Hoarseness and Sore Throat Flashcards
Function of oropharynx
Voice production
Swallowing
Airway
Functions of larynx
Airway (primary role)
Airway protection via vocal cords (act as a valve)
Phonation
Function of oesophagus
Swallowing
Prevention of reflux
Functions of hypopharynx
Airway
Swallowing
Some role in vocal modulation
Function of trachea
Airway (almost exclusively)
Laryngeal symptoms
Airway compromise (felt as difficulty breathing in?) - can cause acute respiratory distress
Stridor
Change in voice (e.g. hoarseness, loss of voice, voice may break/crack/tire)
Overactive airway protection (may be due to irritable larynx; sensation of choking, loss of airway)
Underactive airway protection (symptoms of aspiration, may get frequent chest infections or productive cough; get symptoms when eating or drinking, particularly with fluids; may be unaware of fact due to neurological damage)
Pharyngeal symptoms
Difficulty swallowing
Pain (may be referred)
Change in secretions (too wet, too dry, too thick, increased or decreased)
Issues with airway patency
Globus sensation ("lumpy"/foreign body sensation)
Hoarseness
Obstruction
Bleeding
Poor coordination
Regurgitation/refluxNasopharyngeal carcinoma
SE Asia (provinces of Southern China, Malaysia, Singapore) and Mediterranean
5 important questions to ask
All laryngeal and pharyngeal symptoms
Reach a common understanding (e.g. “I can’t breathe” vs. “I feel breathless”)
Trigger/s (e.g. relationship to eating/environment, acute vocal injury, URTI, trauma e.g. intubation, thyroid/cervical surgery, etc)
Ongoing exacerbating factors (e.g. vocal use, hydration, smoking for risk of malignancy and due to direct irritation, reflux, inhaled steroids - washing mouth out deals with pharyngeal deposition but not laryngeal)
Risk profile of patient (e.g. malignancy, infection)
Concerning laryngeal/pharyngeal symptoms
Rapid, severe onset of pain (supraglottitis, epiglottitis)
Airway symptoms
Constant symptoms
Progressive symptoms
Symptoms that last >2 weeks
Patient factors: risk factors for malignancy (smoking, alcohol, PHx) or uncontrolled infection (immunocompromised patients e.g. diabetics, cancer patients, used of systemic steroids)
Bleeding
Fixed dysphagia (especially dysphagia impacting on what the patient can eat)
Choking/coughing/aspiration
FHx of head and neck malignancy
Without risk factors, not higher than rest of population
Most important thing to clarify in examination: is the airway threatened?
Symptoms of progressive airway compromise (earliest to latest; intervene as early as possible!)
Decreased exercise tolerance Dyspnoea with minor exertion (increased RR) Dyspnoea at rest (increased HR) Can't lie flat Stridor (SaO2 WNL) - take action! (Variable timecourse to get to this point but once at this point can rapidly progress within secs-mins) Eerie silence Cyanosis (decreased SaO2) Death
Any concern that airway is threatened
Do not “tick the boxes”; call for help
18 yo male, previously well Sore throat for 24hrs Built from nothing over a few hours, quite localised to the throat Hurts to talk, to eat, to swallow Both ears hurt Febrile Breathing easily
Most likely tonsilitis
If more severe may be quinsy? (peritonsillar abscess, can spread into pharyngeal space, cause epiglottitis)
Abx and pain relief
3yo boy from Daylesford
Mild URTI beginning yesterday
This evening developed high fever and mild hoarseness
Refusing to eat or drink
Drooling; when asked to lie back, he refuses and becomes more upset
Epiglottitis (rapidly progressive, pharyngeal and laryngeal symptoms)
Needs immediate airway management (intubation or if you can’t tube him, tracheostomy), then Abx later
Don’t upset child because it may cause the larynx to spasm if crying, wailing (also don’t use tongue depressor, etc)
Daylesford - epidemics due to low rates of vaccination
Epiglottitis
Now extremely rare due to vaccination (can get from non-typable Haemophilus, in adults see supraglottitis predominantly from Staph)
55 yo male singer and actor
PHx adult onset asthma, recurrent bronchitis, chest pain last year during a gig (not investigated)
Intermittent sore throat and hoarse voice, gradually getting worse over last 3 months on tour
Now hoarse all the time, coughs +++ when drinks cold fluids
Trauma
Malignancy (may be smoker, drinker)
94yo male nursing home resident
Intermittent hoarseness with a “gurgly” voice
Coughs ++ during meals and for several hours afterwards
2 admissions to RMH for pneumonia in the last 12 months
Underactive vocal cords (may be discoordinated pharyngeal musculature and weak reflexes just due to age or may be neurological problem e.g. stroke, neurodegenerative disorder, trauma from past surgery)
Barium swallow examination in AP and lateral view
Film shows posterior blind-ended duplication arising in the lower cervical area; most likely diagnosis is pharyngeal pouch (Zencker’s diverticulum; out-pouching of mucosa, some food ends up there, stays until pouch is full and then empties out again in laryngeal inlet, causing coughing, choking and aspiration where the airway reflexes are not perfect)
Treatment
Behavioural modification: avoid triggers, diet, exercise, sleep environmental modification, mood management
Non-pharmacological treatments: hygiene measures, moisturisers, saline rinsing, dietary supplements, nasal sprays, etc
Pharmacological: topical, enteral, transcutaneous, injections
Interventional (minimal - endoscopic, angiography, etc; maximal - open surgery, radiation, etc)
Indications for tonsilectomy
> 6 episodes of acute bacterial within 12 months, 4-5 in 2 years, 3/year for 3 years running
2 quinsys (>50% likely to get another)
Diagnostic biopsy if suspected malignancy
Parapharyngeal space, styloid process can be reached through it - access procedure
Adenotonsilar hypertrophy resulting in airway compromise (OSA, sleep disordered breathing, etc)
Indications for adenoidectomy
Nasal obstruction
Recurrent ear infections (halves the chance of needing grommets)
Diagnostic purposes
Sleep disordered breathing
Adenotonsilar hypertrophy (can be presentation of HIV seroconversion illness)
Cricothyroidotomy vs tracheostomy
In adult: cricothyroidotomy preferred, much easier (divet below laryngeal prominence is cricothyroid membrane, quite superficial especially on extension of neck)
Trachea starts anteriorly, slopes posteriorly - lots in front in the way for tracheostomy (thyroid gland, huge risk of bleeding, fat, arteries, etc)
Need tracheostomy if stenosing laryngeal carcinoma
Children require tracheostomy (cricothyroid and thyroid membrane overlap)
