3- Throat (common conditions) Flashcards
tonsilitis background
- Inflammation of the palatine tonsils
- Most commonly viral
Bacterial causes (up to 40% of cases)
- Streptococcus pyogenes (Group A )
- Strep pneumoniae
- Others: H.influenzae, Moraxella catarrhalis, staph aureus
Presentation of tonsilitis
- Fever
- Sore throat
- Pain/difficulty swallowing
- Examination
o Cervical lymph nodes
o Bad breath
o Exudate on tonsils
Criteria to determine if viral or bacterial
- Centor criteria
- FeverPAIN
Criteria to determine if viral or bacterial
- Centor criteria
- FeverPAIN
management of tonsilitis if likely viral
- Safety net
- Simple analgesia with paracetamol and ibuprofen
- Advise patient to return if pain has not settled after 3 days or fever >38.3
management of tonsilitis if likely bacterial
Centor >3, FeverPAIN >4
- Penicillin V for 10 days
- Clarithromycin if penicillin allergic
lower threshold for antibiotics for tonsilitis if
o Immunocompromised
o Young infants
o Co-morbidities
Complications of tonsilitis
- Peritonsillar abscess
- Otitis media
- Scarlet fever
- Rheumatic fever
- Post strep glomerulonephritis or arthritis
Peritonsillar abscess ‘quinsy’
Background
- Arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils
- Complication of untreated tonsillitis -> can arise without tonsillitis
- Affects adults and children more equally than tonsilitis
Causes of quinzy
- Streptococcus pyogenus (step A)
- Or Staph aureus,
- H.influenzae
Presentation of quinsy
- Sore throat
- Painful swallowing
- Fever
- Neck pain
- Referred ear pain
- Swollen tender lymph nodes
- If its unilateral (quinsy) -> will deviate the uvula towards the swelling
Additional symptoms that can indicate a peritonsillar abscess include:
- Trismus, which refers to when the patient is unable to open their mouth
- Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
- Swelling and erythema in the area beside the tonsils
symptoms of quinsy
Symptoms
- Severe throat pain
- Fever
- Bad breath
- Drooling
- Difficulty opening mouth
- Can follow on from untreated or partially treated tonsilitis
- Can arise on its own
o Aerobic and anaerobic bacteria
management of quinsy
Management
- Needle aspiration or surgical incision and drainage to remove pus from abscess
- Antibiotics
- Some ENT surgeons also give dexamethasone to settle inflammation
Tonsillectomy
Tonsillectomy is the name for the surgical removal of the tonsils. Removing the tonsils prevents further episodes of tonsillitis, although patients can still get a sore throat from other causes (e.g., pharyngitis). The procedure is performed under a general anaesthetic as a day case. Patients can usually go home the same day after a period of observation.
indication for tonsillectomy
The number of episodes of acute sore throat they specify for a tonsillectomy are:
- 7 or more in 1 year
- 5 per year for 2 years
- 3 per year for 3 years
Other indications are:
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing difficulty breathing, swallowing or snoring
complications of tonsillectomy
- Sore throat where the tonsillar tissue has been removed (this can last 2 weeks)
- Damage to teeth
- Infection
- Post-tonsillectomy bleeding
- Anaesthetic risks
which is the most important complication of tonsillecvtomy
post-tonsillectomy bleeding
post-tonsillectomy bleeding management
Immediate management
- call ENT registrar and get invovled early
- Get IV access and send bloods: FBC, clotting, group and save and crossmatch
- Keep patient calm and give adequate analgesia
- sit them up and encoruage to spit out blood rather than swallowing
- Make the patient Nill by mouth in case an anaesthetic and operation is required
- IV fluid for maintence and resuscitation
Conservative approach for less severe bleeds
- hydrogen peroxide gargle
- Adrenalin soaked swab applied topically
Definitive/ severe bleeding
- surgery
**If severe bleeding or airway compromise **->
intubate
Croup
Background
- Acute infective respiratory disease affecting young children
