Diseases » Mouth conditions » Diagnosis

Diagnosis of Mouth conditions

Mouth conditions Diagnosis: Book Excerpts

• Ask the Following Questions - SORE THROAT
• Ask the Following Questions - MOUTH PIGMENTATION
• Differential Diagnosis - Sore Throat
• Differential Diagnosis - Oral Lesions
• Differential Diagnosis - Sore Throat
• Approach to the Diagnosis - SORE THROAT
• Approach to the Diagnosis - ORAL OR LINGUAL MASS
• History and physical examination - Mouth lesions
• History and physical examination - Throat pain
• Diagnosis - Stomatitis and other oral infections
• History and physical examination - Mouth lesions
• History and physical examination - Throat pain
• Differential Overview - Sore Throat
• Differential Overview - Oral Lesions
• Diagnosis - Stomatitis and other oral infections
• History - Mouth lesions
• History - Throat pain
• Clinical Features and Diagnosis - Sore Throat
• History and physical examination - Mouth lesions
• History and physical examination - Throat pain
• Approach to the Diagnosis - SORE THROAT
• Approach to the Diagnosis - ORAL OR LINGUAL MASS

Diagnostic Tests for Mouth conditions: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Mouth conditions.

SORE THROAT: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Are there exudates? This is a key question when evaluating a sore throat. Most cases of sore throat with exudates will be found to have streptococcal pharyngitis. Without exudates, one could still have a streptococcal sore throat, but it is less likely.
2. Is there a temperature elevation? A significant elevation of the temperature, with or without exudates, is also characteristic of streptococcal pharyngitis.
3. Are there enlarged lymph nodes? If the lymph nodes are enlarged in the peritonsillar area, this is often a sign of streptococcal sore throat, but it certainly is not diagnostic. Interestingly enough, 90% of patients with infectious mononucleosis have posterior cervical adenopathy.
4. Are there systemic symptoms and signs? Patients who present with exudative tonsillitis and splenomegaly certainly should be considered to have infectious mononucleosis until proven otherwise. Also, an exudative tonsillitis along with a fever and heart murmur should make one consider rheumatic fever. Systemic symptoms such as dry cough, runny nose, and generalized malaise or fatigue should make one think of a viral URI.

DIAGNOSTIC WORKUP

In a sore throat with typical exudates very suggestive of streptococcal pharyngitis, a throat culture may be all one needs before starting definitive antibiotic therapy. In the more difficult cases, screening for streptococcal antigens (streptozyme test and ASO titer) might be indicated. An ASO titer is particularly important when one suspects rheumatic fever. If the patient's streptococcal sore throat persists, a Monospot test and a culture for gonorrhea should be done. Although there are hardly any false-negative Monospot tests, there are 10% false positives, and that should be kept in mind. A blood smear for atypical lymphocytes may be helpful, as well as a heterophile antibody titer in those cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

MOUTH PIGMENTATION: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there generalized pigmentation? The findings of generalized pigmentation would suggest Addison's disease, arsenic poisoning, and occasionally hemochromatosis. When there is no generalized pigmentation, one should suspect Peutz-Jeghers syndrome, chronic cachectic conditions, and acanthosis nigricans.
2. Is there hypotension or weight loss? These findings suggest Addison's disease and arsenic poisoning. If there is no hypotension or weight loss, then the mouth pigmentation and generalized pigmentation may be associated with African ancestry or Fabry's disease.

DIAGNOSTIC WORKUP

Routine laboratory workup includes a CBC, sedimentation rate, urinalysis, chemistry panel, and a VDRL test. If arsenic poisoning is suspected, hair analysis for arsenic should be done. If Addison's disease is suspected, a 24-hr urine collection for 17-hydroxysteroids and 17-ketosteroids should be done. The rapid ACTH test is a suitable alternative but usually more expensive. If Peutz-Jeghers syndrome or acanthosis nigricans is suspected, a GI series with a small bowel follow-through and a barium enema may be necessary. Endoscopy procedures may also be useful in certain cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Sore Throat: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Viral pharyngitis/laryngitis
  –Most common cause of sore throat
  –Associated with cough, low-grade fever, nasal congestion, and sneezing
  –Influenza occasionally causes sore throat with high fever, cough, severe myalgias
  –Rhino-, adeno-, coxsackie-, and herpesvirus
  –Acute HIV infection

