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Differential Diagnosis of Hoarseness Infections to Pharynx and Oral Cavity

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Title: Differential Diagnosis of Hoarseness Infections to Pharynx and Oral Cavity


1
Differential Diagnosis of HoarsenessInfections
to Pharynx and Oral Cavity
  • By
  • Stacey Singer-Leshinsky R-PAC

2
Anatomy of the Pharynx
3
Acute Pharyngitis
  • Can be accompanied by conjunctivitis, cough,
    sputum production, rhinitis or other systemic
    symptoms.
  • Most common in winter and early spring
  • Common patient complaint

4
Acute Pharyngitis Etiology
  • Viral-
  • Respiratory viruses
  • Influenza
  • Epstein-Barr virus
  • Herpes Simplex Virus, Herpangina
  • Bacterial-
  • S. pyogenes, N. gonorrhoeae, Cornynebacterium
    diphtheriae

5
Acute Pharyngitis Etiology
  • Non infectious including
  • Allergy
  • inhalation of irritating fumes
  • gastroesophageal reflux
  • sleep apnea

6
Viral Pharyngitis Respiratory Viral syndromes
  • Etiology Rhinovirus, Adenovirus, Parainfluenza
  • Transmission
  • Clinical Manifestations Sore throat and
  • Coryza
  • Conjunctivitis
  • Cough with/without sputum production
  • Other systemic symptoms.
  • Diagnostics
  • Management Analgesics, cough suppressant
    (Dextromethophan), decongestants

7
Viral PharyngitisInfluenza
  • Etiology orthomyxovirus
  • Transmission
  • Clinical manifestations sore throat, exudates to
    pharynx possible
  • Fever
  • Myalgias
  • Headache
  • Non-productive cough
  • Diagnostics
  • Management Amantadine or Rimantadine

8
Epstein Barr /Mononucleosis
  • Incubation 2-5 weeks.
  • One infection lifelong immumunity
  • Etiology Epstein Barr Virus, CMV
  • Transmission

9
Epstein Barr /Mononucleosis
  • Clinical manifestations
  • Prodrome of malaise, headache, and fatigue
    followed by fever
  • Lymphadenopathy
  • Pharyngeal erythema
  • Splenomegaly-
  • Maculopapular rash

10
Epstein Barr /Mononucleosis
  • Diagnostics
  • Monospot Heterophile antibody.
  • Assay for EBV antibodies.
  • Blood smear Atypical lymphocytosis
  • Throat culture Rule out secondary infection

11
Epstein Barr /Mononucleosis
  • Management
  • Avoid activity if Splenomegaly.
  • Complications
  • Splenic rupture
  • Hepatitis
  • Thrombocytopenia
  • Neurologic Guillain-Barre syndrome

12
Viral PharyngitisHerpangina
  • Due to Coxsackie group A viruses
  • If tender, vesicular lesions on dorsum of hands
    and palms which form bullae and ulcerate, then
    known as hand, foot and mouth disease.
  • Complications CNS disease, myocarditis,
  • Transmitted through fecal/oral or airborne

13
Viral Pharyngitis Herpangina
  • Acute onset of fever, anorexia and malaise
  • Sore throat
  • Grayish white papulovesicular lesions on
    erythematous base that ulcerate. Located on soft
    palate, anterior pillars of the tonsils, and
    uvula.

14
Viral Pharyngitis Herpangina
  • Diagnosis cultures or swabs of nasopharynx,
    Antibody titer
  • Management Hydration, antipyretics, Topical
    analgesics

15
Viral PharyngitisAcute HIV Syndrome
  • Consider in any patient with HIV exposure and
    fever of unknown origin
  • Begins after incubation period of few days to
    weeks post exposure.
  • Flu like illness lasts 7-14 days.

