Throat Flashcards
Investigations for vocal cord palsy
- Chest X-ray
- Computed topography of the skull base to mediastinum (aortic arch) (to check entire course of recurrent laryngeal for lesions / trauma)
+/- USS thyroid
+/- Oesophagoscopy - HBA1C (diabetes)
- ACE-I levels (? Sarcoid)
- Mantoux text (TB)
Remember 1/3 idiopathic 1/3 neoplasia 1/3 iatrogenic / traumatic (surgery)
Causes of unilateral vocal cord palsy
Left > affected than right as longer course, therefore more places for lesions to affect it
Generally:
* 1/3 Trauma (e.g to vocal cord via intubation or to recurrent laryngeal e.g. thyroid surgery, cartoid endarterectomy)
* 1/3 Neoplastic (e.g. Thyroid, bronchus, oesophagus etc.)
* 1/3 Idiopathic (likely viral neuritis)
Other:
- Infective (e.g Viral, Lyme disease, TB)
- Neurotoxins (mercury)
- Autoimmune (Sarcoid, RA, Crohn’s, PGA)
- Diabetes
- Thoracic lesions e.g aortic aneurysm, mitral stenosis etc
Pathology of:
- Recurrent laryngeal nerve (e.g. Iatrogenic - intubation/surgery, trauma, malignancy)
- Cricoarytenoid joint (e.g RA)
- Intrinsic muscle (e.g. myopathy, malignancy)
Vocal cord palsy symptoms
- Breathy voice - adductor palsy
- Weak / hoarse voice - abductor palsy / compensated adductor palsy
- Stridor - bilateral palsy
- Difficulty swallowing
Treatment for unilateral vocal cord palsy (3)
And, when would you surgically intervene and why at this time?
- Speech and language therapy
- Injections of fillers e.g teflon, colloid
- Surgical procedures to medialise the affected cord
Wait 6 months, as occasionally the contralateral cord could compensate for the palsy, and also to allow any viral cause to resolve.
Symptoms of laryngomalacia
Number one cause of infant stridor (harsh inspiratory noises)
Mild tachypnoea
Choking and other feeding difficulties
Chest infections (aspiration)
**Snoring
Noisy breathing
Sleep-disordered breathing
Swallowing dysfunction
Nasal congestion
NORMAL CRY
Laryngomalacia prognosis
90% resolve by 2 years
Stridor characteristics in Laryngomalacia
High pitched
Crowing
Worse when crying and when supine
WILL HAVE NORMAL CRY
Description of what you see on FNE with laryngomlacia:
An omega- shaped retroflexed epiglottis
Shortened aryepiglottic folds
Dynamic collapse of the supraglottic structures on inspiration
Pathophysiology of laryngomalacia
Collapse of the supraglottic structures on inspiration causing stridor
Treatments (mins 3) for laryngomalacia
Conservative:
MDT - paediatrics, dietician, SALT
Feeding advice / upright feeding position / thickened feeds / encouraging burping / paced feeds / treating any reflux to reduce laryngeal oedema
Oxygen administration
Surgery
- supraglottoplasty (e.g if failure to thrive)
- Aryepiglottoplasty (e.g. CO2 laser)
- rarely tracheostomy
Investigations for larygomalacia (min 3)
Flexible nasal endoscopy
Laryngoytracheobronchoscopy
Polysomnography
Embyological origin of Branchial cysts
Failure of **obliteration **of 2nd branchial cleft (by fusion of 2nd branchial arch and epicardial ridge)
Branchial cleft cyst differentials?
Thyroglossal cyst
Reactive lymph node
Metastatic lymph node
Lymphoma
Cystic SCC
Carotid body tumour
Vascular malformation
Cystic hygroma
Ectopic thyroid tissue
Cat scracth disease
Atypical mycobacterium infection
USS Neck of branchial cysts - findings: (5)
- Cystic
- Well defined
- Smooth outline
- Uniformly anechoic
- Posterior enhancement
*
Aspiration of branchial cysts - findings:
- Viscous, turbid, yellow-green
- Cholesterol crystal on microscopy
What is the workup for a head and neck cancer?
