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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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358 SYMPTOM SORTER
Intranasal foreign bodies are relatively common in toddlers – beware the unilateral foul-
smelling nasal discharge in a child.
A persistent bloodstained discharge requires investigation, especially if associated with
unilateral nasal obstruction.
Clear unilateral nasal discharge aer direct trauma to the face may represent CSF leakage
from an ethmoidal skull fracture. Occasionally this can present some time aer the injury
so beware the late presentation.
NOTES:
https://t.me/med1917
359
ORAL
Bad breath 360
Bleeding or painful gums 363
Mouth lumps and marks 365
Mouth ulcers 368
Painful tongue 371
https://t.me/med1917
360
BAD BR E ATH
The GP overview
is common symptom is usually caused by poor dental hygiene. As a presenting complaint it is
seen far more oen by dentists than GPs. It may be detected by a doctor examining a patient for
an unrelated complaint, and rarely but signicantly can herald serious pathology.
Differential diagnosis
COMMON
poor dental hygiene
heavy smoking
gingivitis (including acute necrotising ulcerative gingivitis [ANUG], acute and chronic
gingivitis)
excess alcohol intake (acute and chronic)
discharging dental abscess
OCCASIONAL
ketohalitosis of starvation: especially in people using hig h-protein, high-fat, low-carbohydrate
weight reduction diet regimens (and pre-operatively starved patients)
drugs, e.g. disulram
acute or chronic sinusitis
subjectively perceived (non-existent) halitosis (sometimes a form of somatisation)
GORD or acute gastroenteritis with reux of gas
RARE
bronchiectasis
liver failure: hepatic foetor is said to smell like a freshly opened corpse; this is due to
mercaptans in expired air
true delusional subjective halitosis as part of psychiatric condition, e.g. severe depression with
nihilism, psychotic illnesses
rare oral or nasal conditions (e.g. pyogenic granuloma, discharging sinus from abscess)
https://t.me/med1917
BAD BREATH 361
Ready reckoner
Poor dental
hygiene
Heavy
smoking
Gingivitis Excess
alcohol
Dental
abscess
Painful face/jaw No No Possible No Ye s
Bleeding gums Possible No Ye s Possible Possible
Facial swelling No No No No Ye s
Dental staining Ye s Possible Possible No Possible
Intoxication/stigmata of chronic alcohol abuse No No No Yes No
Possible investigations
It is unlikely that the GP will initiate any investigations other than LFT if alcohol is a likely
aetiology, or liver failure is suspected. CXR may be helpful if bronchiectasis is a possibility.
Dentists may carry out the following investigations.
Plaque and bleeding indexes: For oral hygiene.
Basic periodontal examination: Measurement of pocket depth between gums and teeth
carried out with a specially marked probe.
Oral pantomograph x-ray to investigate general state of teeth.
TOP TIPS
e vast majority of cases will involve oral hygiene. Be certain to exclude this, and other
physical causes, before deciding that the halitosis is entirely subjective. As with other forms
of somatisation, active management – with a psychiatric referral if necessary – is preferable
to sending the patient away, only to return to make more appointments.
If no obvious oral cause is found initially, extend the history and examination to include the
respiratory and gastrointestinal systems.
ANUG is a ‘spot diagnosis’ – the stench usually precedes the patient by some distance.
https://t.me/med1917
362 SYMPTOM SORTER
In the absence of an obvious cause, do not neglect to examine the head and neck including
the buccal cavity and nasal airway. Failure to do so could mean that a serious local cause is
missed.
Do not overlook alcohol abuse as a possible underlying cause.
If the impact of the symptom seems out of all proportion to any objective sign of a problem,
consider depression.
NOTES:
https://t.me/med1917
363
BLEEDING OR
PAINFUL GUMS
The GP overview
e primary cause of this symptom is nearly always infection, usually because of poor dental
hygiene: An endemic problem worldwide. Systemic problems may also cause gum pain or
bleeding. While a dental referral is likely to be the end result, it is worth checking for general
causes or easily remediable problems before directing the patient to the dentist.
Differential diagnosis
COMMON
gingivitis/periodontal (gum) disease
pregnancy gingivitis
acute necrotising ulcerative gingivitis (ANUG): Vincent’s stomatitis
trauma: poorly tting dentures
drugs: warfarin overdosage, long-term phenytoin
OCCASIONAL
aphthous ulceration
acute herpetic gingivostomatitis (occasionally EBV)
autoimmune disease: lichen planus, SLE and others
oral neoplasia (commonest is SCC) (Note: may bleed but usually painless)
blood dyscrasias (especially acute myeloid leukaemia)
RARE
malabsorption (including scurvy)
chemical poisoning: mercury, phosphorus, arsenic and lead
hereditary haemorrhagic telangiectasia
lymphangioma
cavernous haemangioma
https://t.me/med1917
364 SYMPTOM SORTER
Ready reckoner
Gingivitis Pregnancy ANUG Trauma Drugs
Swollen gums Ye s Ye s Ye s Possible Possible
Halitosis Yes No Ye s No No
Painful gums Yes No Possible Yes No
Fever and malaise No No Possible No No
Local lymphadenopathy Possible No Ye s No No
Possible investigations
LI KE LY: None.
POSSIBLE: FBC.
SMALL PRINT: Swab, INR, autoimmune screen, Paul–Bunnell test.
FBC: To check for blood dyscrasias and malabsorption.
Swab may help if obscure infective cause.
