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
What are the clinical features of tonsillitis?
- Pyrexia
- Dysphagia
- Anterior cervical lymphadenopathy
- Odynophagia
- Trismus (inflammed muscles of mastication)
- Swollen red tonsils with or without exudate
- Otalgia (referred pain)
What are some differential dignoses for tonsillitis?
- Head and Neck malignancy
- Haematological malignancy
- Quinsy
- Deep neck space abscess
How do you decide whether to give antibiotics for tonsillitis?
Centor Criteria 3 or more
or
FeverPAIN score 4 or more
How is tonsillitis managed?
- Analgesia: Difflam Spray, NSAIDs, Paracetamol
- Hydration
- Antibiotics if necessary (Phenoxymethylpenicillin PO for 5-10 days - do not give amoxicillin as will cause maculopapular rash if EBV)
- Safety net and advice to return if not settled in 3/7
- Treat any complications and consider need for tonsillectomy
What advice can you give to patients with EBV tonsillitis?
- Avoid contact sports for 2-3 months due to splenomegaly haemorraghe risk
- Avoid alcohol due to deranged LFTs
- Use own cutlery, towels and toothbrush, do not kiss anyone
What are some of the criteria that need to be met for a tonsillectomy?
- 7 episodes of tonsillitis in one year
- 5 episodes of tonsillitis in two recurrent years
- 3 episodes of tonsillitis in 3 consecutive years
- 2 quinsys ever
- Sleep apnoea
- Malignancy suspected
What is the main complication of a tonsillectomy?
- Secondary bleeding due to infection
- Antibiotic and hydrogen peroxide mouth wash
- Surgical intervention to stop haemorraghe in severe cases
How do you manage post-tonsillectomy bleeding?
IMPORTANT SLIDE!
- Call the ENT registrar
- Get IV access and send bloods (FBC, clotting screen, G+S and crossmatch)
- Keep patient calm and give adequate analgesia
- Sit them up and spit out the blood
- Make the patient NBM in case operation is required
- IV fluids for maintenance and resuscitation
- Before surgery try Hydrogen peroxide gargle and adrenaline soaked swab applied topically
What are some of the complications of tonsillitis?
- Quinsy
- Parapharyngeal abscess
- Otitis media
- Scarlet fever
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Post-streptococcal reactive arthritis
How can you tell if tonsils with exudate is due to bacterial tonsilitis or EBV?
- EBV serology and monospot test
- LFTs raised in EBV
- Generalised lymphadenopathy in EBV but anterior cervical chain in bacterial tonsilitis
- EBV often has petichiae on soft pallate
What are some differentials for a unilateral tonsillar enlargement?
- Quinsy
- Parapharyngeal abscess
- Malignancy (BIOPSY)
What is Quinsy and how does it present (signs and symptoms)?
Peritonsillar abscess that can occur as a complication of bacterial tonsilitis
- Severe sore throat
- Severe odynophagia
- Trismus
- Change in voice
- Examination (difficult due to trismus): peritonsillar swelling, deviated uvula, foul smelling breath
What investigations might you want to do with a Quinsy?
- Want to send off pus cultures once drained
- May want to examine to see if has spread to deep neck spaces e.g torticollis
How is a Quinsy managed?
Medical:
- IV dexamethasone to help trismus
- IV benzylpenicillin AND IV metronidazole
- Analgesia and topical analgesic throat sprays
- IV fluids if poor oral intake
Surgical:
- Needle aspiration or I+D (take care of carotid sheath behind)
How can you measure how bad trismus is?
See how many fingers can fit between teeth, each finger 10-20mm
When doing an oral cavity exam where are some important areas to look at?
- Tonsils
- Uvula
- Peritonsillar region
- Soft palate
- Buccal Cavities
- Tongue
- Floor of mouth
- Salivary glands
PALPATE ALL THEN GO TO NECK AND LYMPH NODES
What are some causes of sore throat and dysphagia?
Sore throat:
- Pharyngitis/Laryngitis
- Glandular fever
- Epiglottitis
- Tonsillitis/Quinsy
- Deep neck space abscesses
- Head and neck malignancy
Dysphagia:
- Malignancy
- Inflammatory disease
- Oesophageal stricture
- Globus pharyngeus
- Neuromuscular disease
What is the definition of obstructive sleep apnea and what are some risk factors for this?
Intermittent and recurrent closure of the airways during sleep:
- 5 or more respiratory events an hour
- Associated symptoms
Risks:
- Obesity
- Adenoid hypertrophy
- Middle age
- Male
- Alcohol/Sedating drugs
- Smoking
What are some of the clinical features of OSA?
