Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia

Diseases of the throat

Dr Kavitha Ashokkumar

Oral cavity lesions

• White lesions : oral submucous fibrosis, leukoplakia, oral lichen planus, candidiasis, fordyce spots

• Red lesions: erythroplakia, discoid lupus erythematosus, nicotine stomatitis

• Lesions of the tongue:geographic tongue, hairy tongue, fissured tongue, tongue tie

White lesions in the oral cavity

• candidiasis • Median rhomboid glossitis

Lichen planus

• Reticular lichen planus/Wickman’sstriae

• Erosive lichen planus

Oral submucous fibrosis

Red patches in the oral cavity

Lesions of the tongue

• Geographic tongue/benign migratory glossitis

• Hairy tongue

Ulcers in the oral cavity

• Aphthous stomatitis• Herpes simplex stomatitis• Hand, foot and mouth disease• Herpangina• Bechet’s syndrome• Erythema multiforme• Traumatic ulcers• Blood disorders• Radiation mucositis

ulcers

• Aphthous ulcers • Herpes labialis

Hand,foot and mouth disease

• Low grade fever, oral ulcers,lesions on the palm ,and foot

• Coxsackie virus

Herpes simplex virus infection

• HSV –type 1

• Common in children ,can affect adults too

• Anterior part of the oral cavity affected

• treatment:acylovir

Bechet’s syndrome

• 1937,Turkish dermatologist,Hulusi Behcet

• Immune mediated small vessel systemic vasculitis

• Triple symptom complex of recurrent oral ulcers,genital ulcers and uveitis

Herpangina

• Coxsackie virus

• Contagious

• Symptomatic treatment

Radiation mucositis

• Dosage>5000cGy

• Concomitent chemotherapy

• Direct epithelial injury

• Symptomatic treatment

• Prevention:

• IMRT

• Pentoxifylline,amifostin

Pharynx

• Muscular tube extending from base skull to Lower border of C6/ cricoid cartilage

• Continues as esophagus

• Constrictor muscles+ fascia

• Anteriorly it communicates with

– Nasal cavity

– Oral cavity

– Larynx

3 parts

• Nasopharynx

• Oropharynx

• Laryngopharynx

(Hypopharynx)

Nasopharynx

• Superior: Base skull

• Inferior:– Soft palate in front

– Continues with oropharynx posteriorly

• Anterior- Choanae

• Posterior: posterior pharyngeal wall

• 2 lateral walls

Normal structures in nasopharynx

• Adenoid: Junction of roof and posterior wall- in the midline

• Tubal elevation and ET opening- lateral wall

• Fossa of Rossenmuller-postero-superior to tubal elevation

Post nasal examination

http://www.bartleby.com/107/244.html

http://www.bartleby.com/107/244.html

Nasopharyngealcarcinoma

Adenoid hypertrophy

Fossa of Rossenmuller

• Pharyngeal recess

• Deep recess in lateral nasopharyngeal wall- extends till the foramen lacerum

• Common site of origin of NPC

• Related to ET- ‘Early presentation of NPC’

• Related to the skull base- ‘neurological’– Foramina in the base of middle cranial fossa

– Para-sellar region and cavernous sinus with various cranial nerves

Oropharynx

• Part of pharynx posterior to oral cavity

• Superior: communicates with nasopharynx

• Inferior: Floor of the valleculae/ hyoid bone

• Anterior: oral cavity-demarcated by uvula-anterior pillars- circumvallate papillae

• Rich lymphatic drainage

Parts of oropharynx

• Tonsillar fossae with the faucial tonsils the lateral walls

• Posterior 1/3 of tongue (base of tongue)

• Valleculae

• Posterior pharyngeal wall

Laryngopharynx (Hypopharynx)

• Part of the pharynx posterior to the larynx

• Superior- Floor of valleculae-PE folds

• Inferior- Cricopharyngeal sphincter (lower border of cricoid cartilage/ C6)

