The mouth and throat

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14.3 The mouth and throat

Stuart Lewena, Gervase Chaney, Richard P. Widmer

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

Peritonsillar abscess is the most common deep space head and neck infection in children. It is likely to be an extension of acute tonsillitis. However, it has been suggested that some cases may arise from obstruction and infection of Weber’s glands (mucous glands located in the superior tonsillar pole). It can occur at any age.

History and examination

Presentation is usually with sore throat or neck pain, which is often severe. Odynophagia, dysphagia, and fever are also common. A muffled (or hot potato) voice and trismus occurs in about one-third of cases. Only a minority will have a prior history of tonsillitis (20–30%).

Examination findings include cervical lymphadenopathy, unilateral tonsillar erythema, bulging of the superior aspect of the tonsil and uvular deviation. The differential is peritonsillar cellulitis, where there is no abscess. Clinical differentiation between the two is difficult.

Investigations

The definitive investigation is needle aspiration, but not all children will be co-operative. Computerised tomography scan or ultrasound may assist diagnosis. Microbiological identification of abscess contents probably does not alter management. If performed, the predominant organism found is Streptococcus pyogenes.

Treatment

Initial treatment is rehydration, analgesia and antibiotics (penicillin). Acute drainage is generally recommended, with either intraoral drainage, abscess tonsillectomy or needle aspiration. Needle aspiration alone would appear to be effective in a majority of cases (>90%). Sedation or general anaesthesia may be required.

Abscess tonsillectomy should be reserved for recurrent tonsillitis abscess, but many of these can still be managed with aspiration and delayed tonsillectomy.

Complications

Dehydration is common and will require medical intervention. Uncommon, but dangerous, complications include infection spread, such as to the parapharyngeal space, airway obstruction and aspiration of pus causing pneumonia.

Post-tonsillectomy haemorrhage

Introduction

Tonsillectomy remains a very commonly performed procedure. The most common complication of tonsillectomy is bleeding. Secondary (delayed) haemorrhage, which occurs after the first 24 hours following surgery, complicates about 1.5% of tonsillectomies. The mean time of presentation is about 7 days, with a range up to 15 days. Rarely, haemorrhage is catastrophic and life threatening.

History

Bleeding is usually obvious, although occasionally will be swallowed and not immediately apparent. A history of bleeding or bruising tendency should be sought, although ideally will have been identified prior to surgery.

Examination

Initial assessment should focus on signs of shock or haemodynamic compromise. Examination of the tonsillar fauces for evidence of active bleeding is then important.

Investigations

Full blood examination to monitor for a drop in haemoglobin and taking blood for cross match is recommended in any significant post tonsillectomy bleed. Coagulation profile testing rarely demonstrates abnormality, but is warranted in major haemorrhage.

Treatment

Immediate, preferably large-bore, intravenous access is indicated with cross-matching of blood and commencement of fluid resuscitation as required. Early involvement of an ear, nose and throat surgeon for children with active bleeding is indicated. Transfusions have been reported as being required in 10–12% of secondary haemorrhage. However, a more conservative approach is probably possible with the use of other intravenous fluids and close monitoring. Surgical intervention under general anaesthesia is less frequently required according to a retrospective Australian study (4.3%).

Complications

Post-tonsillectomy bleeding is potentially life threatening, largely from hypovolaemic shock. Massive bleeding may also cause airway obstruction.

Oral/dental trauma

Introduction

The most common reasons for infants and children to present to the emergency department (ED) with oral/dental trauma are falls and sporting injuries. Most of these are relatively minor. Occasionally, higher impact trauma including motor vehicle accidents will produce severe injury requiring maxillofacial reconstructive surgery and early problems of haemostasis and airway compromise.

History

Make specific enquiry with regard to the time and mechanism of trauma and the nature of the dentition prior to injury. This includes the number of deciduous teeth that were present and the presence of any secondary dentition. Determine whether any teeth have been avulsed and their current location and method of storage. Consider the possibility of aspiration if a tooth is missing.