16
Viral PharyngitisAcute HIV Syndrome
  • Sore throat / Oral ulcers
  • Fever
  • Maculopapular rash
  • Lymphadenopathy
  • Arthralgia
  • Malaise
  • Weight loss

17
Viral PharyngitisAcute HIV Syndrome
  • Diagnosis Detection of HIV-1 replication without
    antibodies. Plasma HIV-1 RNA. Follow for positive
    antibodies.
  • Differential Diagnosis Mononucleosis
  • Management Antiretroviral therapy

18
Viral PharyngitisHSV
  • Etiology HSV types I and II
  • Transmission is direct contact with mucous or
    saliva
  • Clinical manifestations
  • First episode involves gingivostomatitis and
    Pharyngitis
  • Can mimic streptococcal infection

19
Viral PharyngitisHSV
  • Clinical Manifestations
  • Fever, malaise, myalgia, anorexia, irritability
  • Cervical lymphadenopathy
  • Pharynx Exudative ulcerative lesions. Grouped
    vesicles on erythematous base to buccal mucosa
    and hard and soft palate.
  • Diagnosis Culture
  • Management Acyclovir, Valacyclovir

20
Bacterial PharyngitisStreptococcal Pharyngitis
  • S. pyogenes Group A Beta hemolytic strep
  • Gram positive bacteria that displays group A
    antigen on cell wall and beta
  • Streptolysin O and S and toxins which produce
    beta-hemolytic properties. Can find antibodies to
    this
  • Transmission is direct contact.

21
Bacterial PharyngitisStreptococcal Pharyngitis
  • Clinical manifestations
  • Acute onset of Severe sore throat and dysphagia
  • NO coryza, NO cough, NO hoarseness
  • Fever gt101f
  • Hyperemic pharyngeal membrane with tonsillar
    hypertrophy and exudates.
  • Tender anterior cervical adenopathy
  • Possible recent exposure. Lasts 7-10 days

22
Bacterial PharyngitisStreptococcal Pharyngitis
  • Diagnosis
  • Throat culture
  • Rapid antigen-detection test
  • Management
  • Penicillin, ten day course.
  • Erythromycin

23
Bacterial PharyngitisStreptococcal Pharyngitis
  • Complications
  • scarlet fever
  • rheumatic fever Heart failure, pain and swelling
    to joints, fever, rash, nodules under skin.
  • Glomerulonephritis 10 days post infection.
    Decreased urine output, dark urine, mild
    swelling, temporary kidney failure that resolves.
  • peritonsillar abscess
  • otitis media, mastoiditis,
  • sinusitis, pneumonia

24
Bacterial PharyngitisGonococcal Pharyngitis
  • Etiology Neisseria gonorrhoeae. Gram-negative
    intracellular aerobic diplococcus.
  • Infection of the throat involving tonsils and
    larynx
  • Risks

25
Bacterial PharyngitisGonococcal Pharyngitis
  • Clinical manifestations
  • Might coexist with genital infection
  • Diagnosis throat swab on Thayer martin media
  • Management ceftriaxone or quinolones.

26
Diphtheria
  • Etiology Corynebacterium diphtheriae
  • Produces a potent exotoxin that causes an
    inflammatory response and formation of
    pseudomembrane on respiratory mucosa.
  • The exotoxin is absorbed. Inhibits protein
    synthesis which can damage kidney, heart, nerves
  • Death secondary to aspiration of membrane or
    toxic effect on heart

27
Diphtheria
  • Severe sore throat
  • Fever
  • Adherent whitish blue pharyngeal exudates that
    cover pharynx. When scraped reveal underlying
    inflammation and edema. Known as pseudomembrane
  • Cervical adenopathy

28
Diphtheria
  • Diagnostics
  • Management Isolation. Antitoxin to neutralize
    toxin, erythromycin, penicillin
  • Complications- myocarditis, peripheral neuritis
  • DPT vaccine at 10 year intervals