- Daytime sleepiness
- Waking up unrefreshed from sleep
- Episodes of apnoea during sleep (reported by their partner)
- Snoring
- Morning headache
- Concentration problems
How can you measure the severity of daytime sleepiness?
Epworth Sleepiness Scale
What investigations can you do to diagnose OSA?
Gold standard: Polysomnography to measure the number of apnoeic or hyponoeic episodes per night.
Apnoea-Hypopnoea Index(AHI)
The severity of OSA is defined by the AHI:
Mild: 5-14 episodes per hour
Moderate: 15-30 episodes per hour
Severe: >30 episodes per hour
How is OSA managed?
- Correct risk factors: weight loss, stop smoking, reduce alcohol
- CPAP
- Mandibular positioning devises
- Surgery: adenotonsillectomy or uvulopalatopharyngoplasty (UPPP)/laser-assisted uvulopalatopharyngoplasty (LAUP)/radiofrequency ablation of the tongue base, or suspension of the hyoid bone
What are some of the complications of OSA?
- Hypertension: increased risk of CVD disease so risk of heart failure, MI and stroke.
- Poor memory, cognitive function and mood
- Need to inform DVLA as could be workplace accidents due to daytime sleepiness
What are some causes of dysphagia?
- If it is associated with sore throat this is a serious sign
- Malignancy
- Oesophageal stricture
- Globus pharyngeus
- Pharyngeal pouch
What are some important questions to ask in a history when a patient has dysphagia?
- Red flags? Any weight loss, lumps, progressive dysphagia
- Is it to fluids or solids or both?
- Is the movement of swallowing difficult?
- Does the neck bulge or gargle on drinking?
What are some investigations you should do when a patient has dysphagia?
- Bloods: FBC, ESR
- CXR
- Barium swallow
- Endoscopy with biopsy
- Oesophageal motility studies
What are some of the symptoms of oesophageal carcinomas?
- Progressive dysphagia
- Weight loss
- Hoarseness
- Cough
- Associated with: Barret’s oesophagus, smoking, alcohol, achalasia
What are some of the signs and symptoms of a pharyngeal pouch?
Signs:
- Dysphagia with gurgling
- Lump in neck
- Halitosis
- Aspiration pneumonia
- Regurgitation of undigested food
Symptoms:
- Dysphagia
- Coughing
- Regurgitation
How is a pharyngeal pouch diagnosed and managed?
Ix
- Barium swallow
- Must also do endoscopy to rule out malignancy
Mx
- If symptomatic can staple the wall that divides the pouch from the oesophagus
What is globus pharyngeus?
Sensation of a lump in the throat that is most noticed on swallowing saliva not food or drink
Patient may also complain of mucous in the throat that they cannot clear
Symptoms come and go depending on mental state of patient e.g worse when stressed or tired
How is globus pharyngeus managed?
- Diagnosis of exclusion, make sure an endoscopy is done to rule out malignancy
- Reassure and inform them of the viscious cycle that it is made worse by anxiety
What are some differentials for neck lumps and what should you do to investigate them?
How can we split the oral cavity and pharynx up into different areas?
Oral cavity: from lips to posterior soft palate
Nasopharynx: superior boundary is base of skull, inferior boundary at level of soft palate
Oropharynx: soft palate to superior border of epiglottis, includes palatine tonsils and anterior/posterior tonsillar pillars
Hypopharynx: from superior epiglottisi to inferior border of cricoid cartilage, posterior to larynx
What are the muscles in the pharynx?
Circular: Superior, middle and inferior constrictors, Cricopharyngeus
Longitudinal (elevate and depress pharynx): stylopharyngeus, salpingopharyngeus, palatopharyngeus
- Between inferior constrictor and cricopharyngeus there is Kilian’s dehiscence where a pharyngeal pouch can occur
What are some causes of glossitis? (smooth tongue due to papilla atrophy)
- Iron deficiency anaemia
- B12 deficiency
- Folate deficiency
- Coeliac disease
- Injury or irritant exposure
What are some causes of angiooedema?
- ACEi
- C1 esterase inhibitor deficiency (hereditary angioedema)
- Allergic reactions
What are some causes of strawberry tongue?
- Kawasaki disease
- Scarlet fever
How is oral lichen planus managed?
- Stop smoking
- Good oral hygiene
- Topical steroids
What vertebral level is the trachea at?
C5-T1
Anterior to the trachea, below the larynx
What is the difference between stridor and stertor?
Stridor: obstruction at or below the level of the larynx
Stertor: obstruction above the larynx e.g oropharyngeal, large adenoids
Which cancer is EBV a risk factor for?
Nasopharyngeal
