Disorders of the Throat Flashcards
Common pathogens causing tonsilitis (6)
VIRUSES
STREP PYOGENES
staph
moraxella
mycoplasma
haemophilus
presentation of tonsilitis
sore throat+/- lymphadenopathy
pus+grey furry tongue=bacterial
DDx for tonsilitis (5)
EBV
lymphoma
scarlet fever, diptheria
if unilateral:malignancy
agranulocytosis
Rx of tonsilitis (5)
(swab useless)
most viral so don’t need Abx
give Abx if =/>3 centor criteria met: -pus on tonsils -temperature -no cough -cervical lymphadenopathy Abx: penicillin+paracetamol/ibuprofen (ery if pen allergic)
AVOID AMOXICILLIN>RASH IF EBV
Tonsilectomy if persistent episodes, significant effect on life, lasting longer than 1yr, resp obstruction or suspected malignancy.
single dose dex given before tonsilectomy to prevent vomitting. post-op risk of bleeding via para-tonsilar vein.
Complications of tonsilitis (7)
otitis media
retropharyngeal abscess:
- exended neck/torticollis
- incise and drain under GA
peritonsilar abscess(quinsy):
- peritonsilar bulge, uveal deviation, trismus (lower jaw spasm)
- Abx (penicillin+metro)+steroids+aspiration of pus+check EBV
parapharyngeal and hypopharyngeal abscesses
Lemierre’s syndrome:
- triad of pharyngotonsilitis, internal jugular thrombophlebitis and septic emboli to lungs
- caused by fusobacerium necrophorum
- IV benpen, clindamycin+metronidazole
scarlet fever:
- strawberry tongue, rash on chest/axilla/behind ears, syndenham’s chorea
- caused by GBS toxin
- Rx w. penicillin
acute mediastinitis-v. rare
Main causes of stridor (3)
croup/epiglottitis
laryngomalacia
laryngeal paralysis
Features and XR signs of croup (3)
stridor+barking cough+low fever+no drooling
parainfluenza
XR shows steeple sign-pointed trachea
Mx of croup (5)
humidified O2
single dose dexamethasone PO
if severe(cyanosis, sternal retraction, raised HR/RR)>nebulised adrenaline
repeat adrenaline
> ITU
Features of epiglottitis (5)
continuous stridor,drooling, no cough, dysphagia, sitting forward
toxic looking
voice change
high grade fever
haemophilus B
Mx of epiglottitis (5)
ET tube
nebulised adrenaline+IV dexamethasone
blood and epiglottic culture
fluids
IV Abx: cefotaxime/cefuroxime
Features of laryngomalacia (6)
Congenital floppy larynx
collapses on inspiration
can develop w. GORD
worse on lying flat
suspect if abnormal voice/cry
should resolve spontaneously by 12-18
Features of laryngeal paralysis (3)
may be due to vagal stretching at birth
can be unilateral or bilateral
if bilateral, may need surgery
Causes of stertor (snoring) (5)
inflammatory: tonsilitis, adenitis, ludwig’s angina, rhinosinusitis
trauma/foreign body
neoplasia
obstructive hyperplasia of tonsils
oropharynx: micrognathia, macroglossia, thyroglossal cyst
Dysphonia Hx questions (5)
GORD
dysphagia
singing/shouting
stress
smoking
Causes of dysphonia (9)
need to exclude laryngeal carcinoma
reflux laryngitis from GORD-Rx w. PPIs
laryngitis
laryngeal nerve palsy
singer’s nodules-vocal abuse, Rx w. speech therapy
functional speech disturbance
hypothyroidism>oedema of vocal cords
RA in cricoarytenoid joint
laryngeal papilloma-from HPV, chronic progressive voice change
Causes, pathogenesis and Mx of laryngitis (4)
often viral
can be caused by strep/staph so can use penicillin
chronic irritation from smoking +/- shouting can>Reinke’s oedema; gelatinous enlargement of vocal cords
if chronic(>3wks)>refer to ENT for biopsy
Features of laryngeal nerve palsy (3)
vocal cord paralysis>:
- hoarse, breathy voice
- repeated coughing/aspiration
- exertional dyspnoea due to narrowed glottis
Causes of laryngeal nerve palsy (5)
cancers
surgery e.g. parathyroidectomy
CNS disease e.g. polio, syringomyelia
aortic aneurysm
TB
Ix for laryngeal nerve palsy (4)
CXR
barium swallow
MRI
panendoscopy (to look at mouth and vocal cords)
Ix for dysphonia (2)
laryngoscopy
slow motion videolaryngostroboscopy
Mechanical causes dysphagia (5)
Malignant stricture:
- oesophageal, gastric, pharyngeal ca.