• Mononucleosis
  –Associated with fever, headache, and excessive fatigue
  –Most common in teen and college ages
  –May have associated lymphadenopathy, splenomegaly, hepatitis, or encephalitis
• Streptococcal pharyngitis
  –May be associated with scarlatiniform rash, fever >101°F (>38.3°C), exudative pharyngitis, tender cervical lymphadenopathy, and absence of cough
  –More common in winter months, ages 5–10, and with history of group A Streptococcus exposure
• Allergic pharyngitis
• Gonococcal pharyngitis
• Fungal pharyngitis (e.g., Candida)
• Foreign body in throat
  –Most often occurs in smaller children
  –Associated with sudden onset of audible wheezing, stridor, drooling
• GERD
• Sore throat secondary to postnasal drip
• Irritation secondary to inhalants (e.g., cigarette smoke), chemicals (e.g., alcohol), hot foods
• Voice abuse (e.g., excessive screaming)
• Deep neck space infections (e.g., retropharyngeal abscess, peritonsillar abscess, Ludwig's angina)
• Epiglottitis/bacterial tracheitis
  –Occurs in children ages 2–7 and increasingly in adults
• Diphtheria
• Trauma
• Lymphadenitis (cervical)
• Cancer (e.g., tonsillar, tongue, laryngeal, esophageal)
• Caustic ingestions
• Thyroiditis
• Angina/acute coronary syndrome

Workup and Diagnosis

• History and physical exam often make the diagnosis
  –Consider exposure history, age, associated symptoms, past medical history (e.g. immunocompromise), use of inhaled steroids (e.g. with Candida pharyngitis), allergy history)
  –Focus on head and neck, lung, and abdominal examinations
• Streptococcal pharyngitis is often a clinical diagnosis
  –Presence of three out of four of the following criteria suggests the diagnosis: Exudative pharyngitis (not just a red throat); tender anterior lymphadenopathy; presence or history of fever; and absence of a cough; whereas if none or one of the criteria exists, group A β-hemolytic streptococcus is unlikely
  –Streptococcal culture is the gold standard (inexpensive; identifies group A and others; 1–2 days for results)
  –Rapid strep testing is more expensive and identifies only group A strep, but gives immediate results; very specific (95%) but less sensitive (60–70%), so consider culture if negative
• Monospot or CBC showing atypical lymphocytes is diagnostic for mononucleosis
• X-ray for foreign body; laryngoscopy if unable to verify
• Lateral neck X-ray may diagnose epiglottitis and retropharyngeal abscess
• Gonococcal and diphtheria cultures if necessary
• Barium swallow, upper GI series, or EGD for GERD

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Source: In a Page: Signs and Symptoms, 2004

Oral Lesions: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Aphthous stomatitis
  –Idiopathic
  –Recurrent, shallow, painful, spontaneously resolving oral ulcers
• Herpes stomatitis
  –Due to a primary outbreak of HSV-1
  –Severe gingivostomatitis with pain, redness, and erosions around the gum line
  –Recurrent oral HSV (“cold sores”) often occur at the lip border
  –Stress, sun exposure, and many other factors contribute to flare-ups
• Self-limited viral disease (e.g., herpangina, hand-foot-mouth disease)
  –Most often seen in children
  –Prodrome of malaise and fever followed by a 5–10 day outbreak of oropharyngeal erosions or vesicles is common
  • Chemotherapy drugs (especially 5-FU and methotrexate)
  • Squamous cell carcinoma should always be considered if a nonhealing ulcer or oral erosion is noted
  • Bullous diseases (e.g., pemphigoid, pemphigus, lichen planus)
    –Recurrent painful oral ulcers and erosions
    –Evaluate for other skin rashes suggestive of these disorders
    • Behçet syndrome
      –Uncommon but well-known cause of oral ulcers
      –Patients must exhibit other symptoms (e.g., uveitis, CNS problems, GI complaints, genital ulcers) before this diagnosis can be made
    • Allergic contact dermatitis to amalgams in dental work may result in buccal tenderness
    • Erythema multiforme (Stevens-Johnson syndrome)
      –Characterized by oral ulcers, ocular involvement, and simultaneous targetoid, erythematous, or bullous skin lesions
      –May be triggered by HSV infection, Mycoplasma infection, or drugs (e.g., phenytoin, sulfonamides)
      • Primary syphilis
        –Painless chancre
      • Agranulocytosis or leukopenia
      • Histoplasmosis (especially in immunosuppressed patients)