• 3 parts– Pyriform fossae– Posterior pharyngeal wall– Post-cricoid area

Pyriform fossae

• ‘Pear’ shaped

• Extends from PE fold to cricopharynx

• Lateral to AE folds

• Pooling of saliva in cricopharyngeal sphincter/ upper esophageal obstruction

• Common site of hypopharyngeal malignancy

Post-cricoid area

• Not visible on indirect laryngoscopy• Extends from upper border to

lower border of body of cricoid cartilage

• Annular segment with anterior and posterior walls

• Common site of malignancy of hypopharynx in females- ‘Plummer Vinson syndrome’

• Laryngeal crepitus

Pharyngeal wall

• Mucosa: – Respiratory in nasopharynx

– Non-keratinizing stratified squamous

• Submucosa– Lymphoid tissue

• Muscular layer– Constrictor and other muscles (striated)

• Pharyngo-basilar fascia

Waldeyar’s ring

• External ring: Cervical lymph nodes

• Intrinsic ring: Submucosal group of lymphoid tissue in the pharynx guarding 2 portals- nose and mouth

• Involved in both humeral and cell mediated immunity

Waldeyer’s ring

Physiology of deglutition

• Process of propulsion of bolus of food from oral cavity to the stomach

• Neuro-muscular activity

• 3 Phases:

– Oral phase: Voluntary

– Pharyngeal phase: Both

– Esophageal phase: Involuntary

Cranial Nerves

• CN V and XII: Chewing & tongue movements

• CN VII: Sensation of oropharynx & taste to anterior 2/3 of tongue

• CN IX: Taste to posterior tongue, sensory and motor functions of the pharynx

• CN X: – Taste to oropharynx, and sensation and motor function to

larynx and laryngopharynx.

– Airway protection

http://rad.usuhs.mil/cranial_nerves/timrad.html

Functions of pharynx

• Deglutition

• Protection from aspiration

• Part of respiratory passage

• Muco-ciliary clearance

• ET to ventilate and drain the middle ear cleft

• Speech- resonance

• Waldeyer’s ring- immunity

• Taste sensation in oropharynx

Diseases of the pharynx

DR KAVITHA ASHOK KUMAR

Chronic adenoiditis/ adenoid hypertrophy/ adenoids

• Chronic inflammation/ enlargement of the adenoids causing obstruction to the nasopharyngeal airway and consequent recurrent naso-sinus infections, otitis media or mal-development of the face (adenoid facies)

Etiology

• Common in children (Immunologically active age)

• Physiological hypertrophy- Peak 2-4 years

• Recurrent upper respiratory tract infections/ allergy

• Low socio-economic status

• Environmental factors- crowding, environmental pollution, etc..

Clinical features

• Nasal (Obstruction/ recurrent naso-sinus infection)– Nasal obstruction, anterior mucoid/ mucopurulent

discharge, mouth breathing, snoring, sleep apnoea, hyponasal speech (Rhinolalia clausa), epistaxis

• Aural (ET dysfunction/AOM/ SOM/ CSOM)– Recurrent otalgia, deafness, ear discharge, etc.

• Throat (Recurrent pharyngitis/ tonsillitis)– Recurrent sore throat, dysphagia, change in voice, poor

eaters, malnutrition

Clinical features (contd)

Facial features (Adenoid facies)

• Pinched nose

• Mouth breathing

• Dribbling of saliva

• Flat nasal arch

• Malar hypoplasia

• Elongated face

• Dull ‘idiotic’ appearance

• Loss of nasolabial fold

• Short protruding upper lip

• Crowding of teeth

• High arched palate

• Deafness-inattentive child

General features

• Growth retardation

• Recurrent LRTI

• Frequent diarrhoea

• Low nutritional status

• Pigeon shaped chest

• Protuberent abdomen

• Enuresis +/-

Investigations

• Clinical diagnosis

• Nasal endoscopy

• Post nasal examination if possible

• X-ray nasopharynx (Lateral view of the head and neck- soft tissue exposure)