Examination

The physical examination should review all orofacial structures with careful scrutiny, digital palpation and observation of normal function. Externally and internally the orofacial region should exhibit consistent symmetry and any departure from this, be it an area of altered facial soft tissue architecture associated with a swelling or altered bony architecture associated with a fracture, will be important. For example chinpoint trauma is a common injury associated with mandibular condylar fracture. Assessment of mandibular opening and malocclusion is vital. In cases where the child has fallen with an object in their mouth, careful assessment for palatal or pharyngeal penetrating trauma is required.

The key points in recognition of a facial fracture are pain, facial swelling, stepping (of the bony border), limited jaw opening, palatal or sublingual haematoma, malocclusion and paraesthesia. The need for tetanus prophylaxis and antibiotics should be considered. Usually, antibiotics (penicillin and metronidazole) should be given for a compound fracture in the mouth.

A common error when assessing a child’s occlusion is to fail to recognise that an anterior open bite (associated with a prior digit or object sucking habits) is a normal anterior relationship for that child and not necessarily evidence of a fracture in the maxilla/mandible. Check the posterior teeth for appropriate occlusion in this situation. The older child will usually be able to tell you if the teeth ‘feel right’ when they bite.

Investigations

The most relevant extraoral radiograph is an orthopantomogram (OPG). This radiograph will give an excellent view not only of the body of the mandible, the dentoalveolar area, but also of the temporomandibular joints (TMJ). However, the child’s co-operation is required. If a TMJ view is specifically required it will be important to notify the radiographer.

Treatment

Management will obviously depend upon the exact diagnosis, which may include the following five factors:

Luxation

This is defined as a slight movement of the teeth as a result of trauma, with or without associated gingival bleeding. These injuries can occur in either the primary or permanent teeth and can be in any direction, i.e. internal, external or lateral. Active intervention may or may not be needed, depending on the extent of movement and interference with the occlusion or risk to the development of the underlying secondary dentition.

The appropriate treatment in luxation may be conservative in minor cases or involve extraction of the damaged primary tooth/teeth or repositioning of displaced teeth and placement of a dental splint with associated suturing of damaged soft tissues.

Avulsion

This is defined as the complete loss of a tooth, primary or permanent. In all situations, if there is any doubt about the nature of the tooth (that is, whether it is primary or not) and given that permanent teeth are always re-implanted, it is prudent, as first-line advice, to suggest that all avulsed teeth are placed in milk or an appropriate tissue-culture medium, if available. The appropriate tissue-culture medium is Hanks’ balanced salt solution. This can be kept frozen in the ED in a small vial. It will provide up to 12 hours’ working time before replanting the avulsed tooth is necessary. It is important not to store the tooth in water. If milk or tissue-culture medium is not available, it is crucial to keep the tooth moist by wrapping it in clingfilm or a gauze that is kept moist with saline or the patient’s saliva. As a general rule, the primary teeth are not re-implanted. Reasons include the potential damage to the developing permanent teeth, difficulties in securing the tooth/teeth in place and the level of co-operation that is required.

Ideally, avulsed permanent teeth should be repositioned/reimplanted in the tooth socket as soon as possible. It is crucial not to handle the root of the tooth. Manipulate using the crown only. This avoids damage to the periodontal ligament cells, which line the root surface and are critical in re-establishing the tooth back in the mouth as a functioning unit. Once re-implanted, avulsed teeth need to be splinted in place. Temporary splints can include moulded aluminium foil around the teeth or a fishing line and super glue. It will be crucial to stress dental follow up to try and avoid the sequelae that lead to tooth loss.

Root factures

The root of the tooth, which is buried in the alveolar bone, can also be fractured, often with minimal damage to the crown of the teeth. This may present at review, if not initially obvious. A particularly mobile or loose tooth/teeth, that is/are slightly extruded are classic signs of associated root fractures.

Hard tissue injuries

This involves a chip off the tooth, whether it is just enamel or involves the deeper layers – such as the dentine. It may involve all three layers of the tooth and ‘expose’ the dental pulp. If a tooth is exposed, then it is important that the exposure is treated immediately so as to preserve the vitality of the dental pulp and thus enable the root to grow to its full length and thickness. This is very important for the tooth’s long-term maintenance as a useful member of the dentition.

Soft-tissue injuries

The soft tissues of the mouth involve the gingival tissues, mucosa and muscle. The soft tissue lacerations, especially of the gingival tissues, need to be carefully assessed for degloving and may need to be repositioned and sutured. Where teeth are significantly displaced there will be associated displacement and laceration of soft tissue and it is very important for the long-term periodontal health of the traumatised teeth that displaced soft tissues are adequately repositioned and sutured. Alveolar bone should not be left exposed to granulate over.