      Workup and Diagnosis

      • Detailed history and physical examination
        –Associated symptoms (e.g., fever, prodrome)
        –Review the patient's past medical history and medication list
        –If ulcers occur in the same location with every episode, oral HSV is likely
        –Is the patient sexually active (consider HIV, immunosuppression, or syphilis)
        –Perform a thorough skin exam to evaluate for rashes or other mucosal lesions (ocular, urethral, or perianal)
        –Lacy white plaques on the tongue or buccal mucosa may suggest lichen planus
        –Ocular or anogenital complaints can be suggestive of Behçet syndrome, pemphigus, or pemphigoid
      • Initial evaluation includes a viral swab for culture and/or serum for HSV-1 IgG detection to diagnose HSV, and consider an RPR and CBC to rule out syphilis and leukopenia, respectively
      • Consider a punch biopsy of the edge of an ulcer/erosion to determine if there are viral changes or cytologic atypia; or evidence of an autoimmune bullous disease
      • Recurrent aphthous stomatitis is a diagnosis of exclusion, but is also the most common diagnosis of recurrent painful oral ulcers after HSV

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Source: In a Page: Signs and Symptoms, 2004

Sore Throat: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Infectious
–Viral
     –Adenovirus
     –Rhinovirus
     –Parainfluenza
     –Influenza
     –Coronavirus
     –Others: EBV RSV, CMV, HSV
–Bacterial
     –Streptococcus
     –Haemophilus
     –Moraxella
     –Staphylococcus
     –Corynebacterium
–Fungal
     –Candida

• 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

Workup and Diagnosis

History
–Duration, onset, severity, frequency, odynophagia, dysphagia, daycare, sick contacts, fever, malaise, headache
–Foreign body and caustic ingestion
–Days of school or work missed
–Immunization history
–Medical history: Systemic disease, connective tissue disorder

• Physical exam
  –Nasal exam: Evidence of rhinosinusitis
  –Mouth: Ulcerations, masses, tonsil size, erythema, exudates
  –Neck: Lymphadenopathy
  –Skin: Rash
  –Chest: Wheezes, asymmetry
• Studies
  –For pharyngitis: A major goal is to differentiate streptococcal pharyngitis from viral etiologies
  –Throat culture: 92% sensitive; 100% specific; requires 24–48 hours
  –Rapid strep test: 72–85% sensitive; 88–100% specific
  –CBC with differential for suspected mononucleosis
  –Chest X-ray (inspiratory and expiratory) for suspected foreign body
  –CT neck: When complication of infection is suspected such as abscess

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

SORE THROAT: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL, U.S.A.) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

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Source: Differential Diagnosis in Primary Care, 2007

ORAL OR LINGUAL MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Most of these lesions are referred to the oral surgeon for diagnosis and treatment, so an elaborate discussion of the workup is unnecessary in a text of this scope. Obviously, cultures should be made in cases of suspected infectious granulomas, whereas biopsy or excision is the main diagnostic tool for neoplasms.

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Source: Differential Diagnosis in Primary Care, 2007

Mouth lesions: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, the frequency of dental examinations, and the date of his most recent dental visit.

Next, perform a complete oral examination, noting lesion sites and character. Examine the patient’s lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.

Palpate the neck for adenopathy, especially in patients who smoke tobacco or use alcohol excessively.

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

Throat pain: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when he first noticed the pain, and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx, using a warmed metal spatula or tongue blade, and the nasopharynx, using a warmed laryngeal mirror or a fiber-optic nasopharyngoscope. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate. Obtain an exudate specimen for culture. Then examine the nose, using a nasal speculum. Also, check the patient’s ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

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

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

Diagnosis is based on the physical examination; in Vincent’s angina, a smear of ulcer exudate allows for identification of the causative organism.

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

Mouth lesions: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed any pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, frequency of dental examinations, and the date of his most recent dental visit.

Next, perform a complete oral examination, noting lesion sites and character. Examine the patient’s lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially any painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.

Palpate the neck for adenopathy, especially in patients who smoke tobacco or use alcohol excessively.

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

Throat pain: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when he first noticed the pain and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx, using a warmed metal spatula or tongue blade, and the nasopharynx, using a warmed laryngeal mirror or a fiber-optic nasopharyngoscope. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate; if exudate is present, obtain a specimen for culture. Then examine the nose, using a nasal speculum. Also, check the patient’s ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

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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

Diagnostic Approach

The most important consideration is whether the patient has a group A strep infection because prompt treatment prevents rheumatic fever. The findings of fever, tender anterior cervical adenopathy, and tonsillar exudate can be combined to make the diagnosis more or less likely. Rapid antigen tests have a sensitivity of 80% to 90% and specificity of 95% to 100%, so give a reasonably accurate diagnosis. Because of limitations in sensitivity however, patients with a high suspicion on clinical grounds should have a backup culture taken.

