THROAT & LARYNX*

Condition of Throat and LarynxAdenoidsTonsilitisPeritonsillar abcess/ QuinsyForeign Body LaryngitisNeoplasm/ Laryngeal Carcinoma*

Side view of Throat/ Larynx*

Normal Tonsilpic*

Adenoids Def: Enlarged adenoids refers to swollen lymphatic tissue at the back of the adenoids. Adenoids become swollen due to viral and bacterial infection, or due to allergic reaction

Large adenoids can cause significant respiratory obstruction, lead to chronic mouth breathingMouth breathing can cause permanent changes in facial shape, i.e., adenoidal facies with elongation of the face and open-mouthed, slack-jaw appearanceRespiratory obstruction at night, with snoring and even sleep apnea can cause significant load upon the right side of the heartChronic adenoid hypertrophy can cause blockage of the eustachian tube and chronic ear disease and hearing loss

*

The tonsils are two areas of lymphoid tissue located on either side of the throat. The adenoids, also lymphoid tissue, are located higher and further back, behind the palate, where the nasal passages connect with the throat. The adenoids are not visible through the mouth.*

Etiology Cause: Staphylococcus, Staphylococcus aurea, Homophylus Influenza, Pneumococcus, Virus

Clinical manifestations:Blocked nose, breathing through mouthDifficulty in breathing, noisy breathing at nightOtalgia (Fallness)/ earacheHalitosis bad breathPain at the back of noseNose discharge

Factor: Poor oral hygiene - infection

*

Treatment AntibioticAnalgesicSurgical Adenoidectomy, for severe cases, but not encourage

Adenoidectomy: Removal of adenoids soft palette by using curette. Gauze is apply to stop bleeding. Remove gauze after 2-3 mins when bleeding stop.Reason for adenoidectomy: impaired breathing through nose, chronic infection or earaches*

Tonsilitis Def: Infection and swelling of the tonsils, which are oval-shaped masses of lymph gland tissue located on both side of the back of throat.Etiology:Microorganism Streptococcus, Staphylococcus aureus, Hemophylus influenza, Pneumococcus, virus, Shibella*

Clinical manifestation of TonsilitisPain and dryness of the throat due to inflammationFever pyrexia temperature 38C as result of infectionTonsil redness and swollen as result of inflammationOtalgia Swelling of cervical lymph nodesHalitosisDifficulty in breathing in severe casesGeneral malaise due to feverLoss of apetiteFatigueWeight loss*

Investigation & treatmentInvestigation:Throat swab C/SBlood C/S

Treatment:Voice testLiquid diet reduce spicy and hot foodBalance dietOral hygiene, N/Saline gargleMedication: Antipyretic, AntibioticTonsillectomy severe and recurrent tonsillitis*

TonsillectomyRecurrent tonsilitis where medical treatment failed to reducePeritonsillar abcessTonsil malignancyEnlargement of tonsil which causes obstruction of airwayHypertrophy (enlargement) causing dental malocclusion or adversely affecting oral-facial (mouth-face) growth as documented by orthodontist Persistent foul taste or breath due to chronic tonsillitis that is not responding to medical therapy*

Tonsillectomy carePre-op care:Explain reasons of the surgery and consentLab investigation: FBC (Hb, Plat, Twdc), PT/PTT, GXM in reserve, blood C/S, Throat swab C/SNBM 6-8hrs before op to prevent aspirationBaseline vital signsProvide emotional supports to pt and family/caregiver

Post-op care:Position: Semi prone to encourage flow of secretion (blood and saliva) and prevent airway obstructionObserve bleeding and vital signsContinue IVFReport signs of difficulty and bleeding, e.g. Frequent swallowing, excessive secretion from mouth, hematoma in throatAnalgesic provide saline gargle to loosen phlegmNutrition encourage soft cold diet, e.g. Blend diet initially , ice cream, ice water, porridge; normal diet when pt can swallow

*

ContdHealth education:Avoid gargle after surgery causes bleedingAvoid sneezing, cough, blowing nose, active exercise for 2 weeks until healedDrink 2-3L of water daily to prevent bad breathAvoid dry, hard and fried foods, e.g. Popcorn until recoveredReport if bleeding is presentThroat discomfort for 4-8 days due to membrane separationBlackish stool due to ingestion of blood post-opConserve energy and rest vocal cord as much as possible *

Peritonsillar abcess (Quinsy)Def: collection of infected material in area around the tonsilsThe infection spreads from the tonsils to surrounding tissue which forms abcess.*

Etiology & IncidenceCausative microbes:StreptococcusStaphylococcus aureasHaemophilus InfluenzaPneumococcusVirus

Incidence:Unilateral or bilateralPeritonsillar abcess in a complication of tonsilitisMost common abcess cause: Group A -hemolytic streptococcus*

