Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2590_Библиотеки_им_академика_М_И_Перельмана
.pdf
198
Squamous cell
https://t.me/med1917
8: THROAT AND MOUTH GUIDELINES
FOLLOW-UP
A. Follow-up care per hospital discharge instructions.
CONSULTATION/REFERRAL
A. Per hospital care team.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Never place a child in supine position because respira-
tory arrest has been reported.
2. Airway obstruction can worsen with increased anxiety.
3. All close contacts (including children and adults)
exposed to a child diagnosed with epiglottitis should be
treated with prophylactic antibiotics, such as rifampin,
20mg/kg, not to exceed 600mg/d for 4 days.
BIBLIOGRAPHY
Lustig, L. R., & Schindler, J. S. (2019). Ear, nose, & throat disorders.
In M. A. PapadakisS. J. McPhee& M. W. Rabow (Eds.),
Current medical diagnosis & treatment. McGraw-Hill. https://
accessmedicine-mhmedical-com.proxy.library.vanderbilt.edu/content.
aspx?bookid=2449§ionid=194433886
Dowdy, R. A. E., & Cornelius, B. W. (2020). Medical management of
epiglottitis. Anesthesia Progress, 67(2), 90–97. https://doi-org.proxy.
library.vanderbilt.edu/10.2344/anpr-66-04-08
Felton, P., Lutfy-Clayton, L., Smith, L. G., Visintainer, P., & Rathlev, N. K.
(2021). A retrospective cohort study of acute epiglottitis in adults. Western
Journal of Emergency Medicine: Integrating Emergency Care with Population
Health, 22(6), 1326–1334. https://doi-org.proxy.library.vanderbilt.
edu/10.5811/westjem.2021.8.52657
ORAL CANCER
DEFINITION
A. Oral cancer is a malignancy of the oral cavity. Subsites
include the buccal mucosa, tongue, gingiva, oor of the
mouth, hard palate, soft palate, and lips. These frequently
begin as leukoplakia (white, raised patches that do not easily scrape away) or erythroplakia (red, velvety patches that
are friable with manipulation) and can occur on any of the
above-listed subsites. Oral cancers are most often squamous
cell carcinoma, or cancer of the lining of the mouth. Less
common types of malignancy, such as mucoepidermoid carcinoma, adenoid cystic carcinoma, and epithelial/myoepithelial carcinoma, affect the major and minor salivary glands.
Mucosal melanoma is rare and accounts for approximately 1%
of all melanomas. They may arise from the mucosal epithelium lining, oral cavity, and oropharynx (see Figure 8.1).
INCIDENCE
A. The average age of most people diagnosed with these
cancers is 62. Oral cancer is rare in children, but a little more
than one-quarter occur in clients younger than 55years. The
male to female predominance is 2 to 1; oral cancer is equal
in African Americans and Caucasian adults. The death rate is
fairly high for oral cancer secondary to the cancer being diagnosed in the late stages of development.
B. Approximately 51,000 Americans are diagnosed with oral
cancer and nearly 10,000 deaths occur each year.
C. Oral cancer represents 3% of all newly diagnosed cancers
and 2% of all cancer-related deaths.
D. Frequency of oral cancer of cheek and gum rises 50-fold
among long-term users of smokeless tobacco.
PATHOGENESIS
A. Pathogenesis is unknown; however, increased risk factors
exist which include the following:
1. Tobacco use: Use of tobacco in all its forms is highly
correlated with risk of oral cancer (cigarette smoking,
smokeless tobacco in Western cultures; betel nut quid is a
signicant factor associated with oral cancer throughout
Asia and India).
2. Alcohol consumption: Alcohol by itself or in com-
bination with smoking increases the risk of oral cancer.
According to some studies, the risk of these cancers in
heavy drinkers and smokers may be as much as 100 times
higher than the risk in people who do not smoke or drink.
3. Poor nutrition: Studies have shown that a diet low in
fruits and vegetables contributes to oral cancer. Chronic
iron deciency leading to Plummer–Vinson syndrome is
known to alter the mucosal tissues, and this change may
be related to increased risk of oral cancer.
4. Graft versus host disease (GVHD): A condition that
sometimes occurs after a stem cell transplant. GVHD
occurs when the donor stem cells recognize the client’s
cells as foreign and launch an attack against them. GVHD
can affect many tissues of the body, including those in the
mouth. This increases the risk of oral cancer, which can
occur as early as 2 years after GVHD.
5. Genetic syndromes: Head and neck cancers are more
common in clients diagnosed with genetic syndromes
such as Fanconi anemia and dyskeratosis congenita.
6. Lichen planus: Autoimmune disorder linked to oral
squamous cell carcinoma.
PREDISPOSING FACTORS
A. Male sex.
B. Age >40 years for males and >50 years for females.
C. African American ancestry.
D. Smoking or use of other tobacco products, including such
smokeless products as snuff and dip.
E. Alcohol consumption.
F. Sun exposure.
G. Poor diet, decient in vitamins A, C, and E, and high in
salted or smoked meats, fats, and oils.
