7. Tonsils, Adenoids, Vocal Cords Flashcards
What causes most sore throats?
In general most sore throats are caused by viruses and do not require antibiotics.
What are tonsils?
Tonsils are large lymphoid tissue situated in the lateral wall of the oropharynx.
They form lateral part of the Waldeyer’s ring.
Tonsil occupies the tonsillar fossa between diverging palato-pharyngeal and palatoglossal folds
Describe the Gross Anatomy of the tonsils?
Rule of 2's Two surfaces: medial and lateral Two borders anterior and posterior Two poles upper and lower Two developmental folds plica triangulris and plica semilumris One cleft = intratonsillar cleft.
Compare the two surfaces of the tonsils?
Medial Surface
Squamous Epithelium containg 15-20 crypts, usually plugged with epithelial and bacterial debris.
Lateral Surface
Fibrous Sheet = Capsule of the tonsil
Capsule = firm antero-inferior attachment to tongue, loose attachment to muscular wall.
What constitutes the bed of the tonsil?
- Loose aerolar tissue
- Pharyngobasilar fascia
- Superior constrictor muscle
Describe the blood supply to the tonsil?
- Tonsillar branch of the dorsal lingual
- Ascending palatine branch of facial artery
- Tonsillar branch of facial artery
- Ascending pharyngeal
- Descending palatine
In whom is acute tonalities more common?
Children <9, but seen at any age.
What is meant by primary/secondary acute tonsillitis?
May occur primarily as infection of the tonsils themselves or may secondarily occur as a result of URTI following viral infection.
Which is more common viral or bacterial tonsillitis?
Mostly Viral
Though age related. 15% GAS (pyogenes) overall/
Age 6-16 50% The proportion of tonsillitis/pharyngitis caused by Streptoccocci.
Describe the different aetiologies of acute tonsillitis?
Beta-haemolytic streptococcus
Staphylococcus
Haemophilus influenzae
Pneumococcus
Viral Aetiology for ACUTE Tonsillitis unknown.
When tonsils are inflamed as part of the generalised infection of the oropharyngeal mucosa?
Catarrhal tonsillitis.
Exudation from crypts may coalesce to form a membrane over the surface of tonsil?
Membranous Tonsillitis
When the whole tonsil is uniformly congested and swollen?
Parenchymatous Tonsillitis
What are the SYMTOMS of Acute Tonsillitis?
Sore throat and dysphagia - small children will not necessarily complain of sore throat but may refuse to eat.
Earache - referred otalgia.
Thick Speech
Headache and malaise/general ache
What are the SIGNS of Acute Tonsillitis?
Pyrexia is always present and may be high - can result in febrile convulsions is some infants. Higher fever in bacterial.
The tonsils are enlarged and hyperaemic and may exude pus from the crypts – follicular tonsillitis.
The pharyngeal mucosa is inflamed.
Foetor (strong, foul smell) is present.
The cervical + jugulo-diagastric lymph nodes are enlarged and tender.
Exudation from crypts may coalesce to form a membrane over the surface of tonsil?
Follicular Tonsillitis (Bacterial)
What is the Tx for Tonsillitis?
- Bed rest.
- Soluble aspirin or paracetamol – held in mouth
- Ensure Hydration
- Antibiotics (If confirmed bacterial – FBC+Culture)
1st Line = Penicillin 10 days
2nd Line = Macrolides if penicillin allergy (Erythr/Clarithomycin 10 days or Azithromycin 12mg.Kg/Day - 5 days)
What are the complications of acute tonsillitis?
- Severe Swelling
- Occasionally Respiratory Obstruction (Rare uncomplicated Acute Tonsillitis)
- Spread of infection to hypopharynx and larynx (from tonsil or more commonly through resulting peritonsillar abscess)
- Recurrent Tonsillitis (esp. Children, consid Tonsillectomy)
- Peritonsillar Abscess (infection spread outside of tonsillar capsule, not same aetiologic make-up however)
- Systemic Complications (Rare, almost always children). Septicemia can result if no treatment, spetic abscess, arthritis and meningitis.
- Acute Rheumatic Fever + Glomerulonephritis (Only after beta-hemolytic strep, anti-body mediated?, arthritis, endocarditis, myocarditis, dermatitis or rheumatic chorea (inflam of cerebral cortex+basal ganglia)
What is a Peritonsillar Abscess?
