Differential Diagnosis of Hoarseness Infections to Pharynx and Oral Cavity By Stacey Singer-Leshinsky R-PAC Anatomy of the Pharynx Acute Pharyngitis • Can be accompanied by conjunctivitis, cough, sputum production, rhinitis or other systemic symptoms. • Most common in winter and early spring • Common patient complaint Acute Pharyngitis: Etiology • Viral– – – – Respiratory viruses Influenza Epstein-Barr virus Herpes Simplex Virus, Herpangina • Bacterial– S. pyogenes, N. gonorrhoeae, Cornynebacterium diphtheriae Acute Pharyngitis: Etiology • Non infectious including – – – – Allergy inhalation of irritating fumes gastroesophageal reflux sleep apnea Viral Pharyngitis Respiratory Viral syndromes • Etiology: Rhinovirus, Adenovirus, Parainfluenza • Transmission: • Clinical Manifestations: Sore throat and – – – – Coryza Conjunctivitis Cough: with/without sputum production Other systemic symptoms. • Diagnostics: • Management: Analgesics, cough suppressant (Dextromethophan), decongestants Viral Pharyngitis Influenza • Etiology: orthomyxovirus • Transmission: • Clinical manifestations: sore throat, exudates to pharynx possible – – – – Fever Myalgias Headache Non-productive cough • Diagnostics: • Management: Amantadine or Rimantadine Epstein Barr /Mononucleosis • • • • Incubation 2-5 weeks. One infection =lifelong immumunity Etiology: Epstein Barr Virus, CMV Transmission: Epstein Barr /Mononucleosis • Clinical manifestations: – Prodrome of malaise, headache, and fatigue followed by fever – Lymphadenopathy: – Pharyngeal erythema – Splenomegaly- • Maculopapular rash: Epstein Barr /Mononucleosis • Diagnostics: – – – – Monospot: Heterophile antibody. Assay for EBV antibodies. Blood smear: Atypical lymphocytosis Throat culture: Rule out secondary infection Epstein Barr /Mononucleosis • Management: – Avoid activity if Splenomegaly. – Complications: • • • • Splenic rupture Hepatitis Thrombocytopenia Neurologic: Guillain-Barre syndrome Viral Pharyngitis Herpangina • Due to Coxsackie group A viruses • If tender, vesicular lesions on dorsum of hands and palms which form bullae and ulcerate, then known as hand, foot and mouth disease. – Complications: CNS disease, myocarditis, • Transmitted through fecal/oral or airborne Viral Pharyngitis Herpangina • Acute onset of fever, anorexia and malaise • Sore throat • Grayish white papulovesicular lesions on erythematous base that ulcerate. Located on soft palate, anterior pillars of the tonsils, and uvula. Viral Pharyngitis Herpangina • Diagnosis: cultures or swabs of nasopharynx, Antibody titer • Management: Hydration, antipyretics, Topical analgesics Viral Pharyngitis Acute HIV Syndrome • Consider in any patient with HIV exposure and fever of unknown origin • Begins after incubation period of few days to weeks post exposure. • Flu like illness lasts 7-14 days. Viral Pharyngitis Acute HIV Syndrome • • • • • • • Sore throat / Oral ulcers Fever Maculopapular rash Lymphadenopathy Arthralgia Malaise Weight loss Viral Pharyngitis Acute HIV Syndrome • Diagnosis: Detection of HIV-1 replication without antibodies. Plasma HIV-1 RNA. Follow for positive antibodies. • Differential Diagnosis: Mononucleosis • Management: Antiretroviral therapy Viral Pharyngitis HSV • Etiology: HSV types I and II • Transmission is direct contact with mucous or saliva • Clinical manifestations • First episode involves gingivostomatitis and Pharyngitis • Can mimic streptococcal infection • Viral Pharyngitis HSV • Clinical Manifestations: – Fever, malaise, myalgia, anorexia, irritability – Cervical lymphadenopathy – Pharynx: Exudative ulcerative lesions. Grouped vesicles on erythematous base to buccal mucosa and hard and soft palate. • Diagnosis: Culture • Management: Acyclovir, Valacyclovir Bacterial Pharyngitis Streptococcal Pharyngitis • S. pyogenes: Group A Beta hemolytic strep • Gram positive bacteria that displays group A antigen on cell wall