Signs & Symptoms of Throat AbcessPeritonsillar abcess and retropharyngeal abcess have different signs and symptoms

Peritonsillar abcess:Severe throat painEar pain on the same side of the abcess (occasional)Tenderness of submandibular glandDysphagia (difficulty in swallowing) causes droolingFever ChillsMalaise Rancid breathNauseaMumbled speechDehydrationCervical adenopathyLocalised/systemic sepsis

*

ContdRetropharyngeal abcess:PainDysphagiaFeverNasal obstruction abcess in upper pharynxDyspnea, progressive inspiratory stridor (from laryngeal obstruction) lower position abcessChildren drooling and muffled crying

A very large abcess may press on the larynx, causing edema, or may erode into major vessels, causing sudden death from asphyxia or aspiration*

Clinical ManifestationThroat and ear pain:Difficulty in speech hoarseness of voiceDifficulty in opening mouthHyperpyrexia followed by rigorDehydration due to lack of fluid intakePus formation around tonsil soft tissueDifficulty in breathing due to enlargement and abscess formationOedema around tonsil (peritonsillitis)Difficulty in swallowing even saliva due to infected throat*

Diagnosis of Throat AbcessPeritonsillar AbcessBased on pt history of bacterial pharyngitisThroat examinations; swelling of soft palate on the abcessed side; displacement of uvula to the opposite side; red, edematous mucous membrane; tonsil displacement toward midlineCulture may reveal streptococcal infection

Retropharyngeal AbcessBased on pt history of naso-pharyngitis or pharyngitisThroat examination; soft, red bulging of posterior pharyngeal wallX-ray: larynx pushed forward and widened space between the posterior pharyngeal wall and vertebrae*

Treatment for Throat AbcessAntibioticAnalgesic/ antipyreticThroat irrigation aspirin mouth gargleTonsillectomy if recurred during 6-8 weeks

Early Stage:Large doses of penicillin or another broad-spectrum antibiotic are necessaryIf pt is immune-compromised or has been repeatedly hospitalized, antibiotic therapy should include average for staphylococci and gram-negative organism*

ContdLate Stage:Peritonsillar abcess with cellulitis of the tonsillar space, primary treatment is usually I & D (Incision & Drainage) under local anaesthetic with antibiotic therapy for 7-10 daysTonsillectomy, scheduled no sooner than 1 month after healing, prevents recurrence but only recommended after several episodesAfter I & D:Give antibiotics, analgesics and antipyretics. Stress the importance of completing the full course of antibiotic therapyMonitor vital signs, and watch for any significant changes or bleeding. Assess pain and treat accordinglyIf pt unable to swallow, ensure adequate hydration with IV therapy. Monitor fluid intake and output, and watch out for dehydrationProvide meticulous mouth care. Apply petroleum to the pts lips. Promote healing with warm water with warm saline gargles or throat irrigation for 24-36hrs after I&D.Encourage adequate rest*

Foreign Body - ThroatUsually sharp objects, e.g. fishbone, chicken bone, dentures which can get stuck and cause obstruction at pharyngeal or laryngeal sphincterYoung children are naturally curious and may intentionally put shiny objects, e.g. coins, button, batteries in their mouthsPhysical assessment:History of neck tenderness during palpations (swollen neck)Pt complains of pain, unable to swallow saliva*

Diagnosis & TreatmentDiagnostic examination:Direct laryngoscopyRadiography lateral neck

Treatment:Doctor remove the foreign body after confirmation of foreign bodys locationLong forceps is used to pull out the object but care is taken not to damage the layers of mucous in the larynx under GAObserve patient for signs and symptoms of shock after procedure, e.g. pallor, tachycardia and decreased blood pressure*

Laryngitis Def: Inflammation of the larynx, resulting in hoarseness of voiceThe tissues below the level of epiglottis are swollen and inflammedCauses swelling around the area of vocal cords, which leads to inability of vocal cords to vibrate normallyHoarseness of voice sig. sign of laryngitisOften occurs during the course of an upper respiratory tract infection - cold*

Etiology of LaryngitisCaused by virus, e.g. upper respiratory infection (colds etc)Parainfluenzae virus, influenza virus, respiratory syncytial virus, rhinovirus, coronavirus, and echovirus. RARE: bacteria e.g. Group A Streptococcus, M. Catacchalis, or that causes TB may cause laryngitisImmunocompromised pt, e.g. Acquired Immunodeficiency syndrome (AIDS), infections with fungi may be responsible for laryngitisIrritation dust and smokeExcessive use of voice TobaccoAlcoholDisturbance of upper respiratory tract*

