Rosen & Barkin's 5-Minute Emergency Medicine Consult (65 page)

• See “Signs and Symptoms.”
  
• Look for signs of dehydration:
  
  • Vital signs should be within normal limits.
    
  • Evaluate mucus membranes.
    
• Evaluate for signs of secondary infection.
  
• Evaluate for signs of systemic causes of ulcers (see “History”).
  

• Diagnosis is made by history and clinical presentation.
  
• Rule out oral manifestation of systemic disease:
  
  • More likely if persists >3 wk or associated with constitutional symptoms
    
• Focus on symptoms of eyes, mouth, genitalia, skin, GI tract, allergy, diet history and physical exam
  

Routine lab testing not indicated:

• Needed only when systemic etiologies causing ulcers are suspected
  
• Biopsy should be considered for ulcers lasting more than 3 wk
  
• Should be guided by history and physical exam:
  
  • CBC series
    
  • Rapid plasma reagin (RPR) (syphilis)
    
  • Fluorescent treponemal antibody-absorption test
    
  • Antinuclear antibody test
    
  • Tzanck stain: Inclusion giant cells (herpes virus)
    
  • Biopsy: Multinucleated giant cells (cytomegalovirus)
    
  • Fungal cultures
    

An outpatient biopsy should be considered for any ulcer >3 wk

• Trauma:
  
  • Biting
    
  • Dentures
    
  • Braces
    
• Drug exposure:
  
  • NSAIDs
    
  • Nicorandil
    
  • β-blockers
    
• Infection:
  
  • Herpes virus:
    
    • Vesicular lesions
      
    • Ulcers on attached mucosa
      
  • Cytomegalovirus:
    
    • Immunocompromised patient
      
  • Varicella virus:
    
    • Characteristic skin lesions
      
  • Coxsackievirus:
    
    • Ulcers preceded by vesicles
      
    • Hand, foot, and buttock lesions
      
  • Syphilis:
    
    • Other skin or genital lesions
      
  • Erythema multiforme:
    
    • Lip crusting
      
    • Lesions on attached and unattached mucosa skin lesions
      
  • Cryptosporidium
    infection, mucormycosis, histoplasmosis
    
  • Necrotizing gingivitis
    
• Underlying disease:
  
  • Behcçet syndrome:
    
    • Genital ulceration
      
    • Uveitis
      
    • Retinitis
      
  • Reactive arthritis (Reiter syndrome):
    
    • Uveitis
      
    • Urethritis
      
    • HLA-B27-associated arthritis
      
  • Sweet syndrome:
    
    • Fever
      
    • Erythematous skin plaques/nodules
      
    • In conjunction with malignancy
      
  • IBD:
    
    • Bloody or mucous diarrhea
      
    • GI ulcerations
      
    • Weight loss
      
  • Gluten-sensitive enteropathy:
    
    • Weight loss
      
  • SLE:
    
    • Malar rash
      
    • ANA positive
      
  • Bullous pemphigoid/pemphigus vulgaris:
    
    • Vesiculobullous lesions on attached and unattached mucosa
      
    • Diffuse skin involvement
      
  • Cyclic neutropenia:
    
    • Periodic fever
      
  • Squamous cell carcinoma:
    
    • Chronic
      
    • Head/neck adenopathy
      
• Immunocompromised patient:
  
  • HIV
    
  • Agranulocytosis
    
  • Malignancy
    

TREATMENT

• Treatment guided by severity and duration of symptoms
  
• Goal is for symptomatic pain relief and reduction of inflammation.
  

• Mild to moderate disease:
  
  • Avoid oral trauma/acidic foods
    
  • Topical anesthetic
    
    • Magnesium hydroxide/diphenhydramine hydrochloride 5 mg/5 mL in 1/1 mix swish and spit
      
    • Viscous lidocaine 2–5%: Applied to ulcer QID after meals until healed
      
  • Protective bioadhesives
    
    • Topical OTC preparations (Orabase, Anbesol): Applied to ulcer QID after meals until healed
      
  • Topical anti-inflammatory
    
    • Amlexanox 5% paste (Aphthasol): applied to ulcer QID after meals until healed
      
  • Antimicrobial mouthwash
    
    • Chlorhexidine gluconate aqueous mouthwash 0.12% (Peridex): Mouth rinse QID after meals until healed
      
• Severe disease:
  
  • Prednisone tablets: 30–60 mg PO per day × 7 d
    
  • Thalidomide: 50–200 mg PO per day × 4 wk
    

FOLLOW-UP

• Unable to eat or drink after appropriate analgesia
  
• Abnormal vital signs or evidence of dehydration
  

• Tolerating fluids
  
• Adequate analgesia
  
• Normal vital signs
  

Follow up with primary care physician if lesions have not resolved within 2 wk.

