diseases of the throat by dr. kavitha ashok kumar msu malaysia
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Diseases of the throat
Dr Kavitha Ashokkumar
Oral cavity lesions
• White lesions : oral submucous fibrosis, leukoplakia, oral lichen planus, candidiasis, fordyce spots
• Red lesions: erythroplakia, discoid lupus erythematosus, nicotine stomatitis
• Lesions of the tongue:geographic tongue, hairy tongue, fissured tongue, tongue tie
White lesions in the oral cavity
• candidiasis • Median rhomboid glossitis
Lichen planus
• Reticular lichen planus/Wickman’sstriae
• Erosive lichen planus
Oral submucous fibrosis
Red patches in the oral cavity
Lesions of the tongue
• Geographic tongue/benign migratory glossitis
• Hairy tongue
Ulcers in the oral cavity
• Aphthous stomatitis• Herpes simplex stomatitis• Hand, foot and mouth disease• Herpangina• Bechet’s syndrome• Erythema multiforme• Traumatic ulcers• Blood disorders• Radiation mucositis
ulcers
• Aphthous ulcers • Herpes labialis
Hand,foot and mouth disease
• Low grade fever, oral ulcers,lesions on the palm ,and foot
• Coxsackie virus
Herpes simplex virus infection
• HSV –type 1
• Common in children ,can affect adults too
• Anterior part of the oral cavity affected
• treatment:acylovir
Bechet’s syndrome
• 1937,Turkish dermatologist,Hulusi Behcet
• Immune mediated small vessel systemic vasculitis
• Triple symptom complex of recurrent oral ulcers,genital ulcers and uveitis
Herpangina
• Coxsackie virus
• Contagious
• Symptomatic treatment
Radiation mucositis
• Dosage>5000cGy
• Concomitent chemotherapy
• Direct epithelial injury
• Symptomatic treatment
• Prevention:
• IMRT
• Pentoxifylline,amifostin
Pharynx
• Muscular tube extending from base skull to Lower border of C6/ cricoid cartilage
• Continues as esophagus
• Constrictor muscles+ fascia
• Anteriorly it communicates with
– Nasal cavity
– Oral cavity
– Larynx
3 parts
• Nasopharynx
• Oropharynx
• Laryngopharynx
(Hypopharynx)
Nasopharynx
• Superior: Base skull
• Inferior:– Soft palate in front
– Continues with oropharynx posteriorly
• Anterior- Choanae
• Posterior: posterior pharyngeal wall
• 2 lateral walls
Normal structures in nasopharynx
• Adenoid: Junction of roof and posterior wall- in the midline
• Tubal elevation and ET opening- lateral wall
• Fossa of Rossenmuller-postero-superior to tubal elevation
Nasopharyngealcarcinoma
Adenoid hypertrophy
Fossa of Rossenmuller
• Pharyngeal recess
• Deep recess in lateral nasopharyngeal wall- extends till the foramen lacerum
• Common site of origin of NPC
• Related to ET- ‘Early presentation of NPC’
• Related to the skull base- ‘neurological’– Foramina in the base of middle cranial fossa
– Para-sellar region and cavernous sinus with various cranial nerves
Oropharynx
• Part of pharynx posterior to oral cavity
• Superior: communicates with nasopharynx
• Inferior: Floor of the valleculae/ hyoid bone
• Anterior: oral cavity-demarcated by uvula-anterior pillars- circumvallate papillae
• Rich lymphatic drainage
Parts of oropharynx
• Tonsillar fossae with the faucial tonsils the lateral walls
• Posterior 1/3 of tongue (base of tongue)
• Valleculae
• Posterior pharyngeal wall
Laryngopharynx (Hypopharynx)
• Part of the pharynx posterior to the larynx
• Superior- Floor of valleculae-PE folds
• Inferior- Cricopharyngeal sphincter (lower border of cricoid cartilage/ C6)
• 3 parts– Pyriform fossae– Posterior pharyngeal wall– Post-cricoid area
Pyriform fossae
• ‘Pear’ shaped
• Extends from PE fold to cricopharynx
• Lateral to AE folds
• Pooling of saliva in cricopharyngeal sphincter/ upper esophageal obstruction
• Common site of hypopharyngeal malignancy
Post-cricoid area
• Not visible on indirect laryngoscopy• Extends from upper border to
lower border of body of cricoid cartilage
• Annular segment with anterior and posterior walls
• Common site of malignancy of hypopharynx in females- ‘Plummer Vinson syndrome’
• