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Mouth lesions

-​include ulcers, cysts, firm nodules, hemorrhagic lesions, papules, vesicles, bullae, and erythematous lesions.

-may occur anywhere on the lips, cheeks, hard and soft palate, salivary glands, tongue, gingiva, or mucous membranes.

-many are painful and readily detected while some, however, don't produce symptoms
​can result from trauma, infection, systemic disease, drug use, or radiation therapy.

Recurrent Herpes Labialis (a form of herpes simplex)

-a viral infection that appears in the formation of painful blisters on the lip.

-Prodrome (itching, burning, tingling) lasts approximately 12 to 36 hours, followed by eruption of clustered vesicles along the vermilion border that subsequently rupture, ulcerate, and crust.

-Reactivation triggers: ultraviolet light, trauma, fatigue, stress, menstruation

Carcinoma

​-caused predominantly by using tobacco, alcohol, overexposure of sunlight. To a lesser extent, it could also come from lack of oral hygiene or poor fitting dentures.

Angioedema (Quinke's Edema)

-​acute edema of the skin, mucosa and submucosal tissues.
-​Affects tissues around the mouth, mucosa of the mouth and/or throat, as well as the tongue, which swell up over the period of minutes to several hours.
​-The swelling can also occur elsewhere, typically in the hands.
-The swelling can be itchy.
-There may also be slightly decreased sensation in the affected areas due to compression of the nerves. ​
-​Urticaria may develop simultaneously if the angioedema is related to allergy.

Etiology:
​allergic stimulation most often; NOT IgE mediated
Common allergens include:
​-medications
​-foods (such as berries, shellfish, fish, nuts, eggs, milk, wheat)
​-pollen
​-animal dander
​-insect bites
​-exposure to water, sunlight, cold or heat
​-emotional stress
​-hives and angioedema may also occur after infections or illness (including autoimmune disorders, leukemia, and others).

Signs & Sxs:
​-painless, nonpruritic, nonpitting, and well-circumscribed areas of edema due to increased vascular permeability.
​-in advanced cases, progresses to complete airway obstruction and death caused by laryngeal edema.
​-considered chronic when it lasts more than 3 weeks
​-may be seen in previously non-allergic people
​-spontaneous remission in 50% within two years

Hereditary Angioedema/Hereditary Angioneurotic Edema

-​rare, autosomal dominant inheritance
​85% are deficiencies of C1 esterase inhibitor
​positive family history

Signs & Sxs:
-​edema is unifocal, indurated, and PAINFUL rather than pruritic
​-usually no associated itch or urticaria as it's not an allergic response.
​-Triggers: stress, infection, trauma, viral illness
-​Edema in body parts, esp. the hands, feet, face, and airway passages.
-​Patients can also have recurrent episodes of abdominal pain, usually accompanied by intense vomiting, weakness, and in some cases, watery diarrhea, and an unraised, non-itchy splotchy/swirly rash.

Mucocele

​-a soft bump or a blister-like lesion in the mouth.
​-can occur on lips, under the tongue, or less commonly roof of the mouth.

Etiology:
-​minor injury to salivary duct by inadvertent trauma such as biting. Biting pinches off the mucus gland, so the mucus builds up.

Signs & Sxs:
-​thick, mucus-type saliva produced by the damaged gland creates a clear or bluish bubble or blister.
-​If the blister is further injured, bleeding can occur within the entrapped pool of saliva that would make it look red or purple.
-​history of enlargement, breaking, and shrinkage is fairly common, and these lesions can be remarkably persistent.
-Some mucoceles spontaneously resolve on their own after a short time. Others are chronic and require surgical removal. Recurrence may occur, and thus the adjacent salivary gland is excised as a preventive measure.
-chronic mucolceles ​rarely go away on their own. they can be drained, but will come back. Easy surgical removal of the gland by dentist would prevent recurrence.

Angular cheilitis (perlèche, cheilosis, angular stomatitis) ​

-​inflammatory lesion at the labial commissure, often occurs bilaterally

Signs & Sxs:
-​deep cracks or splits @ corners of mouth
​-in severe cases, the splits can bleed when the mouth is opened and shallow ulcers or a crust may form.
-usually a chronic problem presenting acutely.

Etiology:
-​initial onset associated with nutritional deficiencies, esp. vitamin B (Riboflavin B2, Cyanocobalamin B12)(think alcoholics!) and iron deficiency anemia which in turn may be evidence of poor diets or malnutrition (e.g. celiac disease).
-​sores may become infected by Candida albicans or other pathogens.
​-may also be part of a group of symptoms (upper esophageal web, iron deficiency anemia, glossitis, and cheilosis) defining the condition called Plummer-Vinson syndrome (aka Paterson-Brown-Kelly syndrome).
-​occurs frequently in the elderly population who experience a loss of vertical dimension due to loss of teeth, thus allowing for over-closure of the mouth.
-​cold (such as in the winter time), and is widely known as having chapped lips.
​-young children may lick their lips in an attempt to provide a temporary moment of relief, only serving to worsen the condition.

Squamous cell cancer

-Usually found on the mucocutaneous junction of the lips; more common on the lower lip
​-painless, sharply demarcated, elevated, indurated (hardened) border with ulcerated base
​-may be verrucous or plaque like
-​high risk factors include chronic smoking and alcohol intake.

Chancre

-Painless ulceration formed during the primary stage of syphilis, ~21 days after the initial exposure to Treponema pallidum,
-these ulcers usually form on or around the anus, mouth, penis, and vagina.
​-chancres may diminish between 3-6 weeks without treatment

Buccal mucosal lesions

-​includes: aspirin burns, Koplik's spots, irritation fibromas due to bite plane irritation

Mucosal lesions accompany the following diseases:
​-measles (Koplik's spots)
​-scarlet fever: raspberry or strawberry tongue
​-syphilis: mucus patches
​-erythema multiforme: ulcers
​-pellagra: smooth fiery tongue and painful mouth
-​scurvy and platelet disorders: hemorrhagic lesions
-​uremia: easy bleeding, low salivation and ammonia odor

-Establishing the cause is not always easy. Need complete history, FH, allergy history.
-PE: check whole body for lesions that may explain the oral ones.
-Direct smears, stains and cultures sometimes helpful.
-A solitary lesions that lasts more than 2 weeks should be examined for malignancy.

Lichen planus

​S/Sxs: painless, white or gray, velvety, threadlike, lacy (aka reticular) papules develop on the buccal mucosa or, less commonly, on the tongue. ​These precede the eruption of violet papules with white lines or spots, usually on the genitalia, lower back, ankles, and anterior lower legs; pruritus; nails with longitudinal ridges; and alopecia.

Frictional hyperkeratosis

-caused by chronic friction against an oral mucosal surface.
-S/Sxs: hyperkeratotic white lesion (a protective response to low-grade, long-term trauma).
​can produce a white line called linea alba if caused by biting.
​-If the cause is uncertain, the lesion should be treated as idiopathic leukoplakia, and biopsy should be obtained.

Denture sore spot

-S/Sxs: small, painful ulcers, characterized by an overlying, grayish necrotic membrane and surrounded by an inflammatory halo.
-​usually heals quickly once denture removed

Denture sore mouth (denture stomatitis)

-very common
-S/Sxs: ​mucosa beneath the denture becomes extremely red and swollen, with either a smooth or granular appearance. Severe burning sensation is common. Redness of the mucosa is sharply outlined and restricted to the tissue that is in contact with the denture which differentiates from erythroplakia.
-Usually from never removing dentures or new dentures.

Irritation Fibroma

-the most common benign oral soft tissue neoplasm
​-any age, most often 20 - 49 years; M = F

Signs & Sxs:
-​frequently in traumatized areas of the mouth, such as the buccal mucosa (chronic cheek biting), lateral border of the tongue and the lower lip
-​painless, sessile or occasionally pedunculated swelling that can be firm and resilient or soft and spongy in consistency
​-color is slightly lighter than the surrounding mucosa, due to a relative lack of vascular channels
​-may be subject to irritation, inflammation or even ulceration​
​-seldom larger than 1 cm in diameter

DDX: based mainly on the location
-on the tongue - neurofibroma, neurilemoma or granular cell tumor
-lower lip or buccal mucosa - lipoma, mucocele or salivary gland tumor.

Fordyce's Granules

-ectopic collection of sebaceous glands (sebaceous choristomas) at various sites in the oral cavity; multiple, often occurring in aggregate or in a confluent arrangement
-A normal variant.
-​most common 20 -30 years; M = F
-Idiopathic

Signs & Sxs:
​-most frequently, bilaterally symmetric on the buccal mucosa opposite the molar teeth
​-also found on the inner surface of the lips, the retromolar region, the tongue, the gingiva, the frenum and the palate
-Look's like chicken skin!

DDX:
-Candida albicans - candida lesions wipe off, but Fordyce's granules do not

Inflammation and Irritation:

-Including: Frictional hyperkeratosis , denture sore spot, denture sore mouth.
-Many of these lesions are denture related.
-​The reaction is not a true allergy to acrylic, since patch testing is usually negative. Fungi are thought to play a major role; yeast-like organisms are cultured in about 90 percent of cases.

Sialadenitis

​-painless benign swelling of salivary glands seen in many systemic diseases

may be seen in
-hepatic cirrhosis
-sarcoidosis
-neoplasms
-infection

-​usually pain with mumps, malignancy and infection; others may be painless

Sialolithiasis

-salivary duct stones, most common in the submandibular glands
-​pain and swelling associated with eating

Sjogren's syndrome

-​Autoimmune systemic inflammation associated with dry eyes, mouth, and mucus
​membranes.
-The body hypertrophies the salivary glands to try to get more saliva, but the glands can't produce it.

Xerostomia

= dry mouth

-tongue sticks to top of mouth. Patient can't form words easily because the mouth is so dry. Very uncomfortable!

-​many causes: drugs (diuretics, anticholinergics), Sjogren's, salivary gland
disorders, dehydration, mouth breathing, radiation to head/neck.

