Causes of Mouth conditions

• Inflammatory
  –Allergy
  –Gastroesophageal reflux disease
  –Sinusitis resulting in postnasal drainage
• Tumors
  –Leukemia
  –Rhabdosarcomas
  –Squamous cell carcinoma secondary to oral ulcerations
• Trauma
  –Foreign body ingestion
  –Caustic ingestion
  –Soft tissue injury from accidental and nonaccidental trauma
• Systemic/rheumatologic disorders
  –Kawasaki disease: Mucocutaneous lymph node syndrome may have sore throat at presentation (other oral findings include strawberry tongue, fissured lips, mucosal erythema, fever, and lymphadenopathy)
  –Behçet syndrome
  –Reiter syndrome
  • Others
    –Cigarette smoke
    –Environmental pollutants
    –Pharyngeal drying: Mouth and pharynx can be dry from mouth breathing, more common in the winter months

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Mouth lesions: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Acquired immunodeficiency syndrome (AIDS)

Oral lesions may be an early indication of the immunosuppression that’s characteristic of AIDS. Fungal infections can occur, with oral candidiasis being the most common. Bacterial or viral infections of the oral mucosa, tongue, gingivae, and periodontal tissue may also occur.

The primary oral neoplasm associated with AIDS is Kaposi’s sarcoma. The tumor is usually found on the hard palate and may appear initially as an asymptomatic, flat or raised lesion, ranging in color from red to blue to purple. As these tumors grow, they may ulcerate and become painful.

Actinomycosis (cervicofacial)

Actinomycosis is a chronic fungal infection that typically produces small, firm, flat, and usually painless swellings on the oral mucosa and under the skin of the jaw and neck. Swellings may indurate and abscess, producing fistulas and sinus tracts with a characteristic purulent yellow discharge.

Behçet’s syndrome

Behçet’s syndrome is a chronic, progressive syndrome that generally affects young males and produces small, painful ulcers on the lips, gums, buccal mucosa, and tongue. In severe cases, the ulcers also develop on the palate, pharynx, and esophagus. The ulcers typically have a reddened border and are covered with a gray or yellow exudate. Similar lesions appear on the scrotum and penis or labia majora; small pustules or papules on the trunk and limbs; and painful erythematous nodules on the shins. Ocular lesions may also develop.

Candidiasis

Candidiasis is a common fungal infection that characteristically produces soft, elevated plaques on the buccal mucosa, tongue, and sometimes the palate, gingivae, and floor of the mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of redness, pruritus, and a foul odor may be present.

Discoid lupus erythematosus

Oral lesions are common, typically appearing on the tongue, buccal mucosa, and palate as erythematous areas with white spots and radiating white striae. Associated findings include skin lesions on the face, possibly extending to the neck, ears, and scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with scale.

Gender Cue:This chronic, recurrent disease is most common in women ages 30 to 40.

Erythema multiforme

Erythema multiforme is an acute inflammatory skin disease that produces a sudden onset of vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia. Lymphadenopathy may also occur. With visceral involvement, other findings include a fever, malaise, a cough, throat and chest pain, vomiting, diarrhea, myalgia, arthralgia, fingernail loss, blindness, hematuria, and signs of renal failure.

Gingivitis (acute necrotizing ulcerative)

Gingivitis is a recurring periodontal condition that causes a sudden onset of gingival ulcers covered with a grayish white pseudomembrane. Other findings include tender or painful gingivae, intermittent gingival bleeding, halitosis, enlarged lymph nodes in the neck, and a fever.

Herpes simplex I

With primary infection, a brief period of prodromal tingling and itching, which is accompanied by a fever and pharyngitis, is followed by eruption of small and irritating vesicles on part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation, halitosis, anorexia, and keratoconjunctivitis.

Herpes zoster

Herpes zoster is a common viral infection that may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small red nodules typically erupt unilaterally around the thorax or vertically on the arms and legs, and rapidly become vesicles filled with clear fluid or pus; vesicles dry and form scabs about 10 days after eruption. A fever and general malaise accompany pruritus, paresthesia or hyperesthesia, and tenderness along the course of the involved sensory nerve.

Inflammatory fibrous hyperplasia

Inflammatory fibrous hyperplasia is a painless nodular swelling of the buccal mucosa that typically results from cheek trauma or irritation and is characterized by pink, smooth, pedunculated areas of soft tissue.

Leukoplakia, erythroplakia

Leukoplakia is a white lesion that can’t be removed simply by rubbing the mucosal surface — unlike candidiasis. It may occur in response to chronic irritation from dentures or from tobacco or pipe smoking, or it may represent dysplasia or early squamous cell carcinoma.

Erythroplakia is red and edematous and has a velvety surface. About 90% of all cases of erythroplakia are either dysplasia or cancer.

Pemphigoid (benign mucosal)

Pemphigoid is a rare autoimmune disease that’s characterized by thick-walled vesicles on the oral mucous membranes, the conjunctiva and, less commonly, the skin. Mouth lesions typically develop months or even years before other manifestations and may occur as desquamative patchy gingivitis or as a vesicobullous eruption. Secondary fibrous bands may lead to dysphagia, hoarseness, and blindness. Recurrent skin lesions include vesicobullous eruptions, usually on the inguinal area and extremities, and an erythematous, vesicobullous plaque on the scalp and face near the affected mucous membranes.

Pemphigus

Pemphigus is a chronic skin disease that’s characterized by thin-walled vesicles and bullae that appear in cycles on skin or mucous membranes that otherwise appear normal. On the oral mucosa, bullae rupture, leaving painful lesions and raw patches that bleed easily. Associated findings include bullae anywhere on the body, denudation of the skin, and pruritus.

Pyogenic granuloma

Typically the result of injury, trauma, or irritation, pyogenic granuloma — a soft, tender nodule, papule, or polypoid mass of excessive granulated tissue — usually appears on the gingivae, but can also erupt on the lips, tongue, or buccal mucosa. The lesions bleed easily because they contain many capillaries. The affected area may be smooth or have a warty surface; erythema develops in the surrounding mucosa. The lesions may ulcerate, producing a purulent exudate.

Squamous cell carcinoma

Squamous cell carcinoma is typically a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is most common on the lower lip, but it may also occur on the edge of the tongue or floor of the mouth. High risk factors include chronic smoking and alcohol intake.

Stomatitis (aphthous)

Stomatitis, a common disease, is characterized by painful ulcerations of the oral mucosa, usually on the dorsum of the tongue, gingivae, and hard palate.

With recurrent aphthous stomatitis minor, the ulcer begins as one or more erosions covered by a gray membrane and surrounded by a red halo. It’s commonly found on the buccal and lip mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the periosteum.

With recurrent aphthous stomatitis major, large, painful ulcers commonly occur on the lips, cheek, tongue, and soft palate; they may last up to 6 weeks and leave a scar.

Syphilis

Primarysyphilis typically produces a solitary painless, red ulcer (chancre) on the lip, tongue, palate, tonsil, or gingivae. The ulcer appears as a crater with undulated, raised edges and a shiny center; lip chancres may develop a crust. Similar lesions may appear on the fingers, breasts, or genitals, and regional lymph nodes may become enlarged and tender.

During the secondary stage, multiple painless ulcers covered by a grayish white plaque may erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular rash appears, usually on the arms, trunk, palms, soles, face, and scalp; genital lesions usually subside. Other findings include generalized lymphadenopathy, a headache, malaise, anorexia, weight loss, nausea, vomiting, a sore throat, a low-grade fever, metrorrhagia, and postcoital bleeding.

At the tertiarystage, lesions (usually gummas — chronic, painless, superficial nodules or deep granulomatous lesions) develop on the skin and mucous membranes, especially the tongue and palate.

Systemic lupus erythematosus

Oral lesions are common and appear as erythematous areas associated with edema, petechiae, and superficial ulcers with a red halo and a tendency to bleed. Primary effects include nondeforming arthritis, a butterfly rash across the nose and cheeks, and photosensitivity.

Other causes

Drugs

Various chemotherapeutic agents can directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine, streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.

Radiation therapy

Radiation therapy may cause oral lesions.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Throat pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Agranulocytosis

With agranulocytosis, sore throat may accompany other signs and symptoms of infection, such as fever, chills, and headache. Typically, it follows progressive fatigue and weakness. Other findings include nausea and vomiting, anorexia, and bleeding tendencies. Rough-edged ulcers with gray or black membranes may appear on the gums, palate, or perianal area.