H. Previous cancer.
FIGURE 8.1 Tongue cancer.
carcinoma
COMMON COMPLAINTS
A. Oral sores that do not heal (most common presenting
factor).
B. Change in how dentures t.
C. Bleeding mucosa or gingiva without apparent cause.
D. Difculty swallowing, usually indicating more advanced
disease.
ORAL CANCER
https://t.me/med1917
199
E. Altered sensations: burning or numbness, usually indi -
cating more advanced disease.
F. Neck mass.
G. Leukoplakia or erythroplakia.
H. Loosening of teeth.
OTHER SIGNS AND SYMPTOMS
A. Sometimes asymptomatic.
B. Decreased appetite related to altered taste.
C. Increased salivation.
D. Sore throat.
E. Foul breath odor.
SUBJECTIVE DATA
A. Review the onset, course, and duration of symptoms.
Question the client regarding altered taste, sensations, difculty swallowing, and foul breath.
B. Evaluate for risk factors. Review the client’s use of tobacco
products, including age of onset, amount of daily use, and quit
dates. Also review pathogenesis and predisposing factors.
C. Ask the client about any history of cancer and treatments.
D. Evaluate the amount of alcohol intake, including age of
onset, amount of daily use, and quit dates.
E. Review the client’s general health history for other chronic
conditions.
F. Review the client’s medication history, including prescrip-
tion and over-the-counter drug use, especially aspirin.
G. Take a dental history, specically any loose or recently lost
teeth, or acute change in denture tting.
H. Assess for weight loss.
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, blood pressure,
and weight.
B. Inspect:
1. Observe general appearance.
2. Note quality of voice patterns and articulation.
3. Note halitosis.
4. Dentures should be removed. Observe the lips, gums,
tongue, and buccal mucosa for swelling, discolo ration,
bleeding, asymmetry, texture, tongue motion, abnormal
ulcerations, leukoplakia, and erythroplakia.
5. Observe lip lesion that fails to heal.
C. Palpate:
1. Palpate the tongue and any lesions noted on exam.
Lesions that are palpable and have submucosal rmness
are especially worrisome. Common ndings of a malignant oral lesion are central ulceration and rm, rolled
borders. Assess at patches of leukoplakia and/or erythroplakia by scraping them with a tongue blade to assess
for removability or friability.
2. Palpate lymph nodes: cervical (anterior/posterior
chain), submandibular, sublingual, and submental, pre-/
postauricular; check nodes for size, texture, mobility, and
tenderness.
D. Auscultate:
1. Lungs: the most frequently involved extranodal meta-
static site.
2. Heart.
DIAGNOSTIC TESTS
A. Obtain biopsy of persistent lesions (more than 2 weeks).
B. Perform neck soft tissue CT and chest radiography to
assess for regional and distant metastasis.
DIFFERENTIAL DIAGNOSES
A. Oral leukoplakia.
B. Pulpitis.
C. Periapical abscess.
D. Gingivitis.
E. Periodontitis.
F. Lichen planus.
G. Oral candidiasis.
H. Discoid lupus.
I. Pemphigus vulgaris.
PLAN
A. General interventions:
1. If oral cancer is suspected, refer to an oral/maxillofa-
cial surgeon or an otolaryngologist/head and neck surgeon for biopsy.
B. Client teaching:
1. Advise the client to stop smoking and using oral
tobacco products.
2. Advise the client to reduce/eliminate alcohol
consumption.
3. Encourage routine dental care and examinations.
4. Review dietary intake and educate the client regard-
ing benets of increasing dietary intake of vitamins A,
C, and E. Encourage the client to reduce dietary intake
of foods that are high in salt, smoked meats, fats, and
oils.
5. Recommend wearing sunscreen/lip balm with sun
protection factor of 15 or greater.
C. Pharmaceutical therapy:
1. This should focus on symptom management, such as
topical formulas that have a topical anesthetic or Magic
mouthwash (common compounded solution includes
Maalox/diphenhydramine/lidocaine combined at a 1:1:1
ratio).
FOLLOW-UP
A. If immediate biopsy is not indicated, ask the client to
return for reevaluation in 2 weeks, after eliminating irritants
and noxious agents.
CONSULTATION/REFERRAL
A. Refer the client to an otolaryngologist and/or a dentist for
immediate biopsy for ulcerative or fungating lesions.
INDIVIDUAL CONSIDERATIONS
A. Adults:
1. The U.S. Preventive Services Task Force (USPSTF) has
concluded that current evidence is insufcient to assess
the balance of benets and harms of screening for oral cancer in asymptomatic adults. The Oral Cancer Foundation
recommends visual and tactile screenings annually starting at the age of 18 for all adults.
2. The American Cancer Society recommends that peo-
ple between the ages of 20 and 40 undergo an oral cancer
screening every 3 years and that those older than 40 years
be screened every year.
3. If an individual uses tobacco products, screening
should begin at the age they commence tobacco use.