- can cause hoarse voice if in upper part of oesophagus
Benign Stricture:
- oesophageal web or ring
- peptic stricture
- can be caused by GORD, corrosives, radiotherapy or surgery.
Extrinsic pressure:
-lung ca., mediastinal LNs, retrosternal goitre, aortic aneurysm, enlarge left ventricle.
Pharyngeal pouch:
- aka zenker’s diverticulum
- herniation via thoro- and cricopharyngeus
- if large can have neck lump which gurgles on palpitation
- common in older men
- presents w. cough, regurgitation, aspiration and halitosis
- Dx w. barium swallow.
Rx of benign oesophageal strictures
balloon dilatation.
Assoc. of malignant strictures (5)
male
barrett’s
achalasia
GORD
smoking
Assoc. of oesophageal webs/rings (2)
bullous diseases
Plummer-Vinson syndrome (chronic IDA+dysphagia+oesophageal web)
Motility disorders causing dysphagia (10)
Achalasia
lack of peristalsis of oesophageal muscles
diffuse oesophageal spasm
systemic sclerosis (CREST)
bulbar/pseudobulbar palsy
Wilson’s/parkinson’s
syringobulbia
bulbar poliomyelitis
chagas disease-ask about travel Hx and CVS Sx
MG-difficulty w. solids+liquids from start
Features and Ix for achalasia (3)
inability of lower oesophageal sphincter to relax due to myenteric plexus dysfunction
XR shows fluid accumulation
Ba swallow shows tapering.
Presentation of “lack of peristalsis of oesophageal muscles” (5)
cough/aspiration pneumonia
difficulty with solids+liquids from the start
retrosternal pain
Ba swallow shows “bird’s beak” appearance
still need subsequent endoscopy to rule out ca.
Rx of paralytic oesophageal muscles (4)
Rx by relaxing sphincter:
- nitrates
- endoscopic dilatation+PPIs to prevent acid reflux
- botulinum toxin
- surgical myotomy
Features and Rx of diffuse oesophageal spasm (3)
nutcracker oesophagus
corkscrew appearance
can Rx w. nitrates.
Other causes of dysphagia (3)
oesophagitis
globus
bisphosphonates-can cause irritation, inflammation and ulceration>take when sitting up w. glass of water and sit up for 30mins after taking it.
Presentation of oesophagitis (3)
worse leaning forward/lying down/w. hot drinks/food/at night
often Hx of heartburn
in serious cases can>dysphagia, haematemesis, malaena
Causes of oesophagitis (6)
commonly GORD
rarely infection (candida), Crohn’s and chemicals
drugs causing irritation:
- bisphosphonates
- doxycycline
- Sando-K (potassium replacement)
drugs relaxing sphincter>GORD:
- amlodipine
- isosorbide mononitrate
Rx of oesophagitis
lanzoprazole
Features and subtypes of globus (3)
feeling of lump in throat, often Hx of anxiety
globus hystericus: functional
globus pharyngeus: due to cricothyroid overactivity
Important questions to ask in dysphagia Hx (6)
difficulty with solids and liquids from start?
- yes>motility
- no>stricture
pain on swallowing? (odynophagia):
-yes>cancer/ulcer/candida
difficulty making swallowing movements?:
-yes>bulbar palsy
intermittent?:
- yes>spasm
- constant+worsening>malignant stricture
does neck bulge/gurgle on drinking?:
-yes>pharyngeal pouch
Hx of foreign travel?:
-yes>chagas
Ix for dysphagia (5)
FBC (anaemia)
U+E (dehydration)
CXR-mediastinal fluid level, no gastric bubble, aspiration
Upper oesophageal endoscopy +/- biopsy
2nd line: video fluoroscopy
