Throat Flashcards
examination foreign body
where the suspected foreign body is located. For the ear, direct visualisation of the FB is usually possible with otoscopy, whilst for the nose, use an age-appropriate Thudicum speculum (size 0 or 1 for children, 2 or 3 for adults) and a head-torch or otoscope is usually required.
For FB in the pharynx, visual examination of oropharynx can be attempted using a Lack’s tongue depressor and head-torch. Palpate for points of tenderness on the neck (and assess whether this moves on swallowing), as well as for surgical emphysema. A flexible nasal endoscopy (FNE) is usually required as an adjunct for examination
red flags for foreign bodies
Any signs of airway compromise, such as stridor, dysphonia, or drooling
Any signs of oesophageal perforation, such as chest pain, features of sepsis, or surgical emphysema
Any history of button battery ingestion
investigations foreign body
not usually required
plain film radiograph lateral soft tissue neck
plain film radiographs - CXR - mediastinal widening
CT neck
management foreign body
ear - microsuction with a Zoelner sucker, crocodile forceps, Jobson-Horne probes, or wax hooks or under GA
nose - similar to ear, removal under anaesthesia
throat - Magill forceps. Otherwise, removal should be attempted with endoscopy under GA (either via pharyngoscopy / laryngoscopy or rigid oesophagoscopy)
urgency of endoscopy
Emergency endoscopy
Any red flag signs
Any sharp or long (>5cm) object in the oesophagus
Urgent endoscopy (within 24 hours)
Oesophageal obstruction (unable to swallow saliva)
Blunt oesophageal FB
Magnets proximal to the duodenum
Non-urgent endoscopy
Disc or cylindrical batteries which have passed into stomach without signs of injury
Coins may be observed for up to 24 hours before removal if asymptomatic
soft food bolus examination
sharp foreign body ingestion (e.g. bones) or any red flag signs, then manage as for an ingested FB. If the patient is unable to swallow their saliva, this is often a serious sign.
food boluses
pre existing oesophageal dysmotility or stricutures
medical therapies - Carbonated drinks (e.g. coke or lemonade)
Glucagon 1-2mg IV
Hyoscine butylbromide (Buscopan) 20mg IV
Prokinetics, such as metoclopramide or erythromycin
red flags for neck lump
Hard, painful and fixed lump
Associated otalgia, dysphagia, stridor, or hoarse voice
Unilateral nasal symptoms such as epistaxis, discharge, or congestion
Unexplained weight loss, night sweats, or fever or rigors
Cranial nerve palsies
In children, red flag symptoms also include the presence of a supraclavicular mass, lumps larger than 2cm, and a previous history of malignancy.
ddx neck lump
Infective
Reactive lymphadenopathy – increase in size of the cervical lymph nodes in response to infection
Sialadenitis
Neoplastic
Lymphoma – a haematological malignancy that commonly causes lymphadenopathy
Head and Neck Cancer or Salivary Gland Tumour
Metastatic disease spread
Skin lump, ranging from benign (e.g. lipoma) to malignant (skin cancer)
Vascular
Carotid body tumour (see below)
Inflammatory
Sarcoidosis
Traumatic
Haematoma
Autoimmune
Thyroid disease, such as Graves’ disease
Congenital
Cystic hygroma (see below)
Thyroglossal cyst (see below)
Branchial cyst (see below)
Dermoid cyst – a cystic type teratoma, form along the lines of embryological fusion, can present as midline painless lumps, more common in children and young adults
investigations neck lump
USS +/- fine needle aspiration
CT/MRI
cystic hygroma
a benign fluid-filled sac caused by a malformation of the lymphatic system. They can be found anywhere on the body, but classically presents in the axilla or posterior triangle of the neck.
diagnosed before aged 2 years, soft painless fluctuant masses that transilluminate. They can be associated with congenital conditions (e.g. Turners syndrome) and can grow large enough to cause airway obstruction or dysphagia
tx with surgical excision or lymphatic sclerotherapy
carotid body tumours
enign neuroendocrine tumours that arise from the paraganglion cells of the carotid body. The carotid body is made up of a cluster of neuroendocrine cells, whereby sporadic (or hereditary) mutations lead to the formation of paragangliomas (Fig. 4).
