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About Throat

Minci © 2007

Tonsillitis

Tonsillitis

Acute, subacute (3 wks – 3 mths: Bacterium Actinomyces), chronic.

Signs /Symptoms:

Red, swollen tonsils White patches may appear Severe sore throat, pain at tonsil area Painful/ difficult swallowing Headache Fever and chills Enlarged and tender lymph nodes Loss of voice

Causes

Bacterial:

Viral:

Superinfection

Treatment

Analgesia, lozenges ± antibiotics

Complication

Peritonsillar abscess (quinsy) Tonsillolith Hypertrophy

STRIDOR

• High pitched sound resulting from turbulent air flow in upper airway. May be inspiratory, expiratory or both.

– Croup – Acute epiglotitis – Acute airway obstruction

• Larynx : Cricoid cartilage (non-compliant cartilage) & subglottis (narrow)

Features

Croup

Epiglotitis

1. Organism

Parainfluenza virus

H. influenzae

2.

Age

<2 years

2 – 6 years

3.

Onset

Gradual

Rapid

4.

Previous attack

Often

No

5.

Cough

Barking (seal)

No

6.

Dysphagia

No

+++

7.

STRIDOR

Inspiratory

Inspiratory/Expiratory

8.

Pyrexia

+

++

9.

Position

Lying down

Sitting forward

10.

Drooling

No

+++

11.

Nodes

+++

+

12.

Behaviour

Struggling

Quiet, terrified

13.

Voice

Hoarse

Muffled

14.

Colour

Pink

Grey

Acute airway obstruction

• Overcome by skilled intubation or needle cricothyrotomy in children : jet oxygen at 15L/min through a wide bore cannula(14G) placed in cricothyroid membrane.

• Surgical cricothyrotomy

• Need tracheostomy – because jet oxygenates rather than ventilates, so CO 2

builds up.

Hoarseness

Medical term : Dysphonia (Abnormality in voice quality)

• Commonly voice overuse or laryngitis.

If > 3 weeks – laryngeal carcinoma until proven otherwise.

Causes ( refer table)

Neoplastic

Vocal cord, laryngeal papilloma, squamous cell cancer of larynx.

Inflammatory

GORD laryngitis, laryngitis (viral, bacterial, allergic, tubercular/ fungal)

Neurological

VC paralysis, spasmodic dysphonia, essential tremor, PD, CVA,

Misc.

Vocal abuse, VC atrophy, VC scarring, hypothyroidism, Reinke’s oedema, drugs.

Singer’s Nodules

Singer’s Nodules • Benign, small swellings situated on the apposing surfaces of the true cords, commonly

Benign, small swellings situated on the apposing surfaces of the true cords, commonly at the junction of the anterior one-third and posterior two-thirds

Symmetrical

Swellings are made of keratin and result from constant banging together of the vocal cords due to vocal overuse - as in singing, teaching - or abuse - poor speed production.

Speech therapy, surgery.

Laryngeal carcinoma

Incidence : 1 in 100 000

• Elderly, almost always smokers, may be heavy drinkers, chews tobacco/betel. M>F

Main features :

– 60% in glottis (good prognosis), present early with hoarseness – Dysphagia – Lump in neck, earache, persistent cough – Squamous cell carcinoma – Early detection has 90% 5 year cure rate – Mx Radiotherapy, resection.

Head & Neck Tumours

• Acoustic neuroma (vestibular schwannoma)

• Progressive, ipsilateral tinnitus ± SN deafness, giddiness.

• May have increased ICP signs, facial numbness, CN V, VI, VII may be affected.

Test : MRI

Rx : Surgery

DYSPHAGIA

difficulty in swallowing food or liquid, the cause of which may be local or systemic

Odynophagia –painful swallowing Globus – sensation of lump in the throat Phagophobia – psychogenic dysphagia Functional dysphagia

• Common in

– Elderly – Stroke patients – Head and neck ca – Progressive neuro disease : PD, MS or ALS.