4. Precancerous lesions might be subtle and asymptom-
atic. Meticulously examine lateral borders of the tongue,
lips, and oor of mouth, where oral cancer most commonly occurs. A lesion may be white or dull red and will
progress to ulceration.
200
https://t.me/med1917
8: THROAT AND MOUTH GUIDELINES
B. Pediatrics:
1. Currently, the highest rate is in smokeless tobacco use.
2. Oral screening should be considered annually in ado-
lescents who use tobacco and/or alcohol.
BIBLIOGRAPHY
American Cancer Society. (2019). About oral cavity and oropharyngeal cancer.
https://www.cancer.org/cancer/oral-cavity-and-oropharyngeal-can
cer/causes-risks-prevention/risk-factors.html
Foy, J. P., Bertolus, C., & Saintigny, P. (2019). Oral cancer prevention worls-
wide: Challenges and prospective. Oral oncology, 88, 91–94.
Shah, P., Roy, N., & Dhandhukia, P. (2022). Algorithm mediated early
detection of oral cancer from image analysis. Oral Surgery, Oral
Medicine, Oral Pathology & Oral Radiology, 133(1), 70–79.
Vail, M., Robinson, S., & Condon, H. (2020). Recognition of oral poten-
tially malignant disorders and transformation to oral cancer. JAAPA:
Journal of the American Academy of Physician Assistant. (Lippincott,
Williams & Wilkins), 33(11), 14–19.
Oral Cancer Foundation. (2019). Oral cancer screening. https://oralcancerf
oundation.org/screening/
PHARYNGITIS
DEFINITION
A. Pharyngitis is inammation of the throat (oropharynx and
hypopharynx) and the surrounding lymph tissue (palatine
and lingual tonsils).
INCIDENCE
A. Pharyngitis and tonsillitis account for >10% of all ofce
visits to primary care clinicians and 50% of outpatient antibiotic use.
PATHOGENESIS
A. Pharyngitis may be due to viral, bacterial, and fungal
agents. Other causes are noninfectious and lead to mucosal
irritation.
1. Respiratory viruses, the most common cause of acute
pharyngitis, account for approximately 50% to 80% of
cases. The most common causative agents are adenovirus,
rhinovirus, and coronavirus. Less common are enteroviruses, inuenza A and B, parainuenza viruses, and respiratory syncytial virus.
2. Common bacterial agents include group A beta-
hemolytic Streptococcus, group C and G Streptococcus,
Neisseria gonorrhoeae, and Corynebacterium diphtheriae.
3. The most common fungal agent is Candida albicans.
4. Atypical agents include Mycoplasma pneumoniae and
Chlamydia trachomatis (rare).
5. Noninfectious causes include allergic rhinitis, gastro-
esophageal reux, postnasal drip, mouth-breathing (especially during dry air months), and trauma.
PREDISPOSING FACTORS
A. Cigarette smoking.
B. Allergies.
C. Upper respiratory infections.
D. Oral sex.
E. Drugs (antibiotics and immunosuppressants).
F. Debilitating illnesses (such as cancer) that can cause
Candida to proliferate.
G. Recent exposure to a person testing positive for group A
beta-hemolytic Streptococcus.
COMMON COMPLAINTS
A. Sore and/or scratchy throat.
B. Fever (>38°C or 100.5°F).
C. Headache.
D. Malaise.
E. Exudate on throat or “beefy” red throat without exudate.
F. Painful lymphadenopathy.
OTHER SIGNS AND SYMPTOMS
A. Oral vesicles and/or strawberry tongue.
B. Fatigue.
C. Dysphasia.
D. Abdominal pain.
E. Vomiting.
POTENTIAL COMPLICATIONS
A. Without proper antimicrobial treatment, streptococcal phar-
yngitis can lead to serious complications such as the following:
1. Suppurative adenitis with tender, enlarged lymph
nodes.
2. Scarlet fever.
3. Peritonsillar abscess.
4. Glomerulonephritis.
5. Rheumatic fever.
SUBJECTIVE DATA
A. Assess onset, course, and duration of symptoms.
B. Inquire about mouth lesions, rhinorrhea, cough, drooling,
and fever.
C. Ask about malaise, headache, fatigue, and fever; these are
symptoms of mononucleosis.
D. Take a sexual history, if indicated. Ask if family mem-
bers or sexual partners have the same signs and symptoms.
Pharyngeal gonorrhea has no symptoms, so high-risk clients
should be tested.
E. Ask whether symptoms have caused decreased intake of
food and uid.
F. Determine history of heart disease, previous strep pharyn-
gitis, rheumatic fever, and other respiratory diseases, such as
asthma, emphysema, and chronic allergies.
G. If rash is present, nd out when it rst occurred and if it
has spread.
H. Ask about signs and symptoms of urinary tract infection
and pyelonephritis.
I. Ask about a history of herpes, immunosuppressive disor-
ders, and steroid use.
