Throat Flashcards
Tonsillectomy is an operation that is usually performed with?
-Adenoidectomy
What are the indications for a tonsillectomy?
- recurrent acute tonsillitis(3 or 4 attacks per year)
- chronic tonsillitis(chronic sore throat in adults)
- snoring and sleep apneoa
- peritonsillar abscess(quinsy)
What are the contraindications to tonsillectomy?
- bleeding disorders
- recent pharyngeal infection
- weight less than 15 kg or obese
What are adenoids?
Adenoids are a collection of lymphoid tissue in the postnasal space
At what age do the adenoids hypertrophy?
The grow rapidly at the age of 6 and then become significantly smaller by 12 years
What are the symptoms of adenoids?
- Anosmia
- nasal obstruction
- malaise
What are two otological conditions associated with eustachian tube blockage in children?
- acute otitis media
- otitis media with effusion
What are the 4 symptoms of adenoid hypertrophy?
- nasal obstruction
- hyponasal speech(sounds like a cold)
- OME, acute otitis media
- snoring and sleep apneoa
What is secondary haemorrhage?
- usually occurs 5-10 days post adenoidectomy
- treated with antibiotics and bed rest
What is the function of the larynx?
- protects the tracheobronchial tree
- voice production
Name the 3 salivary glands?
- parotid glands
- submandibular glands
- sublingual glands
What type of secretion do the parotids produce?
serous
What typeof fluid do the submandibular glands produce?
seromucionous
Why do lymph nodes enlarge?
- primary disease of the nodes
2. secondary to pathology in the head/neck
What is the function of the saliva?
- lubrication of food
- mastication and deglutition(swallowing)
- assists articulation
- oral hygiene
What nerve are the laryngeal nerves supplied by?
recurrent laryngeal nerve
What is the cricothyroid supplied by?
superior laryngeal nerve
Where does sensation to the glottis/subglottis come from?
-recurrent laryngeal nerve
What innervates the supraglottis?
The superior laryngeal nerve
What innervates the tongue muscles?
hypoglossal nerve
Taste to the anterior two thirds of the tongue is via the?
chordi tympani nerve
What are the main signs and symptoms of oral disease?
- pain
- masses
- ulceration
- haemorrhage
- halitosis
- discolouration
Are tongue masses always considered neoplastic/non-neoplastic?
Neoplastic
What is special about median rhomboid glossitis?
It presents as a red lesion on the tongue and is benign
What is a ranula?
It is a cystic lesion in the floor of the mouth(which is caused by blockage of the sublingual salivary gland)
Define aphonia?
It is the absence of a voice or if it is merely a whisper
What is dysphonia?
Dysphonia is the alteration in the quality of voice
What are the causes of dysphonia?
- inflammatory laryngeal lesions
- neoplastic lesions
- neurologivcal lesions
- systemic causes
What is the primary cause of acute laryngitis?
And after how long must we refer to an ENT specialist?
An upper respiratory tract infection and sometimes shouting(vocal abuse)
-after 3 weeks of dysphonia
What causes unilateral inflammatory polyps on the larynx?
–inhalation of fumes, chemicals, tobacco
How do we treat unilateral inflammatory polyps on the larynx?
By removing the polyps on the larynx
What are the risk factors for chronic laryngitis?
- smoking tobacco
- alcohol
- laryngopharyngeal reflux
- abuse of vocal cords
What does the larynx look like on chronic laryngitis?
- leukoplakia(white patches)
- hypertrophic epithelium
What causes laryngopharyngeal reflux?
When Gastro-oesophageal reflux is above the lower oesophageal sphincter and it allows acids, pepsin, and bile salts which can be damaging to the larynx
What are the 3 examples of central neurological lesions of the larynx?
- pseudobulbar palsy
- multiple sclerosis
- cerebral pasly
What are the 3 examples of peripheral neurological lesions of the larynx?