Pus between…
- Fibrous capsule of the tonsil (usually at its upper pole) and…
- The superior constrictor muscle of pharynx.
How does a peritonsillar abscess come about?
- Complication of the acute tonsillitis (usually)
2. Arise de novo with no preceding tonsillitis.
Describe the aetiology of a peritonsillar abscess?
The bacteriology of a peritonsillar abscess is different to the acute tonsillitis of which it a complication.
The bacteriology of the quinsy instead is characterized by mixed flora with multiple organisms both aerobic and anaerobic.
What are the SYMTOMS of Peritonsillar Abscess?
Severe Dysphagia + Referred Otalgia.
High temperature.
Swelling of the tonsillar lymph node.
Malaise.
What are the SIGNS of Peritonsillar Abscess?
Similar to Acute Tonsillitis.
+ Medial displacement of the tonsil to the midline.
+ Trismus (spasm of pharyngeal muscles)
+ Buccal Mucosa is dirty
+ Foetor
+ Distortion of the buccopharyngeal isthmus anatomy
What is the Tx for a Peritonsillar Abscess?
- Antibiotics = High Dose/IV + 5 day course oral
- Incision + Drainage (Indications = Trismus + pus suspected, C/I if early the is peritonsillar cellulitis) (Small I = Mid – Base Uvula – Site of Upper Molar, Then Sinus Forceps to open cavity) (Child = Anaesthetic)
- Tonsillectomy After Six Weeks (If recurrent tonsillitis/2nd Quinsy)
What are the potential complications of Quinsy?
- Pharyngeal+Laryngeal Oedema (Airway)
- Pharyngeal Abscess
- Vascular fibrous tissue found lateral to the tonsil after a quinsy makes tonsillectomy difficult.
- Bleeding from a quinsy is an important and serious sign of complication due to erosion by the peritonsillar pus of the internal carotid artery.
What are the Indications for Tonsillectomy?
Absolute
- Obstructive airway with cor pulmonale
- Suspected Neoplasia/ Tonsillar hyperplasia
- Failure to thrive
Relative
- Recurrent acute tonsillitis
- Chronic tonsillitis
- Obstructive Sleep Apnea
- Peritonsillar Abscess (>2, anytime)
- Halitosis
What are the symptoms of obstructive airway?
- Snoring
- Apneic episodes with gasping or choking
- Daytime hypersomnolence (Daytime sleepiness)
- Nocturnal enuresis (inability to control urination)
- Behavioral disturbances
- Heart failure and Failure to thrive
What is the Gold Standard for Dx of Sleep Apnoea? When should it be used?
Polysomnography.
Imperative in Adults
In children, a convincing history is adequate
Describe the grading of Tonsil sizes?
Grade %
1 =75
What are the Indications for Adenoidectomy?
Absolute
- Airway obstruction w/ cor pulmonale
- Failure to thrive
Relative
- Chronic Nasal Obstruction
- Recurrent/ Chronic Adenoiditis
- Recurrent/ Chronic Sinusitis
- Recurrent acute otitis media/ Recurrent COME
Note:
- Adenotonsillar size may respond to a 1 month course of antibiotic therapy.
- Adenoid hyperplasia may respond to a 6-8 week course of intranasal steroid.
Describe the pre-op work up for adneoidectomy?
Most common lab test is a FBC
Coagulation studies when the history or physical examination suggests a bleeding disorder.
Lateral Neck/Adenoid films ??
List the surgical techniques for tonsillectomy? Most Common?
Cold Dissection
Electrosurgery (most common Equivalent or superior to the other methods of tonsillectomy.)
Intracapsular partial tonsillectomy
Harmonic Scalpel
Radiofrequency tonsillar ablation and coblation.
What potential Tx may be use adjuvantly to Tonsillectomy?
- Perioperative local anesthetic 0.25% bupivicaine w/ 1:100,000 Epinephrine.
Advantages= Ease of dissection, postoperative pain. Disadvantages = Airway obstruction, cardiac dysrrhythmias, seizures) - Perioperative Antibiotics
Fewer episodes of fever, offensive odor, improved oal intake, less pain, fewer days to return to normal activity - Perioperative Steroids
Dexamethasone (0.15-1.0mg/kg).
Two times less likely to have an episode of postoperative emesis, and more likely to advance to eating a soft diet.
