About Throat

Minci © 2007

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

• CausesBacterial: Viral: Superinfection

• Treatment Analgesia, lozenges ± antibiotics

• ComplicationPeritonsillar abscess (quinsy)TonsillolithHypertrophy

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 CO2 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• 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 swallowingGlobus – sensation of lump in the throatPhagophobia – psychogenic dysphagia

Functional dysphagia

• Common in – Elderly – Stroke patients– Head and neck ca– Progressive neuro

disease : PD, MS or ALS.

Dysphagia

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

• 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

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

• 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

MIDLINE:- cysts

SUBMANDIBULAR:-Lymphadenopathy

- Salivary stone-Tumour

-Sialadenitis

ANTERIOR:-Cysts

-Tumour (parotid)

POSTERIOR: -Nodes

-Cervical ribs

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