- motor neurone disease
- myasthenia gravis
- vagus nerve lesions and recurrent laryngeal nerve lesions
Why is the left recurrent laryngeal nerve involved in pathology?
Because the left is longer-it goes from the cranium via the base of the skull, neck, thorax, and into the larynx whereas the right goes into the right
What is the most common cause of vocal nerve palsy?
malignancy in the neck or the chest
What is spasmodic dysphonia? And what is it caused by?
-It is primarily neurogenic can be caused by family conflict, bereavement car accidents etc.
It can be treated with botulinum toxin injection into the vocal cords
What are the systemic causes that cause dysphonia?
- hypothyroidism- causes chronic oedema of the vocal cords
- angioneurotic oedema- type 1 allergic response causing laryngeal oedema
- rheumatoid arthritis can cause vocal cord immobility
What is the management of patients with systemic causes of dysphonia?
medialisation
Why are children more prone to upper airway obstruction?
Because they have narrower airways and they have softer cartilage that collapses
What is stridor?
It is noisy breathing that results from narrowing of the airway at or below the larynx
Narrowing of the __ would cause inspiratory stridor:
-The supraglottis
Narrowing of the ___ would cause biphasic stridor:
-The glottis or the cervical trachea
Narrowing of the ___ would cause expiratory stridor:
-bronchial narrowing
What is stertor?
Noisy breathing due to narrowing above the larynx, for example adenotonsillar hypertrophy
What is another name for laryngotracheobronchitis?
Croup
What is the cause of laryngotracheobronchial bronchitis?
At what age does it usually occur?
para-influenza
From 6 months to 3 years
What are the clinical signs of laryngotracheobronchitis?
- pyrexia
- painful barking cough
- gross mucosal oedema in the lower respiratory tract
- inspiratory stridor which can develop into biphasic stridor
- sometimes complete airway obstruction
What is the management of croup?
- oxygen administration
- humidifier and warm air to loosen the thick mucus
- nebulised or systemic steroids may be helpful
- intubation for progressive and severe cases(for only 2-5 days)
- tracheostomy is the last resort
What organism causes suraglottitis/epiglotitis?
Group B Haemophilus influenza and is characterised by intense swelling in the supraglottis
What age group does supraglottitis/epiglotitis occur in and what is the clinical presentation?
- pyrexia
- stridor
- open mouth breathing and raised chin
- dribbling
Why is epiglottitis an emergency?
Because the time between stridor and total obstruction can be very short
What is the management of epiglottitis?
- adrenaline/epinephrine nebulisers
- intubation by anaethetist and tracheostomy by ENT specialist
- intravenous 3rd generation cephalosporins are also NB
What is the common congenital tumour causing stridor?
- Subglottic haemangioma
- It is self-limiting as it regresses after 1 year
What is laryngomalacia?
It is the weakening of the supra-glottic framework which collapses on inspiration particularly during exertion and crying.
It mostly occurs in boys and presents with the omega sign of the epiglottis
When does laryngomalacia resolve?
It resolves around the age of 2 yrs and surgery is needed if the child fails to thrive
What are 7 signs of severe respiratory failure caused by airway obstruction?
- cyanosis
- nasal flaring
- tachycardia
- tachypnoea
- use of accessory muscles of respiration
- chest wall recession
- tracheal plugging
What is subglottic stenosis and what is it caused by?
- stenosis of the subglottis and is caused by prolonged intubation especially in premature babies. It can also be congenital
- It presents with stridor on exertion and a respiratory infection
What is the management of subglottic stenosis?
- tracheostomy
- laser excision
- laryngeal reconstructive surgery
What isthe cause of foreign body inhalation in 1)adults and 2)children?
1) alcohol or a psychiatric problem
2) most commonly happens
What are the common symptoms of foreign body obstruction?
-sudden coughing, wheezing or stridor in a previously well child
-chest infection from it lodging in a small airway
But sometimes patients are symptomless for a long time
How do you dislodge a foreign body from a 1)child
2)adult?