J. Review immunization history.
PHYSICAL EXAMINATION
A. Check temperature and blood pressure, if indicated.
B. Inspect:
1. Observe general appearance.
2. Examine the mouth, pharynx, tonsils, and hard and soft
palate for vesicles and ulcers, candidal patches, erythema,
hypertrophy, exudate, and stomatitis. Check gum and palate for petechiae and tongue for color and inammation.
a. Herpangina are small oral vesicles on the fauces and
soft palate and are caused by the coxsackievirus.
b. Herpes causes vesicles and small ulcers (stomatitis)
of the buccal mucosa, tongue, and pharynx.
c. Trench mouth (gingivitis) and necrotic tonsil-
lar ulcers (Vincent angina) cause foul breath, pain,
PHARYNGITIS
https://t.me/med1917
201
pharyngeal exudate, and a gray membranous inammation that bleeds easily.
d. C. albicans (thrush) may be painful and causes
cheesy, white exudate.
e. Peritonsillar cellulitis causes inamed, edematous
tonsils, grayish-white exudate, high fever, rigors, and
leukocytosis. Peritonsillar abscess ( palpable mass) may
also develop.
f. Mononucleosis causes tonsillar exudate in 50% of
clients; 33% develop petechiae at the junction of the
hard and soft palate.
g. C. diphtheriae causes a whitish-blue pharyngeal exu-
date “pseudomembrane” that covers the pharynx and
bleeds if removal is attempted.
3. Examine the ears, nose, and throat. Assess patency of
airway if the tonsils are enlarged.
4. Inspect skin for rashes.
a. Pastia lines are petechiae present in a linear pattern
along major skin folds in the axillae and antecubital
fossa that are seen with group A Streptococcus.
b. Erythema marginatum, caused by group A
Streptococcus, is an evanescent, nonpruritic, pink rash
mainly on the trunk and extremities. It may be brought
out by heat application.
C. Auscultate:
1. Heart.
2. Lungs.
D. Percuss:
1. Abdomen, especially spleen area.
2. Chest.
E. Palpate:
1. Lymph nodes, especially of the anterior and posterior
cervical chains, axilla, and groin.
2. Abdomen for organomegaly and suprapubic
tenderness.
3. Back for costovertebral angle tenderness.
F. Perform neurologic examination:
1. Check for nuchal rigidity and meningeal irritation.
G. Use Modied Centor Clinical Prediction Rule for group A
streptococcal infection (Table 8.1).
DIAGNOSTIC TESTS
A. The Centers for Disease Control and Prevention and the
Infectious Diseases Society of America (IDSA) recommend
using two or more Centor criteria as a threshold for selecting
clients for rapid antigen detection testing (RADT) and treating
only those with positive tests.
B. For children and adolescents, throat culture is recom-
mended by the IDSA with a negative RADT. However, a
throat culture is not considered necessary in adults with a
negative RADT due to the low likelihood that it will change
management.
C. Consider monospot test for infectious mononucleosis if
client has palatal petechiae, splenomegaly, and posterior cervical adenopathy as these are highly suggestive of infectious
mononucleosis. The absence of cervical lymphadenopathy
and fatigue makes the diagnosis less likely.
D. Obtain complete blood count with differential.
E. Clients with risk factors for sexually transmitted infec-
tions, particularly receptive oral intercourse, should be tested
for gonococcal pharyngitis.
F. COVID-19 screening is recommended if illness appears
viral.
G. Take blood cultures if sepsis is suspected.
H. Obtain radiograph of the neck if there is possible trauma.
DIFFERENTIAL DIAGNOSES
A. Pharyngitis.
B. COVID-19.
C. Stomatitis.
D. Rhinitis.
E. Sinusitis with postnasal drip.
F. Epiglottis.
G. Peritonsillar abscess.
H. Mononucleosis.
I. Coxsackievirus A16.
J. C. diphtheriae.
K. Trench mouth.
L. Vincent angina.
M. C. albicans.
N. HIV.
TABLE 8.1 MODIFIED CENTOR CLINICAL PREDICTION RULE FOR GROUP A STREPTOCOCCAL INFECTION
Points Criteria
+1 Tonsillar exudates present
+1 Tender anterior chain cervical adenopathy
+1 Absence of a cough
+1 Fever by history
+1 3–14 years of age
0 15–44 years of age
–1 45 years of age or older
Total score
Note: Once scored: If 4 points, + predictive value of 80%, treat empirically. If 2 to 3 points, positive predictive value of 50%, complete rapid strep antigen, treat as group A
beta-hemolytic Streptococcus positive. If 0 or 1 point, positive predictive value of 20%, do not test, treat empirically only with follow-up as needed.
202
https://t.me/med1917
8: THROAT AND MOUTH GUIDELINES
PLAN
A. General interventions:
1. Clients with a history of rheumatic fever and those
who have a household member with a documented group
A streptococcal infection need immediate treatment without prior testing.
2. Do not put instruments in the airway if you suspect
epiglottitis.
B. Client teaching: See Client Teaching Guide for this chapter,
“Pharyngitis.”
