ENT 2

Question 1

Leukoplakia

Answer 1

A white lesion that, unlike oral candidiasis, cannot be removed by rubbing the mucosal surfaces
Hairy Leukoplakia is caused by active Epstein Barr virus (EBV) replication – only observed in HIV patients – on tongue.

Question 2

A white oral lesion that can be removed by rubbing mucosal surface

Answer 2

candidiasis

Question 3

Hairy leukoplakia

Answer 3

Hairy Leukoplakia is caused by active Epstein Barr virus (EBV) replication – only observed in HIV patients – on tongue.

Question 4

Similar to leukoplakia except that it has a definite erythematous component (red)

Answer 4

erythroplakia

Question 5

OLP (Oral lichen planus)

Answer 5

Most commonly present as lacy leukoplakia but may be erosive; definitive diagnosis requires biopsy – OLP is a chronic inflammatory disease of unknown etiology.

Question 6

Early lesions appear as leukoplakia or erythroplakia; more advanced lesions will be larger, with invasion into tongue such that a mass lesion is palpable.( +/- ulceration)

Answer 6

Oral cancer

Question 7

Leukoplakia and Erythroplakia may be associated with

Answer 7

Dysplasia or squamous cell carcinoma (90% of erythroplasia are either dysplasia or carcinoma).

Question 8

Causative agents of peritonsillar or retropharyngeal abscesses

Answer 8

Viruses: none
Bacteria: Group A Streptococcus (most common) , oral anaerobes (Fusarium spp), S. aureus, H. influenza (usually in infants)

Question 9

the most common causative agents of peritonsillar or retropharyngeal abscesses:

Answer 9

GAS

Question 10

Common varieties of OLP and the conditions they mimic:

Answer 10

Reticular (mimicking candidiasis or hyperkeratosis)

Erosive (mimicking squamous cell carcinoma)

Question 11

Painful, creamy white curd-like patches overlying the erythematous mucosa ( can be rubbed off)

Answer 11

Candidiasis – Oral Thrush

Question 12

Candidiasis predisposing conditions

Answer 12

Oral denture use
Chronic debilitated disease association
Diabetes melitus
Severe chronic anemia
Cemohterapy or radiation therapy recipients
Prolonged coricosteroid use
Prolonged antibiotic use
HIV infection – most often an AIDS-defining illness.

Question 13

Yeast endogenous to our mucous membranes and normal flora
Forms germ tubes at 37.0°C in serum
Forms pseudo-hyphae and true hyphae when it invades tissues

Answer 13

Candida albicans

Question 14

Candidiasis
Diagnosis
Treatment

Answer 14

Diagnosis is often made clinically
Diagnosis involves yeast identification: 
Non-septate
hyphae
Pseudo hyphae (photo)
Germ tube

1- Local antifungals
Nystatin mouth rinses; held in mouth before swallowing- 3 times daily, Hydrogen peroxide mouth rinse may provide local relief

2- Systemic antifungals

Question 15

HIV associated oral lesions

Answer 15

Thrush/Candida
Hairy Leukoplakia (EBV)
Kaposi’s Sarcoma (KSHV/HHV-8)

Question 16

Acute Necrotizing Ulcerative Gingivitis (ANUG) or Trench Mouth is characterized by

Answer 16

Characterized by: 
Painful gingival inflammation and necrosis
Bleeding
Halitosis
Fever
Cervical lymphadenopathy

Question 17

Trench mouth (ANUG) causative agents:

Answer 17

Synergistic infection – spirochetes (oral spirochete of Treponema genus; T. denticola) and anaerobic bacteria (Fusobacterium)

Question 18

Fusobacterium

Id.,, Path., Tx

Answer 18

anaerobic gram negative rodGram negative rods, non-spore forming, anaerobes

Resides in mouth and intestine as normal flora

An opportunistic pathogen

Elongated rods with tapered ends

Pathogenesis
is mediated by LPS

Treatment:
Antibiotics

Question 19

ANUG epid

Answer 19

Occurs at any age group (poor mouth care), especially with stress, malnutrition, or immunodeficiency

Question 20

Bacteria responsible for the overwhelming majority of localized abscesses in cranium, thorax, peritoneum, liver and female genital tract

Answer 20

Fusobacterium, peptostreptococcus and bacteroides alone or together with other facultative or obligate anaerobes