You need to lift the child with their legs up and smack them on their back
2) For adults you need to do the Heimlich maneovre
What is a retropharyngeal abscess and how does it occur?
It is now rare but occurs as a swelling and inflammation in the retropharyngeal space secondary to oropharyngeal infection
What is the presentation of a child with a retropharyngeal abscess and how do we treat it?
- Hyperextended neck which is held rigid
- urgent parenteral antibiotics are used and surgical drainage is done to avoid spontaneous rupture and inhalation of pus
What is respiratory papillomata caused by?
It is caused by Human papilloma virus
What is the treatment for respiratory papillomata?
- carbon dioxide laser
- sharp dissection under microscope
- medical treatment like inteferons may be used as well
What does acute laryngitis present with and what is the management?
- it presents with hoarseness and throat discomfort and inflammation of the vocal cords
- management is voice rest, steam inhalation and avoidance of smoke and spirits
What is Ludwig’s angina and how does it what are the risk factors?
It is rapid swelling cellulitis of the sublingual and submaxillary spaces(particularly of the floor of the mouth)
Risk factors include: smoking, poor hygiene, alcohol, dental infection
What is the clinical picture of Ludwig’s angina??
- fever
- pallor
- dysphagia(difficulty swallowing)
- drooling
- odynophagia(pain when swallowing)
What is the management of Ludwig’s angina?
- incision drainage
- antibiotics
- incision and tracheostomy if necessary
What is the clinical presentation of infective conditions associated with sore throats?
- painful throat
- cervical lymphadenopathy
- fever
Candidal infection usually occurs in patients that are immuno-compromised caused by?
- AIDS
- Chemo
- radiotherapy
- diabetes
What is a peritonsillar abscess and what causes it?
-a condition where pus forms between the tonsil capsule and the the constrictor muscle
What are the symptoms/signs of a pt with peritonsillar abscess?
- hot potato voice
- inability to swallow causing dribbling
- trismus(difficulty opening the jaw)
- severe unilateral sore throat
- uvula pushed to the opposite side of the midline
What is the management of peritonsillar absess?
- incision and drainage
- AB(Penicillin as the organism is haemolytic streptococcus. If the patient is allergic then give erythromycin)
If patients have a chronic sore throat, what must we think about?
-malignancy of the oral cavity or pharynx
What are the causes of acute sore throats in children?
- acute pharyngitis
- tonsillititis
When would we consider doing a tonsillectomy in Quinsy?
Type 1. 20% of quinsies recur and 80% do not recur in this group
Type 2. 80% of the quinsies recur and 20% do not and so you need to do a tonsillectomy in these patients
If phayngitis is caused by a viral process, does it need AB?
NO
What is the clinical picture of a child with acue tonsillitis?
- systemically unwell
- dysphagia
- pyrexia
- halitosis
- cervical lymphadenopathy
Whta is the management of a child with acute tonsililitis?
- Bed rest
- Antibiotics-penicillin(parenterally if necessary)
- analgesia(paracetamol to treat the pyrexia)
- Adequate fluids
What gives a similar picture of acute tonsilitis in a child?
Diphtheria tonsil is usually covered in a membrane)
What are the causes of a chronic sore throat?
- chronic tonsilitis
- post-nasal drip
- smoking
- alcohol
- Acid reflux
- chronic laryngitis(non-infective)
What is another name for infectious mononucleosis?
Who does it usually occur in?
- Glandular fever
- It presents in teenagers because of the transmission of saliva
What is the clinical picture of a teenager with infectious mononucleosis?
- cervical lymphadenopathy
- hepatosplenomegaly
- dysphagia
- haemorrhagic petechiae on the hard palate
- membranous exudates on large tonsils
How do we diagnose infectious mononucleosis?
-positive monospot or paul bunnell test
What is Eagle syndrome?