 Prior probability in an adult population with sore throat is 5% to 10%, and in a pediatric population 20% to 25%. A prominent sore throat out of proportion to the degree of pharyngeal inflammation should raise the possibility of acute epiglottitis and acutely impending airway compromise. Persistent unilateral tonsillar enlargement in a young adult without sore throat should raise the suspicion of lymphoma.

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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

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Source: Field Guide to Bedside Diagnosis, 2007

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

Physical examination allows diagnosis. A smear of ulcer exudate allows identification of the causative organism.

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Source: Handbook of Diseases, 2003

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

Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed any pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, frequency of dental examinations, and the date of his most recent dental visit.

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

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

Ask the patient when he first noticed the pain and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

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

Sore Throat: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Infection

Pharyngitis/Tonsillitis

Viral

Severalviruses may cause pharyngitis/tonsillitis, including parainfluenzaviruses, influenza viruses, rhinoviruses, coronaviruses, and respiratorysyncytial virus. Coryza and cough predominate, whereas fever isvariable finding. Nasal wash cultures are diagnostic but usuallyunnecessary for management.

Enteroviruses also may cause sore throatand fever, especially in summer months, but tonsillar exudate isunusual.

Herpanginais characterized by fever and painful vesicular lesions on pharynxand tonsils.

Coxsackie A16 is major cause of hand-foot-mouthdisease, which is characterized by vesicular lesions in the mouthand on hands and feet.

Herpes simplex virus produces acutegingivostomatitis with fever and painful vesicles usually confinedto anterior mouth. However, lesions may extend to anterior tonsillarpillars.

Epstein-Barr virus is common causeof sore throat in adolescents. Other characteristic findings ofinfectious mononucleosis include fever, malaise, fatigue, cervicalor generalized lymphadenopathy, and hepatosplenomegaly. >10% atypicallymphocytes are usually seen on blood smear. Positive mono spottest, which identifies immunoglobulin M (IgM) heterophile antibody,is diagnostic. When this test is negative, IgG and IgM antibodyagainst viral capsid antigen (VCA) should be determined. Presenceof IgM-VCA is associated with recent or current illness and confirmsdiagnosis, whereas IgG-VCA is present continuously after acute infection.

Adenovirus may cause pharyngoconjunctivalfever. Follicular hyperplasia of tonsils and exudate may be seen.

Bacterial

Group A Streptococcus

Most commonbacterial cause of pharyngitis/tonsillitis is group A Streptococcus.

Classic clinical presentation is school-agedchild with acute onset of fever and sore throat. Headache, abdominalpain, and vomiting also may occur. Rhinorrhea, cough, conjunctivitis,hoarseness, and diarrhea are unusual. Tonsils are enlarged and inflamed,with patches of exudate. Petechiae may sometimes be seen on palate.

Anterior cervical lymph nodes may beenlarged on 1 or both sides and are often tender.

Usual clinical dilemma is to distinguishbetween viral infection or group A streptococcal infection. Difficultto distinguish them clinically, except when typical erythematoussandpaper-like rash of scarlet fever occurs, which signifies infectionwith group A Streptococcus.

Rapid techniques are now availablefor detection of streptococcal antigen. Either rapid antigen testor throat culture should be performed if streptococcal pharyngitisis suspected. If antigen assay is negative, throat culture shouldbe obtained.

Other Bacteria

Pharyngitiscaused by group C or G Streptococcus is indistinguishable from that causedby group A Streptococcus.

A. hemolyticum produces illness similarto group A Streptococcus. Scarlet fever–like rash occursmost often in adolescents, but strawberry tongue and palatal petechiaehave not been described.

N. gonorrhoeae pharyngitis can occurin sexually active adolescents as consequence of oral-genital contact.Ulceration of pharynx and tonsils along with exudate may be seen.Its presence in younger children suggests sexual abuse.

M. pneumoniae is uncommon cause ofpharyngitis, whereas C. diphtheriae is rare cause of pharyngitis.With the latter infection, acute onset of fever and sore throatis followed in 1–2 days by grayish membrane over pharynxand tonsils, which may extend into larynx and trachea.

Positive throat culture confirms diagnosisof these pathogens.

Peritonsillar, Retropharyngeal, and Lateral Pharyngeal Abscesses

Generallydue to spread of infection from local sites.