o 6 months – 2 years - URTI causes oedema in the larynx
croup cause
Cause: Parainfluenza virus
- Influenzas
- Adenovirus
- Respiratory syncytial virus
FYI: croup used to be caused by
diphtheria
- Croup caused by diphtheria would lead to epiglottitis and has a high mortality
- Vaccination against diphtheria therefore rare
Presentation of croup
- Increased work of breathing
- Barking cough
- Hoarse voice
- Stridor low grade fever
Management of croup
- Supportive- fluid and rest
- Sit child up during attacks
- Stay off school
- Oral dexamethasone is very affective (single dose of 150mcg/kg) which can be repeated if required after 12 hours
Severe croup management
- Oral dexamethasone
- Oxygen
- Nebulised budesonide
- Nebulised adrenalin
- Intubation and ventilation
Epiglottitis
Background
- Inflammation and swelling of the epiglottis caused by infection
- Typically: haemophilus infleunza type B
- Life threatening emergency due to obstruction
- Now rare due to vaccination programme
o Have high suspicion in those who have not had vaccine
epiglottis causes by
HiB
Presentation of epiglottitis
- Patient presenting with a sore throat and stridor
- Drooling
- Tripod position, sat forward with a hand on each knee
- High fever
- Difficulty or painful swallowing
- Muffled voice
- Scared and quiet child
- Septic and unwell appearance
epiglottiis investigations
Investigations
- If child acutely unwell -> no investigations -> DO NOT DISTRESS PATIENT
- Lateral X-ray will show ‘thumbs sign’
o This is soft tissue shadow that looks like a thumb pressed into the trachea
o Can also exclude foreign body
management of epiglottitis
AIM: Secure airway
- Preparation to perform intubation at any time
o Inc facilities to do tracheostomy if airway closes completely
- IV antibiotics e.g. ceftriaxone
- Steroids e.g. dexamethasone
prognosis of epiglottitis
Prognosis
Most do not require intubation and make a full recovery
- Death if not managed in time
- Common complication is epiglottic abscess
sialolithiasis
- Presence of calculi in the salivary gland or ducts
o Due to stagnation of saliva
salivary calculi composed of
o Calcium phosphate and hydroxyapatite
Salivary gland can enlarge for 3 main reasons
o Stones
o Infection
o Tumours (benign or malignant)
where are most stones located
submandibular glands
Causes of salivary stones
- Diuretics
- Dehydration, reduced salivary flow
- Gout
- Smoking
- hyperparathyroidism
presentation of salivary stone
- Most stoned less than 1cm
- Symptoms (eating)
o Pain in gland
o Swelling
o Infection
investigations for salivary stones
- History
- US
- X-ray
- Sialogram- contrast dye injected into gland
Management of salivary gland
- Hydration, analgesia, sialogues, such as lemon juice (promote saliva)
- If infected -> antibiotics
- Definitive management
o Interventional radiology
o Surgical approach
o Extracorporeal shockwave lithotripsy
o Gland removal is last resort
Enlarged pharyngeal tonsils
Background
Enlarged adenoidss can block eustachian tube
Presentation
- Recurrent/persistent middle ear infection
- Snoring/sleep apnoea
- Sleeping with mouth open
- Chronic sinusitis
- Sore throat
- Nasal tone to voice
false diverticulum pathophysiology
- Caused by a posteromedial (false diverticulum) arises in weakness between the 2 parts of the inferior constrictor (Killians dehiscence)
- Probably due to
o Failure of UOS to relax
o Abnormal timing of swallowing
o Essentially there is a higher pressure in laryngopharynx
o Weakness in inferior constrictor muscle produces outpouching
presentation of false diverticulum
- bad breath
- regurgitation of food
- choking on fluids
- difficulty swallowing
which crnaila nerves can cause symptoms related to mouth if pathology present
Glossopharyngeal (IX)
Vagus (X)
Hypoglossal (XII)
causes of cranial nerve lesions
- Medullary infarct
- Jugular foramen issues (fracture)
presentation if pathology associated with glossopharyngeal or vagus nerve
Obvious things
- Absent gag
