for any undiagnosed leukoplakia

TX: Biopsy and surgical excision,  destructive therapies (eg, laser ablation, cryosurgery), medical therapies (eg, retinoids, vitamin A, carotenoids, NSAIDs), and watchful waiting with close clinical and histologic follow-up

Oral hairy leukoplakia is a separate disorder that is not premalignant. It is an Epstein-Barr virus-induced lesion that occurs almost entirely in HIV-infected patients.

  • Generally affects the lateral portions of the tongue, although the floor of the mouth, the palate, or the buccal mucosa may also be involved

TX: Unlikely to progress to squamous cell carcinoma

  • Treatment with zidovudine, acyclovir, ganciclovir, foscarnet, and topical podophyllin or isotretinoin. Therapy is usually not indicated

 Trauma

Patient will present as → a 20-year-old who presents to the ED 30 minutes after being struck by a hockey puck in the mouth. On physical examination, a central incisor is missing from its socket. The patient has the tooth wrapped in tissue paper and the root appears intact

Dental management of injuries to primary and permanent teeth

Description Primary dentition Permanent dentition
Concussion/subluxation Observe, soft foods for 1 week, dental radiograph to rule out root fracture Observe, soft foods for 1 week, dental radiograph to rule out root fracture
Luxation Reposition tooth or extract, do not splint Dental radiograph, reposition tooth, splint for 4 weeks
Extrusion Reposition tooth or extract, do not splint Dental radiograph, reposition tooth, splint for 2 weeks
Intrusion Dental radiograph, observe and allow to reerupt, extract if alveolar plate is compromised Dental radiograph, observe and allow to reerupt, surgical or orthodontic repositioning, root canal treatment
Uncomplicated crown fracture Restore tooth, smooth sharp edges, dental radiograph to rule out root fracture Restore tooth, smooth sharp edges, radiograph to rule out root fracture
Complicated crown fracture Dental radiograph, pulp treatment, restore or extract tooth, observe for infection Dental radiograph, pulp treatment, restore tooth, observe for infection, may require root canal treatment
Root fracture Dental radiograph, extract if root fracture is in middle or cervical third of root Dental radiograph, splint, may require root canal treatment; if in cervical third, may need to extract
Avulsion Do not replant, dental radiograph to rule out intrusion if tooth is not located Do not handle the root, replant within 30 min or place in recommended transport medium (balanced salt solution, cold milk); dental radiograph, replant and splint as soon as possible; systemic antibiotics, soft diet, chlorhexidine, close follow-up
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