• Sleep studies if sleep apnea is suspected

Treatment

• Mild/ infrequent symptoms- medical management

– Control of recurrent respiratory/ aural infections

– Antihistamies and decongestants

– Improve nutritional status

– Breathing exercises

• Moderate-severe/ persistent symptoms

– Adenoidectomy

PALATINE TONSILS

• Epithelium

• Capsule

• Crypts

• Lymphoid tissue

• Tonsillar bed

• Peritonsillar space

Tonsils V/S Lymph node

TONSILS/ Adenoids

• Submucosal

• Efferents only

• No distinct medulla/ cortex

• Capsule +/-

• Crypts/ furrows +

• Age related

• Local and systemic immunity

LYMPH NODE

• Deep

• Both

• Distinct cortex and medulla

• Capsule

• No crypts/ furrows

• Not age related

• Systemic immunity

Blood supply of the tonsils

Blood supply: (FAIL)

• Facial.A (Tonsillar branch and ascending palatine branch)

• Ascending pharyngeal.A

• Int. maxillary.A (Descending palatine branch)

• Lingual.A

Lymphatic:

• Jugulo-digastric nodes

Acute tonsillitis

• Acute inflammation of the faucial tonsils usually secondary to viral infection and seen commonly in children

Etiology

• Common in children

• Usually bacterial infection follows a viral infection

• Environmental factors- exposure to cold weather/ food, pollutants, etc.- reduced local immunity

• Malnutrition

• Metabolic abnormalities

• Immunological status

Microbioloygy

Viral (50%)

• Rhino/ adeno/ entero virus

Bacterial

• B- hemolytic streptococcus- ‘Rheumatic’

• H.Influenzae

• Streptococcus pneumoniae

• Staphylococcus

Pathological types

• Catarrhal

• Follicular

• Parenchymatous

• Membranous

Clinical features- Symptoms

• Systemic– Fever, malaise, lethargy, headache

• Local– Sore throat- ‘raw’ feeling

– Odynophagia, dysphagia

– Refuse feeds

– Referred otalgia

• Usually symptoms resolve in 1-2 weeks

Signs

• Fever: 103-104 F

• Enlarged and congested tonsils

• Odematous mucosa of the tonsils, pillars and uvula

• Yellowish spots (follicles) on the tonsil/ membrane

• Tonsillar squeeze+ and tender

• Tongue coated and congested

• Tender jugulodigastric nodes

Differential diagnosis

• Acute non-specific pharyngitis

• Acute specific pharyngitis– Diphtheria

– Vincent’s angina

– Monocytic angina (Infectious mononucleosis/ glandular fever)

– Agranulocytic angina

– Leukemic angina

Investigations

• Usually treatment is based on clinical diagnosis

• Recurrent acute tonsillitis/ not responding to medical treatment

– FBP

– Throat swab for C/S

• TRO specific causes of acute pharyngitis

Treatment- Medical only

• Rest, light warm nourishing feeds

• Antibiotics– Broad spectrum penicillin group like amoxycillin/ ampicillin

– Erythromycin or other macrolides if penicillin allergy+

– 7-10 days

• Analgesics

• Fluid electrolyte balance

• Antiseptic gargles/ lozenges- soothing

Complications

• Incomplete resolution—microabscess– chronic tonsillitis

• Intra-tonsillar abscess

• Peritonsillar abscess

• Para/ retropharyngeal abscess

• Laryngeal odema

• AOM

• Systemic- Septicemia/ acute rheumatic fever/ acute nephritis

Chronic tonsillitis

• Chronic bacterial infection of the faucial tonsils usually consequent to incompletely resolved acute/ subacute tonsillitis

Etiopathology

• Common in children

• Improper treatment of acute tonsillitis—microabscess– infection flares up whenever local immunity is reduced like viral infection, cold feeds, exposure to pollutants etc.