Bronchitis (acute)

Acute bronchitis may produce lower throat pain associated with fever, chills, cough, and muscle and back pain. Auscultation reveals rhonchi, wheezing and, at times, crackles.

Chronic fatigue syndrome

Chronic fatigue syndrome is a nonspecific symptom complex that’s characterized by incapacitating fatigue. Associated findings besides sore throat include myalgia and cognitive dysfunction.

Common cold

Sore throat may accompany cough, sneezing, nasal congestion, rhinorrhea, fatigue, headache, myalgia, and arthralgia.

Contact ulcers

Common in men with stressful jobs, contact ulcers appear symmetrically on the posterior vocal cords, resulting in sore throat. The pain is aggravated by talking and may be accompanied by referred ear pain and, occasionally, hemoptysis. Typically, the patient also has a history of chronic throat clearing or acid reflux.

Foreign body

A foreign body lodged in the palatine or lingual tonsil and pyriform sinus may produce localized throat pain. The pain may persist after the foreign body is dislodged until mucosal irritation resolves.

Gastroesophageal reflux disease (GERD)

With GERD, an incompetent gastroesophageal sphincter allows gastric juices to enter the hypopharynx and irritate the larynx, causing chronic sore throat and hoarseness. The arytenoids may also appear red and swollen, resulting in a sensation of a lump in the throat.

Influenza

Patients with the flu commonly complain of sore throat, fever with chills, headache, weakness, malaise, muscle aches, cough and, occasionally, hoarseness and rhinorrhea.

Laryngeal cancer

With extrinsic laryngeal cancer, the chief symptom is pain or burning in the throat when drinking citrus juice or hot liquids or a lump in the throat; with intrinsic laryngeal cancer, the chief symptom is hoarseness that persists for longer than 3 weeks. Later signs and symptoms of metastasis include dysphagia, dyspnea, a cough, enlarged cervical lymph nodes, and pain that radiates to the ear.

Mononucleosis (infectious)

Sore throat is one of the three classic findings in this infection. The other two classic signs are cervical lymphadenopathy and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Splenomegaly and hepatomegaly may also develop.

Necrotizing ulcerative gingivitis (acute)

Also known as trench mouth, necrotizing ulcerative gingivitis usually begins abruptly with sore throat and tender gums that ulcerate and bleed. A gray exudate may cover the gums and pharyngeal tonsils. Related signs and symptoms include a foul taste in the mouth, halitosis, cervical lymphadenopathy, headache, malaise, and fever.

Peritonsillar abscess

A complication of bacterial tonsillitis, this abscess typically causes severe throat pain that radiates to the ear. Accompanying the pain may be dysphagia, drooling, dysarthria, halitosis, fever with chills, malaise, and nausea. The patient usually tilts his head toward the side of the abscess. Examination may also reveal a deviated uvula, trismus, and tender cervical lymphadenopathy.

Pharyngitis

Whether bacterial, fungal, or viral, pharyngitis may cause sore throat and localized erythema and edema. Bacterial pharyngitis begins abruptly with a unilateral sore throat. Associated signs and symptoms include dysphagia, fever, malaise, headache, abdominal pain, myalgia, and arthralgia. Inspection reveals an exudate on the tonsil or tonsillar fossae, uvular edema, soft palate erythema, and tender cervical lymph nodes.

Also known as thrush, fungal pharyngitis causes diffuse sore throat — commonly described as a burning sensation — accompanied by pharyngeal erythema and edema. White plaques mark the pharynx, tonsil, tonsillar pillars, base of the tongue, and oral mucosa; scraping these plaques uncovers a hemorrhagic base.

With viral pharyngitis, findings include diffuse sore throat, malaise, fever, and mild erythema and edema of the posterior oropharyngeal wall. Tonsillary enlargement may be present along with anterior cervical lymphadenopathy.

Sinusitis (acute)

Sinusitis may cause sore throat with purulent nasal discharge and postnasal drip, resulting in halitosis. Other effects include headache, malaise, cough, fever, and facial pain and swelling associated with nasal congestion.

Tongue cancer

With tongue cancer, the patient experiences localized throat pain that may occur around a raised white lesion or ulcer. The pain may radiate to the ear and be accompanied by dysphagia.

Tonsillar cancer

Sore throat is the presenting symptom in tonsillar cancer. Unfortunately, the cancer is usually quite advanced before the appearance of this symptom. The pain may radiate to the ear and is accompanied by a superficial ulcer on the tonsil or one that extends to the base of the tongue.

Tonsillitis

With acute tonsillitis, mild to severe sore throat is usually the first symptom. The pain may radiate to the ears and be accompanied by dysphagia and headache. Related findings include malaise, fever with chills, halitosis, myalgia, arthralgia, and tender cervical lymphadenopathy. Examination reveals edematous, reddened tonsils with a purulent exudate.

Chronic tonsillitis causes mild sore throat, malaise, and tender cervical lymph nodes. The tonsils appear smooth, pink and, possibly, enlarged, with purulent debris in the crypts. Halitosis and a foul taste in the mouth are other common findings.

Unilateral or bilateral throat pain just above the hyoid bone occurs with lingual tonsillitis. The lingual tonsils appear red and swollen and are covered with exudate. Other findings include a muffled voice, dysphagia, and tender cervical lymphadenopathy on the affected side.

Uvulitis

Uvulitis may cause throat pain or a sensation of something in the throat. The uvula is usually swollen and red but, in allergic uvulitis, it’s pale.

Other causes

Treatments

Endotracheal intubation and local surgery, such as tonsillectomy and adenoidectomy, commonly cause sore throat.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Stomatitis and other oral infections: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Acute herpetic stomatitis results from the herpes simplex virus. It’s common in children ages 1 to 3. The cause of aphthous stomatitis is unknown, but predisposing factors include stress, fatigue, anxiety, febrile states, trauma, and solar overexposure. This type is common in girls and female adolescents.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Mouth lesions: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acquired immunodeficiency syndrome (AIDS)

Oral lesions may be an early indication of the immunosuppression that’s characteristic of this disease. Fungal infections can occur, with oral candidiasis being the most common. Bacterial or viral infections of oral mucosa, tongue, gingivae, and periodontal tissue may also occur.

The primary oral neoplasm associated with AIDS is Kaposi’s sarcoma. The tumor is usually found on the hard palate and may appear initially as an asymptomatic, flat or raised lesion, ranging in color from red to blue to purple. As these tumors grow, they may ulcerate and become painful.

Actinomycosis (cervicofacial)

This chronic fungal infection typically produces small, firm, flat, usually painless swellings on the oral mucosa and under the skin of the jaw and neck. Swellings may indurate and abscess, producing fistulas and sinus tracts with a characteristic purulent yellow discharge.

Behçet’s syndrome

This chronic, progressive syndrome that generally affects young males produces small, painful ulcers on the lips, gums, buccal mucosa, and tongue. In severe cases, the ulcers also develop on the palate, pharynx, and esophagus. The ulcers typically have a reddened border and are covered with a gray or yellow exudate. Similar lesions appear on the scrotum and penis or labia majora; small pustules or papules on the trunk and limbs; and painful erythematous nodules on the shins. Ocular lesions may also develop.

Candidiasis

This common fungal infection characteristically produces soft, elevated plaques on the buccal mucosa, tongue, and sometimes the palate, gingivae, and floor of the mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of redness, pruritus, and foul odor may be present.

Discoid lupus erythematosus

Oral lesions are common, typically appearing on the tongue, buccal mucosa, and palate as erythematous areas with white spots and radiating white striae. Associated findings include skin lesions on the face, possibly extending to the neck, ears, and scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with scale.

Gender Cue: This chronic, recurrent disease is most common in women ages 30 to 40.

Epulis (giant cell)

This rare tumor or growth occurs on the gingival or alveolar process, anterior to the molars. Dark red, pedunculated or sessile, and 0.5 to 1.5 cm in diameter, it commonly ulcerates to produce a concave defect in the underlying bone. Gingivae bleed easily with slight trauma.

