20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

ABIM Internal Medicine Exam

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2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

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12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

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13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

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19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

Key Takeaways Explain This Topic AI

Pharyngitis, epiglottitis, deep infections of the head and neck, parotid disease and diseases of the oral mucosa and tongue are enumerated under diseases of the oral cavity, pharynx and salivary glands.

Diseases of the larynx and airway is a separately enumerated blueprint subsection, and disturbances of taste and smell are enumerated under disorders of the nose and paranasal sinuses.

Hoarseness persisting beyond two to three weeks requires laryngoscopy, particularly in a patient who smokes.

An oral leukoplakic or erythroplakic patch that persists beyond two weeks requires biopsy, and erythroplakia carries the higher malignant potential.

Bilateral painless parotid enlargement suggests sialadenosis, Sjogren syndrome, sarcoidosis, HIV or IgG4-related disease rather than infection.

Last updated: August 2026

1. Diseases of the Oral Mucosa and Tongue

The mouth is the most accessible mucosal surface in the body, and the exam uses it as a window onto systemic disease and malignancy.

White and red patches

• Lesion Appearance Significance
• Leukoplakia White patch that does not scrape off Premalignant ; requires biopsy if persistent
• Erythroplakia Red velvety patch Higher malignant potential than leukoplakia ; biopsy mandatory

Oral candidiasis (thrush) White plaques that scrape off leaving erythema Consider inhaled steroids, antibiotics, diabetes, dentures, immunodeficiency including HIV

Oral hairy leukoplakia Corrugated white plaque on the lateral tongue , does not scrape off Epstein-Barr virus ; a marker of HIV or other immunosuppression

Oral lichen planus Lacy white reticular (Wickham) striae , sometimes erosive Associated with hepatitis C; erosive form has small malignant potential

The operational rule: any oral lesion persisting beyond two weeks requires biopsy. Smoking, smokeless tobacco, alcohol and human papillomavirus are the major risk factors for oral squamous cell carcinoma, and the lateral border and ventral surface of the tongue and the floor of the mouth are the highest-risk sites.

Ulcers

Recurrent aphthous stomatitis — painful, shallow, round ulcers with an erythematous halo on non-keratinized mucosa, healing in 1 to 2 weeks. Usually idiopathic, but recurrent or severe ulceration warrants evaluation for celiac disease, inflammatory bowel disease, iron, folate, B12 or zinc deficiency, HIV, and Behcet disease (in which oral ulcers are required for diagnosis).

Herpes simplex — clustered vesicles on keratinized mucosa (hard palate, gingiva) and the vermilion border, in contrast to aphthae.

A solitary ulcer persisting beyond two to three weeks is carcinoma until biopsied.

• Tongue findings
• Atrophic glossitis — smooth, red, depapillated tongue in iron, B12, folate, niacin or riboflavin deficiency
• Geographic tongue — benign migratory glossitis; asymptomatic and requires only reassurance

Macroglossia — amyloidosis (particularly AL amyloidosis, often with periorbital purpura), hypothyroidism, acromegaly

• Angular cheilitis — candidal or nutritional; check iron and B vitamins and denture fit
• Systemic clues in the mouth

Gingival hyperplasia from phenytoin, cyclosporine or calcium channel blockers; gingival bleeding in leukemia and thrombocytopenia; oral ulceration with pancytopenia after methotrexate; buccal pigmentation in Addison disease and Peutz-Jeghers syndrome; Koplik spots in measles.

• 2. Salivary Gland Disease
• Parotid enlargement

The single most useful discriminator is unilateral versus bilateral, and painful versus painless.

Pattern Causes

Acute, unilateral, painful, with purulent duct discharge Acute bacterial sialadenitis — usually S. aureus , in dehydrated, postoperative or anticholinergic-exposed patients. Treat with hydration, sialagogues, massage and antibiotics

Recurrent, unilateral, worse with meals Sialolithiasis — a stone, most often in the submandibular (Wharton) duct

Bilateral, painless, chronic Sialadenosis (alcohol, diabetes, bulimia, malnutrition), Sjogren syndrome , sarcoidosis , HIV , IgG4-related disease , amyloidosis

Unilateral, firm, progressive mass Neoplasm — pleomorphic adenoma is most common overall; facial nerve weakness or fixation strongly suggests malignancy

Acute, bilateral, in an unimmunized patient Mumps

Facial nerve palsy with a parotid mass means malignancy until proven otherwise , because the facial nerve runs through the gland and benign tumors displace rather than invade it.

Sjogren syndrome deserves emphasis: bilateral parotid enlargement with dry eyes and dry mouth, anti-Ro and anti-La antibodies, and a markedly increased risk of MALT lymphoma . Persistent, hard or asymmetric enlargement in a patient with Sjogren syndrome requires evaluation for lymphoma.

Xerostomia is most often medication-induced — anticholinergics, antidepressants, antihistamines, diuretics, opioids — and also follows head and neck radiation. It causes rampant dental caries, candidiasis and dysphagia; management includes reviewing medications, saliva substitutes, meticulous dental care and, in some cases, pilocarpine or cevimeline.