-​contributes to tooth decay

STOMATITIS

​Stomatitis = inflammation of oral tissue often seen as a sign of systemic disease
-​may be accompanied by foul breath and mucosal bleeding

Etiology:
-​infection: strep, candida, Corynebacterium, syphilis, TB, measles, Coxsackie virus, other viruses, IM, fungus (Histoplasmosis, Mucor, Cryptococcus, Coccidiomycosis)
​-avitaminosis: especially B and C
​-iron deficiency anemia with dysphagia (Plummer-Vinson syndrome)
​-leukemia, agranulocytosis (also has mouth ulcers)
-mechanical trauma: poorly fitting dentures, improper nipples on bottles
​-xerostomia from drugs, radiation, aging
-​alcohol, tobacco, hot/spicy foods and drinks
​-mouth breathing, cheek biting, jagged teeth, poor orthodontia
​-chemical stomatitis
​-mercury poisoning with marked salivation
​-allergy - intense shiny erythema with swelling, itching, dryness, burning

Signs & Sxs: depend on the cause of the stomatitis.

Gingivitis

-​inflammation of the gums with redness, swelling, changes in contours of the gums, pocket formation
-​may see watery exudate and bleeding
​-usually begins in the notch of gum tissue between teeth

Etiology:
-​poor oral hygiene (most common), malocclusion, dental calculi, food impaction, faulty dental restorations, mouth breathing
​common in puberty and during pregnancy

Signs & Sxs:
-​swollen gums​
-mouth sores
-​bright-red, or purple gums​
-shiny gums
-​gums are painless, except when pressure is applied
-​gums bleed easily, even with gentle brushing
-gums itch with varying degrees of severity
​receding gum line
​-may be the first sign of systemic disease, like DM, poor nutrition, endocrine disorders, leucopenia, etc.
-​Dilantin causes enlargement of the gums

Prevention
​-regular oral hygiene - daily brushing and flossing.
​-sesame oil pulling, can be effective in significantly reducing gingivitis

Vincent's angina (trenchmouth or ulcerating necrotizing gingivitis)

-​called Vincent (or Vincent's) angina after the French physician Henri Vincent (1862-1950). The word "angina" comes from the Latin "angere" meaning "to choke or throttle."

-As with most poorly understood diseases, Vincent angina goes by many other names including acute necrotizing ulcerative gingivitis (ANUG), acute membranous gingivitis, fusospirillary gingivitis, fusospirillosis, fusospirochetal gingivitis, necrotizing gingivitis, phagedenic gingivitis, ulcerative gingivitis, Vincent stomatitis, Vincent gingivitis, and Vincent infection.

Etiology:
-​fusiform bacteria and spirochetes
-neglectful oral hygiene
-severe stress
-malnutrition
​-more common with alcohol and tobacco use

Signs & Sxs:
-​progressive painful infection with ulceration, swelling and sloughing off of dead tissue
-​ulcerated lesions of the interdental papillae
-can affect all gum tissue
-bad odor
-​lesions are punched out looking with a gray membrane
-bleed easily
-painful
​-much more severe in patients with HIV
-can lead to lots of dead tissue and loss of teeth

Thrush

-​common oral fungal infection by Candida

-S/Sxs: lightly raised soft plaques that look like milk curds that are easily wiped away; hyperemic. ​Usually start on the tongue and buccal mucosa and spread; ​mouth appears dry.

-​more common in elderly, debilitated, people on long term antibiotics or steroids, in xerostomia, and infants.

Pseudomembranous stomatitis:

-​inflammatory reaction that produces a membrane like exudate

-​caused by chemical irritants or bacterial infections

-​fever, malaise, and LA may result or it may be localized to the mouth

Aphthous stomatitis: (aphthous ulcers, canker sores)

-​Acute, painful, recurring, solitary or multiple necrotizing ulcerations of the oral mucosa.

Etiology:​
-cause is unknown​
-​factors that provoke them include: food allergies, citric acid, artificial sugars; gluten​
​stress ​illness​
-​hormonal changes​, menstruation
​-sudden weight loss​
-fatigue
​-foaming agent in toothpaste (Sodium lauryl sulfate)
​-deficiencies in vitamin B12, iron, and folic acid ​
-immune system overreaction

-​Trauma is most common trigger:
-Physical trauma: toothbrush abrasions, laceration with sharp foods or objects,
accidental biting or dental braces
-Chemical irritants or thermal injury

Signs & Sxs:
-​present as painful lesions, occasionally have prodromal burning or tingling
-​occur exclusively on non-keratinized, moveable mucosa, the buccal and labial mucosa, buccal and lingual sulci, ventral tongue, soft palate and floor of the mouth. ​

-Three forms of aphthous ulcers (same disease spectrum and a common etiology)
Minor form, major form, herpetiform ulcers

DDX:
​-secondary herpetic ulceration (A history of vesicles preceding the ulcers, a location on periosteum bound mucosa (gingival, hard palate) and crops of lesions.)
-​also consider trauma, pemphigus vulgaris and cicatricial pemphigoid.
​-systemic disorders such as Crohn's disease, neutropenia and celiac sprue.