Erythema multiforme

This acute inflammatory skin disease produces sudden onset of vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia. Lymphadenopathy may also occur. With visceral involvement, other findings include fever, malaise, cough, throat and chest pain, vomiting, diarrhea, myalgias, arthralgias, fingernail loss, blindness, hematuria, and signs of renal failure.

Gingivitis (acute necrotizing ulcerative)

This recurring periodontal condition causes a sudden onset of gingival ulcers covered with a grayish white pseudomembrane. Other findings include tender or painful gingivae, intermittent gingival bleeding, halitosis, enlarged lymph nodes in the neck, and fever.

Gonorrhea

Painful lip ulcerations may occur, along with rough, reddened, bleeding gingivae (possibly necrotic and covered by a yellowish pseudomembrane), and a swollen, ulcerated tongue. Related effects vary. Most men develop dysuria, purulent urethral discharge, and a reddened, edematous urinary meatus. Most women remain asymptomatic, but others develop inflammation and a greenish yellow cervical discharge.

Herpes simplex 1

With primary infection, a brief period of prodromal tingling and itching, which is accompanied by fever and pharyngitis, is followed by eruption of small and irritating vesicles on any part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation, halitosis, anorexia, and keratoconjunctivitis.

Herpes zoster

This common viral infection may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small red nodules often erupt unilaterally around the thorax or vertically on the arms and legs, and rapidly become vesicles filled with clear fluid or pus; vesicles dry and form scabs about 10 days after eruption. Fever and general malaise accompany pruritus, paresthesia or hyperesthesia, and tenderness along the course of the involved sensory nerve.

Inflammatory fibrous hyperplasia

This painless nodular swelling of the buccal mucosa typically results from cheek trauma or irritation and is characterized by pink, smooth, pedunculated areas of soft tissue.

Leukoplakia, erythroplakia

Leukoplakia is a white lesion that cannot be removed simply by rubbing the mucosal surface—unlike candidiasis. It may occur in response to chronic irritation from dentures or tobacco or pipe smoking, or it may represent dysplasia or early squamous cell carcinoma.

Erythroplakia is red and edematous and has a velvety surface. About 90% of all cases of erythroplakia are either dysplasia or cancer.

Lichen planus

Oral lesions develop on the buccal mucosa or, less commonly, on the tongue as painless, white or gray, velvety, threadlike papules. 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.

Mucous duct obstruction

Obstruction produces a ranula—a painless, slow-growing mucocele on the floor of the mouth near the ducts of the submandibular and sublingual glands.

Pemphigoid (benign mucosal)

This rare autoimmune disease is characterized by thick-walled vesicles on the oral mucous membranes, the conjunctiva and, less often, the skin. Mouth lesions typically develop months or even years before other manifestations and may occur as desquamative patchy gingivitis or as a vesicobullous eruption. Secondary fibrous bands may lead to dysphagia, hoarseness, and blindness. Recurrent skin lesions include vesicobullous eruptions, usually on the inguinal area and extremities, and an erythematous, vesicobullous plaque on the scalp and face near the affected mucous membranes.

Pemphigus

This chronic skin disease is characterized by thin-walled vesicles and bullae that appear in cycles on skin or mucous membranes that otherwise appear normal. On the oral mucosa, bullae rupture, leaving painful lesions and raw patches that bleed easily. Associated findings include bullae anywhere on the body, denudation of the skin, and pruritus.

Pyogenic granuloma

Commonly the result of injury, trauma, or irritation, this soft, tender nodule, papule, or polypoid mass of excessive granulation tissue usually appears on the gingivae but can also erupt on the lips, tongue, or buccal mucosa. The lesions bleed easily because they contain many capillaries. The affected area may be smooth or have a warty surface; erythema develops in the surrounding mucosa. The lesions may ulcerate, producing a purulent exudate.

Squamous cell carcinoma

This is typically a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is most common on the lower lip, but it may also occur on the edge of the tongue or the floor of the mouth. High risk factors include chronic smoking and alcohol intake.

Stomatitis (aphthous)

This common disease is characterized by painful ulcerations of the oral mucosa, usually on the dorsum of the tongue, gingivae, and hard palate.

With recurrent aphthous stomatitis minor, the ulcer begins as one or more erosions covered by a gray membrane and surrounded by a red halo. It’s commonly found on the buccal and lip mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the periosteum.

With recurrent aphthous stomatitis major, large, painful ulcers commonly occur on the lips, cheek, tongue, and soft palate; they may last up to 6 weeks and leave a scar.

Syphilis

Primary syphilis typically produces a solitary painless, red ulcer (chancre) on the lip, tongue, palate, tonsil, or gingivae. The ulcer appears as a crater with undulated, raised edges and a shiny center; lip chancres may develop a crust. Similar lesions may appear on the fingers, breasts, or genitals, and regional lymph nodes may become enlarged and tender.

During the secondary stage, multiple painless ulcers covered by a grayish white plaque may erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular rash appears, usually on the arms, trunk, palms, soles, face, and scalp; genital lesions usually subside. Other findings include generalized lymphadenopathy, headache, malaise, anorexia, weight loss, nausea, vomiting, sore throat, low fever, metrorrhagia, and postcoital bleeding.

At the tertiarystage, lesions (often chronic, painless, superficial nodules or deep granulomatous lesions, called gummas) develop on the skin and mucous membranes, especially the tongue and palate.

Systemic lupus erythematosus

Oral lesions are common and appear as erythematous areas associated with edema, petechiae, and superficial ulcers with a red halo and a tendency to bleed. Primary effects include nondeforming arthritis, butterfly rash across the nose and cheeks, and photosensitivity.

Trauma

The most common cause of oral lesions, trauma can produce ulcers anywhere in the mouth, especially on the tongue and buccal mucosa.

Tuberculosis (oral mucosal)

This rare disorder produces a painless ulcer (usually on the tongue) and, sometimes, caseation. Other findings include lymphadenopathy, fatigue, weakness, anorexia, weight loss, cough, low fever, and night sweats.

Other causes

Drugs

Various chemotherapeutic agents can directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine, streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.

Orthodontics

The rubbing of orthodontic equipment or prosthesis on the buccal mucosa may cause eroded, tender areas.

Radiation therapy

Radiation therapy may cause oral lesions.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Throat pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Agranulocytosis

In this disorder, sore throat may accompany other signs and symptoms of infection, such as fever, chills, and headache. Typically, it follows progressive fatigue and weakness. Other findings include nausea and vomiting, anorexia, and bleeding tendencies. Rough-edged ulcers with gray or black membranes may appear on the gums, palate, or perianal area.

Allergic rhinitis

Occurring seasonally or year-round, this disorder may produce sore throat as well as nasal congestion with a thin nasal discharge, postnasal drip, paroxysmal sneezing, decreased sense of smell, frontal or temporal headache, and itchy eyes, nose, and throat. Examination reveals pale and glistening nasal mucosa with edematous nasal turbinates, watery eyes, reddened conjunctivae and eyelids and, possibly, swollen eyelids.

Avian influenza

Throat pain, muscle aches, cough, and fever are common early symptoms of avian influenza. The most virulent of these viruses, avian influenza A (H5N1), may also cause pneumonia, acute respiratory distress, and other life-threatening complications. A recent outbreak of the H5N1 virus among domesticated birds (chickens, turkeys, geese) in Asian countries has caused human sickness and death in those who contracted the virus from infected poultry and contaminated surfaces. Studies are underway to investigate the effectiveness of antiviral medications and vaccines.

Bronchitis (acute)

This disorder may produce lower throat pain, fever, chills, cough, and muscle and back pain. Auscultation reveals rhonchi, wheezing, and sometimes crackles.

Chronic fatigue syndrome

This nonspecific symptom complex is characterized by incapacitating fatigue. Associated findings include sore throat, myalgia, and cognitive dysfunction.

Common cold

Sore throat may accompany cough, sneezing, nasal congestion, rhinorrhea, fatigue, headache, myalgia, and arthralgia.

Contact ulcers

Common in men with stressful jobs, contact ulcers appear symmetrically on the posterior vocal cords, resulting in sore throat. The pain is aggravated by talking and may be accompanied by referred ear pain and occasionally hemoptysis. Typically, the patient also has a history of chronic throat clearing or acid reflux.

