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

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Anatomy of the Pharynx
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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

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Acute Pharyngitis Etiology

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

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Acute Pharyngitis Etiology

• Non infectious including
• Allergy
• inhalation of irritating fumes
• gastroesophageal reflux
• sleep apnea

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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

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Viral PharyngitisInfluenza

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

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Epstein Barr /Mononucleosis

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

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Epstein Barr /Mononucleosis

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

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Epstein Barr /Mononucleosis

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

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Epstein Barr /Mononucleosis

• Management
• Avoid activity if Splenomegaly.
• Complications
• Splenic rupture
• Hepatitis
• Thrombocytopenia
• Neurologic Guillain-Barre syndrome

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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

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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.

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Viral Pharyngitis Herpangina

• Diagnosis cultures or swabs of nasopharynx,
  Antibody titer
• Management Hydration, antipyretics, Topical
  analgesics

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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.

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Viral PharyngitisAcute HIV Syndrome

• Sore throat / Oral ulcers
• Fever
• Maculopapular rash
• Lymphadenopathy
• Arthralgia
• Malaise
• Weight loss

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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

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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

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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

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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.

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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

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Bacterial PharyngitisStreptococcal Pharyngitis

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

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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

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Bacterial PharyngitisGonococcal Pharyngitis

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

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Bacterial PharyngitisGonococcal Pharyngitis

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

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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

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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

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Diphtheria

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

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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

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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

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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

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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

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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

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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

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Intraoral ulcerative LesionsNecrotizing
Ulcerative Gingivitis

• Etiology Spirochetes and fusiform bacilli
• Risk factors include tobacco, stress, poor
  hygiene, poor nutrition.

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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

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Intraoral ulcerative LesionsNecrotizing
Ulcerative Gingivitis

• Complications fever, cervical lymphadenopathy,
  leukocytosis, destruction of bone and surrounding
  tissue, gangrene
• Management
• Debridement
• Half strength peroxide
• Penicillin

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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

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Intraoral ulcerative LesionsAphthous Ulcer

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

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Intraoral ulcerative LesionsHerpes Simplex Virus
I

• Viral infection
• Infects trigeminal nerve and can remain dormant
  for long periods.
• Found attached to gingiva, hard palate

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Intraoral ulcerative LesionsHerpes Simplex Virus
I

• Burning followed by small vesicles
• Pain
• Fever, headache
• Malaise
• Recurrent

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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

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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

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DentalDental Abscess

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

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Tooth AbscessClinical Manifestations

• Severe toothache
• swelling
• fever, leukocytosis
• Management I/D, oral antibiotics, root canal

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Oral Candidiasis

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

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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

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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

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Oral Leukoplakia

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

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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

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Oral Lichen Planus

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

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Oral Lichen Planus

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

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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

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Glossitis

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

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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

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Diseases of the Salivary GlandsSialadenitis

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

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Diseases of the Salivary GlandsSialadenitis

• Diagnosis Ultrasound
• Complications
• Differential diagnosisDuctal stricture, Stone,
  Tumor
• Management including IV antibiotics such as
  Nafcillin, increase salivary flow

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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.

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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

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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

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Diseases of the Salivary GlandsParotitis

• Swelling and erythema to preauricular and
  postauricular areas
• Fever

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Diseases of the Salivary GlandsParotitis

• Diagnosis
• Aspiration of duct and culture
• Management
• Augmentin or Clindamycin until specific
  microorganism found

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Halitosis

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

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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

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TMJ DysfunctionManagement

• Dietary advice
• Avoid clenching
• Relax muscles with moist heat

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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

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Ludwigs Angina

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

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Ludwigs Angina

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

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Differential Diagnosis of Hoarseness

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

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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

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Differential Diagnosis of HoarsenessTypes of
voice

• Muffled voice- painful dysphagia and dyspnea
• Shaky- high pitch or low soft.
• Elderly
• debilitated

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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

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Differential Diagnosis of HoarsenessAcute
Hoarseness/Acute Laryngitis

• Hoarseness
• Cough
• Sore throat
• Fever
• Vesicles on soft palate
• Lymphadenopathy

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Differential Diagnosis of HoarsenessAcute
Hoarseness/Acute Laryngitis

• Diagnostics Laryngoscopy if suspect mass,
  infection, vocal cord dysfunction
• Management Voice rest, smoking/alcohol
  cessation, hydration

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Differential Diagnosis of HoarsenessVocal Cord
Lesions

• Smooth paired lesions.
• Form due to vocal abuse
• respond to voice rest and vocal therapy
• Surgery

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Leukoplakia on Vocal Cords

• Hyperkeratotic changes
• Presents as hoarseness with no pain
• Premalignant
• Found in smokers

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Laryngeal Carcinoma

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

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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

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Vocal Cord Trauma
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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?

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Differential Diagnosis of HoarsenessPhysical Exam

• Physical Exam
• Airway, Breathing and Circulation
• HEENT exam
• Neck exam
• Thyroid Exam
• Thorax and cardiac
• Laryngoscopy

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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?

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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?

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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?

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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?

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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?

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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?

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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?

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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?

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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?