A carotid body tumour will present as a pulsatile painless neck lump, often with a bruit present on auscultation*. Carotid paragangliomas are slow growing, but can become large enough to compress surrounding cranial nerves, leading to palsies. Rarely, patients can present in cardiac arrhythmia if the carotid sinus is stimulated by compression from the tumour.
Carotid body tumours can be managed conservatively, surgical excision, radiotherapy
thyroglossal cyst
ongenital fluid filled sac, commonly presenting in younger patients (typically <20yrs) and have equal incidence between men and women.
present as a palpable painless midline mass* (Fig. 5A) that move up with swallowing and protrusion of the tongue. When infected, they can increase in size and become painful.
Standard treatment is surgical intervention, with the modified Sistrunk procedure being the most widely used. The central body of the hyoid bone is removed to allow complete removal of the entire thyroglossal tract.
branchial cyst
congenital masses which arise in the lateral aspect of the neck, typically anterior to the sternocleidomastoid (SCM).
During the fourth week of development, branchial clefts form ridges known as branchial arches, involved in the formation of a number of structures in the head and neck. Incomplete obliteration of these clefts will result in the formation of branchial cysts.
They present as palpable masses anterior to SCM, typically unilateral (Fig. 6). When infected, they can increase in size and become painful. Larger branchial cysts can result in dysphagia, dysphonia, and difficulty breathing.
Surgical excision is the definitive treatment. Sclerotherapy can be offered as an alternative to surgery in certain cases
branchial cyst ddx
cystic metastasis from squamous cel carcinoma of head and neck region
epiglottitis
tonsillitis
peritonsillar abscess
glandular fever
laryngomalacia
most common congenital airway disorder and the most common cause of stridor in neonates
laryngomalacia epidemiology
presents within the first few weeks of life and resolves within the first two years, although in rare cases it can extend later into childhood. Symptoms peak at 6-8 months when respiratory function increases before the larynx (and hence diameter for airflow) increases in size
laryngomalacia pathophysiology
characterized by immature laryngeal cartilages collapsing over the inlet to the larynx causing inspiratory stridor. In particular these cartilages are:
A long, curled, ‘omega-shaped’ epiglottis
Tall, bulky aryepiglottic folds
risk factors laryngomalacia
immaturity of the cartilaginous structure or unco-ordinated neuromuscular laryngeal movement
Patients with neuromuscular disease (either acquired or congenital) do appear to have a higher incidence of laryngomalacia. Patients with more severe presentations are also more likely to have associated airway lesions such as vocal cord paralysis, subglottic stenosis and tracheomalaciac
clinical features laryngomalacia
High-pitched inspiratory stridor worse on lying flat or on exertion
Normal cry (but stridor may be worse when distressed)
Episodes may occur with a concurrent URTI which may cause mild inflammation, mucosal oedema and associated narrowing of the airway.
signs of more severe cases laryngomalacia
Respiratory distress
Dyspnoea with intercostal / sternal recession
Feeding difficulties or episodes of suffocation/cyanosis whilst feeding
Poor weight gain
Obstructive sleep apnoea
desaturation
ddx laryngomalacia
vocal cord paralysis
subglottic stenosis
tracheomalacia
management mild case laryngomalacia
not require tx
reassurance - will resolve by 12-16 months but symptoms may peak at 6 months and may be exacerbated following respiratory tract infections.
Gastro-oesophageal reflux can exacerbate symptoms and appropriate anti-reflux medications may be considered.
severe cases management laryngomalacia
elective surgery (e.g. Endoscopic aryepiglottoplasty aka supraglottoplasty)
life threatening laryngomalacia management
keep child calm
senior paediatrician
Humidified oxygen
Nebulised adrenaline (1ml of 1/1000 with 4ml of normal saline)
Oral or IV Dexamethasone (Cannulation should only be carried out only when necessary to not further distress the child. If there is a risk of it precipitating respiratory arrest it should be performed where there are appropriate resuscitation facilities).
Heliox
ventilatory support may be required
laryngomalacia prognosis/complications
self resolve
rare cases - surgical intervention such as aryepiglottoplasty
if have concurrent airway condition poorer outcome
epiglottitis 4d’s
Dyspnoea
Dysphagia
Drooling
Dysphonia (muffled “hot potato” voice in 54%