Foreign body

A foreign body lodged in the palatine or lingual tonsil and pyriform sinus may produce localized throat pain. The pain may persist after the foreign body is dislodged until mucosal irritation resolves.

Gastroesophageal reflux disease

In this disorder, an incompetent gastroesophageal sphincter allows gastric juices to enter the hypopharynx and irritate the larynx, causing chronic sore throat and hoarseness. The arytenoid cartilage may also appear red and swollen, resulting in a sensation of a lump in the throat.

Glossopharyngeal neuralgia

Triggered by a specific pharyngeal movement, such as yawning or swallowing, this condition causes unilateral, knifelike throat pain in the tonsillar fossa that may radiate to the ear.

Herpes simplex virus

Sore throat may result from lesions on the oral mucosa, especially the tongue, gingivae, and cheeks. After causing brief prodromal discomfort, lesions erupt into erythematous vesicles that eventually rupture and leave a painful ulcer, followed by a yellowish crust. In generalized infection, the vesicles accompany submaxillary lymphadenopathy, halitosis, increased salivation, anorexia, and fever of up to 105° F (40.6° C).

Influenza

Patients with the flu commonly complain of sore throat, fever with chills, headache, weakness, malaise, myalgia, cough and, occasionally, hoarseness and rhinorrhea.

Laryngeal cancer

In extrinsic laryngeal cancer, the chief symptom is pain or burning in the throat when drinking citrus juice or hot liquids, or a lump in the throat; in intrinsic laryngeal cancer, it’s hoarseness that persists for longer than 3 weeks. Later signs and symptoms of metastasis include dysphagia, dyspnea, a cough, enlarged cervical lymph nodes, and pain that radiates to the ear.

Laryngitis (acute)

This disorder produces sore throat, but its cardinal sign is mild to severe hoarseness, perhaps with temporary loss of voice. Other findings are malaise, low-grade fever, dysphagia, dry cough, and tender, enlarged cervical lymph nodes.

Monkeypox

Early symptoms of this rare viral disease include sore throat, fever, lymphadenopathy, chills, myalgia, and rash. The virus exhibits some similarities to smallpox, but its symptoms tend to be milder. Monkeypox is spread primarily through contact with lesions or body fluids of infected animals. Although it occurs primarily in central and western Africa, the virus has also been reported in the United States since 2003. There’s no specific treatment for monkeypox, which typically lasts 2 to 4 weeks.

Mononucleosis (infectious)

Sore throat is one of the three classic findings in this infection. The other two classic signs are cervical lymphadenopathy and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Splenomegaly and hepatomegaly may also develop.

Necrotizing ulcerative gingivitis (acute)

Also known as trench mouth, this disorder usually begins abruptly with sore throat and tender gums that ulcerate and bleed. A gray exudate may cover the gums and pharyngeal tonsils. Related signs and symptoms include a foul taste in the mouth, halitosis, cervical lymphadenopathy, headache, malaise, and fever.

Peritonsillar abscess

Pharyngeal burns

First- or second-degree burns of the posterior pharynx may cause throat pain and dysphagia.

Pharyngitis

Whether bacterial, fungal, or viral, pharyngitis may cause sore throat and localized erythema and edema. Bacterial pharyngitis begins abruptly with a unilateral sore throat. Associated signs and symptoms include dysphagia, fever, malaise, headache, abdominal pain, myalgia, and arthralgia. Inspection reveals an exudate on the tonsil or tonsillar fossa, uvular edema, soft palate erythema, and tender cervical lymph nodes.

Also known as thrush, fungal pharyngitis causes diffuse sore throat—commonly described as a burning sensation—accompanied by pharyngeal erythema and edema. White plaques mark the pharynx, tonsil, tonsillar pillars, base of the tongue, and oral mucosa; scraping these plaques uncovers a hemorrhagic base.

Viral pharyngitis produces a diffuse sore throat, malaise, fever, and mild erythema and edema of the posterior oropharyngeal wall. Tonsil enlargement and anterior cervical lymphadenopathy may be present.

Pharyngomaxillary space abscess

A complication of untreated pharyngeal or tonsillar infection or tooth extraction, pharyngomaxillary space abscess causes mild throat pain. Inspection reveals a bulge in the medial wall of the pharynx accompanied by swelling of the neck and at the jaw angle on the affected side. Other signs and symptoms include fever, dysphagia, trismus and, possibly, signs of respiratory distress or toxemia.

Sinusitis (acute)

This disorder may cause sore throat with a purulent nasal discharge and postnasal drip, resulting in halitosis. Other effects include headache, malaise, cough, fever, and facial pain and swelling associated with nasal congestion.

Tongue cancer

The patient with tongue cancer experiences localized throat pain that may occur around a raised white lesion or ulcer. The pain may radiate to the ear and be accompanied by dysphagia.

Tonsillar cancer

Sore throat is the presenting symptom in tonsillar cancer. Unfortunately, the cancer is usually quite advanced before this symptom appears. The pain may radiate to the ear and is accompanied by a superficial ulcer on the tonsil or one that extends to the base of the tongue.

Tonsillitis

Mild to severe sore throat is usually the first symptom of acute tonsillitis. The pain may radiate to the ears and be accompanied by dysphagia and headache. Related findings include malaise, fever with chills, halitosis, myalgia, arthralgia, and tender cervical lymph nodes. Examination reveals edematous, reddened tonsils with a purulent exudate.

Chronic tonsillitis causes a mild sore throat, malaise, and tender cervical lymph nodes. The tonsils appear smooth, pink and, possibly, enlarged, with purulent debris in the crypts. Halitosis and a foul taste in the mouth are other common findings.

Unilateral or bilateral throat pain occurs just above the hyoid bone in lingual tonsillitis. The lingual tonsils appear red and swollen and are covered with exudate. Other findings include a muffled voice, dysphagia, and tender cervical lymph nodes on the affected side.

Uvulitis

This inflammation may cause throat pain or a sensation of something in the throat. The uvula is usually swollen and red but, in allergic uvulitis, it’s pale.

Other causes

Treatments

Endotracheal intubation and local surgery, such as tonsillectomy and adenoidectomy, commonly cause sore throat.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Sore Throat: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Rhinovirus

❑ Group A streptococci

❑ Ebstein-Barr virus

❑ Adenovirus

❑ Influenza

❑ Candida/thrush

❑ Herpes simplex virus

❑ Peritonsillar abscess

❑ Mycoplasma pneumoniae

❑ Coxsackievirus

❑ Primary HIV

❑ Neisseria gonorrhea

❑ Epiglottitis

❑ Corynebacterium diphtheriae

❑ Leukemia

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Source: Field Guide to Bedside Diagnosis, 2007

Oral Lesions: Differential Overview
(Field Guide to Bedside Diagnosis)

Ulceration

❑ Aphthous ulcers

❑ Angular cheilitis

❑ Herpes simplex

❑ Traumatic ulcers

❑ Impetigo

❑ Erythema multiforme

❑ Mucositis

❑ Lichen planus

❑ Squamous cell cancer

❑ Syphilis

❑ Coxsackievirus A

❑ Herpes zoster

❑ Primary HIV

❑ Crohn disease

❑ Behçet syndrome

❑ Acute leukemia

❑ Pemphigoid

Glossitis

❑ Vitamin B₁₂ deficiency

❑ Folate deficiency

❑ Niacin deficiency

❑ Riboflavin deficiency

❑ Leukoplakia

❑ Candida

❑ Geographic tongue

❑ Black hairy tongue

❑ Scarlet fever

❑ Kwashiorkor

❑ Polyarteritis nodosa

Macroglossia

❑ Myxedema

❑ Angioedema

❑ Acromegaly

❑ Amyloidosis

Clinical Findings

Aphthous ulcers  They occur on nonkeratinized mucosa as single lesions or clusters of small, shallow, painful, clearly defined ulcers with an erythematous halo and a white base. There are usually no systemic symptoms or lymphadenopathy. These ulcers stereotypically recur.

Angular cheilitis  Tender fissuring at the corner of the mouth can be caused by Candida and either iron or vitamin B₁₂ deficiency.

Herpes simplex  An acute outbreak consists of labial vesicles that rupture and crust, and intraoral vesicles that quickly ulcerate. The lesions are usually quite painful and associated with fever, malaise, pharyngitis, and tender cervical lymphadenopathy. Recurrent lesions usually occur at the vermilion border and are preceded by localized burning dysesthesias.