Reducing postoperative subglottic edema, pain reduction.
Discuss pain control in the setting of tonsillectomy?
Paracetamol/ codeine are the most commonly used.
Similar pain control, less oral intake with codeine versus Paracetamol alone.
NSAID still controversial.
What are the possible complications of tonsillectomy?
Post operative pain
Trauma (lips, teeth, tongue, uvula, soft palate, TMJ)
Bleeding
Infection
What are the possible complications of adenoidectomy?
Mortality rate is 1 in 16000-35000. Anesthetic complications Eustachian tube injury Nasopharyngeal stenosis Atlanto-axial subluxation
How can the risks of Post Operative Haemorrhage by Mitigated?
The best treatment is prevention. Early vs. Delayed hemorrhage. Overnight observation and i.v. access Surgical intervention. Carotid angiography if any suspicion of carotid artery injury.
What does hoarseness (Dysphonia) actually mean?
An alteration in voice quality. Hoarseness is not a diagnosis in itself, but a common symptom of many different conditions that can affect the larynx
How is hoarsness categorised?
Acute - lasting less than 3 weeks
Chronic - more than 3 weeks.
Describe how you would assess a patient with hoarseness?
HISTORY
Duration of the symptoms.
Constant or intermittent, worsening or static?
Similar previous episodes?
Smoking and alcohol history (malignant disease).
Recent surgery, (particulary on the thyroid gland – RLN damage)
COUGH
Ask the patient to cough.
Bovine= unilateral vocal cord palsy quality ( failure to appose the cords at the beginning of the cough results in an inability to generate an explosive expiratory force.)
EXAMINATION
The mouth and oropharynx should be inspected and the neck palpated with specifc attention paid to any thyroid masses or cervical lymphadenopathy.
FURTHER ASSESSMENT
ENT outpatient setting.
Specialist voice clinic with ENT surgeons and speech and language therapists in attendance and specific equipment available for visualization of the larynx.
Indeed laryngeal visualization is the most important part of the examination of the hoarse patient.
Describe the difference between acute and chronic laryngitis?
ACUTE
Commonly occurs as part of a simple upper respiratory tract infection or acute excessive voice abuse.
Treatment is conservative. Steam inhalation may be helpful, voice rest is advised and the patient reassured.
Smoke inhalation, active or passive, should be avoided.
CHRONIC
The mainstay of treatment is avoidance of precipitating factors eg. smoking, voice abuse and the correction of underlying contributory conditions eg. GORD.
It is estimated that up to 30% of patients with GORD initially present with laryngeal complications.
Where on going voice abuse is an aetiologic factor, speech therapy can help re-educate the patient in correct voice use.
What are the methods for visualising the larynx?
Indirect laryngoscopy. (Difficult)
Flexible fibreoptic nasendoscopy (Excellent view of nasooropharynx, VC etc)
Rigid endoscopy.
Direct laryngoscopy under general anaesthesia may be performed when laryngeal visualisation is impossible. (+if biopsy needed).
What are the acute causes of hoarseness?
Traumatic Laryngitis eg. voice abuse, coughing, blunt trauma.
Infective laryngitis eg. viral,bacterial or fungal.
Inflammatory laryngitis eg. tobacco smoke.
What are the chronic causes of hoarseness?
Chronic Laryngitis eg. voice abuse, smoke, reflux. Nodules. Reinke’s oedema. Vocal cord polyps. Vocal cord palsy. Functional. Laryngeal carcinoma.
List the possible areas in which damage to vocal chord function can be damaged?
- Brainstem Nuclei
- Vagus Nerve
- Recurrent Laryngeal Nerve
Describe briefly the course of the recurrent laryngeal nerve? Implications?
Recurrent Laryngeal Nerve
Arises from the Vagus
Travels further on the left where it loops around the arch of Aorta while on the right, it travels around the subclavian artery.
Supplies all the muscles (post. Cricoarytenoid, interarytenoid, lateral Cricoarytenoid, and Thyroarytenoid muscles) except for Cricothyroid
VC Paralysismore often left sided due to the extended intrathoracis course of the left recurrent laryngeal nerve.
What is the difference between paresis and paralysis?
Paresis = Hypofunction/Hypomobility secondary to neurologic injury
Paralysis = Immobility although some intrinsic re-innervation may occur
What are the possible positions of the true vocal folds (TVFS’)?