Minor form of Apthous Stomatitis

​-most common and least severe form of the disease
​-develops in childhood and adolescence, and then sporadically throughout life
-S/Sxs: ​usually solitary, oval yellow-gray ulcer surrounded by an erythematous halo and under 1 cm in diameter; it lasts seven to 10 days; heal without scars; shallow oval erosions with raised yellowish border; hyperemic around ulcers

Major form of Apthous Stomatitis

-S/Sxs: multifocal, have ragged edges and may be up to 2 cm in diameter, may last up to six weeks and may be immediately succeeded by a recurrent ulcer; heal with scarring and cause severe pain and discomfort
-​typically develop after puberty with frequent recurrences. ​
​-occur on moveable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces

Herpetiform ulcers of Apthous Stomatitis

-most severe form
​-occurs more frequently in females, and onset is often in adulthood.
-S/Sxs: small, numerous, 1-3 mm lesions that form clusters; ​typically heal in less than a month without scarring

Recurrent Aphthous Stomatitis

-​a T-cell mediated localized destruction of oral mucosa associated with an increased relative ratio of CD8+ T-cells to CD4+ T-cells.
​>10% of the population suffers from it; women > men
​~30-40% of patients have + family history.

Oral Herpes Gingivostomatitis

-Common presentation in children with primary herpes simplex infection.
-precursor to cold sores

-​S/Sxs: Multiple painful shallow ulcers (acute) with erythema of the oral mucosa (unmovable) and vermilion border. Often a three day prodrome of fever, malaise, LA, painful eating.
​Self limited in 7-10 days in most cases; may be fatal in infants b/c they will stop eating and drinking if it becomes too painful (worry about hydration!)
​-The initial eruption is most severe

DDX:
​aphthous stomatitis, erythema multiforme, drug eruptions, rarely pemphigus

Oral Erythema Multiforme

S/Sxs: painful stomatitis with sudden onset of diffuse hemorrhagic vesicles and bullae on lips and mucosa
​-systemic symptoms are usual - erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia
​-Prodrome: sinusitis, rhinitis, with multiple vesicles. May see a high fever for 4-5 days, and severe systemic symptoms.

DDX: aphthous stomatitis, allergic stomatitis, pemphigus, herpes

Leukoplakia

​-a nonspecific clinical term used to describe a white patch on the oral mucosa that cannot be rubbed off.
-​does not correlate with any particular microscopic findings and may be related to a variety of lesions, from benign hyperkeratosis to carcinoma.
​~ 90% of the lesions > 40 yrs, males > females

Etiology:
-​trauma from habitual biting, dental appliances
-​tobacco use
-​​alcohol consumption
​-oral sepsis
-​local irritation
​-syphilis​
-vitamin deficiency
-​endocrine disturbances​​
-dental galvanism
​-actinic radiation (in the case of lip involvement).

Signs & Sxs:
-​located on the tongue, mandibular alveolar ridge and buccal mucosa in ~50%.
-​palate, maxillary alveolar ridge, lower lip, floor of the mouth and the retromolar regions are somewhat less frequently involved.
-​may vary from nonpalpable, faintly translucent white areas to thick, fissured, papillomatous, indurated lesions.
-​surface is often wrinkled or shriveled in appearance and may feel rough on palpation.
-​color may be white, gray, yellowish-white, or even brownish-gray in patients with heavy tobacco use.

Physical:
-​lesion cannot be wiped away with a gauze

Diagnosis:
​-should be biopsied to obtain a definitive diagnosis
​-multiple biopsies of large lesions
​-histologic status of the lesion - whether benign or malignant, cannot be distinguished by clinical appearance alone
​~ 6% of patients have invasive carcinoma on initial biopsy, and in 4%, the lesion undergoes subsequent malignant transformation

DDX:
​-candidiasis and aspirin burn - can be wiped away with a gauze
-​erythroplakia (a red plaque that does not rub off), is a dysplastic lesion (or worse) in 90 percent of cases.

"Other" White Oral Lesions That Do Not Wipe Off with Gauze
​-traumatic or frictional keratosis
-​leukoedema
​-galvanic keratosis
​-verrucous carcinoma
​-lichen planus
​-systemic lupus erythematous
​-white sponge nevus
​-squamous cell carcinoma
-fordyce's granules
Prognosis:
​-In the absence of dysplasia or atypical epithelium, periodic and careful follow-up is appropriate. If elements of dysplasia or anaplasia are evident, the lesion must be removed.

Oral Squamous Cell Carcinoma

​~ 30,000 Americans each year; 90% are smokers, alcohol is also a risk factor.
​~ 40% begin on the floor of the mouth or on the lateral and ventral surfaces of the tongue.
​~ 38% occur on the lower lip, 11% begin in the palate and tonsillar area.

S/Sxs:
-early, curable lesions are rarely symptomatic
-may appear in areas of erythroplakia or leukoplakia and may be exophytic or ulcerated.
-Both variants are indurated (hard) and firm with a rolled border
-metastatic mass in the neck may be the first symptom

Palatal or Mandibular Torus

-​a non-neoplastic, slowly growing nodular protuberance of bone.
-Of little clinical significance, except in interference with denture construction and placement.
-​likely both mandibular and palatal tori are hereditary
-​incidence of palatal tori is as high as 20 to 25%;
-females are affected twice as often as males.
-The peak incidence occurs shortly before age 30

Hemangioma

​-a proliferation of blood vessels
-often congenital.
​-85% of the lesions develop by the end of the first year of life. ​
-​females > males: 2:1.

