Throat Flashcards
Define retropharyngeal abscess
Neck infection involving abscess formation in the space between the pre-vertebral fascia and the constrictor muscles
Epidemiology of retropharyngeal abscess
Peak incidence in children between 3-5 years
- increased incidence of URTIs and oropharyngeal trauma
More common in males
Pathophysiology of retropharyngeal abscess
45% occur secondary to URTI - strep viridians - staph aureus - strep epidermis - beta-haemolytic strep Occur with accidental trauma - foreign body ingestion 28% idiopathic
Presentation of RPA
Spiking fever
Neck pain or torticollis - irritation of sternocleidomastoid
Odynophagia/dysphagia - difficult to swallow past abscess, drooling may occur
Neck/oropharyngeal swelling
Lymphadenopathy
Stridor
Decreased oral intake, malaise, irritability
Ix for RPA
FBC
- raised WCC especially neutrophils
CT neck with contrast - ring-enhancing lesion in retropharyngeal space
X-ray of neck - if CT unavailable
USS - lymphadenopathy and fluid collection
Culture of pus from surgical drainage
Mx of RPA
Emergency - airway compromise - IV corticosteroid - nebulised adrenaline - surgical drainage - ceftriaxone + clindamycin - supportive care and analgesia No airway compromise - ceftriaxone + clindamycin - IV corticosteroid - surgical drainage - supportive care + analgesia
Complications of RPA
Recurrence of abscess
Necrotising fasciitis
Mediastinitis
Define Ludwig’s Angina
Infection of space between floor of mouth and mylohyoid
- most commonly a/w dental infection
Presentation of Ludwig’s Angina
Swelling of floor of mouth Painful mouth Protruding tongue Airway compromise Drooling
Ix for Ludwig’s Angina
CT neck
Panoramic x-ray - periapical radiolucency around abscesses and periodontal bone loss
Mx of Ludwig’s Angina
Secure airway
IV abx
Surgery to drain
Define parapharyngeal abscess
Collection in parapharyngeal space - potential space postero-lateral to oropharynx and nasopharynx divided by styloid process Risk of damage to carotid sheath - common carotid artery - internal carotid artery - internal jugular vein - vagus nerve - deep cervical lymph nodes
Presentation of parapharyngeal abscess
Hx of febrile illness Odynophagia Trismus (reduced opening of the jaw) Reduced neck movement Swelling in neck around upper part of SCM
Mx of parapharyngeal abscess
Secure airway
IV abx
Surgical drainage
Define acute epiglottitis
Cellulitis of supraglottis that may cause airway compromise
Epidemiology of acute epiglottis
Most common between 3-5
Pathophysiology of acute epiglottitis
Supraglottis becomes infected
- most commonly haemophilus influenzea
- strep pneumoniae, staph aureus and MRSA
- may occur secondary to trauma, ingestion or thermal injury
Inflammatory pathways lead to oedema and intense swelling of epiglottis
Classification of acute epiglottitis
Class 1 - slight swelling - entire vocal cord visualised Class 2 - moderate swelling of epiglottitis - >50% posterior cord visible Class 3 - severe swelling - < 50% of posterior cord visible
Presentation of epiglottitis
Acute onset High fever in very ill toxic looking child Intensely painful throat - prevents speaking and swallowing, may cause drooling Soft inspiratory stridor Rapidly increasing resp difficulty Tripod position Decreased oral intake Hot potato voice
Ix for epiglottitis
Laryngoscopy - swelling of supraglottic structures
Lateral neck radiograph - enlarged epiglottitis
Blood cultures
Mx of epiglottitis
Urgent hospital admission - call senior anaesthetist, paediatrician and ENT surgeon Secure airway Supplemental O2 IV abx Dexamethasone
Prevention of epiglottitis
HiB vaccine
- part of 6 in 1 at 8, 12 and 16 weeks
HiB/MenC at 1 year
Complications of epiglottitis
Resp failure
Mediastinitis - infection spreads to retropharyngeal then mediastinal space
Features of parotid swelling
Anterior to ear
Swelling may be due to neoplasm, infection, obstruction or autoimmune
75% of tumours are benign
Surgical removal 1st line for neoplasms
Features of jugulodigastric node swelling
Angle of mandible
Commonly enlarged in tonsillitis