29
Peritonsillar Abscess/Cellulitis
  • Infection from the tonsil to the peritonsillar
    fascial planes.
  • Etiology polymicrobial, anaerobic bacteria such
    as S. pyogenes, H. influenzae, Streptococcus
    milleri, Streptococcus viridans
  • Can be complication of mononucleosis,
    tonsillitis, peritonsillar Cellulitis

30
Peritonsillar Abscess/Cellulitis
  • Inflammation, pocket of pus in supratonsillar
    space
  • Trismus
  • Fever, odynophagia, headache, malaise, referred
    ear pain
  • Deviated uvula with peritonsillar swelling and
    erythema to posterior pharynx
  • Lymph node enlargement

31
Peritonsillar Abscess/Cellulitis
  • Diagnosis
  • Management
  • Incision and drainage of pus from peritonsillar
    fold followed by tonsillectomy
  • IM/IV penicillin
  • Complications
  • Extension of infection to retropharyngeal deep
    neck, posterior mediastinal space, and pneumonia

32
Retropharyngeal Abscess
  • Soft tissue infection causing difficulty in
    swallowing, fever and pain.
  • Risk factors including acute pharyngitis, otitis
    media, tonsillitis, dental infections, ludwigs
    angina
  • Etiology Aerobes and anaerobes including Group A
    beta hemolytic streptococci and S. aureus

33
Retropharyngeal AbscessClinical Features
  • Sore throat
  • Fever
  • Dysphagia
  • Neck pain/ stridor
  • Drooling
  • Neck stiffness
  • Cervical adenopathy
  • Bulge in posterior pharyngeal wall
  • Lateral neck or CT show soft tissue mass

34
Retropharyngeal AbscessManagement/Complications
  • Management
  • Airway-
  • Surgical drainage
  • IV antibiotics to cover gram positive, negatives
    and anaerobes such as clindamycin, Penicillin,
    Timentin
  • Complications
  • Extension of disease including
  • Pericarditis
  • Rupture of abscess leading to aspiration
    pneumonia

35
Intraoral ulcerative LesionsNecrotizing
Ulcerative Gingivitis
  • Etiology Spirochetes and fusiform bacilli
  • Risk factors include tobacco, stress, poor
    hygiene, poor nutrition.

36
Intraoral ulcerative LesionsNecrotizing
Ulcerative Gingivitis
  • Clinical features
  • Rapid onset of pain with ulceration, swelling
  • Interdental necrosis and bleeding
  • Foul breath
  • Gray exudate removable with gentle pressure

37
Intraoral ulcerative LesionsNecrotizing
Ulcerative Gingivitis
  • Complications fever, cervical lymphadenopathy,
    leukocytosis, destruction of bone and surrounding
    tissue, gangrene
  • Management
  • Debridement
  • Half strength peroxide
  • Penicillin

38
Intraoral ulcerative LesionsAphthous Ulcer
  • Caused by nonspecific acute inflammation
  • found on buccal and labial mucosa, oropharynx,
    tongue
  • Diagnostics
  • Differential diagnosis Erythema multiforme, Drug
    allergy, Inflammatory bowel disease, Squamous
    cell carcinoma
  • Complications

39
Intraoral ulcerative LesionsAphthous Ulcer
  • Painful small round ulcerations with yellow-gray
    centers surrounded by erythematous halos .
  • Management Self limited, topical analgesics,
    topical steroids

40
Intraoral ulcerative LesionsHerpes Simplex Virus
I
  • Viral infection
  • Infects trigeminal nerve and can remain dormant
    for long periods.
  • Found attached to gingiva, hard palate

41
Intraoral ulcerative LesionsHerpes Simplex Virus
I
  • Burning followed by small vesicles
  • Pain
  • Fever, headache
  • Malaise
  • Recurrent

42
Intraoral ulcerative LesionsHerpes Simplex Virus
I
  • Diagnostics include Tzanck smear with
    multinucleated giant cells
  • Differential diagnosis Erythema multiforme,
    Inflammatory bowel disease, Squamous cell
    carcinoma
  • Management Self limited. Analgesics, hydration,
    Acyclovir or Valacyclovir