Traumatic ulcers  These ulcers occur at the bite margin or adjacent to dentures.

Impetigo  Perioral painful shallow erosions spread rapidly. They are red and weeping, with honey-colored crusts.

Erythema multiforme  The onset is rapid and progresses to systemic toxicity. Intraoral ruptured bullae surrounded by erythema become painful mucosal erosions with gray exudate. Hemorrhagic crusts appear on the lips. An extensive maculopapular rash develops on the extensor surfaces and is characterized by target and polycyclic lesions and persisting urticarial plaques. Target lesions on the hands and feet are pathognomonic.

Mucositis  Initially there is a burning with diffuse mucosal redness and shininess that progresses to painful ulcers, then the tongue and buccal mucosa become denuded. There may also be a yellow pseudomembrane or hemorrhagic crust. This condition is found with Stevens-Johnson syndrome, agranulocytosis, and cancer chemotherapy.

Lichen planus  Lacy mucosal striae break down into painful erosions. This is often associated with drugs such as chloroquine, furosemide, gold, lithium, methyldopa, phenothiazines, propranolol, quinidine, spironolactone, tetracycline, or thiazides.

Squamous cell cancer  The ulcer is painless, malodorous, and indolent. It arises in an area of leukoplakia, bleeds easily, and has an elevated, indurated border. The presenting symptom is often pain, which may be referred to the ear, or dysphonia.

Syphilis  A primary chancre is a painless ulcer with an indurated copper border and unilateral lymphadenopathy. Secondary lesions are linear “snail track” ulcers and gray mucous patches on the lips, tonsils, and palate. There is concurrent generalized rash and fever. A tertiary gumma is a firm, broad, ulcerated plaque that may produce palatal perforation.

Coxsackievirus A  Herpangina presents with fever, sore throat, and grayish-white vesicles with a red halo, which quickly ulcerate. Hand, foot, and mouth disease (A16) has similar pharyngeal lesions accompanied by other lesions in the forenamed distribution.

Herpes zoster  A vesicular eruption with ulceration stops at the midline. Vesicles will also be present on the lower midface. Burning pain is characteristic.

Primary HIV  The most common presentation is a febrile mononucleosislike illness. Acute gingivitis and ulceration may be part of the spectrum.

Crohn disease  Oral ulcers may occur when intestinal disease is active, with symptoms of diarrhea, mucus, and blood.

Behçet syndrome  Multiple aphthous ulcers of the mouth occur with uveitis and genital ulcers.

Acute leukemia  Gingival swelling and superficial ulceration occur; hyperplasia, hemorrhage, and necrosis ensue. Deep ulcers may occur elsewhere on the mucosa, and they often become secondarily infected.

Pemphigoid  Painful grayish-white collapsed vesicles or bullae ulcerate when on the gingiva. Bullae may also involve the eyes, urethra, vagina, or rectum.

Vitamin B₁₂ deficiency  The tongue is beefy red, smooth, edematous, and painful. Pinpoint dots occur as a result of hyperemic capillaries and atrophied papillae. Peripheral neuropathy is commonly concurrent.

Folate deficiency  It is similar in presentation to B₁₂ deficiency but occurs more rapidly with nutritional depletion (e.g., alcoholics).

Niacin deficiency  Pellagra produces a burning sensation with hot or spicy food, without a visible abnormality early in the course. Later there is an increase in papilla and redness of the tongue’s tip and sides, and then fiery redness and swelling with desquamation occur. It is associated with severe watery diarrhea, red skin eruptions, and confusion.

Riboflavin deficiency  When advanced, the tongue looks magenta. Associated findings include a “shark skin” nose and conjunctival injection.

Leukoplakia  Early lesions are thin, pearly, and crinkled, especially on the lateral border of the tongue. A white-gray thickened epithelium without papillae appears later. Oral hairy leukoplakia is a sentinel finding of HIV infection, and is caused by concurrent EBV infection.

Candida  The tongue is bright red with cottage cheese-like material on the surface. Predisposing conditions include diabetes, dentures, recent antibiotics, or chemotherapy. In the absence of these factors, or severe or recalcitrant disease, HIV should be considered.

Geographic tongue  The surface has a changing demarcated pattern. There may be oral discomfort or burning. This finding is present in serious illness with antibiotic use.

Black hairy tongue  Elongated filiform papillae which may be discolored a yellow to brownish tone create the appearance. Associated conditions include antibiotic use, oral candidiasis, and poor oral hygeine.

Scarlet fever  A “strawberry tongue” occurs in a patient with a confluent rash that has the texture of fine sandpaper.

Kwashiorkor  Glossitis occurs early and is later accompanied by generalized edema and ascites.

Polyarteritis nodosa  The patient presents with a diffusely inflamed, orange-red tongue that has a burning sensation.

Myxedema  In addition to tongue enlargement, facial and pretibial skin is coarse, the voice is low and husky, and the relaxation phase of the deep tendon reflexes is delayed.

Angioedema  Acute edema of tissues frequently includes the tongue. Similar findings may occur with food allergies (e.g., shellfish), drug reactions (penicillin), and serum sickness.

Acromegaly  Tissues are generally thickened, and tongue enlargement is associated with jaw protrusion, malocclusion, and teeth that are widely spaced and tilt outward.

Amyloidosis  Tongue enlargement occurs with enlargement of other viscera and with peripheral neuropathy.

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Source: Field Guide to Bedside Diagnosis, 2007

Stomatitis and other oral infections: Causes
(Handbook of Diseases)

Acute herpetic stomatitis results from herpes simplex virus. The cause of aphthous stomatitis is unclear.

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Source: Handbook of Diseases, 2003

Mouth lesions: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Acquired immunodeficiency syndrome

Oral lesions may be an early indication of the immunosuppression that’s characteristic of acquired immunodeficiency syndrome (AIDS). Fungal infections can occur, with oral candidiasis being the most common. Bacterial or viral infections of oral mucosa, tongue, gingivae, and periodontal tissue may also occur.

The primary oral neoplasm associated with AIDS is Kaposi’s sarcoma. The tumor is usually found on the hard palate. Initially producing no symptoms, it may appear as a flat or raised lesion, ranging in color from red to blue to purple. As these tumors grow, they may ulcerate and become painful.

Candidiasis

Candidiasis, a common fungal infection, characteristically produces soft, elevated plaques on the buccal mucosa, tongue, and sometimes the palate, gingivae, and floor of the mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of redness, pruritus, and foul odor may be present.

Discoid lupus erythematosus

Oral lesions are common in discoid lupus erythematosus. They typically appear on the tongue, buccal mucosa, and palate as erythematous areas with white spots and radiating white striae. Associated findings include skin lesions on the face, possibly extending to the neck, ears, and scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with scale.

Erythema multiforme

Erythema multiforme, an acute inflammatory skin disease, produces sudden onset of vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia. Lymphadenopathy may also occur. With visceral involvement, other findings include fever, malaise, cough, throat and chest pain, vomiting, diarrhea, myalgia, arthralgia, fingernail loss, blindness, hematuria, and signs of renal failure.

Gingivitis (acute necrotizing ulcerative)

Gingivitis, a recurring periodontal condition, causes a sudden onset of gingival ulcers covered with a grayish white pseudomembrane. Other findings include tender or painful gingivae, intermittent gingival bleeding, halitosis, enlarged lymph nodes in the neck, and fever.

Gonorrhea

With gonorrhea, painful lip ulcerations may occur, along with rough, reddened, bleeding gingivae (possibly necrotic and covered by a yellowish pseudomembrane), and a swollen, ulcerated tongue. Related effects vary. Most men develop dysuria, purulent urethral discharge, and a reddened, edematous urinary meatus. Most women remain asymptomatic, but others develop inflammation and a greenish yellow cervical discharge.

Herpes simplex 1

With primary herpes simplex infection, a brief period of prodromal tingling and itching, which is accompanied by fever and pharyngitis, is followed by eruption of small and irritating vesicles on any part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation, halitosis, anorexia, and keratoconjunctivitis.

