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Junior Surgery Lecture:
The Mouth and Pharynx

Anna M. Pou, M.D.

Examination of the tongue and oral cavity requires good illumination, manual palpation, and keen observation. Look for: edema, asymmetry, bulging of tissues, changes in color and texture of mucosa.

Median rhomboid glossitis: seen mostly in adults; characterized by a deep red smooth area in the midline tongue; etiology unclear- current hypothesis suggests it is caused by a chronic candida infection

Lingual thyroid: due to failure of thyroid gland to descend into neck; may be asymptotic or present with dysphagia; must determine if it is the only thyroid tissue in the neck; treatment with thyroid suppression. or surgery if symptomatic.

Ankyloglossia: occurs when the frenulum is too short; this condition should be corrected when there is tip restriction, speech defects, restriction of sucking, or dental deformities; treatment usually not before age 4.

Migratory glossitis/geographic tongue: characterized by patchy areas devoid of papillae; etiology unknown, treatment unnecessary.

Burning tongue: very common complaint; nonspecific-may be due to anemia, hyperglycemia, allergy, candidiasis, lichen planus, or geographic tongue; treat underlying cause.

Hairy tongue: black/brown tongue resulting from elongations of filiform papillae; etiology unknown, but may be due to antibiotic use, poor oral hygiene, and nutritional deficiencies; treatment with toothbrush and H2O2; treat underlying cause.

Fungal infections: candidiasis is the most common; lesions appear as whitish areas or erythematous areas; treat with topical or oral antifungals.

Neoplasms: squamous cell carcinoma is the most common; associated risks factors aresmoking, drinking, poor oral hygiene; most common site is lateral border of tongue.

Ulceronecrotic gingivitis: "Vincent's angina"; caused by Borrelia vincentii; treat with dilute H2O2 mouthwashes and penicillin.

Gingival hyperplasia: seen with dilantin use, and in patients with AML.

Leukoplakia: refers to white patches; 80% are histologically benign, and 20% are histologically malignant.

Trismus: inability to open the jaws; differential diagnoses include dental problems, TMJ, arthritis, tumor, deep neck abscesses, tetany, tetanus; tracheotomy may be necessary to maintain airway.

Halitosis is a symptom, not a disease. 90% of cases originate in the oral cavity, with poor oral hygiene being the most common cause. Other common causes include decreased salivary flow, cryptic tonsils, chronic sinusitis, nasal foreign bodies, bronchitis, pneumonia, bronchiectasis, hiatal hernia, Zenker's diverticulum, hepatic failure(sulfur odor), uremia(ammonia odor), and DKA(acetone breath).

Acute throat pain: differential diagnosis

Viral and bacterial (strep, staph, Neisseria) pharyngitis

Scarlet fever: caused by a strep organism which produces an erythrogenic toxin. It is characterized by a strawberry tongue(bright red papillae) or a raspberry tongue(bright red tongue with large papillae). Culture is diagnostic and treatment is with penicillin.

Ludwig's angina: rapidly spreading cellulitis of the submental, submandibular and sublingual spaces. Patient most often requires tracheotomy for airway and I&D, and antibiotics for treatment.

Infectious mononucleosis

Lingual tonsillitis

Ulceronecrotic tonsillitis

Fungal infection

Diphtheria

Retropharyngeal abscess: most commonly occurs in young children, and is most often secondary to a URI. Symptoms consists of dysphagia, high temp, throat pain, stiff neck, enlarged cervical nodes, and airway compromise. Treatment often requires tracheotomy for airway, I&D, IV antibiotics, and hospitalization.

Peritonsillar abscess: exam reveals a unilaterally enlarged tonsil, deviated uvula, trismus, +/- drooling, high temp.

Epiglottis: usually caused by Haemophilus influenzae. Infection can progress to airway obstruction. Patients appear toxic, high temp, airway compromise, drooling. Airway must be controlled by a team of experienced otolaryngologist and anesthesiologists in the OR.

Laryngitis

Foreign body

Neoplasms

Chronic throat pain: differential diagnosis
Pharyngitis
Neoplasms
Neuralgia
Thyroiditis
Hysteria

Indications for tonsillectomy:
3 episodes of tonsillitis/year X 3 years
5 episodes of tonsillitis/year X 2 years
7 episodes of tonsillitis/year X 1 year
Tonsillar hypertrophy with obstruction

Indications for adenoidectomy:
Chronic nasopharyngitis
Chronic adenoiditis
Chronic sinusitis
Adenoid hypertrophy with obstruction

Contraindications for tonsillectomy or adenoidectomy:
Preexisting velopharyngeal incompetence
Bleeding disorders

Last Updated:  11/19/98,10:30 hrs
FN: mouth-pharynx.htm