Question 21

Aphthous ulcers

Answer 21

Canker sore, Ulcerative Stomatitis

Question 22

aphthous ulcers

causative agent, manifestation

Answer 22

Cause remains uncertain; association with HHV6 has been suggested

Found on non-keratinized mucosa
Buccal and labial mucosa
Not on gingiva or palate

Characterized by single or multiple painful ulcers with irregular margin and yellow-grey fibrinoid center surrounded by red halo (2-10 mm)

Recur in relation to stress, menses, local trauma and other non-specific stimuli (similar to herpes)
May be confused with herpetic lesions

Question 23

The oral location at which aphthous ulcers can NOT be found

Answer 23

Not on gingiva or palate

They are found on mucosa: non-keratinized, buccal and labial mucosa

Question 24

Aphthous ulcer tx

Answer 24

Non-specific

Topical corticosteroids
Triamcinolone or fluocinonide ointment

Oral prednisolone- one week tapering course (starting 40-60mg/day)

Thalidomide
in recurrent aphthous ulcerations in HIV-positive patients

Question 25

Noma/ cancrum oris | Sx, epid.

Answer 25

A severe gangrenous stomatitis progressing beyond the mucus membrane to involve soft tissue, skin, and sometimes bone Seen in severely debilitated patients and people with poor oral hygiene; typical cases occur in children with protein-calorie malnutrition and other immunocompromised conditions Measles sometimes precipitate noma

Question 26

Noma/ Cancrum oris etiologic agents

Answer 26

Etiologic agents include Fusobacterium, Bacteroides, and P. aeruginosa

Question 27

``` Herpetic Stomatitis (HSV-1) 3 clinical forms of oral infection ```

Answer 27

Oral infection with herpes simplex virus occurs in three clinical forms: Recurrent small blisters on the lips commonly referred to as fever blisters or secondary herpes labialis (most common type). A generalized oral infection called primary herpetic stomatitis. Small ulcers usually localized on palatal mucosa (rare variety).

Question 28

causative agent of recurrent small blisters on the lips commonly referred to as fever blisters or secondary herpes labialis (most common type).

Answer 28

HSV1

Question 29

Small ulcers usually localized on palatal mucosa are caused by

Answer 29

HSV-1

Question 30

Treatment fro Herpetic labialis (cold sores, fever blisters) and primary herpetic stomatitis

Answer 30

Acyclovir

Question 31

Causative agents of pharyngitis: Viral and Bacterial

Answer 31

Pharyngitis is an acute infection of the pharyngeal mucosa caused by a variety of microorganisms: Majority are viral Rhinoviruses, Enteroviruses, Coronavirus, Adenovirus, Influenza viruses, and Epstein Barr virus (EBV) Minority are bacterial – Group A Streptococcus (GAS) is the most common cause. Other bacterial causes: Non-Group A Strep, C. diphtheriae, N. gonorrhoeae, Y. enterocolitica, and anaerobic bacterial species.

Question 32

Pharyngitis | Sx, O/E

Answer 32

Sore throat Difficulty in swallowing/painful swallowing Fever Lymphadenopathy Vesicles or ulcers (HSV and Enterovirus) Respiratory distress- in severe form of pharyngitis; particularly when pharyngeal edema extends to the larynx On examination: Erythematous pharynx with or without exudates or cervical lymphadenopathy.

Question 33

Sx of HSV/Enterovirus caused pharyngitis in addition to: Difficulty in swallowing/painful swallowing Fever Lymphadenopathy Respiratory distress- in severe form of pharyngitis; particularly when pharyngeal edema extends to the larynx

Answer 33

Vesicles or ulcers (HSV and Enterovirus)

Question 34

Mild pharyngeal symptoms with rhinorrhea suggest a -------etiology.

Answer 34

viral

Question 35

Exudative pharyngitis | causative ag.

Answer 35

Exudative pharyngitis - EBV, HIV | Need to also consider Group A Streptococcus (GAS)

Question 36

Pharyngeal symptoms with vesicular lesions and ulcers - often on hard palate causative ag.

Answer 36

HSV, Coxackievirus

Question 37

causes pharyngeal symptoms with conjunctival inflammation

Answer 37

adenovirus

Question 38

Pharyngitis with generalized rash caused by

Answer 38

EBV, HIV | Streptococcal toxic shock from toxin-producing S. pyogenes strains)

Question 39

Pharyngitis | Serologic testing can establish the diagnosis of

Answer 39