43
DentalDental Carie
  • Tooth decay
  • Etiology as streptococcus mutans present in
    plaque
  • Clinical Manifestations
  • Toothache
  • Presents as aching pain when dentin is exposed
  • Management Analgesics, Antibiotics, dental
    consult

44
DentalDental Abscess
  • Decay of tooth into dentin and tooth pulp
  • Bacterial infection of the periodontal tissues
  • Etiology is Streptococcus mutans present in
    plaque

45
Tooth AbscessClinical Manifestations
  • Severe toothache
  • swelling
  • fever, leukocytosis
  • Management I/D, oral antibiotics, root canal

46
Oral Candidiasis
  • Opportunistic infection in infants, anemia
    patients, nutritional deficiencies,
    corticosteroid use, immunocompromised
  • Complications include spread to esophagus, brain

47
Oral Candidiasis
  • Whitish plaques to mouth/tongue above erythemic
    tissue that may bleed
  • White patches leave a raw, inflamed area
  • Confirmed by KOH prep
  • Management including antifungal mouth wash

48
Oral Leukoplakia
  • Hyperkeratosis
  • Increased thickness of keratin layer and
    neovascularization. Epithelial dysplasia is
    precancerous
  • Risks trauma, alcohol, tobacco
  • Erythroplakia more likely to be cancerous than
    leukoplakia.
  • Hairy leukoplakia

49
Oral Leukoplakia
  • Flat or raise white lesion that cannot be
    removed by rubbing the mucosal surface
  • Erythroplakia is reddish, velvety lesion

50
Oral LeukoplakiaDiagnosis/ Management
  • Diagnosis Biopsy or cytologic examination
  • Complications
  • Differential diagnosis including squamous cell
    carcinoma, oral Candidiasis
  • Management
  • ENT
  • B-carotene and retinoids and Vit E might be
    effective.
  • If Biopsy positive for oral squamous carcinoma,
    surgery and chemotherapy

51
Oral Lichen Planus
  • Chronic autoimmune disease
  • Both cutaneous and mucosal forms
  • Cutaneous presents with 4 Ps
  • Can be aysmptomatic

52
Oral Lichen Planus
  • Painful oral mucosa/gums
  • White striations (wickham striae) with
    erythematous border located bilaterally on buccal
    mucosa
  • Lesions can erode into ulcers

53
Oral Lichen PlanusManagement
  • Differential diagnosis Pemphigus Vulgaris,
    chronic candidiasis or squamous cell carcinoma
  • Diagnosis Biopsy or Immunofluorescence-histologic
    al confirmation. deposition of fibrinogen along
    basement membrane zone
  • Management systemic or topical corticosteroids,
    cyclosporine mouthwash

54
Glossitis
  • Etiology
  • Nutritional deficiencies
  • Drug reactions
  • Dehydration
  • Psoriasis
  • Clinical Manifestations
  • Diagnostics
  • Management correct underlying problem.

55
Diseases of the Salivary GlandsSialadenitis
  • Infection or inflammatory disorder affecting
    either the parotid or submandibular gland
  • Etiology S. aureus, autoimmune, viral
  • Risk factors
  • Sjogrens syndrome

56
Diseases of the Salivary GlandsSialadenitis
  • Acute swelling of the gland
  • Pain and erythema at opening of duct
  • Pus massaged from duct.
  • Fever

57
Diseases of the Salivary GlandsSialadenitis
  • Diagnosis Ultrasound
  • Complications
  • Differential diagnosisDuctal stricture, Stone,
    Tumor
  • Management including IV antibiotics such as
    Nafcillin, increase salivary flow

58
Diseases of the Salivary GlandsSialolithiasis
  • More common in Whartons duct then stensons duct
  • Etiology inspirated secretions, ductal debris,
    calcium phosphate due to inflammation or stasis
  • Management hydration, warm compresses, massage
    to gland area.