Features of submandibular node swelling
Inferior border of mandible
May be enlarged due to salivary duct stones, sialadenitis, Sjogren’s syndrome, cysts or infections
50% of neoplasms are malignant
Features of carotid body swelling
Tumour or aneurysm At bifurcation of common carotid artery Aneurysm mx - watchful waiting - regular CT/MRI, anti-hypertensives, statins, thrombolysis - surgical repair - stent graphting
Features of thyroglossal cyst
Midline between hyoid bone and thyroid gland
Painless, smooth and cystic
Painful if infected
Caused by birth defect - remnant of thyroglossal duct cyst
Moves up on protrusion of tongue and swallowing
Only remove if affects breathing/swallowing or infected
Features of Branchial cyst
Anterior border of SCM
Generally present in late childhood/early adulthood
Painless mass that is noticed when becomes infected secondary to URTI
Remnant of brachial cleft - squamous epithelium surrounded by lymphoid tissue
Does not move on swallowing
Conservative mx of surgical excision - risk of damage to IJV, ICA, CN VII
Features of a thyroid nodule
At level of thyroid
Tissue or fluid within otherwise normal thyroid gland
Malignancy rare
- worrying symptoms = hoarse voice, rapid increase in size
- more common in males or prior radiotherapy
Located at edge of thyroid gland, often felt in a lump in throat
Measure TSH and anti-thyroid antibodies
Consider excision or treatment of thyroid disease
Features of Virchow’s node
Left-sided supraclavicular lymph node
Metastases of malignancy
- abdo - gastric, kidney, ovarian, testicular
- lymphoma - Hodgkin’s
Ix for neck masses
Neck USS
CXR
Bloods - FBC, TFTs
USS guided fine needle aspiration
Define obstructive sleep apnoea
Episodic complete or partial upper airway obstruction during sleep
Epidemiology obstructive sleep apnoea
4% of men
2% of women
Increases with age
Risk factors for OSA
Obesity Large neck circumference Maxillomadibular anomalies - excessive protrusion of upper or lower incisors Adenotonsillar or tongue hypertrophy FHx Hypothyroidism Down's syndrome Smoking
Pathophysiology of OSA
Episodic apnoea caused by dynamic narrowing of upper airway during sleep
Upper pharyngeal dilator muscle activity decreases with sleep onset and more in REM sleep
Pharynx vulnerable to collapse at end of expiration due to loss of neural tone of dilators and loss of positive intraluminal pressure
Presentation of OSA
Collateral hx from bed partner Episodic apnoea - terminated by loud snore Episodic gasping Restless sleep Excessive daytime sleepiness
Ix for OSA
Polysomnography - apnoea hypopnea index Portable multichannel sleep tests - assess nasal pressure, oximetry, thoracoabdominal effort sensors, HR Fibreoptic endoscopy TFTs CXR - obstructive lung disease ECG - right ventricular failure
Mx of OSA
CPAP Upper airway surgery Mandibular position devices Weight loss Modafinil - reduce persistent hypersomnolence Positional therapy
Define tonsillitis
Acute infection of parenchyma of palatine tonsils
Epidemiology of tonsillitis
15-30% of children with sore throat have bacterial tonsillitis
Most common in ages -
Most common in winter and early spring
Pathophysiology of tonsillitis
Usually viral - rhinovirus - coronavirus - adenovirus Common bacteria - group A beta haemolytic strep - strep pneumoniae - haemophilus influenzae Local inflammatory pathways result in oropharyngeal swelling, oedema, erythema and pain
Presentation of tonsillitis
Pain on swallowing Fever Tonsillar exudate Sudden onset sore throat Headache N+V Abdo pain Cough Runny nose Tonsillar erythema and enlargement Swollen, painful anterior cervical lymph nodes
Ix for tonsillitis
Throat culture
Rapid streptococcal antigen test
Criteria for Fever PAIN score
1 point for
- fever
- purulent tonsils
- acute onset - less than 3 days
- inflamed tonsils
- no cough/coryzal symptoms
Significance of fever pain score
0-1 = unlikely bacterial - no abx 2-3 = possible bacterial - delayed abx 4+ = likely bacterial - abx
Mx of tonsillitis