Dysphagia

Odynophagia –painful swallowing Globus – sensation of lump in the throat Phagophobia – psychogenic dysphagia Functional

Mechanical block

Motility disorders

Others -Oesophagitis (infection, reflux) - Globus hystericus

Mechanical Block

• Malignant Stricture

– Cancer (Oesophageal, gastric, pharyngeal)

• Benign stricture

– Oesophageal web or ring – Peptic stricture

• Extrinsic pressure

– Lung ca – Mediastinal LN – Retrosternal goitre – AA – LA enlargement

• Pharyngeal pouch

Motility disorders

• Achalasia • Myasthenia gravis • Diffuse oesophageal spasm

• Palsy (bulbar/ pseudobulbar)

• PD • Stroke

Motility disorders • Achalasia • Myasthenia gravis • Diffuse oesophageal spasm • Palsy (bulbar/ pseudobulbar) •

• Key questions :

– Difficulty swallowing solids & liquids from the start? – Difficult to make swallowing movement? – Odynophagia? – Intermittent, constant or worse? – Neck bulge or gurgle on drinking?

• Examination :

– Cachexic/ anaemia – Mouth – Feel for supraclavicular nodes – Look for Sx of systemic disease

• Investigation :

– FBC, U&Es – CXR (mediastinal fluid level, absent gastric bubble) – Barium swallow – Upper GI endoscopy and biopsy – ENT opinion if suspected pharyngeal cause

Facial Palsy

Causes

Causes Intracranial : -Brainstem -Strokes -Polio -Multiple sclerosis -CBP angle lesions (acoustic neuroma, Meningitis) Intratemporal: -OM

Intracranial :

-Brainstem tumours -Strokes -Polio -Multiple sclerosis -CBP angle lesions (acoustic neuroma, Meningitis)

Intratemporal:

-OM -Ramsay-Hunt -- cholesteatoma

Infratemporal:

-Parotid tumours

-Trauma

Others:

-Lyme disease -GB -Sarcoid -Herpes -Diabetes -Bell’s palsy

Examination & Tests

• Check:

– Face : paralysis, weakness

– Mouth : loss of lacrimation, taste and reduced saliva production

– Ears : exclude OM, zoster, cholesteatoma – Parotid

• Consider temporal bone radiography & EMG

Ramsay Hunt syndrome

Ramsay Hunt syndrome • Also known as herpes zoster oticus • Severe otalgia (elderly), preceding CNVII

Also known as herpes zoster oticus

Severe otalgia (elderly), preceding CNVII palsy.

Zoster vesicles appear around ear, deep meatus.

May have vertigo and sensorineural deafness

Bell’s palsy

Viral polyneuropathy with demyelination : affect V, X, C2 nerves

Abrupt onset, associated with pain

Mouth sags, dribble, taste impaired and watery 9dry) eyes.

Cannot wrinkle forehead, blow forcefully, whistle, or pout cheeks.

Treatment :

– Protect eye – Prednisolone + oral acyclovir – Surgical exploration

Lumps in the neck

• Refer to ENT

– Neck lump clinic : FNA for cytology – CT/ MRI – USS shows lump consistency – Culture specimen for TB

• Diagnosis :

– How long present? – Which tissue layer is the lump? Intradermal? – Location?

LUMPS

LUMPS MIDLINE: - cysts SUBMANDIBULAR: -Lymphadenopathy - Salivary stone -Tumour -Sialadenitis ANTERIOR: -Cysts -Tumour (parotid) POSTERIOR:

MIDLINE:

- cysts

SUBMANDIBULAR:

-Lymphadenopathy - Salivary stone -Tumour -Sialadenitis

ANTERIOR:

-Cysts -Tumour (parotid)

POSTERIOR:

-Nodes -Cervical ribs

Salivary Glands

Salivary Glands

• History & examination :

– Dry mouth/eyes – Lumps – Swelling related to food – Pain – Look for external swellings, secretions

– Bimanual palpation for stones, test VII nerves, regional nodes

– *mumps, acute parotitis, stones, Sjogren’s tumours*

Dry Mouth (xerostomia)

• Signs

– Dry, atrophic, fissured oral mucosa – Discomfort, difficulty eating, speaking, wearing dentures – No saliva pooling in floor of mouth – Difficulty expressing saliva from major ducts

• Complications

– Dental caries – Candida infection

Causes :

– Drugs : tricyclics, antipsychotics, -blockers, diuretics, hypnotics – Mouth breathing – Dehydration – Head & neck radiotherapy – Sjogren’s syndrome, SLE, scleroderma, – Sarcoidosis – HIV/AIDS – Obstruction – Graft-versus-host disease Management:

– Increase oral fluid intake; frequent sips – Good dental hygiene: avoid acidic drinks/food – Try saliva substitute – Chewing sugar-free gum or sweets – Pilocarpine rarely satisfactory – Irradiation xerostomia