Herpes zoster

Herpes zoster is a common viral infection that may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small, red nodules usually erupt unilaterally around the thorax or vertically on the arms and legs and rapidly become vesicles filled with clear fluid or pus; vesicles dry and form scabs about 10 days after eruption. Fever and general malaise accompany pruritus, paresthesia or hyperesthesia, and tenderness along the course of the involved sensory nerve.

Leukoplakia, erythroplakia

Leukoplakia is a white lesion that can’t be removed simply by rubbing the mucosal surface — unlike candidiasis. It may occur in response to chronic irritation from dentures or tobacco or pipe smoking, or it may represent dysplasia or early squamous cell carcinoma.

Erythroplakia is red and edematous and has a velvety surface. About 90% of erythroplakia cases are either dysplasia or cancer.

Lichen planus

With lichen planus, oral lesions develop on the buccal mucosa or, less commonly, on the tongue as painless, white or gray, velvety, threadlike papules. 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.

Squamous cell carcinoma

A squamous cell carcinoma is typically a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is most common on the lower lip, but it may also occur on the edge of the tongue or the floor of the mouth. High risk factors include chronic smoking and alcohol intake.

Stomatitis (aphthous)

Aphthous stomatitis is a common disease characterized by painful ulcerations of the oral mucosa, usually on the dorsum of the tongue, gingivae, and hard palate.

With recurrent aphthous stomatitis minor, the ulcer begins as one or more erosions covered by a gray membrane and surrounded by a red halo. It’s commonly found on the buccal and lip mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the periosteum.

With recurrent aphthous stomatitis major, large, painful ulcers commonly occur on the lips, cheek, tongue, and soft palate; they may last up to 6 weeks and leave a scar.

Syphilis

Primarysyphilis typically produces a solitary painless, red ulcer (chancre) on the lip, tongue, palate, tonsil, or gingivae. The ulcer appears as a crater with undulated, raised edges and a shiny center; lip chancres may develop a crust. Similar lesions may appear on the fingers, breasts, or genitals, and regional lymph nodes may become enlarged and tender.

During the secondary stage, multiple painless ulcers covered by a grayish white plaque may erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular rash appears, usually on the arms, trunk, palms, soles, face, and scalp; genital lesions usually subside. Other findings include generalized lymphadenopathy, headache, malaise, anorexia, weight loss, nausea, vomiting, sore throat, low fever, metrorrhagia, and postcoital bleeding.

At the tertiarystage, lesions (usually gummas — chronic, painless, superficial nodules or deep granulomatous lesions) develop on the skin and mucous membranes, especially the tongue and palate.

Systemic lupus erythematosus

Oral lesions are common with systemic lupus erythematosus (SLE) and appear as erythematous areas associated with edema, petechiae, and superficial ulcers with a red halo and a tendency to bleed. Primary effects include nondeforming arthritis, butterfly rash across the nose and cheeks, and photosensitivity.

Other causes

Drugs

Various chemotherapeutic agents can directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine, streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.

Treatments

Radiation therapy may cause oral lesions.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Throat pain: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Agranulocytosis

With agranulocytosis, sore throat may accompany other signs and symptoms of infection, such as fever, chills, and headache. Typically, sore throat follows progressive fatigue and weakness. Other findings include nausea and vomiting, anorexia, and bleeding tendencies. Rough-edged ulcers with gray or black membranes may appear on the gums, palate, or perianal area.

Allergic rhinitis

Occurring seasonally or year-round, allergic rhinitis may produce sore throat as well as nasal congestion with a thin nasal discharge, postnasal drip, paroxysmal sneezing, decreased sense of smell, frontal or temporal headache, and itchy eyes, nose, and throat. Examination reveals pale and glistening nasal mucosa with edematous nasal turbinates, watery eyes, reddened conjunctiva and eyelids and, possibly, swollen lids.

Bronchitis (acute)

Acute bronchitis may produce lower throat pain associated with fever, chills, cough, and muscle and back pain. Auscultation reveals rhonchi, wheezing and, at times, crackles.

Chronic fatigue syndrome

Chronic fatigue syndrome is a nonspecific symptom complex that’s characterized by incapacitating fatigue. Associated findings besides sore throat include myalgia, lymphadenopathy, and cognitive dysfunction.

Common cold

With the common cold, sore throat may accompany cough, sneezing, nasal congestion, mouth breathing, rhinorrhea, fatigue, headache, myalgia, and arthralgia. The patient may also have a transient loss of taste and smell.

Contact ulcers

Common in men with stressful jobs, contact ulcers appear symmetrically on the posterior vocal cords, resulting in sore throat. The pain is aggravated by talking and may be accompanied by referred ear pain and, occasionally, hemoptysis. Typically, the patient also has a history of chronic throat clearing or acid reflux.

Foreign body

A foreign body lodged in the palatine or lingual tonsil and pyriform sinus may produce localized throat pain. The pain may persist after the foreign body is dislodged until mucosal irritation resolves.

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may cause chronic sore throat and hoarseness. The arytenoids may also appear red and swollen, resulting in a sensation of a lump in the throat. Pyrosis, usually severe, is the most common symptom of this disorder.

Glossopharyngeal neuralgia

Triggered by a specific pharyngeal movement, such as yawning, chewing or swallowing, glossopharyngeal neuralgia causes unilateral, knifelike throat pain in the tonsillar fossa that may radiate to the ear. Eating spicy foods may also trigger this pain.

Herpes simplex virus

Sore throat in those infected with the herpes simplex virus may result from lesions on the oral mucosa, especially the tongue, gingivae, and cheeks. After causing brief prodromal discomfort, lesions erupt into erythematous vesicles that eventually rupture and leave a painful ulcer, followed by a yellowish crust. In generalized infection, the vesicles accompany submaxillary lymphadenopathy, halitosis, increased salivation, anorexia, and fever of up to 105° F (40.6° C).

Influenza

Patients with influenza commonly complain of sore throat, fever with chills, headache, weakness, malaise, muscle aches, cough and, occasionally, hoarseness and rhinorrhea. Chills generally subside after the first few days, but intermittent fever, weakness, and cough may persist for up to 1 week.

Laryngeal cancer

With extrinsic laryngeal cancer, the chief symptom is pain or burning in the throat when drinking citrus juice or hot liquids, or a lump in the throat; with intrinsic laryngeal cancer, it’s hoarseness that persists for longer than 3 weeks. Later signs and symptoms of metastasis include dysphagia, dyspnea, a cough, enlarged cervical lymph nodes, and pain that radiates to the ear.

Laryngitis (acute)

Acute laryngitis produces sore throat. Its cardinal sign, however, is mild to severe hoarseness, perhaps with temporary loss of voice. Other findings are malaise, low-grade fever, dysphagia, dry cough, and tender, enlarged cervical lymph nodes.

Mononucleosis (infectious)

Sore throat is one of the three classic findings in mononucleosis. The other two classic signs are cervical lymphadenopathy and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Splenomegaly and hepatomegaly may also develop.

Necrotizing ulcerative gingivitis (acute)

Also known as trench mouth, necrotizing ulcerative gingivitis usually begins abruptly with sore throat and tender gums that ulcerate and bleed. A gray exudate may cover the gums and pharyngeal tonsils. Related signs and symptoms include a foul taste in the mouth, halitosis, cervical lymphadenopathy, headache, malaise, and fever.

Peritonsillar abscess

A complication of bacterial tonsillitis, peritonsillar abscess typically causes severe throat pain that radiates to the ear. Accompanying the pain may be dysphagia, drooling, dysarthria, halitosis, fever with chills, malaise, and nausea. The patient usually tilts his head toward the side of the abscess. Examination may also reveal a deviated uvula, trismus, and tender cervical lymphadenopathy.

Pharyngeal burns

First- or second-degree burns of the posterior pharynx may cause throat pain and dysphagia. Laryngeal edema, bronchospasm, and stridor may occur if the larynx is involved in the burn.

Pharyngitis

Whether bacterial, fungal, or viral, pharyngitis may cause sore throat and localized erythema and edema. Bacterial pharyngitis begins abruptly with a unilateral sore throat. Associated signs and symptoms include dysphagia, fever, malaise, headache, abdominal pain, myalgia, and arthralgia. Inspection reveals an exudate on the tonsil or tonsillar fossae, uvular edema, soft palate erythema, and tender cervical lymph nodes.