• Low socio-economic status

• Malnutrition

• Environmental factors

Microbiology

• Same as acute tonsillitis

• B-hemolytic streptococcus- ‘Rheumatic’

• H. Influenzae

• Streptococcus pneumoniae

• Streptococcus viridans

• Staphylococcus

Pathological types

• Chronic follicular tonsillitis

• Chronic parenchymatous tonsillitis

• Chronic fibrotic tonsillitis


• Usually pediatric age group- <14-16 years

• Recurrent episodes of sore throat, fever, dysphagia/ odynophagia

• Recurrent painful upper neck swellings

• Refuse feeds/ poor eaters

• Failure to thrive

• Snoring/ stridor if tonsils are grossly enlarged

Cardinal signs of chronic tonsillitis

• Enlarged and congested tonsils (exception: chronic fibrotic tonsillitis)

• Anterior pillars are congested

• Septic squeeze (tonsillar squeeze) may be positive

• Enlarged, discrete, non-tender, bilateral jugulo-digastric nodes– become tender during acute exacerbations

DD

• Chronic non-specific pharyngitis– Infective- Rule out septic foci in nose/ sinuses/

oral cavity/ LRT

– Reactive- allergy/ reflux pharyngitis/ exposure to irritant chemicals/ smoking, secondary to mouth breathing, etc.

• Chronic specific pharyngitis– Granulomatous conditions like TB, syphilis etc.

– Fungal pharyngitis- immunocompromised state

Investigations

• FBP

• Throat swab for culture and sensitivity

• Nasal endoscopy and radiology of PNS/ nasopharynx to rule out septic foci/ associated adenoid hypertrophy if suspected

• If planning for tonsillectomy– Blood grouping and cross matching

– BT/ CT/ PT/ APTT

Treatment

• Medical treatment attempted

– Antibiotics/ analgesics/ improve the nutritional status/ treat associated septic foci, if any.

• Treatment is usually surgical - Tonsillectomy

Complications of chronic tonsillitis

• Local– Peritonsillar abscess

– Para/ retropharyngeal abscess

– Laryngeal odema

– Etc.

• Systemic– Rheumatic fever- carditis, arthritis, acute

glomerulonepritis

– Retarded growth

Tonsillectomy

Types

Dissection and snare method

• Dissection method

• Cryo-surgery

• Cautery- assisted tonsillectomy

• Laser assisted tonsillectomy

• Guillotine tonsillectomy

Indications

• Absolute indications

– Respiratory obstruction

– Peritonsillar abscess (4-6 weeks)

– Chronic tonsillitis

• Suspected case of malignancy

Relative indications

• Acute glomerular nephritis

• Acute rhuematic fever

• Subacute Bacterial endocarditis

• halitosis

• Tumors of tonsils– Benign- papilloma

– Malignant- small tumors confined to tonsils

• Tonsillar cyst, tonsillolith, embedded FB in the tonsils, etc.

• Surgical approach– Elongated styloid process

– Glossopharyngeal neurectomy

– As part of Uvulo-palato-pharyngo-plasty (UPPP)

Contraindications

• Active infection

• Bleeding/ clotting disorders

• Cervical spondylosis

• Diphtheritic tonsillitis

• Endemic of polio

• Failure in controlling systemic diseases like hypertension, diabetes, bronchial asthma, LRTI, etc..

Technique

• GA

• Nasotracheal/ orotracheal intubation

• Rose position

• Boyle-Davis mouth gag

Technique

• Incision at the anterior pillar

• Dissect in the cleavage plane between capsule and bed of the tonsils

• Eve’s tonsillar snare

• Hemostasis

Post-operative care

• Lateral position

• Vital signs

• Look for frequent swallow reflex

• Antibiotics and analgesics

• Cold feeds after 4 hours

• Saline or dilute hydrogen peroxide gargles

Complications

• Hemorrhage

• Aspiration

• Injury to structures- teeth, lips, gums, palate, etc.

