The mouth and throat

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14.3 The mouth and throat

Stuart Lewena, Gervase Chaney, Richard P. Widmer

Essentials

Stomatitis

1 Acute herpetic gingivostomatitis is the most common cause of stomatitis in young children.
2 Early treatment with aciclovir is effective if commenced in the first 72 hours.
3 Aphthous stomatitis or ulcers are more common in young adults, but do occur in children.

Pharyngitis/tonsillitis

1 Most sore throats in children are due to viral infections.
2 Bacterial tonsillitis is more likely in older children with isolated sore throat, high fever and tender cervical lymphadenopathy.
3 Ten days of penicillin is the recommended course of treatment for bacterial infection.

Peritonsillar abscess

1 Peritonsillar abscess is the most common abscess of the head and neck.
2 Diagnosis is not always straightforward.
3 Management is analgesia, antibiotics, fluids and draining the abscess.

Post-tonsillectomy haemorrhage

1 Tonsillectomy remains a relatively common procedure.
2 Post-tonsillectomy bleeding occurs in about 1.5% and although most may be managed conservatively, for some, transfusion and/or surgery are necessary.

Oral/dental trauma

1 Oral/dental trauma is common in children.
2 A careful examination of the orofacial structures is required.
3 Dental consultation is indicated for all but the minor cases.

Oral/dental infection

1 Dental infections are the most common cause of facial cellulitis.
2 There are usually underlying dental caries and tooth extraction is often required.

Stomatitis

Introduction

Acute herpetic gingivostomatitis is the most common cause of stomatitis in young children (1–3 years). It is also the most common clinical presentation of primary herpes simplex infection in young children. It can also occur in older children and adults. Untreated, the course of the illness is 10–14 days. Aphthous ulcers usually occur as single ulcers and are often recurrent.

History

Acute herpetic gingivostomatitis may present suddenly or insidiously – initially with fever and irritability. Mouth pain, often severe, plus drooling and refusal to eat will usually follow. Dehydration can occur if the child refuses to drink. Gingival bleeding can occur

Aphthous ulcers present as recurrent painful lesions of the oral mucosa, usually single and less than 1 cm diameter.

Examination

Early herpetic lesions are vesicles, but usually not seen, due to early rupture. Multiple ulcers up to 1 cm then occur on any part of the oral mucosa and initially are covered with a yellow-grey membrane. Associated gingivitis is usual.

Investigations

Viral swabs and immunofluorescence or viral culture for herpes simplex can confirm the diagnosis if required. However, if this is not readily available, clinical diagnosis is reasonably accurate.

For recurrent aphthous ulcers, checking a neutrophil count to exclude cyclical neutropenia is appropriate.

Differential diagnosis

Initially presentation is non-specific and can be confused with a general viral infection. If the tonsils are involved early, acute tonsillitis or herpangina may be suspected. Some cases are misdiagnosed as oral candidiasis.

Aphthous ulcers are easily distinguished, as these are usually single. Recurrent aphthous ulcers can be seen in cyclical or congenital neutropenia and PFAPA syndrome (fever, malaise, aphthous stomatitis, tonsillitis, pharyngitis and cervical adenopathy).

Treatment

Traditional treatment has been symptomatic, in the form of analgesia and hydration. Analgesia usually requires a combination of topical anaesthetic agents and oral analgesics, such as paracetamol or ibuprofen. Topical lidocaine gel can be very effective. Rehydration may require the use of nasogastric or intravenous fluids.

Recent studies, including a placebo-controlled study, have demonstrated the efficacy of oral aciclovir, if commenced in the first 72 hours of the illness. They have shown a significant reduction in duration of fever, feeding and drinking difficulties and viral shedding. A dose of 15 mg kg–1 per dose (up to 200 mg) five times a day for 5–7 days is recommended.

Aphthous ulcers with an adherent/dental base can be treated with topical corticosteroids (e.g. triamcinolone).

Complications

Acute dehydration has been mentioned. Secondary bacterial infection is uncommon. Primary herpetic infection may progress to generalised vesicular eruption. Also, autoinoculation can occur, particularly to the eye.

Recurrent labial herpes is common and more of an inconvenience. It occurs following exposure to sunlight, stress, trauma or cold. Topical aciclovir may be of use, when applied with the first evidence of symptoms.

Pharyngitis/tonsillitis

Introduction

Sore throat is an extremely common presentation and is predominantly viral in cause. Group A streptococcal infection accounts for 10–20% of cases, and is even less frequent in young children (infants < 1 year < 5%). The concern over potential complications from streptococcal infection, such as rheumatic fever and glomerulonephritis, has led to many children being prescribed unnecessary antibiotics. Most people do not seek medical care for sore throats and the problem resolves spontaneously.

History

Older children will present with a complaint of sore throat, while younger children may be non-specifically unwell. A reluctance to take food or drinks may indicate a sore throat. Associated symptoms include fever, headache, vomiting and abdominal pain, but are not predictive whether bacterial or viral.

Examination

Ulcerative pharyngitis (herpangina) is a helpful finding indicating viral infection, such as coxsackie. Otherwise, it is difficult to differentiate between bacterial and viral causes. Features that suggest bacterial infection are tender cervical lymphadenopathy and absence of other symptoms such as coryza, cough, conjunctivitis and diarrhoea. Tonsillar exudate or pus is not an accurate predictor of bacterial infection and is frequently seen in viral causes such as infectious mononucleosis, Epstein–Barr virus (EBV) and adenovirus. EBV infection may be suggested by the presence of more widespread lymphadenopathy, particularly if there is associated splenomegaly.

Scarlet fever is suggested by a widespread, fine, maculopapular rash with a sandpaper-like feel, with associated pharyngitis and possibly a ‘strawberry-tongue’. Although the scarlatiniform rash is highly specific for streptococcal infection, it only occurs in a minority of cases.

Investigations

Throat swab and culture may be used to assist differentiation between viral and bacterial aetiology. Opinion varies with regard to the value of throat swabs and they should probably only be performed in cases with a high clinical index of bacterial aetiology. (Child older than 4 years, significant fever, pharyngitis in the absence of other upper respiratory tract infection signs, tender tonsillar lymph nodes.)

Blood tests are usually done for investigation of infectious mononucleosis, although in children, the monospot/monotest has a high false-negative rate and serology is more reliable.

Treatment

For the majority of sore throats due to viral pharyngitis/tonsillitis, no antibiotics are necessary. Analgesia in the form of paracetamol or ibuprofen will provide symptomatic relief. For streptococcal pharyngitis, phenoxymethylpenicillin (250 mg or 500 mg) twice daily for 10 days is the recommended treatment, with a cure rate of approximately 90%.

Antibiotics should be routine in groups at high risk of rheumatic fever, those with existing rheumatic heart disease and those with scarlet fever.

Complications

Complications from sore throats are uncommon. Suppurative complications of streptococcal infection include peritonsillar abscess, sinusitis and otitis media. The principal concerns, however, are with the non-suppurative complications: rheumatic fever and glomerulonephritis. Acute tonsillitis can cause airway obstruction, particularly with pre-existing tonsillar hypertrophy and may even warrant admission for monitoring.

Peritonsillar abcess

Introduction

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