It is stylohyoid ligament calcification that presents with unilateral constant pain and responds to NSAIDS and sometimes surgery
What is dysphagia?
Difficulty swallowing
- swallowing occurs in 3 phases: oral, pharyngeal and oesophageal phase
- swallowing takes 8-10 seconds
What disorders make swallowing liquids more difficult than food?
-neurological disorders
How do we examine the throat for causes of dysphagia?
-use a mirror or a flexible rhinolaryngoscope which makes it possible to look at the hypopharynx and view the vocal cord paralysis and possible pooling of saliva
What investigations would you do in Dysphagia?
- lateral X-ray
2. barium swallow to view the hypopharynx, oesophagus and stomach
What are the causes of acute dysphagia?
- Tonsillitis
- Apthous ulceration
- swallowed foreign bodies
- ingestion of caustic liquids
- tracheostomy
What are the causes of chronic dysphagia?
- neuromuscular disorders-myasthenia gravis, multiple sclerosis, stroke , parkinsons disease
- intrinsic causes- neoplasm, achalasia, pharyngeal pouch, strictures
- extrinsic causes-aortic aneurysm, thyroid enlargement
- systemic causes-scleroderma
- psychosomatic- globus pharyngeus
- Age- 2% will present with it after 65 years
Where in the respiratory system does a neoplasm of the intrinsic muscles occur?
- The post cricoid area
- oesophagus
- piriform fossa
What is the management of a neoplasm in the pharyngo-oesohagus?
- radiotherapy
- salvage surgery
What is a pharyngeal pouch?
Also known as Zenkers diverticulum
It is a hernia that occurs in the weakened spot (Killians dehiscence) between the upper thyropharyngeas and the lower cricopharyngesus of the inferior constrictor muscle
What are the complications of having a phyrangeal pouch and how do you treat it?
-food collecting in the pouch
- pneumonitis if overspill happens
You treat it with surgery or cricopharyngeal myotomy
What should we be worried about in oesophageal strictures?
- You must biopsy it in case of malignancy
Because most oesophageal strictures are as a result of GERD, what is your management?
- medical treatment with reflux meds
Achalasia of the oesophagus is?
-failure of the cardia to relax when swallowing
-This causes abnormal stricture in the defective site and proximal dilatation of the oesophagus
This pt needs a cardiomyotomy to relieve the cardia
In which patients does pharyngeal globus usually occur in?
- middle aged women who complain of anxiety
- it could also be acid reflux causing the lump in the throat’
What medications contribute to dysphagia?
- antihistamines
- antihypertensives
- antidepressants
- anticholinergics
What is Plummer-Vinson syndrome and why is it NB regarding dysphagia??
- It’s is precancerous NBNB
- presents with a syndrome of : glossitis, cheilosis, fatigue, Iron defieciency anaemia, and also has post-cricoid oesophageal webs, and achlorhydia(decreased hydrochloric acid in stomach)
- It is associated with Rheumatoid Arthritis and Sjorgens
What are 5 examples of autoimmune causes of dysphagia?
- SLE
- Rheumatoid Arthritis
- Sjorgens syndrome
- Dermatomyositis
In regards to swelling of the salivary glands, how do you classify the pain?
- intermittent
- constant
- progressive
What can cause swelling of the parotid gland?
- neoplasm (90% being benign pleomorphic adenoma)
- Sjorgens syndrome
- sarcoidosis
- systemic diseases
- drugs
What should we worry about if a patients presents with pain, paratomegaly and facial nerve paresis?
malignancy
Describe Sjorgens Syndrome
It is a syndrome that occurs mostly in women It is associated with -xerostomia(dry mouth) -keratoconjunctivitis sicca(dry eyes) -RA And it is an autoimmune disease
What kind of paratomegaly does sarcoidodis present with?
-diffuse
What are the causes of parotid swelling that present with swelling and pain?
- mumps(usually bilateral)
- bacterial parotitis(usually unilateral)
- neoplasia
- parotid calculi
How do patients with mumps present?