Tissue biopsy for histology
Imaging of lesion
- e.g. USS guided core biopsy or USS and EUA
Once CA known:
- CT/MRI (e.g. neck for surgical planning)
- CT Thorax for staging
- PET CT for distant mets / primary
Neck lumps by location e.g. midline, anterior, posterior triangle, anywhere
Anywhere
- sebaceous cysts / other skin lesions
- Lymphadenopathy (reactive / malignant)
- Lymphoma
- Malignancy
- Infection (neck space/Ludwigs/dental abscess)
Midline
- Thyroglossal cysts
- Thyroid goitre / Cancer
- Dermoid cysts (fusion point, abocve hyoid, midline)
Anterior Triangle
- Branchial cysts (young adult, infected often, deep to junction of upper 1/3 and lower 2/3 SCM)
- Parotid lump (benign/malig/infective/stone)
- Submandibular lump (bening/malig/infective/stone)
Posterior triangle
- Cystic hygroma (low posterio triangle new born)
- Cartoid body tumour
Treatment of thyroglossal cysts:
Conservative with long course abx and repeated aspiration can be used for infections
**
They should not be incised and drained because this
would result a persistent discharging sinus.**
Sistrunk procedure (removal of cyst, body of hyoid bone, wedge of tongue base)
Risks of sistrunk procedure
Recurrence (2-8% if hyoid body excised)
Postoperative accumulation of infection or hematoma
may push the tongue base up into the airway and give rise to a ‘Ludwig’s’ angina type of airway emergency.
Why do thyroglossal cysts form?
Failure of closure of the thyroglossal duct extending from the foramen cecum in the tongue to the thyroid’s location in the neck
….following migration of the thyroid gland from tongue base (foramen caecum) to its position in the neck
Symptoms and presentatio of thyroglossal cysts
Most occur in children - mean 4yrs old, but adults can get
Midline (in 90%) swelling
Move upwards with tongue protrusion and swalling (attached to larynx)
Intermittent swelling, pain due to infection
Note left sided in 10%, right in 1%
Investigation of thyroglossal cysts
Ultrasound scan
Radio-iodine uptake scan (Prior to excision as there may be active thyroid tissue in the cyst)
MRI
What pathology is geneally found in midline between hyoid bone and cricoid cartilage?
Thyroglossal cyst
Symptoms & signs acute tonsillitis
Odynophagia
Referred otalgia
Trismus
Drooling
Fever
Fatigue
Abdo pain (kids)
Vomiting (kids)
Enlarged tonsils, hyperaemic, pus in tonsillar crypts
Tender cervical lymphadenopathy
Treatment of tonsillitis
Analgesia (paracetamol - NOT aspirin, risk Reye’s syndrome)
Fluid replacement (IV if necessary)
Antibiotics (if bacterial - Penicillin V (allergy: Clarithroymcin) or IV Benzylpenicillin, never Amoxicillin
Corticosteroids (more contraversial)
What is associated with aspirin in children and what is it:
Reye’s syndrome: rapidly worsening brain disease associated with aspirin use post virally, generally in children
What type of reaction does amoxicillin cause in GF?
Type IV hypersensitivity - rash
Post tonsillectomy haemorrhage rates and the study/audit names
NPTA (National Post Operative Tonsillectomy Audit 2005):
Post operative haemorrhage for cold steel tonsillectomy - 1.3% (1% return to theatre rate)
Post operative haemorrhage rate (all techniques, adult + children) - 3.5% with 0.8% return to theatre.
GIRFT (Getting it right first time 2019)
Post operative haemorrhage rate (all techniques, adult + children) - 8% with 1.3% return to theatre.
Indications for tonsillectomy (min. 5)
Paradise Criteria & SIGN criteria
Recurrent quinsy
Recurrent severe tonsillitis for > 1 year
Treatment for obstructive sleep apnoea
Diagnosis of tonsillar malignancy with unilaterally enlarged tonsillar
7 or more documented, clinically significant, adequetely treated sore throats in the last year
5 or more (as above) in last 2 years
3 or more (as above) in last 3 years
Tonsillits differential diagnosis (min 3)
Glandular fever (EBV)
Diptheria
Agranulocytosis
Leukeamia
Most common organism bacterial tonsillitis
Group A Beta Haemolytic Streptococcus
Investigations for tonsillitis
FBC - (Neutrophilia = Bacterial, Leucocytosis > GF)
Monospot / Paul -Bunnell test
Throat swab
Define - Supraglottis, Glottis and Subglottis
Supraglottis – From inferior surface of the epiglottis to the vestibular folds (false vocal cords) including them to the superior surface of the true cords
Glottis – Contains true vocal cords and 1cm below them (opening between the vocal cords is known as rima glottidis)
Subglottis – From inferior border of the glottis to the inferior border of the cricoid cartilage.