``` Serologic testing can establish the diagnosis of EBV HIV CMV Influenza M. pneumoniae C. pneumoniae ```

Question 40

Pharyngitis | Special culture media should be requested for

Answer 40

Special culture media should be requested for N. gonorrhea C. diphtheria

Question 41

Associate symptos of phartngitis

Answer 41

Myalgia Fever Rhinorhea and lymphadenopathy Pharyngeal erythema with or without exudates or lymphadenopathy Leukocytosis, rapid strep test and bacterial cultures or other serologies may provide the definitive microbiologic diagnosis

Question 42

Adenoviral pharyngitis

Answer 42

``` This patient presented with Sore throat: Strep test negative Cough Fever Red, inflamed conjunctiva Lyphadenopathy involved - anterior and other groups of LNs. ```

Question 43

Rapid Antigen Detection Test

Answer 43

All available RADTs involve the detection of the Lancefield group A carbohydrate, a GAS‐specific cell‐wall antigen

Question 44

S. Pyogenes | Colony morphology

Answer 44

Colony Morphology - Culture ●Grow best in enriched media e.g. blood agar ● Small colonies (pinpoint-2mm), may have a surrounding zone of hemolysis -B-hemolysis- a clear zone surrounding the colony (complete hemolysis) They appear in chain like arrangements

Question 45

S. Pyogenes | Biochemistry

Answer 45

``` Glucose fermentation test yield lactic acid Catalase negative (Staphylococcus: catalase positive) ```

Question 46

S. Pyogenes | Cell morphology

Answer 46

Gram-positive round cells growing in chains non acid-fast Nonmotile May or may not have capsules

Question 47

Differentiation of GAS from other b- hemolytic pathogens

Answer 47

Group B Streptococci (GBS) also produce b-hemolysis (and a positive CAMP test) Enterococci also produce b-hemolysis Only GAS is bacitracin sensitive

Question 48

Gram + cocci that result in complete lysis of RBCs on Blood Agar How to differentiate them

Answer 48

GAS (S. aureus), GBS ( S. agalactiae) and Staph aureus are all B-Hemolytic. Staph aureus: Cat +, Coag + GAS: Cat - , Bacitracin sensitive (-CAMP) GBS: Cat -, Bacitracin Resistant ( + CAMP)

Question 49

Sore Throat | Clinical ft,

Answer 49

Symptoms are variable from individual to individual and some people may remain asymptomatic and serve as carriers Soreness of throat and difficulty in swallowing Fever, malaise and headache Redness of throat White patches of pus with hemorrhagic spots or yellowish white exudates Enlarged and tender cervical lymph nodes Abdominal pain (not always)

Question 50

S. Pyogenes | Immunity

Answer 50

Immunity Type-specific IgA prevents adhesion and IgG against M-protein protects against invasion Repeat infections due to the large number of GAS strains (over 80 serotypes**) **Serotypes are performed using antibody against M protein

Question 51

Complications of Acute Streptococcal Pharyngitis

Answer 51

Scarlet fever rashes and strawberry tongue Signs & Symptoms ● Fever, lethargy, sore throat, and a sand paper-like rash. ● The patient usually has a "strawberry tongue." ● Finally, dark red lines (called Pastia's lines) may appear in the creases of skin folds

Question 52

Scarlet fever

Answer 52

Scarlet fever is the result of infection with an S. pyogenes strain that is itself infected with a bacteriophage (T12) Erythrogenic toxin enters blood stream and cause the rashes to appear Children are commonly affected Usually self-limiting but antibiotics are preferred to avoid additional complications Penicillin is the drug of choice, but some resistance has been reported.

