3/19/2014 Lesions of the Oral Cavity Jason C. Fowler, MPAS, PA‐C Meadville ENT – Meadville, PA Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Disclosures Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Learning Objectives • Identify common oral cavity infections, lesions and illnesses, as well as form a differential diagnosis • Select appropriate testing based on the history and physical findings • Develop a medical management plan including referral and follow up as necessary Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 1 3/19/2014 Lesions of the Oral Cavity Head and Neck Anatomy Oral Cavity: • Functions: respiration, digestion, swallowing, taste • External components (vestibule) – Lips, – vermillion border, / philtrum • Internal components – Tongue – palate (hard / soft) – buccal mucosa, – Gingiva / alveolar ridges – major salivary ducts Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Anterior view of the Oral Cavity www.cancer.gov Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Anatomy of the Tongue Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 2 3/19/2014 Clinical History • Important factors to consider – Age and gender – Constitutional symptoms: e.g. Weight loss, fevers, night sweats – Duration of symptoms – Co-morbid medical conditions: e.g Immunocompromise – Environmental risk factors (ETOH / TOBACCO) – Dysphagia / Odynophagia / hemoptysis / Halitosis – Respiratory distress / Shortness of Breath • Duration of symotoms – Acute: usually < 7 days – suggests inflammatory – Chronic: present for years, often asymptomatic – suggests congenital – Recurrent: multiple x per year, often painful – suggests infectious / autoimmune / nutritional – Weeks: months, +/- painful – suggests possible neoplastic process •Pain – Need to localize and quantify as accurately as possible. Malignancy may often be masked by low degree of pain – REFERRED EAR PAIN – unilateral ear pain with a normal ear exam should raise suspicion for oropharyngeal or laryngeal malignancy, especially in patients with social risk factors such as alcohol and tobacco Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Oral cavity –Basic Anatomy Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Normal Anatomy Gingiva Gingival‐labial fold Soft palate and uvula Frenulum RM T Submandibular duct Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 3 3/19/2014 Physical Exam of the Oral Cavity • Extra‐oral exam – Carefully exam the skin and symmetry of the head / neck – Examination of lymphatic zones in the neck – Palpation of parotid and submandibular glands • Intra‐oral Exam *MUST REMOVE DENTURES!!!* – Start with vestibule and upper / lower lips – Buccal mucosa (including parotid ducts) and alveolar ridge – Retromolar trigone – Tongue –dorsal / ventral and lateral – Floor or Mouth (incl. submandibular ducts) *BIMANUAL PALPATION* – Hard / Soft Palate and uvula – Palpate tonsillar fossae and base of tongue Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Examination of the oral Cavity Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Oral Cavity Exam cont. Palpation of Left Base Of Tongue and Left tonsil Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 4 3/19/2014 Floor Of Mouth exam with bimanual palpation Fowler 2014 Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Ulcerative Lesions of the Oral Cavity Fowler 2014 Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Stomatitis – defined as inflammation of the mouth with or without ulceration • Oral Causes • Systemic Causes – Poor hygiene – Infection – Poor fitting dentures • Viral – Trauma (hot foods, • Fungal chemicals) • Bacterial – Ingested toxins – Drug reactions – Allergic reactions – Chemotherapy / Radiation Gingivostomatitis – when inflammation – Nutritional deficiencies also affects the gingiva Mucositis – not to be used interchangeably, as this refers to systemic mucosal pathology often as a result of chemo / RT Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 5 3/19/2014 Examples of Severe Stomatitis Fowler 2014 Fowler 2014 Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Evaluating Stomatitis and Oral Ulcers • Questions to Consider: – Acute or chronic process – Single or multiple lesions – Location of lesion(s) Aphthous ulcer of hard palate – Duration of symptoms – Associated pain or prodrome of pain? Fowler 2014 – Systemic symptoms or mucocutaneous lesions elsewhere? – Medications – Timing of symptoms – i.e., triggers Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Systemic disease associated with oral ulcers Fowler 2014 Preeti et al. J Oral Maxillofac Pathol. 