and beta – • Streptolysin O and S and toxins which produce beta-hemolytic properties. Can find antibodies to this • Transmission is direct contact. Bacterial Pharyngitis Streptococcal Pharyngitis • Clinical manifestations: – Acute onset of Severe sore throat and dysphagia – NO coryza, NO cough, NO hoarseness – Fever >101f – Hyperemic pharyngeal membrane with tonsillar hypertrophy and exudates. – Tender anterior cervical adenopathy – Possible recent exposure. Lasts 7-10 days Bacterial Pharyngitis Streptococcal Pharyngitis • Diagnosis: – Throat culture – Rapid antigen-detection test • Management: – Penicillin, ten day course. – Erythromycin Bacterial Pharyngitis Streptococcal Pharyngitis • Complications: – scarlet fever – rheumatic fever: Heart failure, pain and swelling to joints, fever, rash, nodules under skin. – Glomerulonephritis: 10 days post infection. Decreased urine output, dark urine, mild swelling, temporary kidney failure that resolves. – peritonsillar abscess – otitis media, mastoiditis, – sinusitis, pneumonia Bacterial Pharyngitis Gonococcal Pharyngitis • Etiology: Neisseria gonorrhoeae. Gramnegative intracellular aerobic diplococcus. • Infection of the throat involving tonsils and larynx • Risks: Bacterial Pharyngitis Gonococcal Pharyngitis • Clinical manifestations: • Might coexist with genital infection • Diagnosis: throat swab on Thayer martin media • Management: ceftriaxone or quinolones. Diphtheria • Etiology: Corynebacterium diphtheriae • Produces a potent exotoxin that causes an inflammatory response and formation of pseudomembrane on respiratory mucosa. • The exotoxin is absorbed. Inhibits protein synthesis which can damage kidney, heart, nerves • Death secondary to aspiration of membrane or toxic effect on heart Diphtheria – Severe sore throat – Fever – Adherent whitish blue pharyngeal exudates that cover pharynx. When scraped reveal underlying inflammation and edema. Known as “pseudomembrane” – Cervical adenopathy Diphtheria • Diagnostics: • Management: Isolation. Antitoxin to neutralize toxin, erythromycin, penicillin • Complications- myocarditis, peripheral neuritis • DPT vaccine at 10 year intervals Peritonsillar Abscess/Cellulitis • Infection from the tonsil to the peritonsillar fascial planes. • Etiology: polymicrobial, anaerobic bacteria such as S. pyogenes, H. influenzae, Streptococcus milleri, Streptococcus viridans • Can be complication of mononucleosis, tonsillitis, peritonsillar Cellulitis Peritonsillar Abscess/Cellulitis • Inflammation, pocket of pus in supratonsillar space • Trismus • Fever, odynophagia, headache, malaise, referred ear pain • Deviated uvula with peritonsillar swelling and erythema to posterior pharynx • Lymph node enlargement Peritonsillar Abscess/Cellulitis • Diagnosis: • Management: – Incision and drainage of pus from peritonsillar fold followed by tonsillectomy – IM/IV penicillin • Complications – Extension of infection to retropharyngeal deep neck, posterior mediastinal space, and pneumonia Retropharyngeal Abscess • Soft tissue infection causing difficulty in swallowing, fever and pain. • Risk factors including acute pharyngitis, otitis media, tonsillitis, dental infections, ludwig’s angina • Etiology :Aerobes and anaerobes including Group A beta hemolytic streptococci and S. aureus Retropharyngeal Abscess Clinical Features • • • • • • • • • Sore throat Fever Dysphagia Neck pain/ stridor Drooling Neck stiffness Cervical adenopathy Bulge in posterior pharyngeal wall Lateral neck or CT show soft tissue mass Retropharyngeal Abscess Management/Complications • Management – Airway– Surgical drainage – IV antibiotics to cover gram positive, negatives and anaerobes such as clindamycin, Penicillin, Timentin • Complications – Extension of disease including • Pericarditis • Rupture of abscess leading to aspiration pneumonia Intraoral ulcerative Lesions Necrotizing Ulcerative Gingivitis • Etiology: Spirochetes and fusiform bacilli • Risk factors include: tobacco, stress, poor hygiene, poor nutrition. Intraoral ulcerative Lesions Necrotizing Ulcerative Gingivitis • Clinical features – Rapid onset of pain with ulceration, swelling – Interdental necrosis and bleeding – Foul breath – Gray exudate removable with gentle pressure Intraoral ulcerative Lesions Necrotizing Ulcerative Gingivitis • Complications: fever, cervical lymphadenopathy, leukocytosis, destruction of bone and surrounding tissue, gangrene • Management: – Debridement – Half strength peroxide – Penicillin Intraoral ulcerative Lesions Aphthous Ulcer • Caused by nonspecific acute inflammation • found on buccal and labial mucosa, oropharynx, tongue • Diagnostics: • Differential diagnosis: Erythema multiforme, Drug allergy, Inflammatory bowel disease, Squamous cell carcinoma • Complications: Intraoral ulcerative Lesions Aphthous Ulcer • Painful small round ulcerations with yellow-gray centers surrounded by erythematous halos . • Management Self limited, topical analgesics, topical steroids Intraoral ulcerative Lesions Herpes Simplex Virus I • Viral infection • Infects trigeminal nerve and can remain dormant for long periods. • Found attached to gingiva, hard palate Intraoral ulcerative Lesions Herpes Simplex Virus I • Burning followed by small vesicles • Pain • Fever, headache • Malaise • Recurrent Intraoral ulcerative Lesions Herpes Simplex Virus I • Diagnostics include Tzanck smear with multinucleated giant cells • Differential diagnosis Erythema multiforme, Inflammatory bowel disease, Squamous cell carcinoma • Management: Self limited. Analgesics, hydration, Acyclovir or Valacyclovir Dental Dental Carie • Tooth decay – Etiology as streptococcus mutans present in plaque – Clinical Manifestations: • Toothache • Presents as aching pain when dentin is exposed – Management: Analgesics, Antibiotics, dental consult Dental Dental Abscess • Decay of tooth into dentin and tooth pulp • Bacterial infection of the periodontal tissues • Etiology is Streptococcus mutans present in plaque Tooth Abscess Clinical Manifestations • • • • Severe toothache swelling fever, leukocytosis Management: I/D, oral antibiotics, root canal Oral Candidiasis • Opportunistic infection in infants, anemia patients, nutritional deficiencies, corticosteroid use, immunocompromised • Complications include spread to esophagus, brain Oral Candidiasis • Whitish plaques to mouth/tongue above erythemic tissue that may bleed • White patches leave a raw, inflamed area • Confirmed by KOH prep • Management including antifungal mouth wash Oral Leukoplakia • Hyperkeratosis • Increased thickness of keratin layer and neovascularization. Epithelial dysplasia is precancerous • Risks: trauma, alcohol, tobacco • Erythroplakia more likely to be cancerous than leukoplakia. • Hairy leukoplakia Oral Leukoplakia • Flat or raise white lesion that cannot be removed by rubbing the mucosal surface • Erythroplakia is reddish, velvety lesion Oral Leukoplakia Diagnosis/ Management • Diagnosis: Biopsy or cytologic examination • Complications • Differential diagnosis including squamous cell carcinoma, oral Candidiasis • Management: – ENT – B-carotene and retinoids and Vit E might be effective. – If Biopsy positive for oral squamous carcinoma, surgery and chemotherapy Oral Lichen Planus • Chronic autoimmune disease • Both cutaneous and mucosal forms • Cutaneous presents with 4 P’s • Can be aysmptomatic Oral Lichen Planus • Painful oral mucosa/gums • White striations (wickham striae) with erythematous border located bilaterally on buccal mucosa • Lesions can erode into ulcers Oral Lichen Planus Management • Differential diagnosis: Pemphigus Vulgaris, chronic candidiasis or squamous cell carcinoma • Diagnosis: Biopsy or Immunofluorescencehistological confirmation. deposition of fibrinogen along basement membrane zone • Management: systemic or topical corticosteroids, cyclosporine mouthwash Glossitis • Etiology – – – – Nutritional deficiencies Drug reactions Dehydration Psoriasis • Clinical Manifestations: • Diagnostics: • Management: correct underlying problem. Diseases of the Salivary Glands Sialadenitis • Infection or inflammatory disorder affecting either the parotid or submandibular gland • Etiology: S. aureus, autoimmune, viral • Risk factors – Sjogren’s syndrome Diseases of the Salivary Glands Sialadenitis • Acute swelling of the gland • Pain and erythema at opening of duct • Pus massaged from duct. • Fever Diseases of the Salivary Glands Sialadenitis • Diagnosis: Ultrasound • Complications: • Differential diagnosis:Ductal stricture, Stone, Tumor • Management including IV antibiotics such as Nafcillin, increase salivary flow Diseases of the Salivary Glands Sialolithiasis • More common in Wharton’s duct then stenson’s duct • Etiology: inspirated secretions, ductal debris, calcium phosphate due to inflammation or stasis • Management: hydration, warm compresses, massage to gland area. Diseases of the Salivary Glands Sialolithiasis • Clinical manifestations – Partial obstruction leads to enlargement and pain on eating – Total obstruction leads to chronic enlargement and infection – Palpate gland for calculi, examine all glands for masses, symmetry, purulence • Diagnosis: x-ray/CT Wharton duct usually radiopaque, stenson smaller – sialography Diseases of the Salivary Glands Parotitis • Inflammation or infection of one or both of the parotid salivary glands. • Chronic bilateral parotitis associated with autoimmune disease, unilateral associated with stones. • Etiology is viral or bacterialparamyxoviral most common viral and s. aureus most common bacterial Diseases of the Salivary Glands Parotitis • Swelling and erythema to preauricular and postauricular areas • Fever • Diseases of the Salivary Glands Parotitis • Diagnosis: – Aspiration of duct and culture • Management – Augmentin or Clindamycin until specific microorganism found Halitosis • Foul breath odor • Etiology can be impaired salivary flow • Management TMJ Dysfunction • Consequence of bruxism leading to masticatory muscle fatigue and spasm. • Clinical features include – chronic, dull, aching, unilateral discomfort to the jaw, behind eyes, ears or neck – Patient complains of clicking sounds TMJ Dysfunction Management • Dietary advice: • Avoid clenching • Relax muscles with moist heat Ludwig’s Angina • Severe Cellulitis of the submaxillary space with involvement of the sublingual and submental space. • Etiology: Infection to lower molars, penetrating injury to mouth floor. • Etiology: Ludwig’s Angina • • • • • • Fever Edema and erythema Floor of mouth rigid Neck movement Tongue displaced Dysphonia, dysphagia, trismus, drooling, stridor Ludwig’s Angina • Diagnosis: culture, CT • Management: – – – – ENT/dental consult I/D IV antibiotics Admit to ICU • Complications: Differential Diagnosis of Hoarseness • Vocal quality- determined by: – distance between vocal cords, – tenseness of the cords – how rapid cords vibrate • Hoarseness is caused by – Differential Diagnosis of Hoarseness Types of voice • Breathy- vocal cords do not approximate so air escapes. • Raspy- harsh voice. Cord thickening due to edema or inflammation. Voice is low in pitch and poor quality Differential Diagnosis of Hoarseness Types of voice • Muffled voice- painful dysphagia and dyspnea • Shaky- high pitch or low soft. – Elderly – debilitated Differential Diagnosis of Hoarseness Acute Hoarseness/Acute Laryngitis • Laryngeal mucous membrane infection, usually viral (adenovirus/ influenza, RSV, coxsackie, rhinovirus) • Also can be due to trauma to throat, vocal abuse, toxic exposure, GI complications, smoking, allergy Differential Diagnosis of Hoarseness Acute Hoarseness/Acute Laryngitis • • • • • • Hoarseness Cough Sore throat Fever Vesicles on soft palate