22 - Throat Flashcards
What are the borders of the anterior and posterior triangle of the neck?
Anterior:
- Midline of neck
- Inferior border of mandible
- Anterior border of SCM
Posterior:
- Posterior border of SCM
- Anterior edge of trapezius
- Middle third of clavicle
What are the different fascias in the neck?
Superficial Cervical Fascia: contains platysma, superficial lymph nodes, nerve supply to skin, superficial veins
Deep Cervical Fascia: Investing layer, Pre-tracheal layer (thyroid, parathyroid, larynx, trachea, pharynx, oesophagus), Pre-Vertebral layer (Vertebrae and Paravertebral muscles)
Carotid Sheath: Common carotid artery, Internal jugular vein, Vagus nerve
Where are the fascial spaces in the neck?
Retropharyngeal space:
- Between buccopharyngeal fascia (posterior pretracheal fascia) and the prevertebral fascia
- Extends from base of skull to posterior mediastinum
Visceral Space:
- Enclosed by the visceral pretracheal fascia
- Goes from hyoid to superior mediastinum
Why are deep neck space infections important and what are the main types of these infections?
Usually have spread from oropharyngeal infection and can quickly deteriorate and cause airway compromise
Parapharyngeal Abscess: Most common, infection spread to space posterolateral to nasopharynx
Retropharyngeal Abscess: Spread to posterior pre-tracheal fascia, often from necrotising lymph node
What organisms usually cause deep neck space infections?
- Streptococcus viridans
- Staphylococcus anaerobes
- Gram negative bacilli
What are the clinical features of a deep neck space infection such as a retropharyngeal abscess?
- Neck rigid and upright with reluctance to move
- Systemically unwell
- Airway compromise/Stridor
- Dysphagia/Odynophagia
- Cervical lymphadenopathy
- Trismus
USE IMAGE!!!!
What are some red flags for deep neck space infections (meaning urgent ENT senior input is needed)?
- Sore throat but normal oropharyngeal examination
- Severe neck pain or stiffness
- Signs of airway compromise, such as stridor, dyspnoea, drooling, dysphonia
Need urgent management as can quickly decompensate
What are some investigations you should do if you suspect a deep neck space infection (retropharyngeal abscess) and what will they show?
- Flexible Nasendoscopy: inflammed and oedematous
- Urgent CT neck with IV contrast!!!!
- Blood cultures
- CRP
- Plain film lateral view neck X-ray can show widening of retropharyngeal tissue
What are some differential diagnoses for a deep neck space infection?
- Foreign body
- Tonsillitis or peritonsillar abscess
- Ludwig’s angina
- Epiglottitis
- Meningitis
- Encephalitis
How is a retropharyngeal abscess managed?
General
- Secure airway
- Nurse at 45 degrees
- IV fluids
- Humidified oxygen with saline nebulisers
Medical
- Broad spectrum IV Co-Amoxiclav
Surgical
- Incision, drainage and washout
- Can re-accumulate and need repeat procedure. Monitor patient clinically and chemically
What is the complication with a retropharyngeal abscess?
- Can spread and cause mediastinitis
- Airway compromise
- Sepsis
What is Ludwig’s angina?
Infection of the space between the floor of the mouth and mylohyoid
Usually from dental infection
Serious as can cause airway compromise
How does Ludwig’s angina present?
- Swelling of the floor of the mouth
- Painful mouth
- Protruding tongue
- Airway compromise
- Drooling
How is Ludwig’s angina investigated and managed?
Ix
- CT neck
- Orthopantamograph (OPG)
Mx
- Secure airway
- IV Benzylpenicillin and IV metronidazole
- Surgical drainage
How does a parapharyngeal abscess present and why is it a serious pathology?
- Febrile illness
- Odynophagia
- Trismus
- Reduce neck movement
- Swelling at upper part of SCM
- Can look like a peritonsillar abscess
Parapharyngeal space contains the carotid sheath so at risk of damaging this
How is a parapharyngeal abscess managed?
- Secure airway
- IV Co-Amoxiclav (or IV vancomycine if pen allergic)
- Surgical I+D
How does epiglottitis present and why is it an emergency?
Caused by Haemophilus Influenza B but declining as vaccine. Usually in children but some adults
Can cause airway obstruction if laryngospasm - EMERGENCY
Presentation:
- Stridor
- Drooling
- Pyrexia
- Sore throat
- Painful swallowing
- No cough
How should epiglottitis managed?
General
- Do not examine patient as could cause airway obstruction
- Keep child in calm environment with parents and avoid distressing them e.g cannula
- Keep the patient upright
Definitive
- See image
- Intubate the patient with paediatric anaesthetist and ENT surgeon on stanby in theatre if need surgical airway. If cannot transfer do in A+E
- Give IV dexamethasone and IV ceftriaxone then when they have responded they can be extubated
How does epiglottitis present in adults?
Very sore throat and painful swallowing
Which locations for foreign bodies are an emergency for ENT?
- Ear: not emergency
- Nose and Throat: emergency as can cause airway compromise and Oesophageal perforation if ingested
- Battery is always emergency
What questions in the history and examination do you need to ask someone with a foreign body in their:
- Ear
- Nose
- Throat
History
Ear: pain, discharge, hearing loss?
Nose: breathing issues, discharge?
Throat: dysphagia, can you swallow saliva, what was the nature of the object e.g sharp, soft?
Examination
Ear: Otoscopy
Nose: Thudicum speculum or Headtorch and Otoscope
Throat: Tongue Depressor (palpate for points of tenderness and surgical emphysema) and FNE
What are some red flags for a patient presenting with a foreign body?
- Signs of perforation
- Signs of airway compromise (stridor, dysphonia, drooling)
- Button battery
What investigations can you do for a foreign body?
Nose and Ears: just examinations needed
Ingested:
- Plain film lateral neck radiograph: assess foreign body, surgical emphysema, any widening of retropharyngeal tissue ( >7mm at C2, >22mm at C7), or loss of cervical lordosis
- CT neck: if above doesn’t show anything
- CXR: if widened mediastinum then red flag
How are ENT foreign bodies managed?
Any button batteries must be removed immediately as can cause irreversible burns
Ears: not urgent, use microsuction, crocodile forceps, Jobson-Horne probes, or wax hooks
Nose: emergency removal under GA if distressed or difficulty breathing, if not then same as above
Ingested: If the FB is visualised in the oropharynx removal may be attempted using Magill forceps. Otherwise, removal should be attempted with endoscopy under GA
How should you follow up with an ENT patient after removal of a foreign body?
Nasal or Ear:
- Can be discharged without follow up if non-complicated
- If unilateral symptoms after removed consider Head and Neck cancer so urgent follow up
- If TM perforation follow up in primary care
Ingested:
- After rigid endoscopy need to monitor for perforation afterwards, then can slowly introduce sterile water
How should you deal with a food bolus which is stuck in the throat?
- If sharp food or red flag signs treat as foreign ingested body. If cannot swallow saliva it is emergency
- Otherwise observe patient to see if resolves with medical management. If not, do urgent upper GI endoscopy
Need to look for malignancy if recurrent
What is tonsillitis and what are some of the organisms that cause tonsillitis?
Inflammation of the palatine tonsils
Viral (Most common):
- Rhinovirus
- Adenovirus
- Enterovirus
- EBV
Bacterial:
- Strep Pyogenes
- Strep Pneumoniae
- Staph Aureus
- Haemophilus Influenzae
- Moraxhella Catarrhalis