2011 Sep‐Dec; 15(3): 252–256 –with permission Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 6 3/19/2014 Common Forms of Stomatitis • Aphthous • Viral – Herpetic – Herpangina – Zoster • Fungal – Angular Chelitis – Diffuse oral candidiasis (“Thrush”) Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Recurrent Aphthous Stomatitis • A.k.a. Canker Sores • Affect 30‐35% of the population Equal age / gender distribution • Last 10‐30 days on average • Vary in size and shape – Minor: 80% <1cm heal without scarring – Major: >1cm often associated with delayed healing and scarring • Clinical features – White‐gray ulceration with erythematous halo, occasionally with fibrinopurulent exudate – Buccal, labial, soft palate, FOM, lateral / ventral tongue • Treatment aimed at pain reduction and promoting healing – Topical/ systemic corticosteroids (Kenalog in Orabase, prednisolone liquid) – Topical pain relief (2% viscous lidocaine) – Identifying systemic triggers (e.g., nutritional deficiency or systemic disease) Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Treatment of Aphthous Stomatitis Preeti et al. J Oral Maxillofac Pathol. 2011 Sep‐Dec; 15(3): 252–256 –with permission Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 7 3/19/2014 Many types of “Magic Mouthwash” • 80ml each: • Other preparations may – Nystatin 100,000U suspension include: Sucralfate (coating – Prednisolone 15mg / 5ml agent), erythromycin or solution tetracycline – Benadryl 12.5mg / 5ml elixir • Need to be aware of potential – Maalox drug interactions / side effects – 2% viscous lidocaine – Distilled H2O • Sig: 10ml swish, gargle, spit q 6hr as needed. • BMX –variant with only lidocaine, Maalox and benadryl Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Aphthous Stomatitis • Work‐up for recurrent ulcerative stomatitis may include – CBC – ESR / CRP – Iron studies – B12 titiers – SS‐A / SS‐B, autoimmune studies – Glucose levels – Thyroid function – HSV titers – HIV Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Oro‐labial Herpes Simplex (HSV‐1) • DNA virus transmitted via saliva • Up to 90% of adults are have antibodies to HSV‐1 • Increase prevalence with age • Associated with lower socioeconomic status • Clinical: may have fever, lymphadenopathy, fatigue with multiple painful mucosal ulcers • May have prodrome of pain / burning • Treatment with topical / Fowler 2014 systemic antivirals Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 8 3/19/2014 Oro‐labial HSV1 • Ulcerated vesicles often in groups • Typically found on keratinized mucosa – Lips – Gingiva – Hard palate Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Treatment of Primary HSV‐1 Acyclovir 400 mg Sig: 400mg PO TID x 7‐10 days Famvir 250 mg Sig: 250mg PO TID x 7‐10 days (recurrence = 1000mg PO x 1d) Treat early; meds are no help after day 5 or 6. Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Treatment of recurrent oro‐labial HSV‐1 Topical Therapy: Systemic Therapy: • Acyclovir 5%ointment • RX: Valacyclovir 1 gm (Zovirax) (Valtrex) Disp: 15 gm • RX: Famciclovir 500 mg Sig: Apply hourly at sx (Famvir) onset • RX: Acyclovir 400mg • Pencyclovir 1% cream (Zovirax) (Denavir) Disp: 2 gm Sig: Apply every 2 hrs for 4 days • Give multiple refills Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA 9 3/19/2014 Herpangina • Not as common as Herpetic lesions of the oral cavity • Coxsackie A virus • Typically multiple small ulcers on palate • May have single larger ulcerations or bullae • Hand‐Foot‐Mouth Disease if similar eruptions on hand and feet • Usually self‐limited within 10 days Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Herpes Zoster / Shingles • May present as clusters of vesicular ulcers in a dermatomal‐ like distribution • Varizella‐Zoster virus (Human Herpes Virus HHV‐3) • May have prodrome of burning or itching mimicking tooth pain • Post‐herpetic neuralgia may linger for a month or more after resolution of oral ulcerations • Antiviral tx within 48‐72 hours of treatment • Vaccination booster over 60 yrs if not contraindicated Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA Oral Candidiasis • Most common fungal infection of oral cavity. Detected in 55% of healthy individuals – Very young / elderly common • Dependent on host immune status – DM, HIV, pregnancy, chemo / RT – Pulmonary inhalers (eg Advair) • Usually mild‐self limiting with recurrent infections necessitating underlying disease • Treat with topical / systemic antifungal therapy Fourth Annual ENT for the PA-C | April 24-27,