- Uvula deviated away from lesion (Lower Motor Neurone lesion)
More subtle
- Dysphagia
- Taste impairment (posterior tongue IX)
- Loss of sensation oropharynx
presentation if pathology associated with hypoglossal nerve
- Wasted tongue
- Stick tongue out- tongue may deviated
o Damage to nerve itself (LMN)- points to side of the lesion (tongue never lies)
o Muscle wasting
o Fasciculations
Head and neck cancers general
Background
- Usually squamous cell carcinomas arising from mucosa
- Associated with HPV and smoking and chewing tobacco
Location
- Nasal cavity
- Paranasal sinuses
- Mouth
- Salivary glands
- Pharynx (throat)
- Larynx (epiglottitis, supraglottitis, vocal cords, glottis, subglottis)
Pre-malignant conditions
- Leucoplakia (white patches)
- Erythroplakia (red patches)
- Erythroleukoplakia (red and white patches)
- Oral lichen planus
- Actinic cheilitis
where do H+ N cancers metastasise to
- Lymph nodes first
- look for lymphadenopathy
Risk factors for H and N cancer
- Male
- Smoking
- Chewing tobacco
- Chewing betel quid (south-east Asian habit)
- Alcohol
-
HPV especially strain 16
o Gardasil does protect against strains 6,11,16 - Epstein Barr virus
Red flags for H+N cancer
- Lump in the mouth or on the lip
- Unexplained ulceration in the mouth lasting more than 3 weeks
- Erythroplakia or erythroleukoplakia
- Persistent neck lump
- Unexplained hoarseness of voice
- Unexplained thyroid lump
Red flags for H+N cancer
- Lump in the mouth or on the lip
- Unexplained ulceration in the mouth lasting more than 3 weeks
- Erythroplakia or erythroleukoplakia
- Persistent neck lump
- Unexplained hoarseness of voice
- Unexplained thyroid lump
Investigations
for H + N cancer
- Biopsy lesion
- Flexible nasal endoscopy (FNE)
- If lesion found: examination under anaesthesia
- fine needle aspiration of lymphadenopathy
- Imaging for stagig
Staging investigations for H+N cancer
- CT scan of neck and chest
- PET CT for metastasis
- MRI for best in oral cavity and oropharyngeal lesions
H+N management
Management
- Chemotherapy
- Radiotherapy
- Surgery
- Targeted cancer drugs (monoclonal antibodies)
o E.g. Cetuximab – targets epidermal growth factor receptor, inhibiting growth and metastasis of the tumour
- Palliative care
Presentation
General H+N cancer
- Weight loss
- Cervical lymphadenopathy
Oral Cavity Cancer
Most commonly oral cavity cancers will present as a mass, typically painless, being felt on the inner lip, tongue, floor of the mouth, or hard palate.
Less commonly, these cancers will present in more non-specific means*, such as oral cavity bleeding, localised pain within the oral cavity, or jaw swelling.
*Premalignant conditions (erythroleukoplakia) may be noticed initially, prompting further investigations which reveal the malignant transformation
Pharyngeal Cancer
Many cases of pharyngeal cancer can present* initially as odynophagia, dysphagia, stertor, or referred otalgia. Nasopharyngeal carcinoma patients can present initially with a neck lump.
Majority of these tumours, specifically of the hypopharynx, frequently will have an advanced stage at the time of diagnosis as they will often metastasise early due to the extensive lymphatic network.
Trotters Syndrome is a triad of clinical features suggestive of nasopharyngeal malignancy, comprised of
(1) unilateral conductive deafness (secondary to middle ear effusion),
(2) trigeminal neuralgia (secondary to perineural invasion), and
(3) defective mobility of the soft palate
Laryngeal Cancer
The clinical features of a laryngeal malignancy can include hoarse voice, stridor (if advanced), dysphagia, persistent cough, or referred otalgia. Laryngeal cancers are divided anatomically (mainly for the purpose of tumour staging) into glottis, supraglottis, and subglottis, with most malignancies originating in the glottis region.
Patients with glottic tumours have better prognosis as they present earlier with hoarse voice and there is no lymphatic drainage from the glottis, hence limits any metastatic spread locally.