• Injury to posterior pillars- speech/ reflux

• Residual tonsils

• Lingual tonsillitis

Tonsillectomy hemorrhage

• Primary

– During surgery

– Poor selection of the case, improper technique

– Ligate/ cauterize the bleeding vessel

Reactionary hemorrhage• Post-operative within 24 hours

• Failure to ligate all vessels or slippage of sutures

• Hypotensive anesthesia- BP returns to normal post-operatively

• Increased arterial or venous pressure during recovery

• Clot in the fossa- prevents contraction and retraction of the vessels

• Remove clot- apply pressure- usually bleeding stops

• If persistant bleeding- shift patient to OT- Ligation of the vessels

Secondary hemorrhage

– Due to sepsis and usually occurs on 5th-7th day post-operative

– Start parenteral antibiotics

– Persistent bleeding- shift patient to OT- interpillar suturing

Adenoidectomy

Indications

• Adenoid facies

• Septic focus- Otitis media, chronic rhinosinusitis

• Snoring

• Sleep apnea syndrome

Technique

• Orotracheal intubation

• Rose position till curettage

• Boyle-Davis mouth gag

• Palpate nasopharynx

• St.Clair Thomson’s adenoid curette with/ without cage

• Insert behind the soft palate till posterior end of septum is felt

• Flex the neck

• Push curette backwards to trap adenoids inside the curette

• Curette with sweeping motion- downwards and forwards

Complications

• Bleeding

• Aspiration

• ET orifice injury– Otitis media

• Injury to soft palate, posterior pharyngeal wall, etc..

• Injury to anterior longitudinal ligament--subluxation of the atlanto-occipetal joint--quadriplegia

Peritonsillar space

• Potential space

• Loose areolar tissue

• Between tonsillar capsule and tonsillar bed formed by superior constrictor muscle

7/25/2014 Dr. Kavitha Ashok Kumar

Peritonsillar abscess / Quincy

• Usually consequent to acute tonsillitis

• More common in adults- reason?

• Predisposed by immuno-compromised state, diabetes mellitus

• Tonsillitis—peritonsillitis—peritonsillarabscess

• Streptococcus/ staphylococus, anaerobic bacteriae


Clinical features-Symptoms

• Any age- common in adults• Acute pain in the throat• Odynophagia- usually more on one side• Referred otalgia• Fever, malaise, lethargy• Dribbling of saliva• Unable to open mouth (trismus)• Difficulty in articulation- ‘hot potato voice’• Painful neck swelling• Laryngeal odema—hoarseness—stridor


Clinical features-Signs

• Fever, toxic appearance, rapid pulse

• Trismus, Dribbling of saliva

• Tonsil pushed medially and uvula pushed to opposite side

• Tender jugulo-digastric lymph nodes


Investigations

• Start treatment with clinical diagnosis

• Throat swab for C/S

• Hb., TC/DC, ESR, Peripheral smear

• Blood sugar

• CT scan


Treatment

• Hospitalize

• IV antibiotics and analgesics

– Penicillin group preferred

• IV fluids- electrolyte/ fluid balance

• I&D

– Site of I&D

• Point where 2 imaginary lines meet- vertical line along anterior pillar and horizontal line at the base of the uvula

– Guarded knife/ quinsy knife- 1 cm. deep

•Tonsillectomy7/25/2014 Dr. Kavitha Ashok Kumar

Complications

• Laryngeal odema- stridor

• Spread to other neck spaces

• Dehydration/ electrolyte imbalance

• Septicemia


RETROPHARYNGEAL ABSCESS


Retropharyngeal space(Space of Gillette/ Lincoln’s highway)


Retropharyngeal abscess

• Inflammation and accumulation of pus in the retropharyngeal space

Types

• Acute (Suppuration of retropharyngeal lymph nodes)

• Chronic (Due to Tuberculosis of the spine)


Etiopathology

ACUTE

• Common in children (<3years)

– Retropharyngeal lymph nodes-active

– Adenoiditis/ tonsillitis—suppuration of retropharyngeal lymph nodes (Streptococcus usually)