Signs & Sxs:
​-flat or raised, with a deep red or bluish-red color
​-most common sites: lips, tongue, buccal mucosa and palate.
-Because of location, frequently traumatized and can undergo ulceration and secondary infection.
​-many spontaneously regress at an early age

DDX:
​-primary lesion to rule out is Arteriovenous Fistula. A history of trauma to the area of the lesion at the time the lesion is discovered makes arteriovenous fistula more likely.

Papillomas

​-papillary and verrucal growths (WARTS!) that are composed of benign epithelium and a small amount of supporting connective tissue

Etiology:
​-not clear whether all intraoral squamous papillomas are etiologically related to cutaneous verruca vulgaris
-​some oral papillomas have been associated with the same HPV subtype that causes cutaneous warts, as well as with other subtypes of the virus

Signs & Sxs:
​-asymptomatic, well-circumscribed, usually pedunculated growths with numerous, small finger-like projections
-​generally < 1 cm in diameter and are most often solitary​
-​found on any intraoral mucosal site and the vermillion border of the lips, but they have a predilection for the hard and soft palate, the uvula, and the tongue (most common site is the soft palate)

DDX:
​-Verruciform Xanthomas - distinct predilection for the gingiva and alveolar ridge
​-Warty Dyskeratoma tends to occur as multiple lesions
-Condylomata Acuminata are usually larger and multifocal, with a broader base than papillomas

Epulis Fissura (denture-induced fibrous hyperplasia)

-​common tissue reaction to chronically ill-fitting dentures
-​usually occurs in the vestibular mucosa

Signs & Sxs:
​-painless folds of fibrous connective tissue that are firm to palpation and into which the denture flange conveniently fits​
-​usually not highly inflamed, but may be irritated or even ulcerated in the base where the edge of the denture flange fits

Varicosities

​-dilated, tortuous veins in the oral cavity are attributed to increased hydrostatic pressure and poor support by surrounding tissues​
​-commonly located on the ventral aspect of the tongue, but may also be found on the upper and lower lips, the buccal mucosa and the buccal commissure
-Sign of venous congestion

Signs & Sxs:
-​blue
-blanch when compressed
-​occasionally accompanied by thrombosis, which gives them a firm texture
​-of little clinical significance

Difficulty Moving The Tongue

-​most often caused by nerve damage, nerve root disorder, cancer
​-may also be caused by ankyloglossia (short frenulum)
​-may result in speech difficulties or difficulty moving food during chewing and swallowing

Deviation Of Tongue:

-hypoglossal paralysis (deviates to the paralyzed side)

Taste Abnormalities

caused by:
-damage to the taste buds
-nerve problems
-side effects of medications
-an infection
-other condition

Color Changes

Can Occur With:​
-Glossitis - papillae are lost, causing the tongue to appear smooth
-​Geographic Tongue (circular areas of denuded epithelium with yellow margins); aka benign migratory glossitis

-white or yellow - local irritation; smoking and alcohol use

-​red (ranging from pink to magenta) tongue:
+​folic acid and vitamin B-12 deficiency
+pellagra
+​pernicious anemia
+​Plummer-Vinson syndrome
+celiac disease
+​Non-specific glossitis secondary to pharyngitis
+​"strawberry tongue" of scarlet fever

Hairy Tongue

-​distal third looks hairy (black or green) due to hyperplasia of filiform papillae

possible causes of a hairy tongue:
-​AIDS​
-antibiotic therapy
-​Candida or Aspergillis infection after antibiotic
-​drinking coffee
-​dyes in drugs and food
-​chronic medical conditions
-overuse of mouthwashes containing oxidizing or astringent agents.
-radiation of the head and neck
-tobacco use​
-prednisone
-estrogen use

Pain In The Tongue

​-may occur with glossitis and geographic tongue.
-​minor infections or irritations most common cause
-​injury, such as biting the tongue, can cause painful sores. ​​
-heavy smoking will irritate the tongue and make it painful.
​-diabetic neuropathy
-oral cancer
-mouth ulcers
-leukoplakia.
​-after menopause, some women have a sudden feeling that their tongue has been burned; called burning tongue syndrome or idiopathic glossopyrosis.​

-Burning: - DM, depression, anxiety, glossitis, heavy metal poisoning, early pellagra

other possible causes of tongue pain include:
-​anemia
-​cancer
-​oral herpes (ulcers)​
-neuralgia
​-dentures that irritate the tongue
-referred pain from teeth and gums
-referred pain from the heart

Tongue Tremor

​-hyperthyroidism (fine tremor)​
-nervousness (coarse tremor)​
-​alcoholism​
-paresis
-​drug dependence ​
-debilitation​

Tongue Furrows

-deep transverse furrows (aka scrotal tongue) is congenital
-long dry furrows: ​think of dehydration
-longitudinal with desquamation: syphilis

Dry Tongue

-without furrows: Sjogren's syndrome
-with furrows: ​dehydration

Smooth Tongue (Atrophic Glossitis)

-​intermittent burning, paresthesias of taste
​-may see small shiny tongue that is red and painful, or may be swollen.