Define laryngeal vestibule vs ventricle
Laryngeal Ventricle / sinus of Morgagni:
slitlike, mucosa-lined, space located between the true and false vocal cords.
Laryngeal vestibule:
The part of the laryngeal cavity lying between the laryngeal inlet and vocal folds.
Classification for H&N cancer?
8th Edition of the TNM classification for head and neck cancer
Symptoms of pharyngeal pouch (8)
Halitosis
Regurgitation
Dysphagia
Weight loss
Chest infections
Aspiration
Swelling of the neck (left sided usually)
Gurgling on palpation (Boyce’s sign)
Epidemiology pharyngeal pouch
1:200,000 per year
Aetiology of pharyngeal pouch
Weakness at Killian dehiscence through the inferior constrictor between the thyropharyngeus and cricopharyngeus muscles of the infderior constrictor.
It’s a posterior pharyngeal pulsion (Zenker’s) diverticulum through the pharyngeal mucosa.
Treatment options for pharyngeal pouch (4)
- Conservative
- Laser / diathermy myotomy (Dohlmann’s procedure - divides the wall between the pouch and oesophagous)
- Endoscopic stapling (first line generally)
- Open surgical excision
Investigations for pharyngeal pouch
Flexible nasendoscopy
Contrast swallow
Complications from pharyngeal pouch surgery (10)
IMMEDIATE:
Primary haemorrhage
Surgical emphysema
Pneuomothorax
Injury to teeth
Oesophageal perforation
INTERMEDIATE:
Secondary haemorrhage (infection)
Hoarseness (recurrent laryngeal damage, permanent if divided)
Wound infection
Fistula
Mediastinitis
LATE:
Stricture
Recurrence
Causative agent of laryngeal papillomas?
HPV 6 and 11 (11 = moe aggressive disease)
Epidemiology of laryngeal papillomas
- peak incidence
- risk factors
- what dictates how aggressive disease is?
- can remission occur ?
Any age from birth to around age 5 (peal incidence 3-5).
Earelier age on onset = more aggressive disease
Remission can occur at any age
Maternal warts dsuring pregnancy a risk factor
Symptoms of laryngeal papillomas (3)
Hoarseness
Abnormal cry
Shortness of breath
Stridor (late)
Investigations for laryngeal papillomas
Microlaryngoscopy + tissue biopsy
Treatment for laryngeal papillomas
Surgical:
Microdebridement /cold steel excision or C02 laser ablation
If on both cords or at anterior commisure two operations 4 weeks apart are required to prevent web formation.
Adjuvant Medical (if px has > 4 procedures a year):
- Gardasil Vaccine (quadrivalent, given in 3 IMs)
- Antivirals e.g. Cidofovir (prevents HPV DNA synthesis) injected into lesion a number of times
- Alpha interferon
- indole-3-carbinol
(cabbage juice derivative) and immunostimulants.
Single laryngeal papilloma in and adult - management:
Liable to recur and become malignant
Remove at direct laryngoscopy.
Follow up for 5 years
Tracheostomy in laryngeal papillomas
Used rarely (as a last resort)
as risk of spreading disease distally
Risk factors for oral cancer
Smoking
Excessive alcohol consumption
Betel nut chewing
Investigations for oral cavity cancer
Biopsy
+/-Orthopantomogram (useful if ? mandible involved)
Staging CT head / neck / chest
MRI useful for soft tissue delineation
PET CT if concerns for occult spread
Treatment options for oral cavity cancer (3)
Palliation
Radiotherapy / Chemotherapy
Surgery - excision +/- neck dissection +/- reconstruction (e.g radial forearm free flap if T1/T2 / hemiglossectomy, free fibular if mandible resection)