• Avoid oral trauma (hard foods) or acidic foods.
  
• Referral to a specialist if underlying disease suspected
  

• The vast majority of aphthous ulcers are benign, self-limited, and treated symptomatically
  
• ED physicians must consider underlying systemic cause of ulcers.
  

• Akintoye SO, Greenberg MS. Recurrent aphthous stomatitis.
  Dent Clin North Am
  . 2005;49:31–47.
  
• Brocklehurst P, Tickle M, Glenny AM, et al. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers).
  Cochrane Database Syst Rev
  . 2012;(9). Art No.: CD005411. doi:10.1002/14651858.CD005411.pub2.
  
• Chattopadhyay A, Shetty KV. Recurrent aphthous stomatitis.
  Otolaryngol Clin North Am
  . 2011;44:79–81.
  
• Chavan M, Jain H, Diwan N, et al. Recurrent aphthous stomatitis: A review.
  J Oral Pathol Med
  . 2012;41:557–583.
  
• Scully C. Aphthous ulceration. Clinical practice.
  N Engl J Med
  . 2006;355:165–172.
  
• Wanda C, Chi AC, Neville BW. Common oral lesion: Part I. Superficial mucosal lesions.
  Am Fam Physician
  . 2007;75:501–507.
  

CODES

• 528.2 Oral aphthae
  
• 608.89 Other specified disorders of male genital organs
  
• 616.50 Ulceration of vulva, unspecified
  

BASICS

• Absence of respiratory airflow for a period of 20 sec, with or without decreased heart rate:
  
  • Central apnea:
    
    • Disruption in the generation or propagation of respiratory signals in the brainstem and descending neuromuscular pathways
      
  • Obstructive apnea:
    
    • Respiratory effort is present, but there is no airflow
      
    • Structural airway obstruction, often with paradoxical chest wall movement
      
    • Functional obstruction from airway collapse
      
  • Mixed
    
• Apparent life-threatening event (ALTE):
  
  • Episode that is associated with a combination of apnea, color change, change in tone, choking, or gagging
    
  • A clinical presentation, not a diagnosis
    

• Infection:
  
  • Sepsis
    
  • Meningitis or encephalitis
    
  • Pneumonia
    
  • Pertussis/chlamydia
    
  • RSV and other viral respiratory infections
    
• Respiratory:
  
  • Obstructive airway lesions
    
    • Enlarged tonsils and adenoids
      
    • Vocal cord dysfunction
      
    • Laryngotracheomalacia
      
    • Vascular ring
      
    • Foreign body
      
    • Craniofacial abnormality
      
    • Choanal atresia or stenosis
      
  • Functional obstruction from airway collapse
    
  • Infection
    
  • Immaturity/prematurity
    
  • Abnormal ventilatory response to hypoxia/hypercarbia
    
• Neurologic:
  
  • Seizure
    
  • Intracranial hemorrhage
    
  • Increased intracranial pressure
    
  • Tumor
    
  • Arnold–Chiari or other CNS malformation
    
  • Ingestion
    
  • Toxin
    
  • Carbon monoxide
    
  • Hypoxic injury
    
  • Neuromuscular disorder
    
  • Central hypoventilation syndrome
    
• Cardiac:
  
  • Dysrhythmia
    
  • Congenital heart disease
    
  • CHF
    
  • Myocarditis
    
  • Cardiomyopathy
    
• GI:
  
  • GERD
    
  • Volvulus
    
  • Intussusception
    
• Child abuse
  
• Endocrine/metabolic:
  
  • Hypoglycemia
    
  • Electrolyte disorders
    
  • Inborn errors of metabolism
    
• Other:
  
  • Transient choking episode
    
  • Laryngospasm
    
  • Periodic breathing
    
  • Breath-holding spell