59
Diseases of the Salivary GlandsSialolithiasis
  • Clinical manifestations
  • Partial obstruction leads to enlargement and pain
    on eating
  • Total obstruction leads to chronic enlargement
    and infection
  • Palpate gland for calculi, examine all glands for
    masses, symmetry, purulence
  • Diagnosis x-ray/CT Wharton duct usually
    radiopaque, stenson smaller
  • sialography

60
Diseases of the Salivary GlandsParotitis
  • Inflammation or infection of one or both of the
    parotid salivary glands.
  • Chronic bilateral parotitis associated with
    autoimmune disease, unilateral associated with
    stones.
  • Etiology is viral or bacterial- paramyxoviral
    most common viral and s. aureus most common
    bacterial

61
Diseases of the Salivary GlandsParotitis
  • Swelling and erythema to preauricular and
    postauricular areas
  • Fever

62
Diseases of the Salivary GlandsParotitis
  • Diagnosis
  • Aspiration of duct and culture
  • Management
  • Augmentin or Clindamycin until specific
    microorganism found

63
Halitosis
  • Foul breath odor
  • Etiology can be impaired salivary flow
  • Management

64
TMJ Dysfunction
  • Consequence of bruxism leading to masticatory
    muscle fatigue and spasm.
  • Clinical features include
  • chronic, dull, aching, unilateral discomfort to
    the jaw, behind eyes, ears or neck
  • Patient complains of clicking sounds

65
TMJ DysfunctionManagement
  • Dietary advice
  • Avoid clenching
  • Relax muscles with moist heat

66
Ludwigs Angina
  • Severe Cellulitis of the submaxillary space with
    involvement of the sublingual and submental
    space.
  • Etiology Infection to lower molars, penetrating
    injury to mouth floor.
  • Etiology

67
Ludwigs Angina
  • Fever
  • Edema and erythema
  • Floor of mouth rigid
  • Neck movement
  • Tongue displaced
  • Dysphonia, dysphagia, trismus, drooling, stridor

68
Ludwigs Angina
  • Diagnosis culture, CT
  • Management
  • ENT/dental consult
  • I/D
  • IV antibiotics
  • Admit to ICU
  • Complications

69
Differential Diagnosis of Hoarseness
  • Vocal quality- determined by
  • distance between vocal cords,
  • tenseness of the cords
  • how rapid cords vibrate
  • Hoarseness is caused by

70
Differential Diagnosis of HoarsenessTypes of
voice
  • Breathy- vocal cords do not approximate so air
    escapes.
  • Raspy- harsh voice. Cord thickening due to edema
    or inflammation. Voice is low in pitch and poor
    quality

71
Differential Diagnosis of HoarsenessTypes of
voice
  • Muffled voice- painful dysphagia and dyspnea
  • Shaky- high pitch or low soft.
  • Elderly
  • debilitated

72
Differential Diagnosis of HoarsenessAcute
Hoarseness/Acute Laryngitis
  • Laryngeal mucous membrane infection, usually
    viral (adenovirus/ influenza, RSV, coxsackie,
    rhinovirus)
  • Also can be due to trauma to throat, vocal abuse,
    toxic exposure, GI complications, smoking, allergy

73
Differential Diagnosis of HoarsenessAcute
Hoarseness/Acute Laryngitis
  • Hoarseness
  • Cough
  • Sore throat
  • Fever
  • Vesicles on soft palate
  • Lymphadenopathy

74
Differential Diagnosis of HoarsenessAcute
Hoarseness/Acute Laryngitis
  • Diagnostics Laryngoscopy if suspect mass,
    infection, vocal cord dysfunction
  • Management Voice rest, smoking/alcohol
    cessation, hydration