Also known as thrush, fungal pharyngitis causes diffuse sore throat — commonly described as a burning sensation — accompanied by pharyngeal erythema and edema. White plaques mark the pharynx, tonsil, tonsillar pillars, base of the tongue, and oral mucosa; scraping these plaques uncovers a hemorrhagic base.

With viral pharyngitis, findings include diffuse sore throat, malaise, fever, and mild erythema and edema of the posterior oropharyngeal wall. Tonsillary enlargement may be present along with anterior cervical lymphadenopathy.

Pharyngomaxillary space abscess

A complication of untreated pharyngeal or tonsillar infection or tooth extraction, pharyngomaxillary space abscess causes mild throat pain. Inspection reveals a bulge in the medial wall of the pharynx accompanied by swelling of the neck and at the jaw angle on the affected side. Other signs and symptoms include fever, dysphagia, trismus and, possibly, signs of respiratory distress or toxemia.

Sinusitis (acute)

Acute sinusitis may cause sore throat with purulent nasal discharge and postnasal drip, resulting in halitosis. Other effects include headache, malaise, cough, fever, and facial pain and swelling associated with nasal congestion.

Tongue cancer

With tongue cancer, the patient experiences localized throat pain that may occur around a raised white lesion or ulcer. The pain may radiate to the ear and be accompanied by dysphagia.

Tonsillar cancer

Sore throat is the presenting symptom in tonsillar cancer. Unfortunately, the cancer is usually quite advanced before the appearance of this symptom. The pain may radiate to the ear and is accompanied by a superficial ulcer on the tonsil or one that extends to the base of the tongue.

Tonsillitis

With acute tonsillitis, mild to severe sore throat is usually the first symptom. The pain may radiate to the ears and be accompanied by dysphagia and headache. Related findings include malaise, fever with chills, halitosis, myalgia, arthralgia, and tender cervical lymphadenopathy. Examination reveals edematous, reddened tonsils with a purulent exudate.

Chronic tonsillitis causes mild sore throat, malaise, and tender cervical lymph nodes. The tonsils appear smooth, pink and, possibly, enlarged, with a purulent debris in the crypts. Halitosis and a foul taste in the mouth are other common findings.

Unilateral or bilateral throat pain just above the hyoid bone occurs with lingual tonsillitis. The lingual tonsils appear red and swollen and are covered with exudate. Other findings include a muffled voice, dysphagia, and tender cervical lymphadenopathy on the affected side.

Uvulitis

Uvulitis is an inflammation that can cause throat pain or a sensation of something in the throat. The uvula is usually swollen and red but, in allergic uvulitis, it’s pale.

Other causes

Treatments

Endotracheal intubation and local surgery, such as tonsillectomy and adenoidectomy, commonly cause sore throat.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Sore Throat: Principal Causes of Sore Throat
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Infection
   1. Pharyngitis/tonsillitis
      1. Viral
      2. Bacterial
         1. Group A Streptococcus
         2. Other bacteria
   2. Peritonsillar, retropharyngeal, andlateral pharyngeal abscesses
2. Irritants
   1. Excessive dryness
   2. Dust
   3. Smoke
   4. Postnasal drip secondary to allergicrhinitis or sinusitis
3. Trauma
   1. Vocal abuse
   2. Thermal injury
4. Foreign body
5. Caustic substances
6. Psychogenic

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Mouth lesions: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acquired immunodeficiency syndrome (AIDS).Oral lesions may be an early indication of the immunosuppression that's characteristic of AIDS. Fungal infections can occur, with oral candidiasis being the most common. Bacterial or viral infections of the oral mucosa, tongue, gingivae, and periodontal tissue may also occur.

The primary oral neoplasm associated with AIDS is Kaposi's sarcoma. The tumor is usually found on the hard palate and may appear initially as a flat or raised lesion that produces no symptoms and ranges from red to blue to purple. As these tumors grow, they may ulcerate and become painful.

Actinomycosis (cervicofacial).Actinomycosisis a chronic fungal infection that typically produces small, firm, flat, and usually painless swellings on the oral mucosa and under the skin of the jaw and neck. Swellings may indurate and abscess, producing fistulas and sinus tracts with a characteristic purulent yellow discharge.

Behçet's syndrome.Behçet's syndrome produces small, painful ulcers on the lips, gums, buccal mucosa, and tongue. In severe cases, the ulcers also develop on the palate, pharynx, and esophagus. The ulcers typically have a reddened border and are covered with a gray or yellow exudate. Similar lesions appear on the scrotum and penis or labia majora; small pustules or papules on the trunk and limbs; and painful erythematous nodules on the shins. Ocular lesions may also develop.

Candidiasis.Candidiasis characteristically produces soft, elevated plaques on the buccal mucosa, tongue, and sometimes the palate, gingivae, and floor of the mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of redness, pruritus, and a foul odor may be present.

Discoid lupus erythematosus.Oral lesions are common with discoid lupus erythematosus, typically appearing on the tongue, buccal mucosa, and palate as erythematous areas with white spots and radiating white striae. Associated findings include skin lesions on the face, possibly extending to the neck, ears, and scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with scales.

Erythema multiforme.Erythema multiforme produces a sudden onset of vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia. Lymphadenopathy may also occur. With visceral involvement, other findings include fever, malaise, cough, throat and chest pain, vomiting, diarrhea, myalgia, arthralgia, fingernail loss, blindness, hematuria, and signs of renal failure.

Gingivitis (acute necrotizing ulcerative).Gingivitiscauses a sudden onset of gingival ulcers covered with a grayish white pseudomembrane. Other findings include tender or painful gingivae, intermittent gingival bleeding, halitosis, enlarged lymph nodes in the neck, and fever.

Herpes simplex I.With primary herpes simplex I infection, a brief period of prodromal tingling and itching, which is accompanied by fever and pharyngitis, is followed by eruption of small and irritating vesicles on part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation, halitosis, anorexia, and keratoconjunctivitis.

Herpes zoster.Herpes zoster may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small red nodules typically erupt unilaterally around the thorax or vertically on the arms and legs, and rapidly become vesicles filled with clear fluid or pus; vesicles dry and form scabs about 10 days after eruption. Fever and general malaise accompany pruritus, paresthesia or hyperesthesia, and tenderness along the course of the involved sensory nerve.

Inflammatory fibrous hyperplasia.Inflammatory fibrous hyperplasia is a painless nodular swelling of the buccal mucosa characterized by pink, smooth, pedunculated areas of soft tissue.

Leukoplakia, erythroplakia.Leukoplakia is a white lesion that can't be removed simply by rubbing the mucosal surface—unlike candidiasis. It may occur in response to chronic irritation from dentures or from tobacco use or pipe smoking, or it may represent dysplasia or early squamous cell carcinoma.

Erythroplakia is red and edematous and has a velvety surface. About 90% of all cases of erythroplakia are either dysplasia or cancer.

Pemphigoid (benign mucosal).Pemphigoid is characterized by thick-walled vesicles on the oral mucous membranes, the conjunctiva and, less commonly, the skin. Mouth lesions typically develop months or even years before other manifestations and may occur as desquamative patchy gingivitis or as a vesicobullous eruption. Secondary fibrous bands may lead to dysphagia, hoarseness, and blindness. Recurrent skin lesions include vesicobullous eruptions, usually on the inguinal area and extremities, and an erythematous, vesicobullous plaque on the scalp and face near the affected mucous membranes.

Pemphigus.Pemphigus is characterized by thin-walled vesicles and bullae that appear in cycles on skin or mucous membranes that otherwise appear normal. On the oral mucosa, bullae rupture, leaving painful lesions and raw patches that bleed easily. Associated findings include bullae anywhere on the body, denudation of the skin, and pruritus.

Pyogenic granuloma.Pyogenic granuloma is a soft, tender nodule, papule, or polypoid mass of excessive granulated tissue that usually appears on the gingivae, but can also erupt on the lips, tongue, or buccal mucosa. The lesions bleed easily because they contain many capillaries. The affected area may be smooth or have a warty surface; erythema develops in the surrounding mucosa. The lesions may ulcerate, producing a purulent exudate.

Squamous cell carcinoma.Squamous cell carcinoma is typically a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is most common on the lower lip, but it may also occur on the edge of the tongue or floor of the mouth. High risk factors include chronic tobacco use and alcohol intake.

