Mouth and Throat Questions for the Physician Assistant Exam - dummies

Mouth and Throat Questions for the Physician Assistant Exam

By Barry Schoenborn, Richard Snyder

For the Physician Assistant Exam, you will need to know about the exciting world of the pharynx, the larynx, and other aspects of the mouth. Fasten your seatbelts, because our brief, fast ride down the Grand Canal is about to get wild!

The sore throat

Acute pharyngitis (called “strep throat” by the common folk) can be painful. It can also be a source of test questions, which can also be painful. Acute pharyngitis, like sinusitis, can be bacterial or viral. It affects kids a lot.

A common cause of acute bacterial pharyngitis is Group A beta-hemolytic strep (GABHS), which can be diagnosed by a rapid strep test (RST) in the office. Clinical signs and symptoms can include difficult and painful swallowing, anterior cervical adenopathy, and fevers.

The patient may have other associated upper respiratory infection symptoms. On physical examination, you can see an exudative pharyngitis with increased pharyngeal injection. The initial treatment for an acute bacterial (Strep) pharyngitis is penicillin, usually amoxicillin (Amoxil). For someone who is penicillin-sensitive, the next treatment of choice is erythromycin.

Recall the complications of a strep pharyngitis infection, including the risk of rheumatic fever and post-streptococcal glomerulonephritis. With each diagnosis that you read about, see whether you can make connections with other disease processes to help you on the test.

A very common cause of viral pharyngitis is mononucleosis via the Epstein-Barr virus. Splenomegaly can be present with Epstein-Barr virus, and the affected kid can’t play contact sports for several weeks until the splenomegaly resolves. Other viral causes of pharyngitis include adenovirus, influenza, and the rhinovirus.

On a PANCE question, the difference between bacterial and viral causes of pharyngitis may depend on the type of cervical adenopathy. Anterior cervical adenopathy is more associated with a bacterial form of pharyngitis (GABHS), whereas posterior cervical adenopathy is more associated with a viral infection.

Connect oral ulcers to other conditions

Oral aphthous ulcers can be very painful. A test question may ask you about conditions that can predispose someone to oral aphthous ulcer formation. A big one is systemic lupus erythematosis (SLE). In fact, oral ulcers are one of the diagnostic criteria for SLE.

You can see mouth ulcers with Crohn’s disease as well as with herpes. Women are affected more than men.

The treatment is supportive, and it can include topical steroids and pain medication, such as oral lidocaine. Evaluating for the underlying cause is also important.

Inflamed glands

For the PANCE, you should have some familiarity with the salivary glands. If you remember your anatomy, you’ll recall that you have major and minor salivary glands. For the purposes of the test, focus on the two major salivary glands: the parotid gland and the submandibular gland.

Parotitis: The parotid gland

Parotitis is a condition in which the parotid gland is inflamed. One of the most common viral causes is mumps. A bacterial infection can cause parotitis as well. For test-taking purposes, one of the most common causes of bacterial parotitis is Staphylococcus aureus.

The clinical presentation of parotitis is asymmetric swelling of one cheek, especially with a mumps parotitis. The affected area can be erythematous. The person may experience a dry mouth and have pain over the affected area, especially when trying to open the mouth. Food may taste bad as well.

Which of the following is a cause of parotitis?

(A) Measles

(B) Fifth disease

(C) Hypercalcemia

(D) Sjögren’s syndrome

(E) Sickle cell anemia

The correct answer is Choice (D). Parotitis is a complication of Sjögren’s syndrome, an autoimmune disease characterized by dry eyes and dry mouth. Concerning Choice (A), mumps, not measles, is a cause of parotitis; measles are associated with Koplik spots.

Fifth disease is an example of a viral exanthema in children. Hypercalcemia (Choice [C]), especially caused by hyperparathyroidism, is a cause of kidney stones. Sickle cell anemia, Choice (E), is a cause of gallstones, usually pigment stones secondary to a hemolytic anemia.

Sialadenitis: The salivary gland

Sialadenitis is a fancy term just meaning an inflamed salivary gland. This term encompasses parotitis as well as inflammation of the submandibular gland. Here are three key points about sialadenitis:

  • The treatment of a bacterial infection includes an antibiotic, usually a penicillin derivative.

  • Just as the kidney can have kidney stones, so, too, can the salivary glands (well, not kidney stones but something similar). The parotid and submandibular glands can both get salivary duct stones. The treatment is pain relief and adequate hydration.

  • The ingestion of foods to increase saliva production is encouraged. Go suck on a lemon!

A complication of an infected gland can be an abscess. Often, imaging needs to be done — a CT scan is usually first-line.

Other than occurring in the same general place, oral and throat cancers have three things in common:

  • Risk factors include smoking cigarettes and chewing tobacco.

  • The most common histologic cell type is squamous cell cancer.

  • Treatment is a multifaceted approach, including surgery, chemotherapy, and/or radiation, depending on the extent of metastasis.

Oral cancer

As the name implies, oral cancer refers to malignancies that affect the mouth, including the lips, palate, and tongue.

  • Symptoms can include dysphagia and/or odynophagia.

  • A hard “lump” or oral ulceration can be an initial sign of a malignancy.

Throat cancer

Throat malignancies primarily involve the pharynx and the larynx. Here are some key points to be familiar with:

  • Initial symptoms can include hoarseness, if the larynx is affected.

  • Presenting symptoms can consist of neck pain, dysphagia, a palpable neck mass, weight loss, and other type B constitutional symptoms, including fever, chills, and night sweats.

  • Other symptoms can be present, depending on other areas that may be affected. For example, ear pain (otalgia) can be a symptom of a malignancy of the head and neck.

  • Human papillomavirus (HPV) is a risk factor for many cancers of the pharynx and of the oral cavity as well.