75
Differential Diagnosis of HoarsenessVocal Cord
Lesions
  • Smooth paired lesions.
  • Form due to vocal abuse
  • respond to voice rest and vocal therapy
  • Surgery

76
Leukoplakia on Vocal Cords
  • Hyperkeratotic changes
  • Presents as hoarseness with no pain
  • Premalignant
  • Found in smokers

77
Laryngeal Carcinoma
  • Laryngeal carcinoma
  • History of smoking and drinking
  • Usually pain when swallowing only second to
    ulceration
  • Fetid breath

78
Vocal Cord Paralysis
  • Usually affects one cord
  • Nerve often injured in surgery
  • Vocal cord trauma second to traumatic or chronic
    intubation
  • Systemic disorders such as hypothyroidism,
    rheumatoid arthritis, GERD

79
Vocal Cord Trauma
80
Differential Diagnosis of HoarsenessHistory
Questions
  • Discuss history and physical exam questions
    important in distinguishing the etiology of
    hoarseness including
  • Onset-
  • Exacerbating factors
  • Recent URI
  • Exposure to irritants
  • History of Hypothyroidism?
  • History of smoking, cancer?

81
Differential Diagnosis of HoarsenessPhysical Exam
  • Physical Exam
  • Airway, Breathing and Circulation
  • HEENT exam
  • Neck exam
  • Thyroid Exam
  • Thorax and cardiac
  • Laryngoscopy

82
Review 1
  • A 21 year old female presents to you complaining
    of runny nose and cough. She is afebrile. What is
    the most likely diagnosis and etiology of this
    diagnosis?

83
Review 2
  • This patient had a prodrome of malaise and
    headache followed by fever and sore throat. On
    physical exam you note this and petechiae on
    junction of hard and soft palate. Also anterior
    and posterior cervical adenopathy.
  • What is your differential?
  • What lab results are expected to confirm this?
  • What is a complication of this?

84
Review 3
  • A mom brings in her 4 year old who has had an
    acute onset of fever, anorexia, and sore throat.
    On PE you note vesicles and ulcers on the tonsil
    pillars and soft palate.
  • What is your differential?
  • What is the management for this?
  • What is hand, foot and mouth disease and a
    complication of this?

85
Review 4
  • This patient had an acute onset of sore throat
    and fever of 102 with no coryza or cough. On PE
    you note anterior cervical adenopathy
  • What is this?
  • How is this diagnosed?
  • How is this managed?
  • What are some complications of this?

86
Review 5
  • A 6 year old presents with severe sore throat and
    fever. On PE you note a adherent whitish blue
    pharyngeal exudate that causes bleeding if
    removed.
  • What is this?
  • What is the management of this?
  • Can this be prevented?
  • What causes the damage in this condition?

87
Review 6
  • A 32 year old male presents with a painful lesion
    to his mouth for two days. On PE you note a small
    round ulceration with yellow gray center
    surrounded by red halos.
  • What is this?
  • What is the possible etiology of this?
  • What is in the differential diagnosis?
  • How is this treated?

88
Review 7
  • A 32 year old male presents with this. He
    described the onset of this as burning followed
    by small vesicles that ruptured and turned into
    ulcers.
  • What is this?
  • How is this diagnosed?
  • What is the management of this?

89
Review 8
  • This patient is an asthmatic who uses
    corticosteroids. She is concerned over these
    white painful lesions she has developed in her
    mouth.
  • What is this?
  • What will happen when we attempt to remove this
    white film?
  • How is this managed?

90
Review 9
  • This lesion was noted by patients dentist.
    Patient complains of painful gums. On PE you note
    Wickham striae.
  • What is this?
  • How is this diagnosed?
  • How is this treated?

91
Review 10
  • This patient presents with edema and erythema of
    upper neck, under chin and floor of mouth. She
    has pain on neck movement.
  • What is this?
  • How is her tongue displaced?
  • What is the management?
  • What complications exist?
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