Signs & SymptomsSore, scratchy throat, runny nose, itchiness and fatigue may occurDifficulty in swallowing with streptococcal infectionsPt may cough and wheeze, the voice will sound strained, hoarse, and raspyIn extremely rare cases, the swelling of the larynx may cause airway obstructionMore common in infants, due to the small diameter of their airways. They may have a greatly increased respiratory rate, and exhibit loud high-pitched sounds with breathing (stridor)*

Clinical manifestation & InvestigationClinical manifestion:Voice changes hoarseness, loss of voice (aphonia)Dysphagia during swallowing and talkingSore throat especially larynx and throatCough (no phlegm)Systemic disturbances, e.g. fever, fatigue

Investigation:History of smoking or alcoholismSurgery Upper respiratory tract infectionFamily history of nasopharyngeal carcinomaHigh risk occupations dusty places, e.g. Sawmill Lab test: throat swab C/S*

Treatment Talk less to rest vocal cordAnalgesic reduce painGargle Thymol gargleCough mixture reduce irritationAlternative treatments, e.g. Aromatherapy, inhalation (benzoin), lavender, frankincense, thyme, sandalwood*

Cancer of the LarynxDef: mostly begin in the glottis. The inner walls of the larynx are lined with cells called squamous cells.Almost all laryngeal cancers begin in these cells. These cancers are called Squamous Cell Carcinoma (SCC)If cancer of the larynx spreads (metastasizes), the cancer cells often spread to the back of the tongue, other parts of the throat and neck, lung, and other parts of the body. *

Etiology & Types of Laryngeal CancerMale >55 yearsSmokerVocal abuse excessive use of voicePeople who suffer chronic laryngitisGeneticExposure to radiation, chemicals

Types of Laryngeal Cancer:Supra glottis infection: Epiglottis, False Vocal cordGlottis true vocal cordSub glottic below vocal cord*

Clinical ManifestationSore throat for many weeksA lump in the neck/ swellingBurning sensation when taking fruit juice or drinking hot waterWeight lossLoss of appetiteHoarseness or continuous voice changes 3-4 weeksA sore throat or feeling that something stuck in throatPersistent coughProblem in breathingBad breathEaracheDysphagiaItchiness in throatDyspnoea (shortness of breath)Aphonia (inability to make a sound)Haemopstasis (cough blood)*

Investigation & TreatmentInvestigation:Indirect laryngoscopy examination of larynx using mirrorBiopsy HPERadiology CT Scan, Neck X-rayPhysical examination neck, thyroid, larynx and lymph nodes for abnormal lumps or swelling

Treatment:Radiation for carcinoma larynx without involving cervical lymph nodesEmergency tracheostomy If tumor is enlarged and involved subglotis, it can cause airway obstruction, increase stridorLaryngectomy follow by radiation on the tumor for carcinoma larynx involving cervical lymph nodes*

Laryngectomy Def: partial or complete surgical removal of the larynx, usually as a treatment for cancer of the larynxOnce the larynx is removed, air can no longer flow into the lung. During surgery, the surgeon removes the larynx through the incision in the neckTracheostomy is also performed by surgeon by making an artificial opening called stoma in front of the neckUpper portion of trachea is brought to the stoma and secured, making it a permanent alternative to get air into the lungs*

*

*

ContdThe connection between throat and esophagus is not normally affected, so after healing, the person whose larynx has been removed can eat normally.However, normal speech is no longer possibleSeveral alternate means of vocal communication can be learned with the help of speech pathologist

PREPARATION:Obtain consent after the procedure is thoroughly explainedLab investigation: blood and urine test. Chest X-ray and EKG as per hospital protocol, e.g. patient > 40 years oldIf total laryngectomy is planned, it may be helpful to meet with speech pathologist for discussion of post-op expectation and support *

Aftercare A person undergoing laryngectomy spends several days in ICU and receives IVF and medicationMonitor vital signs regularlyPatient is encouraged to turn, cough, and deep breathe to help mobilize secretions in the lungsOne or more drains are usually inserted in the neck to remove any fluids that collected in the surgical site.Drains are removed after 2 days, or when drainage become minimalExcess secretion suctionBreathing exercise physiotherapistDaily and PRN dressing on tracheostomy tubeSTO after 7-10 days post-opIt takes 2-3 weeks for the tissues of the throat to heal, during this time pt must receive nutrition through Naso-gastric tubeWhen air is drawn in through the stoma, it does not have opportunity to be warmed and humidified. To keep it from drying out and crusted, pt is encouraged to breathe artificial humidified air*

ContdAfter surgery, an alternate method of the stoma is usually covered with alight cloth to keep out unwanted particles from entering the lungsCare of stoma is extremely important, since it is the persons only way to get air inside lungsAfter laryngectomy, pt and his/her caregivers will be taught on stoma careImmediate communication such as writing notes, gestures or pointing can be usedPt with partial laryngectomy will gradually regain some speech several weeks after the surgery, but the voice may be hoarse, weak and strainedSpeech pathologist will work with patient with total laryngectomy to establish new ways of communicatingMany pt resume daily activities after surgerySpecial precautions must be taken during showering or shavingSpecial instruction and equipment is required for those who wish to swim or water ski, as it is dangerous for water to enter the windpipe and lungs via stoma. *