Prevention

Advice on prevention is never misplaced and recommendation of well-made and fitted mouth guards is encouraged.

Oral/dental infection

Introduction

Dental infections are the most frequent cause of acute facial cellulitis, accounting for about 50% of all cases. Therefore, for children presenting with a facial swelling associated with fever and general malaise, a dental cause must be high on the list of differentials.

History

Facial cellulitis will present as above, with facial redness and tenderness. The upper face is affected more frequently, particularly in younger children. The lower face is affected relatively more often in older children, probably related to caries patterns.

Examination

A thorough examination, particularly intra-orally is required and early dental involvement is very helpful in determining a dental source.

Investigations

Appropriate radiographs are frequently indicated to determine a dental aetiology. These may be extraoral, e.g. an OPG, and/or intraoral.

Treatment

The usual treatment involves the use of antibiotics (usually penicillin will be adequate) and repair or removal of the offending tooth/teeth. Metronidazole may be added in cases of significant infection requiring hospitalisation.

Prevention

Lifting the upper lip in all children seen is a useful way of detecting early dental decay, which presents with whitening of the teeth at the gum margins and later staining. A significant cause of tooth decay in infants and young children is inappropriate feeding habits based on the use of a night-time feeding bottle containing sweetened liquids, which end up causing extensive dental damage. Advice should be given to parents to go from breast to cup with their babies or to wean from the bottle by 12 months. Also, infants should not be put to bed with a bottle.

Other dental issues

Spontaneous oral haemorrhage

Oral bleeding is still a very important sign for the diagnosis of underlying generalised bleeding disorders. It is important to determine the actual site of the bleeding and consequently a through oral examination will be required. Try to rinse the child’s mouth with water or saline and use gauze to remove any blood clots and identify the source of the oral bleeding. In many instances this may be a tooth socket associated with a recent extraction. However, life-threatening disorders such as haemangiomas and arteriovenous malformations may present in the same fashion.

If a tooth-extraction socket is identified as the cause of bleeding, local measures to control the bleeding will usually be sufficient. This involves applying digital pressure to the bleeding socket or having the child bite down on a gauze pad for 15 minutes. Bleeding disorders such as von Willebrand’s disease and haemophilia should be considered in cases that continue to bleed.

Pharyngitis/tonsillitis

Although antibiotics have a protective effect in the prevention of rheumatic fever, the evidence does not support a similar effect on prevention of glomerulonephritis.

Tonsillectomy

Antibiotics post-tonsillectomy do lessen morbidity, in particular pain, analgesic use and delay in resumption of oral diet. Amoxicillin and amoxicillin + clavulanate have been shown to be effective. The studies have not had the numbers to demonstrate whether this is also true for post-tonsillectomy haemorrhage.

Oral/dental trauma

The management of avulsed permanent teeth centres on the prescription of routine antibiotics post-re-implantation in an effort to limit the unwanted side effects associated with re-implantation, such as an ankylosis of the teeth and inflammatory root resumption. This prescription of antibiotics is not universally accepted.

The immediate disimpaction of the traumatically intruded permanent tooth/teeth using orthodontic appliances is proposed as the most appropriate care, especially when trying to limit the unwanted sequelae of poor alveolar bone height and gingival attachment. However, there is a school of thought that proposes to partially disimpact surgically, and then complete the job of realignment orthodontically.

Oral/dental infection

Antibiotic choice is not universally agreed in either delivery (oral vs. intravenous) or type (penicillin vs. cephalosporins).

Further reading

Amir J., Harel L., Smetana Z., et al. Treatment of herpes simplex gingivostomatitis with aciclovir in children: A randomised double blind placebo controlled study. Br Med J. 1997;314(7097):1800-1803. [comment]

Cmejrek R.C., Coticchia J.M., Arnold J.E. Presentation, diagnosis, and management of deep-neck abscesses in infants. Arch Otolaryngol Head Neck Surg. 2002;128(12):1361-1364.

Dawes L.C., Bova R., Carter P. Retropharyngeal abscess in children. Aust N Z J Surg. 2002;72(6):417-420.