-pyrexia
-tender bilateral parotid swelling
-trismus
Complication: orchitis and SNHL
How do patients with bacterial parotitis present?
- Usually older and debilitated
- unilateral tender parotid with pus in the parotid duct orifice sometimes
Any swelling in the submandibular gland that only presents with swelling and no pain should be considered as?
malignant
Why is the most common cause of submandibular swelling secondary to infection in the oral cavity?
Because they are so close to the lymph nodes that are situated in the submandibular region
What are submandibular calculi?
They are calculi that exist in the submandibular duct and are more palpable when eating in the floor of the mouth
If the parotid gland and the submandibular gland have localised swelling always look for:
A neoplasm
What is snoring caused by?
Vibration of the pharyngeal wall, the tongue and the soft palate
What is the definition of sleep apnoea in adults?
-30 episodes of cessation of breathing for a duration of about 10 seconds over a 7 hour period of sleep
What 3 things cause secondary sleep apnea?
- central sleep apnea-due to a defect in the respiratory drive in the brainstem
- Obstructive sleep apnea(OSA)- Presents with chest movements and shifting of air- the site of obstruction may nasal,pharyngeal or laryngotracheal
- Mixed type
What are the complications of having sleep apnea?
- Cardiac problems: pulmonary hypertension, cor pulmonale, right sided heart failure, cardiac dysrhythmias
- CNS- fatigue, loss of concentration and memory
- children: failure to thrive, SIDS
What are the different investigations you do in a aptient with obstructive sleep apnea?
- CT and Xray to look at the post-nasal spaces
- Rhinolaryngoscopy(flexible scope that can have a view of what’s going on back there)
- Sleep studies
- STOP-BANG scoring system comprised of 8 questions
What is the management of sleep apnea?
- CPAP
- reducing alcohol consumptions and losing weight
- surgery-adenotonsillectomy and laser assisted palotoplasty
Foreign bodies in the thraot are usually:
- Inhaled
2. Swallowed
In which group of people does inhaled foreign bodies occur in and what is the percentage?
Usually children under the age of 4 and it is 75%
WHAT IS WORSE BETWEEN ORGANIC MATERIAL(VEGETABLES, PEANUTS, SEEDS AND POPCORN AND NON-ORGANIC A MATERIAL LIKE COINS AND BUTTONS?
-Organic materials is worse because it causes a mucosal reaction
Why is laryngeal impaction an emergency?
-Because it can lead to total respiratory obstruction
What is the clinical picture of a patient with inhalational foreign body?
- choking
- wheezing
- coughing
What difference will it have if the foreign body is lodged in the trachea vs the bronchi?
In the trachea it will be bilateral wheezing
Bronchi is unilateral
What are the things that people swallow?
- fish bones
- meat bones
- coins if children
What are the narrowest parts that get food lodged there?
oropharynx- the tonsils, posterior tongue, vallecular
-pharyngo- oesophagus- the piriform fossa and the post cricoid
What are the clinical features of someone with swallowed foreign body?
- acute dysphagia
- difficulty swallowing even saliva
- tachycardia and dyspneo
- otalgia, neck tenderness, and fever point to it being a ruptured oesophagus
What would neck tenderness point towards?
It would pint towards pharyno-oesophagus rupture
How can you visualise the foreign body?
By using a tongue depressor and a laryngeal mirror
What is the Management of a foreign body?
- Removal using anglled forceps
- local anaesthesia would be nice
- If a food bolus is stuck in the oesophagus then you ca leave it for 6-12 hours and then give sedativesto help move it down
What is important about the management of an oesophageal rupture?
- It is important because 50% of them cause mortality within the first 24 hours if not treated
- Patient must be nil by mouth, get a intravenous line in, parenterally fed and given broad spectrum antibiotics
- contrast swallow may help us visualise the lesion
- surgical intervention may be NB