Causes:
-​low HCl​
-macrocytic anemia
-post gastrectomy​cirrhosis
-some iron deficiencies
-B complex deficiency

Enlargement Of The Tongue

Causes:
-​acromegaly​
-amyloidosis​
-​allergic reaction to food/ Rx
-angioedema
​-cancer of the tongue​
-Down's syndrome
-hypothyroidism
-​infection
-leukemia
-​lymphangioma
-​neurofibromatosis​
-pellagra
-pernicious anemia
-​strep infection
-tumor of the pituitary gland

Glossitis

-​acute or chronic inflammation that can be primary or secondary

Etiology:
-bacterial or viral infections (including oral herpes simplex).
-poor hydration and low saliva
-mechanical irritation or injury from burns, rough edges of teeth or dental appliances, or other trauma
-exposure to irritants such as tobacco, alcohol, hot foods, or spices.
-allergic reaction to toothpaste, mouthwash, breath fresheners, dyes in candy, plastic in dentures or retainers, or certain blood-pressure medications (ACE inhibitors).
-iron deficiency anemia​
-pernicious anemia
​-other B-vitamin deficiencies ​
-oral lichen planus
-​erythema multiforme ​
-aphthous ulcer
-​pemphigus vulgaris
-​syphilis

Signs & Sxs:
-​tongue swelling
-smooth appearance to the tongue
-tongue color changes (usually dark "beefy" red)
-pale, if caused by pernicious anemia
-​fiery red, if caused by deficiency of B vitamins
-sore and tender tongue
-difficulty with chewing, swallowing, or speaking

Pharynx

= base of the skull to cricoid cartilage in three parts:
-​nasopharynx: nasal cavity and Eustachian tube communication
-​oropharynx: from soft palate to larynx and anterior communication
​with the oral cavity
-​hypopharynx: surrounds larynx and leads to the esophagus

-contains: palatine tonsils, lymph aggregates, adenoids, lingual tonsils;
-tonsillar mass greatest in childhood
-ring of lymph tissue around the pharynx is known as Waldeyer's ring.

Inflammation of the Pharynx

-​diagnosis usually possible through history and PE
-​consider malignancy in chronic cases
-​Plummer-Vinson syndrome: dysphagia for solids, with severe untreated iron
deficiency
-​lifestyle an important part of history: trauma, spicy or hot foods, vocal abuse, tobacco and alcohol
-​consider Vitamin D deficiency, leukemia, hiatal hernia, chronic sinusitis
​-examination: mouth, neck for LA, and nose; vitals

Pharyngitis Etiology

1. Inflammatory
​-viral infections (~90%)​ bacterial infections (strep, staph, H. flu)
-​aphthous ulcers​
-herpes
​-fungus (oral thrush - babies)
2. Traumatic
​-foreign bodies​
-irritant fluids
​-overheated food and drink​
-mouth breathing, low humidity
​-industrial fumes​
-gastric reflux
3. Neoplasm
4. Glossopharyngeal neuralgia, elongated styloid process

Viral sore throats

​~90% of all infectious cases, many different types
1. Adenovirus - most common
​lymph node enlargement is modest, throat often does NOT appear RED, although is VERY PAINFUL; first a runny nose (thin discharge), stuffiness, nose and throat discomfort; within 24-48 hours sore throat develops

2. Orthomyxoviridae which cause influenza - rapid onset of high temperature, headache and generalized ache

3. Infectious mononucleosis (Epstein-Barr virus) - significant lymph gland swelling and an exudative tonsillitis with marked redness and swelling of the throat

4. Herpes simplex virus can cause multiple mouth ulcers
5. Measles
6. Common cold

Bacterial sore throats

Group A streptococcal, Diphtheria

Group A streptococcal Pharyngitis

-most common bacterial agent
​-tends to be more generalized symptoms
​S/Sxs: typically enlarged and tender lymph glands, with BRIGHT RED inflamed and swollen throat, often unilateral, progresses more RAPIDLY than viral infections; may have a high temperature, headache, myalgia, arthralgia

The four best predictors of streptococcus:
1. Lack of cough
​sensitivity = 56%
​specificity = 74%
2. Swollen tender anterior cervical nodes
​sensitivity = 80%
​specificity = 55%
3. Marked tonsillar exudates.
​sensitivity = 65%
​specificity = 69%
4. History of fever
​sensitivity = 78%
​specificity = 45%

the probabilities of positive cultures with:
​4 findings -&gt; 55.7%
​3 findings -&gt; 30.1 - 34.1%
​2 findings -&gt; 14.1 - 16.6%
​1 findings -&gt; 6.0 - 6.9%
​0 findings -&gt; 2.5%

What are potential (but rare) complications?
​1. Non-suppurative: ​all these are extremely rare, whether treated with antibiotics or not
-rheumatic fever
-toxic shock syndrome
-glomerulonephritis
-PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (presents with episodes of OCD))

2. Suppurative: all these conditions are infrequently encountered but remain the compelling reason for antibiotics
-tonsillopharyngeal cellulitis
-peritonsillar and retropharyngeal abscess
-sinusitis
-meningitis
-brain abscess
-otitis media
-strep bacteremia

Diphtheria induced Pharyngitis

​-potentially life threatening URI
-caused by Corynebacterium diphtheriae
-​largely eradicated in developed nations, but still reported in the Third World


​viral​bacterial​ fungal​
prevalence​common​less common​least common
fever​low <102​101-104​none
nodes​little change​common LA​occasional LA
pain​mild-mod​mod-severe​moderate
erythema​1+​3-4+​white or red
​red around ​beefy red​patches
​tonsils​
​cobblestoning

