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
• 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 CO2
builds up.
 Hoarseness

Medical term : Dysphonia

(Abnormality in voice quality)
 Neoplastic Vocal cord, laryngeal
papilloma, squamous
cell cancer of larynx.
• Commonly voice
overuse or Inflammatory GORD laryngitis,
laryngitis. laryngitis (viral, bacterial,
allergic, tubercular/
• If > 3 weeks – fungal)
laryngeal
carcinoma until Neurological VC paralysis, spasmodic
dysphonia, essential
proven otherwise. tremor, PD, CVA,
• Causes ( refer
table) 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 swallowing
Globus – sensation of lump in the throat
Phagophobia – psychogenic dysphagia
Functional dysphagia

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

Others
-Oesophagitis
Mechanical block Motility disorders (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 : Others:
-Brainstem tumours -Lyme disease
-Strokes Intratemporal: Infratemporal: -GB
-Polio -OM -Parotid tumours -Sarcoid
-Multiple sclerosis -Ramsay-Hunt -Trauma -Herpes
-CBP angle lesions -- cholesteatoma -Diabetes
(acoustic neuroma, -Bell’s palsy
Meningitis)
 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

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