ContdRegular follow-up visits are important, because there is a higher-than-average risk of developing a new cancer in the mouth, throat, or other regions of the head or neck.Self-help and support groups are available to help pts meet other who face similar problems*

ComplicationsComplication:Accumulation of secretions/ airway obstructionsInjury to operation siteStoma stenosis

Long term complication:Infection to the lungs due to aspirationRecurrentMetastases, cancer spread to the neck*

Problems Faced by Tracheostomy PatientsSecretionObstructionInfectionEmphysemaHaemorrhageAccidental decanulationAxphysiaLoss of voice*

pic*

pic*

pic*

Throat - ProcedureExamination of the throatTaking throat swab C/SThroat paintingExamination under laryngoscope*

Examination of the ThroatAim:To observe for any abnormalities, e.g. foreign body, tonsilitis, abcess, adenoid gland enlargementEquipment:Tray:-Tongue depressor/ spatula, laryngeal mirror2 Gallipots: i) swab and gauze ii) N/SalineSterile swab stick for specimen1 dissecting forceps1 bowl of warm water/ lamp for warming the laryngeal mirrorCap mackintoshreceiver

*

pic*

pic*

Procedure Responsibilities BEFORE:Inform ptPrepare equipment and bring to ptProvide privacyPosition pt head tilted and instruct pt to open mouth

Responsibilties DURING:Assist doctor in the procedure, e.g. direct the light, stabilize the position, instruct pt to keep mouth open throughout the procedure, assist in taking specimen

Responsibilities AFTER:Ensure pt comfortClear and clean equipmentLabel specimen, lab form and send to lab ASAP *

Taking throat swab (collect specimen)Aim:To collect throat specimen for culture and sensitivity (identify type of microbes and suitable antibiotics)For pt with URTI, sinus infection, throat infectionEquipment:Tongue depressor, spotlight/ torchlight/ headlightSterile cotton tipped swab stickSterile specimen container with culture mediumSterile gloveBiohazard bag*

pic*

Procedure Inform pt to get cooperationWear glovesInstruct pt to sit up right, open mouth and say AH~~Direct torchlight in pts mouthObserve for redness or whitish spots in the throatHold tongue depressor and press on tongue firmlyWith right hand/ dominant hand, quickly swab the tonsil to avoid gag reflexAvoid touching the oral cavity, if accidentally touched, the specimen is contaminatedPlace swab inside the sterile specimen bottleLabel specimen, place in the biohazard bag and send to labDiscard gloves and wash handsRecord the procedure*

Throat PaintingAim:To apply local medication, e.g. chronic pharyngitisEquipment:Tray:-Medication in gallipot1 artery forceps spencer wells artery forcep1 dissecting forcepTongue depressortorchlightCap mackintoshreceiver*

Procedure Inform ptPrepare equipment and bring to side of ptProvide privacyPatient position recumbent or sitting, head tiltedPlace gauze in between forcepsDip in medicationInstruct pt to open mouth and press tongue firmly with tongue depressorWipe throat with gauze dip in medicationGive good lighting so that it is done properlyComfort the patientClear and clean equipmentdocumentation*

Medications used for throat paintingChronic Pharyngitis:Mandls paintPotassium iodine 5%Iodine 5%Peppermint oil 1%Glycerin

Fungal infection:Gentian violet 0.5%*

Endoscopic examination/ LaryngoscopyExamination of larynx with use of scope, to see the condition of back of the throat, larynx (voice box), vocal cords.Procedure done under local analgesia, e.g. 10% Xylocaine throat spray or GA if done in OT, sedative is given 1 hour before examination, e.g. secorbarbitor, mereridine, narcoticAtropine sulphate suitable for local and GA in reduction of secretion*

Nursing ResponsibilitiesBefore (Pre-Laryngoscopy):Pt is given explanation by doctor and consent is takenInstruct pt to brush teeth and gargle with antiseptic solution night and morning before procedureNBM 8hrs before procedureRemove dentures and acknowledge doctor if pt has any loose teethReassure pt to reduce anxietyExplain to pt short acting sedative is given in OT before procedure and local analgesia (e.g. Lidocaine) is sprayed on the throatAfter (Post-Laryngoscopy):NBM until gag reflex return, e.g 2hrsAssess gag reflex slowly, irritate the back of the throat with spatulaIf gag reflex assist, start with sips of water follow by liquid / food to avoid aspirationIf vocals cords were affected during procedure, advice pt to rest voice for 3 days*