Chapter 16: Nose, Mouth & Throat

deciduous

temporary

Stensens Duct

the opening of the parotid salivary gland

Gingival Hyperplasia

Painless enlargement of the gums, sometimes overreaching the teeth. This occurs with puberty, pregnancy, and leukemia and with long therapeutic use of phenytoin (Dilantin).

Geographic Tongue (Migratory Glossitis)

Pattern of normal coating interspersed with bright red, shiny, circular bald areas caused by atrophy of the filiform papillae, with raised pearly borders. Pattern resembles a map and changes with time. Not significant, and its cause is not known.

Dental Caries

Progressive destruction of tooth. Decay initially looks chalky white. Later it turns brown or black and forms a cavity. Early decay is apparent only on x-ray image. Susceptible sites are tooth surfaces where food debris, bacterial plaque, and saliva collect.

Bednar aphthae

traumatic areas or ulcers on the posterior hard palate on either side of the midline. They result from abrasions while sucking.

Aphthous Ulcers

A common "canker sore" is a vesicle at first and then a small, round, "punched-out" ulcer with a white base surrounded by a red halo. It is quite painful and lasts for 1 to 2 weeks. The cause is unknown, although it is associated with stress, fatigue, and food allergy.

Cleft Palate

A congenital defect, the failure of fusion of the maxillary processes. Wide variation occurs in the extent of cleft formation, from upper lip only, palate only, uvula only, to cleft of the nostril and the hard and soft palates.

Perforated Septum

A hole in the septum, usually in the cartilaginous part, may be caused by snorting cocaine or methamphetamine, chronic infection, trauma from continual picking of crusts, or nasal surgery. It is seen directly or as a spot of light when the penlight is directed into the other naris.

Epulis

A nontender, fibrous nodule of the gum seen emerging between the teeth; an overgrowth of vascular granulation tissue.

Retention Cyst (Mucocele)

A round, well-defined, translucent nodule that may be very small or up to 1 to 2 cm. It is a pocket of mucus that forms when a duct of a minor salivary gland ruptures. The benign lesion also may occur on the buccal mucosa, on the floor of the mouth, or under the tip of the tongue.

Ankyloglossia

A short lingual frenulum, here fixing the tongue tip to the floor of the mouth and gums (tongue-tie). This limits mobility and affects speech (pronunciation of a, d, n) if the tongue tip cannot be elevated to the alveolar ridge. A congenital defect.

Furuncle

A small boil located in the skin or mucous membrane; appears red and swollen and is quite painful. Avoid any manipulation or trauma that may spread the infection.

Candidiasis (Monilial Infection)

A white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that bleeds easily. Termed thrush in the newborn. It is an opportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed people.

Carcinoma

An ulcer with rolled edges; indurated. Occurs particularly at sides, base, and under the tongue. It grows insidiously and may go unnoticed for months. It may have associated leukoplakia. Risk for early metastasis is present because of rich lymphatic drainage. Smoking and heavy alcohol use are associated; the incidence of human papilloma virus (HPV)-related oral pharyngeal cancers also is increased.

Acute Tonsillitis and Pharyngitis

Bright red throat; swollen tonsils; white or yellow exudate on tonsils and pharynx; swollen uvula; and enlarged, tender anterior cervical and tonsillar nodes. Accompanied by severe sore throat, painful swallowing, fever >101° F of sudden onset. Bacterial infections may have absence of cough. With severe symptoms (listed above) or sore throat lasting >3-5 days, consider streptococcal infection and confirm with rapid antigen testing or throat culture. Treat positive tests with antibiotics. Untreated GAS pharyngitis may produce peritonsillar abscess, lymphadenitis, or acute rheumatic fever (although this is now rare in the United States).

Oral Kaposi Sarcoma

Bruiselike, dark red or violet, confluent macule, usually on the hard palate, may be on soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.

Leukoplakia

Chalky white, thick, raised patch with well-defined borders. The lesion is firmly attached and does not scrape off. It may occur on the lateral edges of tongue. It is caused by chronic irritation and occurs with heavy smoking and alcohol use. Lesions are precancerous; must refer to specialist. (Here the lesion is associated with squamous carcinoma.)

Foreign Body

Children particularly are apt to put an object up the nose (here, yellow plastic foam), producing unilateral mucopurulent drainage and foul odor. Because some risk for aspiration exists, removal should be prompt. Watch out for impaction from a small button battery from an electronic device (watch, video game). Once occluding the nostril, the battery can release voltage or chemicals that cause burns, necrosis, or perforation.