Tonsillitis

-​Acute inflammation of the palatine tonsils due to strep or viruses

Etiology:
​A. Bacterial - may be caused by Group A strep
​B. Viral - may be caused by numerous viruses (Epstein-Barr, Adenovirus)

3 main types:
​1. Acute - either bacterial (red, swollen tonsils w/ white patches, swollen uvula, grey furry tongue) or viral (red, swollen tonsils) in origin
​2. Subacute - (between 3 weeks and 3 months) is caused by the bacterium Actinomyces
​3. Chronic - can last for long periods, almost always bacterial​

S/Sxs: Looks like pharyngitis as far as symptoms are concerned
-high fever, malaise, vomiting common
​-enlarged hyperemic tonsils with purulent exudate
-​may see membrane on tonsils
​-fetid breath
-sudden onset
​-in chronic cases the tonsils become fibrotic- so should consider surgery in these cases

Complications:
​A. peritonsillar abscess (quinsy)
​-abscess lateral to the tonsil during an infection, typically several days after the onset of tonsillitis
​B. tonsilloliths
-​whitish-yellow deposits produced by bacteria feeding on mucus which accumulates in crypts. -These &quot;tonsil stones&quot; emit a very pungent odor due to the presence of volatile sulphur compounds
​C. hypertrophy of the tonsils: can result in snoring, mouth breathing, disturbed sleep, and obstructive sleep apnea

DDX:
-trenchmouth
-diphtheria

Peritonsillar abscess: (quinsy)

-​a type of cellulitis; acute infection between the tonsil and pharyngeal constrictor muscle
-VERY SERIOUS! Worry about occlusion of the airway or meningitis. Needs surgical intervention to drain abscess or remove tonsils.

Etiology:
-​usually arises as a complication of an untreated or partially treated acute tonsillitis as the infection spreads to the peritonsillar area
​-both aerobic and anaerobic bacteria can be causative commonly involved species include strep, staph and H. flu

Signs & Sxs:
​-affects children to adults, rare in small children
-​sxs start ~ 2-8 days before the formation of abscess.
-​earliest symptoms are progressively worsening unilateral sore throat and pain during swallowing
-​as abscess develops, persistent pain in the peritonsillar area, fever, malaise, headache and change in voice (hot potato voice) may appear
-​signs include neck pain associated with tender, swollen lymph nodes, referred ear pain and breath odor. PTA should be specifically considered if there is limited ability to open the mouth (trismus)
-​redness and edema in the tonsillar area of the affected side and the uvula may be displaced towards the unaffected side

Parapharyngeal abscess

-SERIOUS! Needs surgical intervention!!
​-suppuration of the parapharyngeal lymph nodes with abscess formation secondary to tonsillitis or pharyngitis
​-can occur at any age
​-abscess is lateral to the superior constrictor muscle and close to the carotid sheath;
-markedly swollen anterior triangle in the neck
​throat itself may appear normal

Retropharyngeal abscess

-​an infection in one of the deep spaces of the neck
-SERIOUS! ​an immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications​

​-usually occur in small children or infants as complication of suppurative retropharyngeal lymph nodes, where infection has spread from the nose, ears, sinuses or tonsils; once almost exclusively a disease of children, is observed with increasing frequency in adults

Signs & Sxs:
​-may complain of sore throat, difficulty swallowing (dysphagia), pain on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness (torticollis)
-​may also complain of muffled voice, the sensation of a lump in the throat, and/or pain in the back and shoulders upon swallowing​
​-constitutional complaints such as fever, chills, malaise, decreased appetite, and irritability
-​difficulty breathing is an ominous complaint that signifies impending airway obstruction.

Recurrent Infections of the Pharynx

-Most common in people who have chronically inflamed tonsils due to incomplete resolution of previous infections.
-​scarring, fibrosis and abscess formation in the tonsils
-​treatment varies according to age as tonsils are more important in terms of immune function before age 12.
​-removal of tonsils has less impact on children older than 12 and adults
-​antibiotics of limited value in chronic infections

Chronic irritation of the pharynx

​-duration and nature of the complaint will suggest the diagnosis
​-mostly a disease of adults, with discomfort rather than pain

Etiology:​
-​chronic sinusitis​
-allergies
​-dental problems​
-chronically infected tonsils
-​chronic bronchitis​
-mouth breathing
-​septal deviation​
-vocal abuse
​-tobacco
-​alcohol
​-low humidity
-​industrial fumes
-​hot or spicy foods
​-may be a complication of nephritis, cirrhosis, cardiac disease, AIDS, gastric reflux, hiatal hernia, obesity and pregnancy

S/Sxs:
-​thickened mucosa, increased mucus, hypertrophic lymph tissue
​-check for chronic infection of the nose and gums, for mouth breathing
​-barium swallow may be needed to rule out malignancy

Velopharyngeal insufficiency

-​incomplete closure of the sphincter between the oro- and nasopharynx, resulting in impaired deglutition and speech
-​nasal speech and weakness of the voice
requires surgery if there is significant regurgitation of food

