PANCE Blueprint EENT (7%)

Oropharyngeal disorders (PEARLS)

Diseases of the teeth and gums (ReelDx) Gingivitis: patient should be counseled about increases 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 Single or multiple small, shallow ulcers with a yellow-gray fibrinoid center with red halos, a biopsy should be considered for ulcers lasting more than 3 weeks

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

Candidiasis
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
  • 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 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
  • Computed tomography (CT) is the imaging modality of choice for the diagnosis of deep neck space infection
  • The most common organisms isolated from deep neck space infections are viridans streptococci

TX: Antibiotics, aspiration or surgical drainage should be performed

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

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

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

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 Almost always viral, hoarseness following a URI

  • Consider squamous cell carcinoma if hoarseness persists > 2 weeks, history of ETOH and or smoking, laryngoscopy is required for symptoms persisting > 3 weeks

TX: Relax voice, supportive

  • Oral or IM corticosteroids may also hasten recovery for performers but requires vocal fold evaluation before starting therapy
Peritonsillar abscess 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

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 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. Centor Criteria: Absence of a cough, exudates, fever, cervical lymphadenopathy. Throat culture is the gold standard

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 Pen allergic. Complications: Rheumatic fever and post-strep glomerulonephritis
  • Gonorrhea pharyngitis: follows the same principles for the approach to therapy of uncomplicated urogenital gonococcal infections, with a preferred regimen of intramuscular ceftriaxone (250 mg) and azithromycin as a second agent
Sialadenitis
Sialadenitis is a bacterial infection of a salivary gland usually caused by sialolithiasis which is an obstructing stone in the salivary gland

  • Acute swelling of the cheek which worsens with meals
  • etiology: S. aureus
  • Diagnose with CT, ultrasonography, or MRI

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

Parotitis Mumps is caused by paramyxovirus. Likely in a child without a complete vaccination series

  • Typically, it begins with a few days of fever, headache, myalgia, fatigue, and anorexia, followed by parotitis; the illness is usually self-limited
  • In adult males look for an associated orchitis
  • Viral infections associated with parotitis include influenza A virus, parainfluenza, adenovirus, coxsackievirus, Epstein-Barr virus (EBV), cytomegalovirus, herpes simplex virus, human immunodeficiency virus (HIV), and lymphocytic choriomeningitis virus

TX: Self-limiting treat with hydration and rest

  • Vaccination is effective for prevention
Leukoplakia 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)

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
Nasal foreign body (ReelDx) (Prev Lesson)
(Next Lesson) Diseases of the teeth and gums (ReelDx)
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