Choanal Atresia

Congenital bony septum between the nasal cavity and the pharynx is not common in the newborn; but when bilateral, it is an airway emergency because newborns are obligate nose breathers. Note airway obstruction, stridor, and paradoxical cyanosis (i.e., crying turns the baby pink because now breathing through the mouth).20 When unilateral, the infant may be asymptomatic until the onset of the first respiratory infection.

Fissured or Scrotal Tongue

Deep furrows divide the papillae into small irregular rows. The condition occurs in 5% of the general population and in Down syndrome. The incidence increases with age. (Vertical, or longitudinal, fissures also occur with dehydration because of reduced tongue volume.)

Baby Bottle Tooth Decay

Destruction of numerous deciduous teeth may occur in infants and toddlers who take a bottle of milk, juice, or sweetened drink to bed and prolong bottle-feeding past the age of 1 year. Liquid pools around the upper front teeth. Mouth bacteria act on carbohydrates in the liquid, especially sucrose, forming metabolic acids. Acids break down tooth enamel and destroy its protein.

Angular Cheilitis

Erythema, scaling, and shallow and painful fissures at the corners of the mouth occur with excess salivation and Candida infection. It is often seen in edentulous persons and those with poorly fitting dentures, causing folding in of corners of mouth, which creates a warm, moist environment favoring growth of yeast.

Gingivitis

Gum margins are red and swollen and bleed easily. This case is severe; gingival tissue has desquamated, exposing roots of teeth. Inflammation is usually caused by poor dental hygiene or vitamin C deficiency. The condition may occur in pregnancy and puberty because of changing hormonal balance.

Herpes Simplex 1

Herpes infection on the hard palate

Meth Mouth

Illicit methamphetamine abuse (crystal meth, meth ice) leads to extensive dental caries, gingivitis, tooth cracking, and edentulism. Methamphetamine causes vasoconstriction and decreased saliva, and its use increases the urge to consume sugars and starches and give up oral hygiene. Absence of the buffering saliva leads to increased acidity in the mouth, and the increased plaque encourages bacterial growth. These conditions and the presence of carbohydrates set up an oral environment prone to caries, cracking of enamel, and the damage seen here.

Sinusitis

Inflamed infected sinus areas following URI are most often viral in origin and do not require antibiotics. Consider bacterial infection when signs last >7-10 days. Major signs are mucopurulent drainage, nasal obstruction, facial pain or pressure, and loss of sense of smell. May also have fever, chills, malaise. Maxillary sinusitis has dull, throbbing pain in cheek and teeth and pain with palpation and when bending over. Frontal sinusitis has pain above supraorbital ridge.

Cleft Lip

Maxillofacial clefts are the most common congenital deformities and are associated with phenytoin (Dilantin), maternal smoking and alcohol use, benzodiazepines, and corticosteroids.1 Early treatment preserves the functions of speech and language formation and deglutition (swallowing).

Rhinitis

Nasal mucosa is swollen and bright red with URI. Discharge is common with rhinitis and sinusitis, varying from watery and copious to thick, purulent, and green-yellow.

Rhinorrhea

Occurs with colds, allergies, sinus infection, trauma

Koplik Spots

Small blue-white spots with irregular red halo scattered over mucosa opposite the molars. An early sign, and pathognomonic, of measles.

Nasal Polyps

Smooth, pale gray nodules, which are overgrowths of mucosa, are most commonly caused by chronic allergic rhinitis. May be stalked. A common site is protrusion from the middle meatus. Often multiple, they are mobile and nontender in contrast to turbinates. They may obstruct air passageways as they get larger. Symptoms include the absence of a sense of smell and a "valve that moves" in the nose as the person breathes.

Candidiasis in the adult

The Candida species as normal oral flora is present in 60% of healthy adults. Overgrowth of Candida occurs with steroid inhaler use, HIV infection, use of broad-spectrum antibiotics or corticosteroids, leukemia, malnutrition, or reduced immunity.

Herpes Simplex 1

The cold sores are groups of clear vesicles with a surrounding indurated erythematous base. These evolve into pustules, which rupture, weep, and crust and heal in 4 to 10 days. The most likely site is the lip-skin junction; infection often recurs in the same site. Caused by the herpes simplex virus (HSV-1), the lesion is highly contagious and is spread by direct contact. Recurrent infections may be precipitated by sunlight, fever, colds, and allergy. It is very common, affecting 50% of adults.