Urgent INR if patient on warfarin.
Paul–Bunnell test: EBV infection may cause gingivostomatitis.
Autoimmune screen if autoimmune disease suspected.
TOP TIPS
Patients with manifestly ‘ dental’ problems may attend the GP because they view the doctor’s
service as cheaper or more accessible. Direct them rmly to the dentist to discourage
inappropriate attendance in the future.
Review the patient’s medication – it is easy to overlook iatrogenic causes of gum soreness or
bleeding.
Patients with aphthous ulcers are likely to have read that their problem is associated with
vitamin deciencies or systemic illness. In primary care, it almost never is.
Ulcerative gingivitis can oen be diagnosed as soon as the patient walks into the consulting
room, because of the characteristic odour.
Children with primary attacks of herpetic gingivostomatitis can become quite ill and
dehydrated. Consider early review or admission.
Petechiae on the so palate in conjunction with gingivostomatitis raise the possibility of
EBV infection, acute leukaemia or scurvy.
Enquire about skin problems elsewhere, or you may miss a signicant diagnosis – SLE,
pemphigus, pemphigoid, bullous erythema multiforme, epidermolysis bullosa and lichen
planus can all aect the mouth.
https://t.me/med1917
365
MOUTH LUMPS
AND MARKS
The GP overview
Mouth lumps and marks can be unfamiliar territory – partly because it is rarely an area of
expertise for many GPs, and partly because many mouth problems are picked up by, or presented
to, dentists in the rst place. A proportion of patients will choose a GP as the rst port of call,
so a working knowledge of the area is useful.
Differential diagnosis
COMMON
apical tooth abscess (gumboil)
aphthous ulceration
Fordyce spots (tiny white or yellow spots, on mucosa opposite molars and vermilion border
of lips; they are sebaceous glands)
oral candida infection
mucocoele (solitary cystic nodule inside lip)
OCCASIONAL
lichen planus
trauma: bitten cheek
ranula
torus: benign maxillary or mandibular outgrowth of bone (very common but usually
asymptomatic so not commonly seen)
premalignant coloured areas: erythroplakia (red), leukoplakia (white), speckled leukoplakia
(red and white), or verrucous leukoplakia
geographical and hairy tongue
tonsillar concretions
other forms of oral ulceration (see ‘Mouth ulcers’ section)
RARE
malignancy: SCC or melanoma
pachyderma oralis (from irritants)
heavy metal poisoning (lead, bismuth, iron): a dark line below the gingival margin
cancrum oris
https://t.me/med1917
366 SYMPTOM SORTER
sublingual dermoid cyst
sublingual gland tumour
pigmentation due to oral contraceptive pill: black or brown areas anywhere in the mouth
Addison’s disease: bluish hue opposite molars
Peutz–Jeghers spots: brown spots on the lips
telangiectasia: may be a sign of Osler–Weber–Rendu syndrome
Stevens–Johnson syndrome
Ready reckoner
Abscess Ulcer Fordyce spots Candida Mucocoele
Lesion tender Ye s Ye s No Possible No
Flat lesion No Ye s No Ye s No
Multiple lesions No Possible Ye s Ye s No
White lesions No Ye s Possible Ye s No
Lesion scrapes off No No No Yes No
Possible investigations
LI KE LY: None.
OCCASIONAL: FBC, ESR, CRP, ferritin, B
12
and folate, fasting glucose or HbA1c, swab of lesion,
HIV test.
SMALL PRINT: Biopsy (performed at hospital).
FBC, ESR, CRP and HIV are useful if immune deciency (e.g. as a background to Candida
infection) is suspected; FBC and ESR or CRP may be helpful in suspected malignancy too.
Ferritin, B
12
and folate deciency are sometimes associated with oral aphthous ulceration–
worth checking these in cases of recurrent or chronic ulceration (and see other possible
investigations in ‘Mouth ulcers’ section).
Fasting glucose or HbA1c to investigate possible diabetes if candidal infection otherwise
unexplained.
Mouth swab to conrm candidal infection, though a diagnostic trial of treatment is oen
the practical rst step.
Biopsy: Of suspicious lesions – this is inevitably performed in secondary care.
TOP TIPS
Recurrent oral aphthous ulceration is a feature of a few systemic diseases (e.g. coeliac disease,
Crohn’s disease, Behçet’s disease and AIDS) so be prepared to re-evaluate the history and
widen the net of information gathering in repeat presentations.
https://t.me/med1917
MOUTH LUMPS AND MARKS 367
It is tempting to give antibiotics for a dental abscess, but the old surgical maxim ‘if there’s pus
about, let it out’ still holds true. Antibiotics may help reduce pain and surrounding infection
but are only a temporary measure and may delay denitive treatment in those trying to avoid
seeing a dentist, and increase the risk of complications. Encourage patients to see a dentist in
the rst place – oering a referral letter can be helpful and may help to overcome any possible
barrier to urgent access to a dentist at the dental reception desk.
Always examine lumps by palpation from inside as well as outside the mouth. Wash latex
gloves before the examination. Glove powder tastes foul!
Always refer the patient with permanent red or white buccal mucosal patches. Biopsy is
indicated.
If an ulcer fails to heal within a few weeks, especially if it is painless, refer for a specialist
opinion as a suspected malignancy.
Do not fail to examine regional lymph nodes. Enlarged nodes would be a signicant nding,
especially if they are non-tender and persistent.
NOTES:
https://t.me/med1917
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