Stomatitis (aphthous).Stomatitis is characterized by painful ulcerations of the oral mucosa, usually on the dorsum of the tongue, gingivae, and hard palate.

With recurrent aphthous stomatitis minor, the ulcer begins as one or more erosions covered by a gray membrane and surrounded by a red halo. It's commonly found on the buccal and lip mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the periosteum.

With recurrent aphthous stomatitis major, large, painful ulcers commonly occur on the lips, cheek, tongue, and soft palate; they may last up to 6 weeks and leave ascar.

Syphilis.Primary syphilis typically produces a solitary painless, red ulcer (chancre) on the lip, tongue, palate, tonsil, or gingivae. The ulcer appears as a crater with undulated, raised edges and a shiny center; lip chancres may develop a crust. Similar lesions may appear on the fingers, breasts, or genitals, and regional lymph nodes may become enlarged and tender.

During the secondarystage, multiple painless ulcers covered by a grayish white plaque may erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular rash appears, usually on the arms, trunk, palms, soles, face, and scalp; genital lesions usually subside. Other findings include generalized lymphadenopathy, headache, malaise, anorexia, weight loss, nausea, vomiting, a sore throat, low-grade fever, metrorrhagia, and postcoital bleeding.

At the tertiarystage, lesions (usually gummas—chronic, painless, superficial nodules or deep granulomatous lesions) develop on the skin and mucous membranes, especially the tongue and palate.

Systemic lupus erythematosus (SLE).Oral lesions are common with SLE and appear as erythematous areas associated with edema, petechiae, and superficial ulcers with a red halo and a tendency to bleed. Primary effects include nondeforming arthritis, a butterfly rash across the nose and cheeks, and photosensitivity.

Other causes

Drugs.Various chemotherapeutic agents can directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine, streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.

Radiation therapy.Radiation therapy may cause oral lesions.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Throat pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Agranulocytosis.With agranulocytosis, throat pain may accompany other signs and symptoms of infection, such as fever, chills, and headache. Typically, it follows progressive fatigue and weakness. Other findings include nausea and vomiting, anorexia, and bleeding tendencies. Rough-edged ulcers with gray or black membranes may appear on the gums, palate, or perianal area.

Avian influenza.Throat pain, muscle aches, cough, and fever are common early symptoms of avian influenza. The most virulent of these viruses, avian influenza A (H5N1), may also cause pneumonia, acute respiratory distress, and other life-threatening complications.

Bronchitis (acute).Acute bronchitis may produce lower throat pain associated with fever, chills, cough, and muscle and back pain. Auscultation reveals rhonchi, wheezing and, at times, crackles.

Chronic fatigue syndrome.Chronic fatigue syndrome is characterized by incapacitating fatigue. Associated findings include throat pain, myalgia, and cognitive dysfunction.

Contact ulcers.Common in men with stressful jobs, contact ulcers appear symmetrically on the posterior vocal cords, resulting in sore throat. The pain is aggravated by talking and may be accompanied by referred ear pain and, occasionally, hemoptysis. Typically, the patient also has a history of chronic throat clearing or acid reflux.

Gastroesophageal reflux disease (GERD).With GERD, an incompetent gastroesophageal sphincter allows gastric juices to enter the hypopharynx and irritate the larynx, causing chronic throat pain and hoarseness. The arytenoids may also appear red and swollen, resulting in a sensation of a lump in the throat.

Influenza.Patients with the flu commonly complain of throat pain, fever with chills, headache, weakness, malaise, muscle aches, cough and, occasionally, hoarseness and rhinorrhea.

Laryngeal cancer.With extrinsic laryngeal cancer, the chief symptom is pain or burning in the throat when drinking citrus juice or hot liquids or a lump in the throat; with intrinsic laryngeal cancer, the chief symptom is hoarseness that persists for longer than 3 weeks. Later signs and symptoms of metastasis include dysphagia, dyspnea, cough, enlarged cervical lymph nodes, and pain that radiates to the ear.

Monkeypox.Early symptoms of this rare viral disease include throat pain, fever, lymphadenopathy, chills, myalgia, and rash. The virus exhibits some similarities to smallpox, but its symptoms tend to be milder.

Mononucleosis (infectious).Throat pain is one of the three classic findings in this infection. The other two classic signs are cervical lymphadenopathy and fluctuating temperature with an evening peak of 1018 to 1028 F (38.38 to 38.98 C). Splenomegaly and hepatomegaly may also develop.

Necrotizing ulcerative gingivitis (acute).Also known as trench mouth, necrotizing ulcerative gingivitis usually begins abruptly with throat pain and tender gums that ulcerate and bleed. A gray exudate may cover the gums and pharyngeal tonsils. Related signs and symptoms include a foul taste in the mouth, halitosis, cervical lymphadenopathy, headache, malaise, and fever.

Peritonsillar abscess.A complication of bacterial tonsillitis, this abscess typically causes severe throat pain that radiates to the ear. Accompanying the pain may be dysphagia, drooling, dysarthria, halitosis, fever with chills, malaise, and nausea. The patient usually tilts his head toward the side of the abscess. Examination may also reveal a deviated uvula, trismus, and tender cervical lymphadenopathy.

Pharyngitis.Whether bacterial, fungal, or viral, pharyngitis may cause throat pain and localized erythema and edema. Bacterial pharyngitis begins abruptly with a unilateral throat pain. Associated signs and symptoms include dysphagia, fever, malaise, headache, abdominal pain, myalgia, and arthralgia. Inspection reveals an exudate on the tonsil or tonsillar fossae, uvular edema, soft palate erythema, and tender cervical lymph nodes.

Also known as thrush, fungal pharyngitis causes diffuse throat pain—commonly described as a burning sensation—accompanied by pharyngeal erythema and edema. White plaques mark the pharynx, tonsil, tonsillar pillars, base of the tongue, and oral mucosa; scraping these plaques uncovers a hemorrhagic base.

With viral pharyngitis, findings include diffuse throat pain, malaise, fever, and mild erythema and edema of the posterior oropharyngeal wall. Tonsillary enlargement may be present along with anterior cervical lymphadenopathy.

Sinusitis (acute).Sinusitis may cause throat pain with purulent nasal discharge and postnasal drip, resulting in halitosis. Other effects include headache, malaise, cough, fever, and facial pain and swelling associated with nasal congestion.

Tongue cancer.With tongue cancer, the patient experiences localized throat pain that may occur around a raised white lesion or ulcer. The pain may radiate to the ear and be accompanied by dysphagia.

Tonsillar cancer.Throat pain is the presenting symptom in tonsillar cancer. Unfortunately, the cancer is usually quite advanced before the appearance of this symptom. The pain may radiate to the ear and is accompanied by a superficial ulcer on the tonsil or one that extends to the base of the tongue.

Tonsillitis.With acute tonsillitis, mild to severe throat pain is usually the first symptom. The pain may radiate to the ears and be accompanied by dysphagia and headache. Related findings include malaise, fever with chills, halitosis, myalgia, arthralgia, and tender cervical lymphadenopathy. Examination reveals edematous, reddened tonsils with a purulent exudate.

Chronic tonsillitis causes mild throat pain, malaise, and tender cervical lymph nodes. The tonsils appear smooth, pink and, possibly, enlarged, with purulent debris in the crypts. Halitosis and a foul taste in the mouth are other common findings.

Unilateral or bilateral throat pain just above the hyoid bone occurs with lingual tonsillitis. The lingual tonsils appear red and swollen and are covered with exudate. Other findings include a muffled voice, dysphagia, and tender cervical lymphadenopathy on the affected side.

Upper respiratory infection (URI).With a URI, throat pain may accompany coughing, sneezing, nasal congestion, rhinorrhea, fatigue, headache, myalgia, and arthralgia.

Uvulitis.Uvulitis may cause throat pain or a sensation of something in the throat. The uvula is usually swollen and red but, in allergic uvulitis, it's pale.

Other causes

Foreign body aspiration.A foreign body lodged in the palatine or lingual tonsil and pyriform sinus may produce localized throat pain. The pain may persist after the foreign body is dislodged until mucosal irritation resolves.

Treatments.Endotracheal intubation and local surgery, such as tonsillectomy and adenoidectomy, commonly cause throat pain.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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