Most common pathogens are aerobes (groupA Streptococcus, S. aureus, H. influenzae) and anaerobes (Peptostreptococcus,Fusobacterium, Prevotella, Porphyromonas species), although manyinfections are polymicrobial.

Peritonsillar abscess generally occursas complication of acute bacterial tonsillitis in older childrenand adolescents. Sore throat, fever, pain on swallowing, drooling,and trismus characterize this infection. Ipsilateral otalgia alsomay occur. Swollen inflamed tonsil has fluctuant quality and oftenpushes uvula across midline of oral cavity. Diagnosis is clinical,although specific pathogen can be cultured from infected tonsilor abscess drainage.

Although retropharyngeal abscess/cellulitisis uncommon cause of sore throat, it usually occurs in children <4yrs. Most children appear toxic and are in respiratory distress,but some complain of sore throat and painful swallowing early incourse. Often direct visualization is impossible and lateral neck radiographyshows bulge of posterior pharyngeal wall. If diagnosis is uncertain,CT can be performed.

Lateral pharyngeal abscess usuallypresents with fever and trismus as well as swelling and tendernessbelow mandible. CT is helpful in determining extent of abscess.

Irritants

Upon awakeningin morning, otherwise well child may have scratchy sore throat, whichusually improves over several hours. This sensation is usually dueto dryness of pharynx and frequently occurs with rhinitis, especiallyduring winter months when humidity is low and mouth breathing islikely because of nasal congestion.

Exposure to dust or smoke also maycause irritation of pharynx.

Postnasal drip secondary to allergicrhinitis or sinusitis also may cause pharyngeal irritation and mildsore throat.

Trauma

Excessiveuse of voice due to prolonged shouting or singing may cause sore throat.

Burn secondary to exposure of hot gasesor liquid also may cause pharyngeal pain.

Foreign Body

Foreignbody lodged in pharynx causes acute onset of choking, dysphagia,and sometimes upper airway obstruction.

Commonly, fish bone or chicken bonecan be seen in pharynx. Otherwise, neck radiography may be diagnostic.

Only symptom of retained foreign bodyin upper airway may be persistent stridor. In this circumstance,laryngoscopy is usually diagnostic.

Caustic Substances

Ingestionof caustic substances may cause inflammation of pharynx.

History and physical exam are diagnostic.

For suspected esophageal injury, esophagoscopyshould be performed.

Psychogenic

Sometimes there does not seem to be explanationfor sore throat after history, physical exam, negative throat culture,and normal neck radiographs. In this case, psychosocial historyis most valuable clinical tool.

Diagnostic Approach

Historyand physical exam provide important clues for proper diagnosis ofsore throat.

Most common clinical dilemma in childwith pharyngitis is whether pathogen is virus or group A Streptococcus.Tests to detect streptococcal antigen may be diagnostic, but ifresults of such tests are negative, throat culture should be performed.

Because many cases of pharyngitis aredue to viruses, antibiotic use should be guided by antigen detectiontests or culture. Presence of conjunctivitis, cough, rhinitis, andhoarseness suggests viral etiology. Infectious mononucleosis isalso a consideration, especially in older children and adolescents.

Neck radiography, flexible laryngoscopy,and CT are useful with suspected foreign body or retropharyngeal/lateralpharyngeal abscess.

>

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

Mouth lesions: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed odor or drainage or experienced pain. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, the frequency of dental examinations, and the date of his most recent dental visit.

Next, perform a complete oral examination, noting lesion sites and character. Examine the patient's lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums. Note any odor.

Palpate the neck for adenopathy, especially in patients who use tobacco or ingest alcohol excessively.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Throat pain: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when he first noticed the pain, and have him describe it. Has he had throat pain before? How was it treated? Is it accompanied by fever, ear pain, or dysphagia? Review the patient's medical history for throat problems, allergies, and systemic disorders.

Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx and the nasopharynx. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate. Obtain an exudate specimen for culture. Then examine the nose. Also, check the patient's ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

SORE THROAT: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and to start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

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Source: Differential Diagnosis in Primary Care, 2007

ORAL OR LINGUAL MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Most of these lesions are referred to the oral surgeon for diagnosis and treatment, so an elaborate discussion of the workup is unnecessary in a text of this scope. Obviously, cultures should be made in cases of suspected infectious granulomas, whereas biopsy or excision is the main diagnostic tool for neoplasms.

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Source: Differential Diagnosis in Primary Care, 2007

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