Lymphadenopathy Differential Diagnosis of Hoarseness Acute Hoarseness/Acute Laryngitis • Diagnostics: Laryngoscopy if suspect mass, infection, vocal cord dysfunction • Management: Voice rest, smoking/alcohol cessation, hydration Differential Diagnosis of Hoarseness Vocal Cord Lesions – Smooth paired lesions. – Form due to vocal abuse – respond to voice rest and vocal therapy – Surgery Leukoplakia on Vocal Cords • Hyperkeratotic changes • Presents as hoarseness with no pain • Premalignant • Found in smokers Laryngeal Carcinoma • Laryngeal carcinoma – History of smoking and drinking – Usually pain when swallowing only second to ulceration – Fetid breath Vocal Cord Paralysis • Usually affects one cord • Nerve often injured in surgery • Vocal cord trauma second to traumatic or chronic intubation • Systemic disorders such as hypothyroidism, rheumatoid arthritis, GERD Vocal Cord Trauma Differential Diagnosis of Hoarseness History Questions • Discuss history and physical exam questions important in distinguishing the etiology of hoarseness including – – – – – – OnsetExacerbating factors Recent URI Exposure to irritants History of Hypothyroidism? History of smoking, cancer? Differential Diagnosis of Hoarseness Physical Exam • Physical Exam – – – – – – Airway, Breathing and Circulation HEENT exam Neck exam: Thyroid Exam Thorax and cardiac Laryngoscopy: Review 1 • A 21 year old female presents to you complaining of runny nose and cough. She is afebrile. What is the most likely diagnosis and etiology of this diagnosis? Review 2 • This patient had a prodrome of malaise and headache followed by fever and sore throat. On physical exam you note this and petechiae on junction of hard and soft palate. Also anterior and posterior cervical adenopathy. • What is your differential? • What lab results are expected to confirm this? • What is a complication of this? Review 3 • A mom brings in her 4 year old who has had an acute onset of fever, anorexia, and sore throat. On PE you note vesicles and ulcers on the tonsil pillars and soft palate. • What is your differential? • What is the management for this? • What is hand, foot and mouth disease and a complication of this? Review 4 • This patient had an acute onset of sore throat and fever of 102 with no coryza or cough. On PE you note anterior cervical adenopathy • What is this? • How is this diagnosed? • How is this managed? • What are some complications of this? Review 5 • A 6 year old presents with severe sore throat and fever. On PE you note a adherent whitish blue pharyngeal exudate that causes bleeding if removed. • What is this? • What is the management of this? • Can this be prevented? • What causes the damage in this condition? Review 6 • A 32 year old male presents with a painful lesion to his mouth for two days. On PE you note a small round ulceration with yellow gray center surrounded by red halos. • What is this? • What is the possible etiology of this? • What is in the differential diagnosis? • How is this treated? Review 7 • A 32 year old male presents with this. He described the onset of this as burning followed by small vesicles that ruptured and turned into ulcers. • What is this? • How is this diagnosed? • What is the management of this? Review 8 • This patient is an asthmatic who uses corticosteroids. She is concerned over these white painful lesions she has developed in her mouth. • What is this? • What will happen when we attempt to remove this white film? • How is this managed? Review 9 • This lesion was noted by patients dentist. Patient complains of painful gums. On PE you note Wickham striae. • What is this? • How is this diagnosed? • How is this treated? Review 10 • This patient presents with edema and erythema of upper neck, under chin and floor of mouth. She has pain on neck movement. • What is this? • How is her tongue displaced? • What is the management? • What complications exist?