1. Recommend rest, uids and staying well-hydrated.
2. Avoid contact with others for 24 hours after starting
antibiotics.
3. Treat symptomatically: ibuprofen/acetaminophen
as needed for body aches/sore throat/fever; warm
saltwater gargles/throat lozenges for sore throat. Sterilize
toothbrush or buy new toothbrush.
4. Take antibiotics/medication as prescribed.
5. Call for fever not responding to medication/treatment,
worsening symptoms, or not improving in the next 3 to 4
days.
6. Call 911 for difculty with breathing, throat/neck
swelling, drooling, or other severe symptoms.
7. If concerns of mononucleosis, advise no contact sports
until diagnosis has beenmade to prevent injury to spleen.
C. Pharmaceutical therapy:
1. Treatment of group A strep pharyngitis: rst-line drugs
of choice:
a. Penicillin V potassium (Pen-Vee K):
i. Children under 27 kg: 250 mg orally two to
three times daily for 10 days; children >27kg, adolescents, and adults: 500 mg, two to three times
daily for 10 days.
b. Penicillin G benzathine:
i. Less than 27kg: 600,000 U × 1 dose intramuscu-
larly (IM); ≥27kg: 1,200,000 U × 1 dose IM.
c. Amoxicillin:
i. Children: 50 mg/kg once daily for 10 days
(maximum 1,000 mg); alternative, 25mg/kg/dose
(maximum 500mg) BID for 10 days.
ii. Adolescents and adults: 500mg BID for 10 days
or 1,000 mg once daily for 10 days.
2. Treatment of group A strep in penicillin-allergic clients:
a. Cephalexin 20 mg/kg/dose BID (maximum
500mg/dose) for 10 days.
b. Cefuroxime 10mg/kg/dose orally BID for 10 days
(maximum 250mg/dose).
c. Cefdinir 7 mg/kg/dose orally Q12H for 10 days
or 14 mg/kg/dose Q24H for 10 days (maximum
600mg/d).
d. Azithromycin: 12 mg/kg once daily (maximum
500mg) daily for 5 days.
e. Clarithromycin: 7.5 mg/kg/dose BID (maximum
250mg/dose) for 10 days.
f. Clindamycin: 7 mg/kg/dose TID (maximum
300mg/dose) for 10 days.
3. Treatment of recurrent group A strep pharyngitis:
a. If due to noncompliance with oral antibiotics in a
client without penicillin allergy, use penicillin G benzathine: less than 27 kg, use 600,000 U × 1 dose IM;
≥27kg: use 1,200,000 U × 1 dose IM.
b. For clients with persistent infection or an ini-
tial recurrence, amoxicillin-clavulanic acid 40 mg
amoxicillin/kg/d divided Q8H (maximum 2,000 mg
amoxicillin/d) for 10 days.
c. For clients with multiple recurrences or penicillin
allergy, clindamycin 20 to 30mg/kg/d in three divided
doses (maximum 300mg/dose) for 10 days.
4. Treatment of pharyngeal gonorrhea:
a. Adults: ceftriaxone (Rocephin) 500mg to 1g by IM
injection.
b. Children: ceftriaxone (Rocephin) 50 to 75mg/kg in
one dose by IM injection.
5. For M. pneumoniae and C. trachomatis:
a. Erythro mycin (E-Mycin) 250mg orally three to four
times daily for 10 days.
6. For pharyngeal candidiasis in the immunocompro-
mised client:
a. Oral nystatin suspension (100,000 U/mL) 15mL by
swish-and-swallow method QID.
b. Clotrimazole troche 10mg held in the mouth 15 to
30 minutes TID.
FOLLOW-UP
A. Client should return to clinic if symptoms do not improve
in 3 to 4 days.
B. Treat sexual partners of clients with pharyngeal gonorrhea.
CONSULTATION/REFERRAL
A. Consult a physician if the client has severe dysphagia or
dyspnea, signaling possible airway obstruction.
B. Refer the client to an otolaryngologist or to the ED if peri-
tonsillar abscess is noted.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Rheumatic fever follows between 0.5% and 3% of inef-
fectively treated cases of group A streptococcal upper
respiratory infections.
2. Approximately 20% of children aged 5 to 15 years who
are diagnosed with rheumatic fever had pharyngitis in the
preceding 3 months.
B. Adults:
1. Oral candidiasis may be the rst symptom of HIV.
2. Antibiotic treatment for pharyngitis is warranted if
client is ≥65 years old with an acute cough and has two
or more of the following criteria: hospitalized in the past
year, diabetic, congested heart failure, and on glucocorticoid therapy. If the client is ≥80 years old with pharyngitis
and a cough, then treat with antibiotic if one or more of the
latter criteria applies.
3. Older clients with chronic illnesses (e.g., diabetes, con-
gested heart failure, and skin diseases) who have pharyngitis caused by group A streptococci are at an increased risk of
bacteremia and are more likely to die from complications.