Phenoxymethylpenicillin - amoxicillin will cause maculopapular rash in presence of EBV Supportive care - paracetamol and ibuprofen Corticosteroids - severe swelling in children > 12 Tonsillectomy - recurrent episodes
Differentials for tonsillitis
Infectious mononucleosis - doesn't resolve within 1 week - associated with generalised lymphadenopathy, splenomegaly, hepatomegaly, persistent weight loss - avoid contact sports Peri-tonsillar abscess (quinsy) - more severe symptoms - sore throat lateralised to one side - hot potato voice - confirmed by aspirate - mx by draining abscess
Epidemiology of head and neck cancers
M:F = 2:1
Risk factors for head and neck cancers
Alcohol
Tobacco
Beetle nut chewing - oral cavity
Chinses ethnic origin - nasopharyngeal
Pathophysiology of head and neck cancers
90% squamous cell
Presentation of head and neck cancers
Dysphonia Dysphagia Stridor / dyspnoea Neck mass/lump Pain Bleeding from nose/mouth Nasal blockage
Ix for head and neck cancers
Examination under anaesthetic - laryngopharyngoesophagoscopy CT neck USS guided fine needle aspiration Open biopsy CT chest
Mx of head and neck cancers
Palliation Curative - radiotherapy - chemotherapy surgery
Approach to a goitre
Confirm whether intra or extra thyroidal
Neck USS
Cervical lymph node USS to exclude malignancies
Assess hormonal activity
Presentation of a goitre
Hyperthyroidism Hypothyroidism Local compressive symptoms - dysphonia - dysphagia - stridor
Risk factors for thyroid malignancy
Male < 20 or > 60 Rapid growth Prior neck radiotherapy FHx
Causes of thyroid swelling
Benign, euthyroid hyperplasia/neoplasm - colloid nodules - overgrowth of thyroid tissue - thyroid adenomas - homogenous, solitary, well-encapsulated tumours of follicular epithelium Benign, hyperthyroidic hyperplasia - toxic adenoma - autonomously hyper-functioning thyroid nodules, increased uptake of radioactive iodine Malignant neoplasm - papillary thyroid cancer - follicular thyroid cancer - medullary thyroid cancer - anaplastic thyroid cancer Congenital - thyroid cysts - thyroglossal duct cysts Infections/inflammatory - acute suppurative thyroiditis - subacute granulomatous thyroiditis - hasimoto's - graves Non-thyroidal - enlarged parathyroid glands - metastasis
Mx of goitre
Non-neoplastic
- conservative
- surgery - compressive symptoms, cosmesis or patient preference
- hemithyroidectomy preferable
Neoplastic
- adenomas
- no further treatment after diagnostic hemithyroidectomy
- carcinoma
- total thyroidectomy
- post op radio-iodineComplications of thyroid surgery
Post-op haemorrhage
Vocal cord palsy
Airway obstruction
Hypocalcaemia
Define acute sialadenitis
Inflammation and swelling of salivary glands
Causes of acute sialadenitis
Viral - mumps - coxsackievirus - echovirus - HIV Bacterial - staphylococcus Chronic sialadenitis is rare - TB - sarcoidosis - HIV - syphilis
Presentation of acute sialadentits
Fever Pain Dysphagia Facial swelling - unilateral Exudates of pus from salivary gland opening
Ix of acute sialadenitis
Culture and sensitivities of exudate from duct
FBC - raised WCC
Facial radiographs - sialoiths
Mx of acute sialadentitis
Broad spec abx Conservative - hydration - pain relief - sialagogues
Define sialoliths
Stones in salivary duct causes obstruction and subsequently to pain and swelling
- worse during meals
Most likely in submandibular gland
Ix for sialoliths
USS
Sialogram - x-ray looking at glands and ducts
Mx for sialoliths
Conservative - analgesia - hydration - sialagogues Radiological removal Surgery - intraoral removal of palpable stones - removal of salivary gland
Complications of sialothis
Sialadenitis
Abscess formation
Define Sjogren syndrome
Autoimmune lymphocytic inflammation into ductal tissue of secretory glands
Presentation of sjogren syndrome
Dry eyes
Dry mouth
Enlarged salivary glands
Increased risk of lymphoma
Types of Sjogrens syndrome
Primary
- without connective tissue disease
Secondary
- with connective tissue disease - RA
Diagnosis of Sjogrens syndrome
Schirmer’s test - measures tears
Anti-Ro and anti-La antibodies
Minor salivary gland biopsy
Mx of Sjogrens syndrome
Artificial tears
Salivary subsitutes