Question 53

Complications of bacterial pharyngitis

Answer 53

Peritonsillar or retropharyngeal abscesses Jugular vein thromobosis and embolic complications (Lemeire’s syndrome) in Fusobacterium necrophorum infection Rheumatic heart disease (GAS) Post-streptococcal glomerulonephritis (GAS) Acute airway obstruction (C. diphtheriae) Myocarditis (C. diphtheriae) Neuritis (C. diphtheriae)

Question 54

Complications of C. diphtheriae pharyngitis

Answer 54

Acute airway obstruction (C. diphtheriae) Myocarditis (C. diphtheriae) Neuritis (C. diphtheriae)

Question 55

Complications of GAS pharyngitis

Answer 55

Rheumatic heart disease (GAS) | Post-streptococcal glomerulonephritis (GAS)

Question 56

Complications of viral pharyngitis

Answer 56

Viral pharyngitis Secondary bacterial infections of sinus Secondary bacterial infections of lower respiratory tract

Question 57

Control of pharyngitis

Answer 57

Penicillin prophylaxis for patients with rheumatic heart disease Acyclovir for recurrent HSV pharyngitis Treatment of sexual partner in gonorrheal pharyngitis Good hand washing, especially if there is an infected person in the family Tonsillectomy in recurrent pharyngitis as appropriate Active immunization for influenza A/B and diphtheria Prophylactic measures

Question 58

Laryngitis | Causes (more and less)

Answer 58

Laryngitis: infection of the larynx that results in an inflammatory reaction and consequent symptoms and signs. Most commonly, viral pathogens: Rhinovirus, adenovirus, influenza virus, RSV or parainfluenza virus Less commonly, bacterial pathogens: S. pyogenes, Moraxella catarrhalis Rare causes: Mycobacterium tuberculosis, Treponema pallidum and fungal pathogens (Histoplasma, Blastomyces, Candida)

Question 59

Laryngitis | Sx and symp

Answer 59

``` Hoarseness Aphonia Associated symptoms Rhinitis, or pharyngitis Features of respiratory obstruction ``` Hyperemic (increased blood flow), edematous, with or without ulcerations Exudative in diphtheria, GAS, EBV laryngitis

Question 60

Laryngitis | Imaging

Answer 60

Lateral X-ray of neck would help exclude: - acute bacterial epiglottitis - bacterial tracheitis When hoarseness persists longer than 2 weeks, direct laryngoscopy should be done. A lateral neck X-ray should be done if the patient has associated symptoms of stridor* (harsh vibrating noice when breathing) or respiratory compromise to rule out laryngeal obstruction.

Question 61

Laryngitis differential dx

Answer 61

``` Voice abuse Tumor Paralysis of the vocal cord Chemical irritants Gastroesophageal reflux ``` Also, should be differentiated from acute bacterial epiglottitis and acute bacterial tracheitis (presents with more systemic manifestations)

Question 62

Laryngitis tx

Answer 62

``` Viral laryngitis Mostly supportive treatment including Voice rest Warm saline gargling Increased humidity ``` Bacterial laryngitis Specific antibiotic should be administered

Question 63

Laryngitis | Ess of Dx

Answer 63

Hoarseness or loss of voice (aphonia). Associated symptoms of rhinitis, pharyngitis, or cough. Children tend to develop airway obstruction. Mostly viral, occasionally bacterial. Persistent hoarseness lasting more than 10 days should prompt laryngoscopy to exclude other etiologies. The larynx is hyperemic and edematous, with or without ulcerations.

Question 64

Croup (Acute Laryngotracheitis)

Answer 64

Croup is a clinical syndrome due to subglottic inflammation and edema caused by a viral or bacterial infection of the larynx, trachea, and bronchi. This is the most common cause of upper respiratory tract obstruction in children between the ages of 6 months to 6 years, with peak occurrence at 2 years. Mostly caused by viruses with occasional bacterial involvement.

Question 65

Frequent pathogens causing croup in Child a d Adults

Answer 65

Children:Parainfluenza virus type I and II Influenza A or B RSV Adults: HSV Influenza A or B

Question 66

Croup Sx

Answer 66

Hoarsness of voice Brassy cough Stridor* (inspiratory or expiratory) Fever Rhinorrhea preceding the above complaints Sore throat On examination: Lung sounds reveal ronchi*, crepitations* or wheezing* Diminished breath sound due to upper airway obstruction Stridor: harsh vibrating noise when inhaling or exhaling due to obstruction of larynx or trachea. Ronchi: coarse rattling noise during respiration, most often caused by secretions in the bronchial airways. Crepitations: crackling sounds in the lungs during respiration detected with a stethoscope, caused by lung inflammation. Wheezing: a whistling or hissing chest noise during respiration due to obstruction of airways.