• 3. Pharyngitis, Epiglottitis and Deep Neck Infection
• Pharyngitis

Most is viral . The Centor criteria — tonsillar exudate, tender anterior cervical adenopathy, fever, and absence of cough — estimate the probability of group A streptococcal infection and guide testing.

Treat confirmed group A streptococcal pharyngitis with penicillin or amoxicillin to prevent acute rheumatic fever (though not poststreptococcal glomerulonephritis) and suppurative complications.

Do not miss the mimics:

Infectious mononucleosis — exudative pharyngitis with posterior cervical adenopathy, fatigue, splenomegaly and atypical lymphocytosis. Avoid amoxicillin , which produces a florid rash, and advise avoidance of contact sport because of splenic rupture risk.

Acute HIV (retroviral) syndrome — pharyngitis without exudate, fever, rash, adenopathy and mucocutaneous ulcers. Antibody testing may be negative; HIV RNA is required.

Gonococcal pharyngitis — often asymptomatic; requires a sexual history.

Peritonsillar abscess — unilateral severe pain, trismus , a muffled hot-potato voice , and uvular deviation. Requires drainage.

Epiglottitis

An enumerated blueprint topic. Now predominantly an adult disease since Haemophilus influenzae type b vaccination.

Presentation: rapid onset of severe sore throat with odynophagia disproportionate to a normal-appearing oropharynx , muffled voice, drooling, and the tripod position . Stridor is a late and ominous sign.

Management priority: the airway. Avoid agitating the patient or examining the pharynx with a tongue depressor if there is any airway compromise. Definitive assessment is direct visualization by an experienced clinician in a setting prepared for emergency airway management , with intravenous antibiotics and corticosteroids.

Deep neck infections

Ludwig angina — bilateral submandibular space cellulitis, usually odontogenic, causing tongue elevation and airway compromise. A surgical and airway emergency.

Retropharyngeal abscess — neck pain, odynophagia, fever, neck stiffness; can extend into the mediastinum.

Lemierre syndrome — Fusobacterium necrophorum pharyngitis progressing to septic internal jugular vein thrombophlebitis with septic pulmonary emboli . Suspect it in a young adult with pharyngitis followed by persistent fever, unilateral neck pain and pulmonary nodules.

4. Diseases of the Larynx and Airway

A separately named blueprint subsection.

Hoarseness lasting more than two to three weeks requires laryngoscopy , and this is the most testable statement in the subsection. Causes:

• Cause Features
• Laryngeal carcinoma Smoking and alcohol; persistent hoarseness is the earliest symptom

Vocal cord paralysis Recurrent laryngeal nerve injury — thyroid or cardiothoracic surgery, lung cancer or mediastinal mass (left nerve loops under the aortic arch), aortic aneurysm

• Vocal cord nodules or polyps Voice overuse; breathy hoarseness
• Laryngopharyngeal reflux Morning hoarseness, throat clearing, globus
• Inhaled corticosteroids Dysphonia and candidiasis; rinse after use
• Hypothyroidism, acromegaly Deepened or coarse voice

Vocal cord dysfunction Paradoxical adduction on inspiration , mimicking asthma; enumerated in the blueprint as an asthma mimic; flattened inspiratory limb on flow-volume loop

New hoarseness in a smoker is laryngeal cancer until proven otherwise. New hoarseness with a normal larynx should raise the possibility of a left vocal cord paralysis from an intrathoracic lesion , prompting chest imaging.

Angioedema of the larynx — from ACE inhibitors or hereditary angioedema — is an airway emergency in which the absence of urticaria points to a bradykinin mechanism that will not respond to epinephrine, antihistamines or corticosteroids.

5. Disturbances of Taste and Smell

Enumerated under disorders of the nose and paranasal sinuses.

Most reported taste loss is actually olfactory loss , because flavor perception is dominated by retronasal olfaction. True gustatory loss is uncommon.

Causes of olfactory dysfunction:

• Category Examples
• Conductive (obstruction) Chronic rhinosinusitis with nasal polyps , severe allergic rhinitis, septal deviation
• Post-infectious Viral upper respiratory infection , notably COVID-19
• Trauma Head injury shearing olfactory fibers at the cribriform plate

Neurodegenerative Parkinson disease and Alzheimer disease — olfactory loss often precedes motor or cognitive symptoms by years

• Toxic and drug Zinc-containing intranasal products, chemotherapy, tobacco, solvents
• Nutritional Zinc deficiency
• Structural Esthesioneuroblastoma, meningioma of the olfactory groove

Two clinically important consequences: anosmia is a safety hazard — patients cannot detect smoke, gas leaks or spoiled food — and it commonly causes reduced appetite, weight loss and depression , which are particularly consequential in older adults.

Unilateral olfactory loss, or loss with neurologic findings, warrants imaging. Persistent post-viral loss may improve slowly over months, and olfactory training has modest supporting evidence.