- Median
- Paramedian .
- Intermediate .
- Abducted
Describe the different etiologies of vocal chord paralysis?
1 – Malignancy (25%) . 2 – Iatrogenic Surgical Trauma (25%) . 3 – Idiopathic (20%) . 4 – Non-surgical Trauma (11%). 5 – Intubation and Neurologic Disorders (Each 7%)
What syndrome describes the association of cardiovascular pathology and left recurrent laryngeal nerve palsy?
Ortner’s Syndrome
List the malignancies which most commonly affect the vocal chords?
Usually Laryngeal or Pulmonary
- Bronchogenic carcinoma with invasion into mediastinum. (Most Common)
- Mediastinal.
- Carotid Body Tumors .
- Paragangliomas near the skull base .
- Thyroid
Which surgical interventions most often cause paralysis of the vocal chords?
- Anterior Cervical Spine Surgery – 2 to 21.6 %
- Thyroid Surgery – 0.3 to 13.2 %.
- Thoracic Surgery (e.g. Aortic Arch Repair)
- Vascular Surgery (Carotid Endarterectomy)
How might intubation lead to VCP?
Compression of Anterior Rami of RLN int he Subglottis by Inflating Cuff.
Describe the work-up for vocal chord dysfunction?
- History
Rheumatoid Arthritis, Gout, Neurological Disorders, Smoking/Alcohol Use, Past Surgical History, Trauma, Recent Infections - Physical Exam
Evaluate all Cranial Nerves.
Vagus can be evaluated by observing Palate+Gag Reflex.
Careful Analysis of the Voice. Hoarseness. Breathiness?
3. Other Exams Laryngeal EMG CT Head+Neck MRI Brain CxR CT Chest w/contrast
What are the two types of Vocal Cord Palsy?
Unilateral cord Palsy. (Treatable)
Bilateral Cord Palsy (No Treatment)
What are the signs which suggest an neurological VCP?
VocalFatigue Vocal Tremor Weak or Breathy Voice Vocal Strain or Stoppage Altered Resonance Acquired Dysarthria Associated Dysphagia
What is normally done (Tx) before considering surgery?
Many cases of Unilateral TVF paralysis resolve
- Minimum waiting time is usually agreed to be around 9-12 months after injury. w/wo SALT.
- Injection laryngoplasty (fat or Calcium Hydroxylapatite paste).
What is the mainstay of surgical Tx for VCP? What material achieve this? 2nd Line?
Objective is Medialisation, Achieved by Injection Techniques)
Injection Laryngoplasty? Teflon (can cause granulomatous inflammatory reaction) Fat (3-4 months but effects last longer) Gelfoam (3 months, temporary) Collagen (Incorp to tissue, 3 years)
Injection Thyroplasty? Calcium Hydroxylapatite (Longesvity, greatest benefit, giant cell changes but not chronic changes)
What is the surgical alternative to injection medialisation for VCP?
Laryngeal Framework Surgery: Type 1 Thyroplasty.
Arytenoid adduction procedures.
How is Bilateral Vocal Cord Palsy Managed?
No treatment.
Laser Cordotomy.
Laser Arytenoidectomy.
Tracheostomy.
Narrowing of the airway below the true vocal folds?
Subglottic Stenosis
Can be congenital or aquired?
What are the main functions of the larynx?
Breathing Protect from aspiration Phonating Coughing Valsalva Maintaining PEEP
Describe the grading of SGS?
I – 0-50% narrowing
II – 51-70% narrowing
III – 71-99% narrowing
IV – Complete obstruction with no lumen
What are the risk factor for
voice overuse or misuse
Smoking + Alcohol
Laryngopharyngeal reflux (78% w/ VC nodules had this)
What are the symptoms of nodules of the VC?
- Decreased closure: hourglass-shape glottal closure
- Chronic hoarseness
- Singers: frequent voice breaks, breathiness, vocal fatigue
Decreased amplitude mucosal wave +
Symmetric mucosal wave
What are vocal cord nodule?
Localised, small, benign nodules
Arising at the junction of the anterior and middle thirds of the vocal cord. (Maximum point of contact of the vocal cords during vocalization).
Usually they are bilateral and symmetrical.
What is the Tx for Vocal Cord Nodule?