• Adults

– FB

– Immunocompromised

– From other spaces

CHRONIC

• >Middle ages/ adults

• TB of spine

• Abscess posterior to prevertebral fascia


Clinical features -Symptoms

ACUTE

• Acute onset

• Fever, toxic

• Odynophagia- rapidly progressive- severe

• Hot potato voice/ hoarseness

• Nasal obstruction if at the level of nasopharynx

• Trismus absent usually

• Stridor

CHRONIC

• Insidious onset

• Systemic features of TB +/-

• Painless lump in the throat

• Dysphagia

• Throat symptoms are usually mild

• Cervical pain


Clinical features- Signs

ACUTE

• Paramedian bulge on the posterior pharyngeal wall

• Signs of acute inflammation +

• Neck: Larynx appears prominent as it is pushed forwards

CHRONIC

• Median bulge on the posterior pharyngeal wall

• No signs of acute inflammation


Investigations

ACUTE

• Neutrophilia

• Radiology (X-ray lateral view neck/ CT)

– Prevertebral widening

– Larynx and trachea displaced forwards

– Fluid level

– Straightening of spine (Prevertebral muscle spasm)

– Look for FB

CHRONIC

• Lymphocytosis

• Radiology (X-ray lateral view neck/ CT)

– Prevertebral widening

– Destruction of the cervical vertebral bodies

– Collapse of body of vertebrae

– Can extend inferiorly beyond the superior mediastinum


Treatment

ACUTE

• Hospitalize

• IV antibiotics, analgesics, fluid-electrolyte balance

• I&D:

– ‘Transoral’ – stab incision on the posterior pharyngeal wall at the most prominent site

– Supine-head end low

– LA usually

– GA- only if awake intubation possible

– Tracheostomy if stridor+

CHRONIC

• ATT

• I&D:

– ‘Transcervical’

– GA

– Lateral neck incision

– Orthopedic/ spine surgeon for further surgical treatment


Parapharyngeal space


Parapharyngeal abscess-Etiology

• Common in adults

• >Immuno-compromised state (Diabetes, IV drug abuse)

Septic foci:

• Pharynx: Acute tonsillitis/ adenoiditis, quinsy

• Teeth: Apical abscess of last molar tooth

• Ear: Bezold’s abscess

• Suppurative lymphadenitis

• Spread from other neck spaces

• Trauma- external/ FB7/25/2014 Dr. Kavitha Ashok Kumar

Clinical features-Symptoms

• Acute and rapidly progressive

• Fever, toxic, malaise, lethargy

• Sore throat

• Odynophagia

• Torticolis- muscle spasm

• Painful neck swelling behind the angle of the mandible



• Fever, toxic appearance, rapid pulse

• Trismus- if anterior compartment involved

• Neck swelling behind angle of mandible (Anterior and deep to SCM muscle)- signs of acute inflammation +

• Oropharynx:

– Tonsil/ lateral pharyngeal wall pushed medially-depends on the compartment involved

– Look for septic focus-teeth/ tonsils

• Paralysis of IX, X, XI, XII CN/ Jugular venous thrombophelebitis may be present if posterior compartment is involved


Investigations

• Hb., TC/DC

• Blood sugar

• X-ray neck-AP/ lateral views

• CT scan

–Abscess cavity- site and extent

–Assess airway patency

• Rule out immunodeficiency states if suspected


Treatment

Medical

• Hospitalize

• IV antibiotics and analgesics

• IV fluids- fluid and electrolyte balance

I&D

• Transcervical’ approach

• If stridor/ difficulty in intubation: Tracheostomy

• Transverse incision about 2-3 cms below the angle of the mandible

• Blunt dissection medial to SCM muscle and carotid sheath and along inner surface of medial pterygoidmuscle


Diseases of the Larynx

Dr Kavitha Ashokkumar


Types

• Acute simple laryngitis

• Acute epiglottitis

• Acute laryngo-tracheo-bronchitis (ALTBS)

• Diphtheritic laryngitis



• Severity variable. In professional voice users even minimal catarrh may give rise to severe symptoms

• Hoarseness usually following URTI or voice abuse

• Complete loss of voice in severe cases (aphonia)

• Dysphonia- difficulty in speaking

• Pain in the throat > on swallowing and speaking

• Voice fatigue (phonesthenia)

• Painful irritant cough with thick expectoration

• Fever +/-



• Fever +/-

• Husky-hoarse voice

• Generalized nasal and pharyngeal congestion

• ILS:

– Congestion and edema of epiglottis, ventricular bands and vocal cords

– Thick mucus



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Treatment

• Voice rest

• Tackle etiological factors, if any. Stop smoking.