BIBLIOGRAPHY
Pallon, J., Roost, M., Sundquist, M., & Hedin, K. (2021). The etiology of
pharyngotonsillitis in primary health care: A prospective observational study. BMC Infectious Disease, 21(1), 1–11.
Wolford, R. W., Goyal, A., Belgam Syed, S. Y., & Schaefer, T. J. (2021,
January). Pharyngitis. In Stat Pearls [Internet]. Stat Pearls Publishing.
Williams, B. D., Usatine, R. P., & Smith, M. A. (2019). Pharyngitis. In
R. P. Usatine, M. A. Smith, Mayeaux. E. J Jr., & H. S. Chumley (Eds.),
The color atlas and synopsis of family medicine (3rd ed.). McGraw-Hill.
https://accessmedicine-mhmedical-com.proxy.library.vanderbilt.
edu/content.aspx?sectionid=206778481&bookid=2547&Result
click=2
STOMATITIS, MINOR RECURRENT APHTHOUS STOMATITIS
https://t.me/med1917
203
STOMATITIS, MINOR RECURRENT APHTHOUS
STOMATITIS
DEFINITION
A. Stomatitis is a general term indicating inammation of
the oral cavity. It includes the synonyms canker sores, recurrent aphthous ulcer (RAU), aphthous stomatitis, and recurrent aphthous stomatitis (RAS). Typical presentation is that of
a discrete round or oval, tender, supercial ulcer involving the
mucosa of the oral cavity. The ulcers are usually gray, white,
or yellow in color and surrounded by erythematous halos.
1. Minor aphthous ulcers are characterized by lesions <1
cm in diameter, mildly painful, and usually lasting 7 to 14
days.
2. Major aphthous ulcers are characterized by lesions >1
cm in diameter, extremely painful, and lasting up to 4 to 6
weeks.
INCIDENCE
A. RAS is estimated to affect approximately 20% of the gen-
eral population.
PATHOGENESIS
A. Etiology and pathogenesis are unclear. Host, environmen-
tal, and nutritional causes are implicated.
PREDISPOSING FACTORS
A. Oral trauma.
B. History of RAS.
C. Possible nutritional deciency in iron, folic acid, or zinc.
D. Hormonal changes.
E. Stress and anxiety.
F. Food and chemical sensitivities.
COMMON COMPLAINT
A. Painful sore in mouth.
OTHER SIGNS AND SYMPTOMS
A. Prodromal burning sensation in mouth for 24 to 48 hours
before the lesions appear.
SUBJECTIVE DATA
A. Inquire about personal and family history of aphthous
stomatitis.
B. Ask the client about prodrome of burning or stinging in
the mouth.
C. Elicit information regarding previous illness and trauma.
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood pressure.
B. Inspect:
1. Mouth for ulcers.
2. Ears, nose, and throat.
3. Skin, especially palms and soles, for lesions; indicates
hand, foot, and mouth disease.
C. Auscultate:
1. Heart.
2. Lungs.
DIAGNOSTIC TESTS
A. There is no specic diagnostic testing for stomatitis.
B. Consider herpes simplex virus (HSV) culture if HSV is
considered for diagnosis.
C. If syphilis is of concern, order serum rapid plasma reagin
(RPR).
DIFFERENTIAL DIAGNOSES
A. Aphthous stomatitis.
B. Oral HSV.
C. Behçet disease.
D. Crohn disease.
E. HIV.
F. Kawasaki syndrome.
G. Hand, foot, and mouth disease (coxsackievirus A16).
H. Consider less common etiologies for large, persistent areas
of ulcerative stomatitis such as erythema multiforme or drug
allergies, pemphigus, pemphigoid, epidermolysis bullosa
acquisita, bullous lichen planus, Behçet disease, or inammatory bowel disease.
PLAN
A. General interventions:
1. Avoid spicy, salty, or hot foods.
2. Encourage cold foods, such as uids, ice pops, and so
forth, to help with pain.
3. Avoid hard, sharp food that is difcult to chew.
4. Recommend using a soft-bristle toothbrush when
brushing teeth.
5. Avoid toothpaste containing sodium lauryl sulfate
(SLS).
B. Client teaching: See Client Teaching Guide for this chapter,
“Aphthous Stomatitis.”
C. Pharmaceutical therapy:
1. Magic mouthwash (common compounded solution
includes Maalox/diphenhydramine/lidocaine combined
at a 1:1:1 ratio).
2. Sucralfate (Carafate) suspension (1 teaspoon QID) may
be used to swish in mouth and spit out for oral comfort.
3. Glucocorticoid gel, such as uocinonide gel (Lidex)
0.05%, may be taken two to four times a day, one of which
is always at bedtime.
4. Orabase with or without triamcinolone acetonide
(Kenalog)may be used.
5. Amlexanox 5% paste (Aphthasol) is an over-the-coun-
ter product applied directly to ulcers QID until ulcers heal.