- Conservative voice use
- Speech therapy to address technique
- Microsurgery when speech tx and other contributing factors optimized
What are vocal cord polyps?
Generally a single polyp occurs in the adult patient and is easily treated by surgical removal.
What are the symptoms of VC polyps?
Asymmetric mass produces more chaotic vibrations and aperiodic mucosal waves
Larger polyps cause decreased wave amplitude
Excessive air egress during phonation
Fatigue
Frequent voice breaks
decreased vocal power
What is the Tx for VC polyps?
Conservative for small polyps
Microsurgery mainstay of therapy
Hemorrhagic polyps
Pulsed-dye lasers absorbed by hemoglobin (585 nm)
Lasers more effective for smaller polyps
Mucus retaining, epithlial lined sacs within the lamina propria?
Vocal Fold Cysts
What are the potential complications of a vocal fold cyst?
Ruptured cyst may result in LP scarring or in a sulcus
May cause reactive lesion on contralateral VF
What is the Tx for Vocal Fold Cysts?
Does not resolve with conservative management
SURGERY
Dissection in submucosal plane with complete cyst removal
Prolonged mucosal wave recovery
Discuss risks with pt
What precautions should be taken when operating on a young female for a vocal fold cyst?
Size may vary with menstrual cycle
What is a reactive Vocal Fold Lesion?
It is a reaction to a unilateral VF lesion on the contralateral side. A callus with epithelial hyperplasia?
What are the charateristics of reactive vf lesions
Bilateral like nodules
Strobe: asymmetry not seen in nodules
What is the Tx for a reactice VF lesion?
Tx: treatment of primary lesion, may resolve with conservative management
What is intracordal scarring and what causes it?
Scarring in Reinke space after repeated inflammation, trauma (iatrogenic) or vocal hemorrhage.
What are the characteristics of intracordal Scarring?
Hoarseness
Vocal fatigue
Breathiness
Loss of projection
What test is used to detect and measure mucosal waves?
Stroboscopy
What are the stroboscopy findings for intracordial scaring?
Markedly reduced or absent mucosal wave
Asymmetry affects phase closure
What is the Tx for vocal scar?
Microflap to remove cyst elements and adynamic fibrous components
Medialization thyroplasty for glottic gaps
Replacement soft tissue (Fillers = Collagen. Fat. Hyaluronic acid)
What is Reinke’s Space?
Reinke’s space is a potential space beneath the epithelium of the vocal fold.
What condition is common in reinke’s space?
Reinke’s Oedema
Descibe the pathophysiology of reinke’s oedema?
Smoking, LPR, occupational exposure etc…
Diffuse Polyps (polypoid corditis)
Proliferation of superficial lamina propria
An established inflammatory process affecting the larynx can result in exudation of fluid into this space causing bulkiness of the vocal fold and possible redundant mucosal folds.
Ball Valving Effect
What is the Tx for Reinke’s Oedema?
Surgery (Airway compromise, Preserve some superficial lamina propria and overlying epithelium to preserve mucosal wave)
Stage for bilateral disease to prevent anterior web (joining of the vocal folds)
Remove irritants and treat LPR
Growths at the columnar and squamous junction?
Vocal Papillomas.
What causes papillomas of the VC?
HPV (Strain 6 and 11 most common)
HPV 11 growth more aggressive during pregnancy
40% HPV+ larynx without RRP
What is the rate of malignant transformation,and the rate of spread to other sites in VC papillomas
2% malignant transformation (HPV 16 and 18)
10% rate of spread to other sites (trachea, supraglottis, NP)
Keratosis on the vocal folds?
Leukoplakia
What is the progression pattern in leukoplakia?
Superficial, broad
Verrucous, exophytic with surrounding erythema
SEQUENCE HyperkeratosiS Dysplasia (mild, moderate) CIS/ severe dysplasia 8% to 14% rate of malignant transformation
Note: Appearance does not correlate with degree of dysplasia
What is the Tx for leukoplakia in the vocal cords?
CO2 laser
PDL
Microflap excision
Preservation of normal mucosal wave for mild dysplasia
More aggressive excision with increasing dysplasia
What examination should be carried out for a patient complaining of globus who has a normal ENT exam?
A barium swallow and meal is carried out. `
Abnormal/Normal wHigh Risk = Endoscopy
Normal = Reassure, Advice Sheet, Discharge.