• Humidification- medicated steam inhalation (mucolytic and soothing)

• Warm saline gargles

• Mucolytics like Bromhexine

• Irritant and painful cough may be suppressed by linctus codiene, dextromethorphan, etc.

• NSAIDS

• Usually resolves in 1-2 weeks

• If secondary infection present- broad spectrum 7/25/2014 Dr. Kavitha Ashok Kumar

Acute epiglottitis(Acute supraglottitis)

• Acute inflammation of the supraglottis, common in children, usually caused by Hemophilusinfluenzae-type B and may lead to fatal respiratory obstruction



• Pediatric age group (> 2-7 years)

• Usually starts as an URTI- sore throat, fever, dysphagia/ odynophagia

• Acute onset and rapidly progressive—may lead to respiratory obstruction within few hours

• ‘Hot potato voice’/ FB sensation in the throat

• Stridor- Inspiratory, increases on supine position—patient tends to sit up leaning forward supporting on upper limbs ‘Tripod sign’


Signs

• Fever, toxic appearance and flushed skin

• Tripod sign

• Dribbling saliva

• On depressing the tongue or on protrusion of tongue—may see red and edematous epiglottis popping up— ‘Cherry red epiglottis’

‘Sun-rise sign’

• Examination of the throat may precipitate respiratory obstruction due to laryngospasm

• Inspiratory stridor- intercostal retraction, active accessory respiratory muscles, perioral cyanosis +/-


Investigations

• Clinical diagnosis

• Flexible scopy may precipitate or increase stridor

• Throat swab/ blood culture

• X-ray lateral view neck (soft tissue exposure)

– ‘Thumb sign’- grossly edematous epiglottis

– Narrowed supraglottic airway

• TC/DC- leucocytosis



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Vocal nodules

• Syn: Singer’s nodules, teacher’s nodules, screamer’s nodules, juggler’s nodules, etc.

• Defined as disorder of voice abuse commonly seen in professional voice users, characterized by hoarseness, vocal fatigue and presence of pin head sized raised lesions on both the vocal cords at the junction of its anterior I/3 and posterior 2/3.


Etiopathology

‘Hyperkinetic voice’

• Voice abuse- ‘professional voice users’

– Increased intensity

– Altered pitch

– Long duration

• Chronic cough

• Reflux laryngitis (GERD)


• Hyperkinetic voice

• Maximum vibration at the junction of anterior 1/3 and posterior 2/3

• Trauma leading to odema and submucosal microhaemorrhage

• Epithelial hyperplasia and subepithelial hyalinization and fibrosis

• Bilateral vocal nodules in the free edge of the cords


Symptoms

• Professional voice users

• Hoarseness

• Improves initially with voice rest

• Voice fatigue (Phonesthenia)

• Strained speech- pain in the neck/ throat


Signs

Indirect laryngoscopy

• Pin-head sized pearly white projections on the free edge of the vocal cords at the junction of anterior 1/3 and posterior 2/3

• Vocal cord movements are normal

• Congestion of the cords +/-


Investigations

• Diagnosis usually made clinically

• If ILS is difficult

– Flexible laryngoscopy

– Rigid angled laryngeal endoscopy (70°/ 90°)

– Stroboscopy


Treatment- Conservative

• Voice rest- ‘Absolute’

• Treatment of local sepsis, cough, reflux, etc.

• Speech therapy

– Vocal hygiene

– Relaxing exercises

• Early lesions may disappear


Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia

Health & Medicine

Transcript of Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia