Junior
Surgery Lecture:
The
Mouth and Pharynx
Anna
M. Pou, M.D.
SLIDE
1: 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. This is a picture of a normal oral
cavity and oropharynx.
SLIDE 2: This is an example of an asymmetric tonsil. One should consider lymphoma in the differential diagnosis.
The
following are common conditions that you should become familiar with. There are clinical photographs for some
of these.
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
SLIDE
3: 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.
SLIDE
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.
SLIDE
5: 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.
SLIDE
6: Neoplasms:
squamous cell carcinoma (SCCA) is the most common; associated risks factors are
smoking, drinking, poor oral hygiene; most common site is lateral border of
tongue. This is an example of SCCA
of the tongue.
SLIDE
7: Ulcer necrotic
gingivitis:
"Vincent's angina"; caused by Borrelia vincentii; treat with dilute H2O2
mouthwashes and penicillin.
SLIDE
8: Gingival
hyperplasia:
can result from Dilantin use, acute myelogenous leukemia and poor oral
hygiene.
SLIDE
9: 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).
SLIDE
10: Lichen planus: milky-white papules and
white lacework on the buccal mucosa.
Differential diagnosis:
candidiasis/leukoplakia
SLIDE
11: Lingual varices: varicosities on the
ventral surface (under) of the tongue; normal variant.
SLIDE
12: Large circumvallate
papillae: these
papillae are found on the posterior third of the tongue; they separate the oral
from the base of tongue; these are normal.
SLIDE 13: Atrophic glossitis:
associated with pernicious anemia (Vit B12 defic); tongue looks
smooth.
SLIDE
14: Fissured tongue (scrotal
tongue): deep
furrows; occasionally food and debris get trapped; treat with local
hygiene.
SLIDE
15: Ranula (frog
skin): mucous retention cyst; located in the
floor of mouth.
SLIDE 16: Torus:
benign bony growths on the maxilla: can occur on the mandible; can become
troublesome when fitting dentures.
SLIDE
17: Hemangioma of the
tongue: purplish lesions made of blood vessels;
can cause troublesome bleeding.
SLIDE
18: Stone in Wharton’s
duct: Wharton’s duct is located in the floor
of the mouth; obstruction of this duct with a stone causes pain and swelling in
the submandibular gland, particularly following meals when saliva production is
great; treatment is removal of the stone with marsupialization of the duct; if
the stone is in the hilum of the gland, the submandibular gland is
excised.
SLIDE
19: Periodontitis: inflammation/infection of the
gums
SLIDE
20: Angular
cheilitis: fissuring of the commissure of the
mouth; seen in Vit B complex deficiency.
Acute
throat pain: differential diagnosis
Viral
and bacterial (strep,
staph, Neisseria) pharyngitis
Scarlet
fever:
caused by a strep organism that 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: 50%
of patients have a concurrent Strep infection: diagnosis is with a monospot;
treatment is hydration and steroids.
Lingual
tonsillitis: “hot
potato” voice; enlarged lingual tonsils; treatment with
antibiotics.
Ulcer
necrotic tonsillitis:
Vincent’s
angina involving the tonsils
Fungal
infection: (see
above)
Diphtheria: gray-white
pseudomembrane; securing airway is paramount.
Retropharyngeal
abscess: most commonly occurs in young children,
and is most often secondary to a URI.
Symptoms consist 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
SLIDE
21: Picture of Tonsillitis:
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