PANCE Blueprint EENT (7%)

Infectious and inflammatory disorders (PEARLS)

NCCPA™ PANCE EENT Content BlueprintOropharyngeal disorders ⇒ Infectious and inflammatory disorders

Aphthous ulcers (ReelDx)
ReelDx Virtual Rounds (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 (ReelDx)
ReelDx Virtual Rounds (Oral 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 (ReelDx)
ReelDx Virtual Rounds (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

  • M.cat, H.flu
  • Consider squamous cell carcinoma if hoarseness persists > 2 weeks, history of ETOH and or smoking
  • Absence of pain or sore throat

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

TX: Relax voice (vocal rest), supportive therapy

  • Oral or IM corticosteroids may also hasten recovery for performers but requires vocal fold evaluation before starting therapy
  • Bacterial → erythromycin, cefuroxime, or Augmentin for cough or hoarseness
Peritonsillar abscess (ReelDx)
ReelDx Virtual Rounds (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 (ReelDx)
ReelDx Virtual Rounds (Acute 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.
Diseases of the teeth and gums (ReelDx) (Prev Lesson)
(Next Lesson) Aphthous ulcers (ReelDx + Lecture)
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