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–
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Respiratory viruses
Influenza
Epstein-Barr virus
Herpes Simplex Virus, Herpangina
• Bacterial– S. pyogenes, N. gonorrhoeae,
Cornynebacterium diphtheriae
Acute Pharyngitis: Etiology
• Non infectious including
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Allergy
inhalation of irritating fumes
gastroesophageal reflux
sleep apnea
Viral Pharyngitis
Respiratory Viral syndromes
• Etiology: Rhinovirus, Adenovirus, Parainfluenza
• Transmission:
• Clinical Manifestations: Sore throat and
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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
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Fever
Myalgias
Headache
Non-productive cough
• Diagnostics:
• Management: Amantadine or Rimantadine
Epstein Barr /Mononucleosis
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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:
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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:
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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
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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
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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
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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
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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
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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
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Fever
Edema and erythema
Floor of mouth rigid
Neck movement
Tongue displaced
Dysphonia, dysphagia,
trismus, drooling,
stridor
Ludwig’s Angina
• Diagnosis: culture,
CT
• Management:
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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
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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
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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
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OnsetExacerbating factors
Recent URI
Exposure to irritants
History of Hypothyroidism?
History of smoking, cancer?
Differential Diagnosis of Hoarseness
Physical Exam
• Physical Exam
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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?