Pain in the oral cavity or throat can be caused by a variety of conditions which are addressed in detail below.
II. Diagnostic Approach.
A. What is the differential diagnosis for this problem?
Common causes of mouth/throat pain include:
Infections such as pharyngitis, tonsillitis, tooth infection/abscess, gingivitis, thrush, esophageal candidiasis.
Ulcers or mucositis.
Masses such as those related to head/neck cancer.
Trauma related to procedures such as intubation, endoscopy.
B. Describe a diagnostic approach/method to the patient with this problem.
Pertinent history and examination of the oropharyngeal cavity/neck is required.
1. Historical information important in the diagnosis of this problem.
In particular, one must ask about the onset, duration, quality and intensity of pain. Exacerbating or alleviating factors must be noted, along with past history of similar pain. Fever, chills or sick contacts may provide a clue to infectious etiology. A list of active medications should be made including any recent chemotherapy drugs. A detailed smoking history and history of oral tobacco intake should be noted. Weight loss or constitutional symptoms should be paid attention to. A history of dysphagia/odynophagia, hoarseness, and any recent procedures should be obtained.
2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.
Examination of the oropharyngeal cavity with tongue depressor and penlight is required.
In addition, neck should be examined for cervical lymphadenopathy or masses.
3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.
A complete blood count is suggested along with testing for rapid streptococcal antigen and throat culture in cases of suspected infection. Computed tomography (CT) neck to evaluate for mass if cancer suspected.
C. Criteria for Diagnosing Each Diagnosis in the Method Above.
Centor criteria for diagnosing streptococcal throat infection include fever, tonsillar exudate, tender anterior cervical lymphadenopathy, absence of cough. Clinical scoring systems can help identify patients at low risk for streptococcal infection but rapid antigen diagnostic testing (RADT) and/or throat culture are required for confirmation in patients at high-risk. The sensitivity of RADT for diagnosis of streptococcal throat infection is 80% or less, but specificity is excellent (> 95%). If properly performed, the sensitivity of throat culture can exceed 90%.
A complete blood count may show leukocytosis/neutrophilia in acute infection. Rapid strep antigen and throat culture may confirm streptococcal throat infection.
In cases of suspected tooth infection/abscess, oropharyngeal exam may reveal gingival swelling, tenderness over tooth or foul smell.
In cases of suspected oral thrush/candidiasis, a whitish plaque on tongue/oral cavity may be noted.
In patients with reactive arthritis, drug reaction and chemotherapy, visual inspection of inflamed mucosa may reveal ulcers/mucositis.
In patients with head/neck cancer, a localized mass with/without cervical lymphadenopathy may be noted.
D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.
CT neck only if suspicious for cancer/abscess.
III. Management while the Diagnostic Process is Proceeding.
A. Management of Clinical Problem Mouth/Throat Pain.
In cases of Group A beta-hemolytic streptococcus, a narrow spectrum penicillin the first choice antibiotic. In patients with penicillin allergy, erythromycin is recommended.
In cases of tooth infection/abscess, ampicillin-sulbactam is the drug of choice. Clindamycin is recommended in penicillin-allergic patients.
Oral thrush/candidiasis is usually treated with Nystatin swish and swallow for topical therapy or Fluconazole for systemic therapy.
Ulcers/mucositis can be treated with formulations containing viscous lidocaine as local anesthetic.
All cases of suspected or proven head/neck cancer require oncology consult.
B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.
Mouth/throat pain commonly reported and can be caused by a variety of factors as listed. The key is to establish a likely diagnosis and initiate treatment/palliative measures as soon as possible.
IV. What's the evidence?
Centor, RM, Witherspoon, JM, Dalton, HP, Brody, CE, Link, K. “The diagnosis of strep throat in adults in the emergency room.”. Med Decis Making.. 1981. pp. 1239-46.
Bisno, AL, Gerber, MA, Gwaltney, JM, Kaplan, EL, Schwartz, RH. “Practice guidelines for the diagnosis and management of Group A Streptococcal Pharyngitis.”. Clin Infect Dis.. vol. 35. 2002. pp. 113-25.
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