FOLLOW-UP
A. Follow up as needed for treatment of recurrences.
CONSULTATION/REFERRAL
A. Refer client to an oral/maxillofacial provider or an otolar-
yngologist if the ulcers are deeper than 1 to 5 mm or if the
lesion(s) last longer than 3 weeks.
B. Cardiology referral is needed if Kawasaki disease is
suspected.
C. Any lesion lasting longer than 3 weeks should be evalu-
ated by a dentist or an oral surgeon to rule out cancer.
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. Avoid use of uocinonide and triamcinolone acetonide
(Kenalog) in pregnant or nursing females.
B. Pediatrics:
1. Avoid use of uocinonide and triamcinolone acetonide
(Kenalog).
2. Do not use viscous lidocaine.
C. Geriatrics:
1. Ask elderly clients about their dentures. Check ade-
quate t (looseness or too tight) and if there is any pain.
2. Oral inammation and denture-related stomatitis have
recently been linked through evidence-based research with
204
https://t.me/med1917
8: THROAT AND MOUTH GUIDELINES
the pathogenesis of cardiovascular disease (atherosclerosis
and hypertension). Geriatric clients must be screened for
denture-related stomatitis and immediate antifungal treatment is advised.
3. Nutritional challenges in the elderly population can
lead to stomatitis and aphthous ulcers. Assess chewing
ability. Evaluate geriatric clients for iron, B12, and folic acid
deciencies.
BIBLIOGRAPHY
Lee, Y. C., Jeong, S. J., Eun, Y., Song, R., & Oh, I. (2021). Risk of auto-
immune diseases in recurrent aphthous ulcer patients: A nationwide
population study. Oral Diseases, 27(6), 1443–1450. https://doi-org.
proxy.library.vanderbilt.edu/10.1111/odi.13659
Usatine, R. P., Gonsalves, W. C., & Diaz, D. (2019). Aphthous ulcer. In R. P.
Usatine, M. A. Smith, Mayeaux. E. J Jr., & H. S. Chumley (Eds.), The color
atlas and synopsis of family medicine (3rd ed.), McGraw-Hill. https://
accessmedicine-mhmedical-com.proxy.library.vanderbilt.edu/content.
aspx?bookid=2449§ionid=194433886
THRUSH
DEFINITION
A. Thrush is a fungal infection of the oral cavity and/or the
pharynx caused by Candida species.
INCIDENCE
A. It is estimated that 5% to 7% of babies younger than 1
month, both bottle-fed and breastfed infants, will develop oral
candidiasis.
B. Approximately 9% to 31% of AIDS clients and 20% of cli-
ents diagnosed with cancer will have thrush.
C. It is also common in older adults who wear dentures.
D. Clients with pulmonary disorders treated with inhaled
corticosteroids are also at risk.
PATHOGENESIS
A. Thrush is an overgrowth of yeast cells, C. albicans, on the
oral mucosa, which leads to desquamation of the epithelial
cells.
B. Pseudomembranous thrush is the most common form; it
appears as white plaques on the oral mucosa and/or oropharynx.
C. Atrophic thrush, also called denture stomatitis as it occurs
most frequently in denture wearers, is typically found on the
maxillary gingiva and is characterized by erythema without
the usual white plaques of the pseudomembranous type.
PREDISPOSING FACTORS
A. Use of broad-spectrum antibiotics.
B. Adults:
1. HIV.
2. Prolonged steroid use (systemic or inhaled
corticosteroids).
3. Cancer treatments (radiation/chemotherapy).
4. Dentures.
5. Malnutrition.
6. Diabetes mellitus.
C. Children:
1. Endocrine disorders (thyroid disease, diabetes melli-
tus, and Addison disease).
2. HIV.
3. Cancer.
COMMON COMPLAINTS
A. Soreness and pain in the mouth.
B. White plaques coating buccal mucosa.
OTHER SIGNS AND SYMPTOMS
A. Irritability in infants.
B. Refusal to eat in infants.
SUBJECTIVE DATA
A. Determine the onset, duration, and course of illness.
B. Inquire about oral intake or refusal to eat.
C. Has the client used antibiotics or other medications in the
previous weeks?
D. Does the client use inhaled or systemic steroids on a daily
basis?
E. Is the client currently receiving chemotherapy and/or
radiation treatment for cancer?
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood
pressure.
B. Inspect:
1. Oral cavity for white, curd-like plaques that cannot be
removed.
2. Erythematous changes of the gingiva in denture wearers.
3. Ears, nose, and throat.
DIAGNOSTIC TESTS
A. If diagnosis is certain, no testing is recommended.
B. If uncertain of diagnosis, swab lesion for potassium
hydroxide testing.
C. If treatment prescribed is not working, fungal culture
should be sent for diagnosis.
DIFFERENTIAL DIAGNOSES
A. Thrush.
B. Leukoplakia.
C. Lichen planus.
D. Stomatitis.
E. Aphthous ulcer.
F. Hairy leukoplakia.
PLAN
A. General interventions:
1. If the infant is breastfeeding, instruct the mother to
clean breasts and nipples well with warm water between
feedings to prevent contamination. Consider prescribing
antifungal cream to be applied to breasts; this should be
washed off before feedings.
