Disorders of the Throat

Question 1

Common pathogens causing tonsilitis (6)

Answer 1

VIRUSES

STREP PYOGENES

staph

moraxella

mycoplasma

haemophilus

Question 2

presentation of tonsilitis

Answer 2

sore throat+/- lymphadenopathy

pus+grey furry tongue=bacterial

Question 3

DDx for tonsilitis (5)

Answer 3

EBV

lymphoma

scarlet fever, diptheria

if unilateral:malignancy

agranulocytosis

Question 4

Rx of tonsilitis (5)

Answer 4

(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.

Question 5

Complications of tonsilitis (7)

Answer 5

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

Question 6

Main causes of stridor (3)

Answer 6

croup/epiglottitis

laryngomalacia

laryngeal paralysis

Question 7

Features and XR signs of croup (3)

Answer 7

stridor+barking cough+low fever+no drooling

parainfluenza

XR shows steeple sign-pointed trachea

Question 8

Mx of croup (5)

Answer 8

humidified O2

single dose dexamethasone PO

if severe(cyanosis, sternal retraction, raised HR/RR)>nebulised adrenaline

repeat adrenaline

> ITU

Question 9

Features of epiglottitis (5)

Answer 9

continuous stridor,drooling, no cough, dysphagia, sitting forward

toxic looking

voice change

high grade fever

haemophilus B

Question 10

Mx of epiglottitis (5)

Answer 10

ET tube

nebulised adrenaline+IV dexamethasone

blood and epiglottic culture

fluids

IV Abx: cefotaxime/cefuroxime

Question 11

Features of laryngomalacia (6)

Answer 11

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

Question 12

Features of laryngeal paralysis (3)

Answer 12

may be due to vagal stretching at birth

can be unilateral or bilateral

if bilateral, may need surgery

Question 13

Causes of stertor (snoring) (5)

Answer 13

inflammatory: tonsilitis, adenitis, ludwig’s angina, rhinosinusitis

trauma/foreign body

neoplasia

obstructive hyperplasia of tonsils

oropharynx: micrognathia, macroglossia, thyroglossal cyst

Question 14

Dysphonia Hx questions (5)

Answer 14

GORD

dysphagia

singing/shouting

stress

smoking

Question 15

Causes of dysphonia (9)

Answer 15

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

Question 16

Causes, pathogenesis and Mx of laryngitis (4)

Answer 16

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

Question 17

Features of laryngeal nerve palsy (3)

Answer 17

vocal cord paralysis>:

• hoarse, breathy voice
• repeated coughing/aspiration
• exertional dyspnoea due to narrowed glottis

Question 18

Causes of laryngeal nerve palsy (5)

Answer 18

cancers

surgery e.g. parathyroidectomy

CNS disease e.g. polio, syringomyelia

aortic aneurysm

TB

Question 19

Ix for laryngeal nerve palsy (4)

Answer 19

CXR

barium swallow

MRI

panendoscopy (to look at mouth and vocal cords)

Question 20

Ix for dysphonia (2)

Answer 20

laryngoscopy

slow motion videolaryngostroboscopy

Question 21

Mechanical causes dysphagia (5)

Answer 21

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.

Question 22

Rx of benign oesophageal strictures

Answer 22

balloon dilatation.

Question 23

Assoc. of malignant strictures (5)

Answer 23

male

barrett’s

achalasia

GORD

smoking

Question 24

Assoc. of oesophageal webs/rings (2)

Answer 24

bullous diseases

Plummer-Vinson syndrome (chronic IDA+dysphagia+oesophageal web)

Question 25

Motility disorders causing dysphagia (10)

Answer 25

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

Question 26

Features and Ix for achalasia (3)

Answer 26

inability of lower oesophageal sphincter to relax due to myenteric plexus dysfunction

XR shows fluid accumulation

Ba swallow shows tapering.

Question 27

Presentation of “lack of peristalsis of oesophageal muscles” (5)

Answer 27

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.

Question 28

Rx of paralytic oesophageal muscles (4)

Answer 28

Rx by relaxing sphincter:

• nitrates
• endoscopic dilatation+PPIs to prevent acid reflux
• botulinum toxin
• surgical myotomy

Question 29

Features and Rx of diffuse oesophageal spasm (3)

Answer 29

nutcracker oesophagus

corkscrew appearance

can Rx w. nitrates.

Question 30

Other causes of dysphagia (3)

Answer 30

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.

Question 31

Presentation of oesophagitis (3)

Answer 31

worse leaning forward/lying down/w. hot drinks/food/at night

often Hx of heartburn

in serious cases can>dysphagia, haematemesis, malaena

Question 32

Causes of oesophagitis (6)

Answer 32

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

Question 33

Rx of oesophagitis

Answer 33

lanzoprazole

Question 34

Features and subtypes of globus (3)

Answer 34

feeling of lump in throat, often Hx of anxiety

globus hystericus: functional

globus pharyngeus: due to cricothyroid overactivity

Question 35

Important questions to ask in dysphagia Hx (6)

Answer 35

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

Question 36

Ix for dysphagia (5)

Answer 36

FBC (anaemia)

U+E (dehydration)

CXR-mediastinal fluid level, no gastric bubble, aspiration

Upper oesophageal endoscopy +/- biopsy

2nd line: video fluoroscopy