Today with the help of our wonderful ENT expert discussant, Dr. Josh Stramiello, we went over the diagnostic approach and work-up to tongue lesions, specifically ulcerative lesions in the outpatient setting. We started with a case of a young man with incidentally noted atropic areas of his tongue. He was asymptomatic and without constitutional symptoms. Ultimately he was diagnosed with geographic tongue, the most common outpatient tongue condition that is benign and self-limiting. We used this as a launching point to go through other common tongue conditions that internists should be aware of, infectious (candidiasis, EBV-oral hair leukoplakia, HSV, VZV), inflammatory/autoimmune (SLE, Crohn’s/UC, Behcet’s, sarcoidosis, amylodosis) and pre-malignant/malignant (leukoplakia, erythroplakia, oral lichen planus, SCC) and benign conditions (geographic tongue, median rhomboid glossitis and black hair tongue).
1) Remember on physical exam to use a good light sources and tongue depressor to look at the oral cavity. Don’t be afraid to put on gloves and palpate the tongue. Use gauze to help grip and mobilize it to check both the dorsal and ventral aspects!
2) Send patients with possible leukoplakia, oral lichen planus and erythroplakia (as well as SCC/adenocarcinoma) to ENT for surgical evaluation. Erythroplakia has a 20% chance of being cancer on biopsy and 80% of future malignant transformation.
3) Risk factors for SCC include: HPV exposure, heavy tobacco use, and etoh use, so be sure to screen them in your history. Most pre-malignant and malignant lesions are on the lateral or ventro-lateral aspects of the tongue so be suspicious of solitary, nonhealing lesions in those areas!
Thanks again for lending your time and expertise, Dr. Stramiello!
Today we walked through the mechanism of hearing to explore why a elderly man might be having sudden hearing loss. We reminded ourselves of the three types: conductive, sensorineural and mixed heading loss and causes of each based on anatomic location.
Remember to ask about the characteristics of the hearing loss, the events surrounding it (ie noise exposure, trauma, instrumentation, medication exposures), and associated symptoms to help narrow your differential.
We then went through using otoscopy, the Whisper Test and Rinne/Weber to further distinguish the etiology of the hearing loss. Send all your patients that you are concerned about sudden hearing loss to audiology within 14 days of your visit! If acute hearing loss is confirmed on audiogram, they will need a stat ENT consult. About 90% of cases of sudden sensorineural hearing loss is idiopathic in nature and treatment may include oral steroid taper (starting at 1 mg/kg, max initial dose of 60 mg) or intratympanic steroids with a follow-up audiogram to look for improvements after 10 days. If treated within 2 weeks of onset, there is a better chance of recovery of hearing!
Today with the help of our ENT colleague Dr. Robert Saddawi-Konefka, we walked through the diagnosis and work-up of deep neck tissue infections. We first went over how to do a thorough exam of the oropharynx and the neck-don’t be afraid to get on a pair of gloves and examine all the dentition and tongue manually! Then we discussed the different potential spaces in the neck and how most infections in the deep spaces will occur from a odontogenic origin. Beware of the danger space, the potential space between the retropharnygeal and pre-vertebral space that will allow for direct seeding down to the mediastinum if infection spreads! We then discussed two types of deep neck infections to be aware of: peritonsillar abscess and Ludwig’s Angina and how to be mindful of airway compromise for most of these cases. Often IV Unasyn 3g q6h is a good empiric antibiotic to start for many of these infections, +/- steroids.
Thank you Dr. Saddawi-Konefka for the images and your teaching! Feel comfortable doing a thorough oropharynx exam on your own but don’t hesitate to consult ENT for any concerns of deep neck space infections.
Today, the interns and resident taught their chief how to manage a busy clinic. The last patient on their “schedule” was an older adult complaining of odynophagia. Turns out, he was receiving radiation for head and neck cancer. He had lost 20 lbs over the course of therapy, and he was in severe pain. Take Aways 1. Odynophagia diagnostic schema: a. neoplasm/malignancy (think this with voice changes, dysphagia, weight loss, history of smoking/ETOH use) b. infection/inflammatory (think CMV, HSV, candida in a patient with immunosuppression, such as HIV or a person undergoing chemotherapy) c. iatrogenic (radiation, medication/caustic ingestion) d. dysmotility (ask Paul Hsu about this one) 2. Odynophagia treatment: a. viscous lidocaine b. stomatitis mixture (viscous lidocaine, diphenhydramine, maalox) c. opioids d. gabapentin!!! (see paper :The novel role of gabapentin in managing mucositis pain in patients undergoing radiation therapy to the head and neck) Remember, think about a patient’s trajectory; ask WHY? Do not just assume because a specialist said NO
We had a joint IM-neuro case conference this morning at the VA with Dr. Chamindra Konersman (neuro guru) as our expert discussant. One of our stellar PGY3’s, Dr. Amit Pandey, presented a case of a patient who presented with a facial droop, ipsilateral hearing loss and vesicular rash, found to have Ramsay-Hunt Syndrome (AKA: herpes zoster oticus). We reviewed a mnemonic to help remember the cranial nerve functions (see left). Remember that the facial nerve (CN VII) also innervates the anterior 2/3 of the tongue, so patients with Ramsay-Hunt Syndrome may have a rash there (example below). Dr. Konersman reminded us that a single physical exam maneuver can really help to guide your diagnostic approach to facial droop. If a patient is unable to raise their eyebrow on the affected side, then it suggests a lower motor neuron lesion in the facial nerve itself. If the patient is able to raise their eyebrow, then it suggests an upper motor neuron
This morning, Dr. Joseph Califano and Dr. Ezra Cohen presented grand rounds entitled “Oral Sex, Cancer, and the Immune System – How HPV Has Changed the Landscape”. Dr. Califano is a Professor of Surgery and Director of the Head and Neck Cancer Center at UCSD. Dr. Cohen is a Professor of Medicine in the Division of Hematology/Oncology, Associate Director of Translational Science at Moores Cancer Center, and team leader in Head and Neck Oncology. Dr. Califano started off the presentation with a review of head and neck cancers. Head and neck cancer is most often squamous cell carcinoma due to one of two major factors – long term exposure to smoking and/or alcohol, or HPV infection. HPV-associated head and neck squamous cell cancer occurs at a younger age, often occurs in the absence of other risk factors, and has unique pathology. HPV was first demonstrated to be an independent risk factor for oropharynx cancer in the NEJM article by Mork
A 60yo M presents to outpatient clinic endorsing bilateral hearing difficulty. He reports bilateral worsening hearing loss over 1-2 years that began gradually but has recently progressively worsened. Hearing loss seems to be worse with high pitch noises. Denies tinnitus, vertigo, trauma, infection, pain. No changes to his medications recently. History is notable for T2DM, HTN, and low testosterone. Medications include lantus, actos, tradjenta, metformin, simvastatin and losartan. V: T 98F, BP 148/83, HR 74, RR12, SpO2 99% on RA E: HEENT exam notable for normal appearing TMs without scars, effusion or perforations. Normal external auditory canals with small amount of non-obstructing cerumen. Normal oropharynx. No cervical or supraclavicular lymphadenopathy. Key Points About Hearing Loss for the Internist: The patient undergoes screening audiometry in clinic which is “grossly abnormal.” He is referred to ENT and discloses that he was treated for *** 10 years ago with a shot of IM PCN. His symptoms subsequently resolved. He is diagnosed with severe