Malignancies in the pharynx

-​pain accompanied by an abnormal sensation in the throat of something being stuck there
​-in early stages the tumor appears as a red smooth mass, sometimes with surface keratinization;
-usually squamous cell cancers
-​sometimes a mass in the neck is a first sign
-​oral cancers can also affect the salivary glands and present as neck lumps, or on the face or under the ear

Differences between viral, bacterial and fungal pharyngitis:​

Viral:
-Prevalence: common
-Fever: low <102
-Nodes: little change
-Pain: mild-moderate
-Erythema: 1+ ,red around tonsils, cobblestoning

Bacterial:
-Prevalence: less common
-Fever: 101-104
-Nodes: common LAD
-Pain: moderate-severe
-Erythema: 3-4+, beefy red

Fungal:
-Prevalence: least common
-Fever: none
-Nodes: occasional LAD
-Pain: moderate
-Erythema: white or red patches

Hoarseness

-​due to structural changes in the vocal cords that impair their ability to vibrate
-​common in all age groups and usually due to self-limiting conditions

-​Recent onset: URI, polyps of the vocal cords; rule out sinus and respiratory disease

-​Chronic:
A. in children usually due to vocal abuse, or allergies
​B. in adults: alcohol and tobacco are common causes

-Local causes: inflammation, polyps, hypothyroidism, fibrous nodes, leukoplakia, papilloma, carcinoma

-Neurological causes: nerve impairment in the cords, MG, Parkinson's, ​recurrent nerve paralysis

-General causes: weak expiratory airflow due to tracheal compression, or general weakness

-emotional causes

-systemic causes: aortic aneurysm, TB, syphilis, hypothyroidism

Vocal cord polyps

​-benign, fluid-filled lesion​

Etiology:
​-vocal abuse
-allergies
-inhalation of irritants

Signs & Sxs:
​-hoarseness and a breathy voice quality
​-visualize with indirect laryngoscopy

Vocal cord nodules

-​bilateral benign growths
-a result of voice overuse or misuse (eg singers)

​S/Sxs: are the same as for polyps
-hoarseness and a breathy voice quality
​-visualize with indirect laryngoscopy
-biopsies should be performed

Vocal cord contact ulcers

​-unilateral or bilateral ulcers on the mucus membrane over the vocal process of the arytenoids cartilage

Causes:
-vocal abuse
-gastric reflux most commonly

​S/Sx:
-mild pain on speaking and swallowing
-hoarseness

-prolonged ulceration leads to granulomas formation

Laryngitis

-​hoarse voice or the complete loss of the voice because of irritation to the vocal cords​

Etiology:
-viral infection
-​bacterial or fungal infection
-inflammation due to overuse of the vocal cords
-​excessive coughing

Signs & Sxs:
-​voice change, hoarseness and aphonia, tickling sensation in the throat, clearing the throat a lot
​-symptoms vary; may be severe with pain and dysphagia, dyspnea
​-can accompany other URI, allergies
​-Acute: lasts less than a few days
-Chronic: may last over 3 weeks

Epiglottitis

Etiology:
-​bacterial infection of the epiglottis, most often caused by Haemophilus influenzae type B, although some cases are attributable to Streptococcus pneumoniae or Streptococcus pyogenes.
-​MEDICAL EMERGENCY (Can occlude the trachea)

Signs &amp; Sxs:
​-typically affects children 2-5 years (not as common -Hib vaccine?)
​-associated with fever, difficulty swallowing, drooling, and stridor.
-​appears acutely ill, anxious, and has very quiet shallow breathing with the head held forward,
-insisting on sitting up in bed. ​
​-early symptoms are insidious but rapidly progressive, and swelling of the throat may lead to cyanosis and asphyxiation.

Diagnosis:
​-DO NOT try to visualize throat (may provoke airway spasm and obstruct airway)
​-on lateral C-spine X-ray, the thumbprint sign is a finding that suggests the diagnosis of epiglottitis.
-​confirmed by direct inspection using laryngoscopy, although this may provoke airway spasm.

Differential diagnosis
​-croup, peritonsillar abscess, and retropharyngeal abscess.

Squamous cell cancer

​-most common type of cancer in the head and neck
​-represents more than 90% of all head and neck cancers.
-​alcohol and tobacco predispose
-more common in males
​-most common site is the true vocal cords

S/Sx: main symptom is hoarseness, or pain on swallowing or chewing

Lumps in the neck

​History: patient's age, general state of health, presence of pain and associated symptoms

Etiology:
​-in Adults: most are due to inflammatory or neoplastic conditions of the cervical lymph nodes
-in Kids: usually due to recurrent tonsillitis
​also, TB and brachial cysts.
​-children often have enlarged cervical lymph nodes

​-general LAD, suspected when there is acute inflammation of the tonsils, often with a white membrane and severe systemic symptoms.

​-Neoplasm of the lymphatic chain: presents with cervical LAD; confirm with biopsy

-enlargement of the nodes can also occur with metastases from other areas

-Salivary gland swelling: may be inflammatory (mumps, bacteria) or the result of a stone in the duct. May also result from primary malignancy: early removal is generally curative

-​Medial neck swellings: usually due to the spread of infection from other areas or more commonly is the result of thyroid disease

-​thyroglossal cysts are medial swellings close to the body of the hyoid bone that become recurrently inflamed

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