Del Mar C.B., Glasziou P.P., Spinks A.B. Antibiotics for sore throat. Cochrane Database Syst Rev 2000;4 [update of Cochrane Database Syst Rev. 2, 2000. CD000023; PMID 10796471]

Delaney J.E., Keels M.A. Paediatric oral pathology Soft tissue and periodontal conditions. Paediatr Clin N Am. 2000;47(5):1125-1147.

Edmond K.M., Grimwood K., Carlin J.B., et al. Streptococcal pharyngitis in a paediatric emergency department. Med J Aust. 1996;165(8):420-423.

Febres C., Echeverri E.A., Keene H.J. Parental awareness, habits, and social factors and their relationship to baby bottle tooth decay. Paediatr Dentistry. 1997;19(1):22-27.

Gianoli G.J., Espinola T.E., Guarisco J.L., Miller R.H. Retropharyngeal space infection: Changing trends. Otolaryngol Head Neck Surg. 1991;105(1):92-100.

Goldenberg D., Golz A., Joachims H.Z. Retropharyngeal abscess: A clinical review. J Laryngol Otol. 1997;111(6):546-550.

Graham D.B., Webb M.D., Seale N.S. Paediatric emergency room visits for nontraumatic dental disease. Paediatr Dentistry. 2000;22(2):134-140.

Herzon F.S., Nicklaus P. Paediatric peritonsillar abscess: Management guidelines. Curr Probl Paediatr. 1996;26(8):270-278.

Irani D.B., Berkowitz R.G. Management of secondary hemorrhage following paediatric adenotonsillectomy. Int J Paediatr Otorhinolaryngol. 1997;40(2–3):115-124.

Myssiorek D., Alvi A. Post-tonsillectomy hemorrhage: An assessment of risk factors. Int J Paediatr Otorhinolaryngol. 1996;37(1):35-43.

Nussinovitch M., Finkelstein Y., Amir J., Varsano I. Group A beta-hemolytic streptococcal pharyngitis in preschool children aged 3 months to 5 years. Clin Paediatr. 1999;38(6):357-360.

Ripa L.W. Nursing caries: A comprehensive review. Paediatr Dentistry. 1988;10(4):268-282.

Schraff S., McGinn J.D., Derkay C.S. Peritonsillar abscess in children: A 10-year review of diagnosis and management. Int J Paediatr Otorhinolaryngol. 2001;57(3):213-218.

Schwartz B., Marcy S.M., Phillips W.R., et al. Pharyngitis: Principles of judicious use of antimicrobial agents. Paediatrics. 1998;101(1):171-174.

Schwartz S.S., Rosivack R.G., Michelotti P. A child’s sleeping habit as a cause of nursing caries. J Dentistry Child. 1993;60(1):22-25.

Sharma H.S., Kurl D.N., Hamzah M. Retropharyngeal abscess: Recent trends. Auris, Nasus. Larynx. 1998;25(4):403-406.

Spruance S.L., Stewart J.C., Rowe N.H., et al. Acyclovir cream for treatment of herpes simplex labialis: Results of two randomized, double-blind, vehicle-controlled, multicenter clinical trials. Antimicrob Agents Chemother. 2002;46(7):2238-2243.

Tsevat J., Kotagal U.R. Management of sore throats in children: A cost-effectiveness analysis. Arch Paediatr Adolesc Med. 1999;153(7):681-688. [comment]

Unkel J.H., Mckibben D.H., Fenton S.J., et al. Comparison of odontogenic and nonodontogenic facial cellulitis in a paediatric hospital population. Paediatr Dentistry. 1997;19(8):476-479.

van Everdingen T., Eijkman M.A., Hoogstraten J. Parents and nursing-bottle caries. J Dentistry Child. 1996;63(4):271-274.

Wilson S., Smith G.A., Preisch J., Casamassimo P.S. Nontraumatic dental emergencies in a paediatric emergency department. Clin Paediatr. 1997;36(6):333-337.

Windfuhr J.P., Chen Y.S. Hemorrhage following paediatric tonsillectomy before puberty. Int J Paediatr Otorhinolaryngol. 2001;58(3):197-204.

Textbook of Paediatric Emergency Medicine