Acute Rhinitis

The first sign is a clear, watery discharge, rhinorrhea, which later becomes purulent. This is accompanied by sneezing, nasal itching, stimulation of cough reflex, and inflamed mucosa, which causes nasal obstruction. Turbinates are dark red and swollen.

Carcinoma

The initial lesion is round and indurated; it becomes crusted and ulcerated with an elevated border. Most occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.

Epistaxis

The most common site of a nosebleed is Kiesselbach plexus in the anterior septum. Peak incidence is bimodal, <18 years and >50 years. Causes include nose picking, forceful coughing or sneezing, fracture, foreign body, illicit drug use (cocaine), topical nasal drugs, warfarin (Coumadin), aspirin, or a coagulation disorder. Bleeding from the anterior septum is easily controlled and rarely severe. A posterior hemorrhage is less common (<10%) but more profuse, harder to manage, and more serious.

Seasonal Allergic Rhinitis (Hayfever)

The most common type of rhinitis presents with rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and sneezing. Note serous edema and swelling of turbinates to fill the air space. Turbinates are usually pale (although they may appear violet), and their surface looks smooth and glistening. Common allergens are dust mite, animal dander, mold, pollen. When severe, allergic rhinitis produces disordered sleep, obstructive sleep apnea, sinusitis, and poor work performance.11

Smooth, Glossy Tongue (Atrophic Glossitis)

The surface is slick and shiny; the mucosa thins and looks red from decreased papillae. Accompanied by dryness of tongue and burning. Occurs with vitamin B12 deficiency (pernicious anemia), folic acid deficiency, and iron deficiency anemia. Here also note angular cheilitis.

Enlarged Tongue (Macroglossia)

The tongue is enlarged and may protrude from the mouth. The condition is not painful but may impair speech development. Here it occurs with Down syndrome; it also occurs with cretinism, myxedema, and acromegaly. A transient swelling also occurs with local infections.

Bifid Uvula

The uvula looks partly severed and may indicate a submucous cleft palate, which feels like a notch at the junction of the hard and soft palates. This may affect speech development because it prevents necessary air trapping. The incidence is more common in American Indians.

Black Hairy Tongue

This is not really hair but rather the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. Color varies from black-brown to yellow. It occurs after use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus, and with heavy smoking.

Peritonsillar Abscess

Untreated acute pharyngitis may cause suppurative complications, peritonsillar abscess, or suppurative thrombophlebitis. Thrombophlebitis is Lemierre syndrome caused by the gram-negative Fusobacterium necrophorum. This microbe occurs as often as streptococcal pharyngitis in adolescents and young adults. In this age-group, the two major red flags with this pharyngitis are worsening symptoms or neck swelling.

Malocclusion

Upper or lower dental arches are not in alignment, and incisors protrude from developmental problem of mandible or maxilla or incompatibility between jaw and tooth size. The condition increases risk for facial deformity, negative body image, chewing problems, or speech dysfluency.

Frenulum

a midline fold of tissue that connects the tongue to the floor of the mouth

Oral Cavity

a short passage bordered by the lips, palate, cheeks, and tongue. It contains the teeth and gums, tongue, and salivary glands

Xerostomia (dry mouth)

a side effect of many drugs: antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, bronchodilators

Sucking Tubercle

a small pad in the middle of the upper lip from friction of breastfeeding or bottle-feeding

Torus palatinus

benign bony ridge running in the middle of the hard palate

Leukoedema

benign, milky, bluish-white opaque appearance of the buccal mucosa that occurs commonly in African Americans

Ethmoid Sinuses

between the orbits

Sphenoid sinuses

deep within the skull in the sphenoid bone

Nose

first segment of the respiratory system. It warms, moistens, and filters the inhaled air, and it is the sensory organ for smell

Frontal Sinuses

in the frontal bone above and medial to the orbits

Maxillary Sinuses

in the maxilla (cheekbone) along the side walls of the nasal cavity

Tongue

mass of striated muscle arranged in a crosswise pattern so it can change shape and position. The papillae are the rough, bumpy elevations on its dorsal surface

torus palatinus

normal variation is a nodular bony ridge down the middle of the hard palate

Dysphagia

occurs with pharyngitis, gastroesophageal reflux disease, stroke and other neurologic diseases, esophageal cancer.

Fordyce Granules

small, isolated white or yellow papules on the mucosa of cheek, tongue, and lips

Epstein Pearls

small, whitish, glistening, pearly papules along the median raphe of the hard palate and on the gums, where they look like teeth. They are small retention cysts and disappear in the first few weeks.