2. If bottle feeding, boil all bottles, nipples, and paciers
to kill the organism.
3. Instruct the caregiver to attempt removal of large
plaques with a moistened cotton-tipped applicator and/
or a small, moist gauze pad before inserting medication in
mouth.
4. If thrush is recurrent or resistant, consider checking the
mother for candidal vaginitis.
5. For adults, instruct the client/family on proper use and
cleaning/rinsing of inhalers/dentures to prevent reoccurrence of thrush.
B. Client teaching: See Client Teaching Guide for this chapter,
“Oral Thrush in Children.”
C. Pharmaceutical therapy:
1. Oral candidiasis: nystatin (Mycostatin) oral suspension
1 mL QID for 1 week. Place medication in front of mouth
on each side. Rub directly on plaques with a cotton swab.
For adults, pastilles 200,000-unit lozenge QID for 14 days,
or swish-and-swallow 500,000 units QID for 14 days or
two 500,000-unit tablets TID for 14 days.
THRUSH
https://t.me/med1917
205
2. Clotrimazole troche (Mycelex): 10mg ve times daily
for 14 days; monitor for side effects.
3. Fluconazole: for adults, 200mg × 1, then 100mg daily
for 5 to 7 days; for children, 5 mg/kg PO every day for 5
days or 6 to 12mg/kg on rst day, then 3 to 6 mg/kg for
10 days.
FOLLOW-UP
A. Instruct caregiver to telephone the ofce if the child refuses
to eat, if there is no improvement, if thrush lasts more than 10
days, or if there is unexplained fever.
CONSULTATION/REFERRAL
A. Consult an oral surgeon or an otolaryngologist if thrush
does not resolve with adequate antifungal treatment.
INDIVIDUAL CONSIDERATIONS
A. Geriatrics:
1. Nutritional challenges in the elderly population can
lead to stomatitis and aphthous ulcers. Assess theirchewing ability. Evaluate geriatric clients for iron, B12, and folic
acid deciencies.
2. Certain conditions may cause overgrowth of Candida
thrush and/or increase occurrences of aphthous stomatitis in the geriatric population, which could include use of
steroid inhaler, tobacco use, systemic steroid/antibiotics,
radiation/chemotherapy, food allergies, asthma, diabetes
or other endocrine disorders, anxiety, and lack of sleep.
BIBLIOGRAPHY
Fang, J., Huang, B., & Ding, Z. (2021). Efcacy of antifungal drugs in
the treatment of oral candidiasis: A Bayesian network meta-analysis.
Journal of Prosthetic Dentistry, 125(2), 257–265. https://doi-org.proxy.
library.vanderbilt.edu/10.1016/j.prosdent.2019.12.025
Papadakis, M. A., & McPhee, S. J. (Eds.). (2019). Candidiasis, mucocuta-
neous. In M. A. Papadakis& S. J. McPhee (Eds.), Quick medical diagnosis
& treatment. McGraw-Hill. https://accessmedicine-mhmedical-com.
proxy.library.vanderbilt.edu/content.aspx?bookid=2566§ionid=
206879921
https://t.me/med1917
207
https://t.me/med1917
CLIENT TEACHING GUIDE
APHTHOUS STOMATITIS
PROBLEM Aphthous stomatitis describes tender ulcers in the mouth that recur.
CAUSE The cause is unknown. Possible causes include diet (lack of iron, zinc, or B vitamins), menstrual or hormonal changes,
and viruses.
PREVENTION/CARE
A. Preventing ulcers in the mouth can be difcult when the cause is unknown. Some suggestions for prevention include the
following:
1. Avoiding trauma/injury to the inside of the mouth (biting cheek, etc.).
2. Avoiding toothpastes and mouth rinses that include sodium lauryl sulfate.
3. Avoiding certain foods that tend to trigger the onset of an ulcer (spicy foods, nuts, cheese, coffee, acidic food, etc.).
4. Maintaining a healthy diet with vitamin B12, folate, iron, and/or zinc.
5. Avoiding stress.
TREATMENT PLAN
A. Use an over-the-counter gel such as Anbesol or Orajel four times daily.
B. You may be prescribed a mouthwash made of diphenhydramine (Benadryl), Maalox, and lidocaine or uocinonide gel to
“swish” in your mouth two to four times daily.
Activity: No restrictions are required.
Diet:
A. Avoiding spicy, salty, or hot foods may help.
B. Using a straw when drinking may reduce pain.
C. Cold foods may be easier to tolerate.
D. Avoid hard or sharp food.
E. Use a soft toothbrush.
Medications:
You Have Been Prescribed:
You Need to Take:
You Need to Notify the Office If You Have:
A. Worse symptoms than seen at the ofce visit today.
B. Ulcers that do not heal in approximately 1 to 2 weeks.
C. Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
Соседние файлы в папке Библиотека им академика М.И. Перельмана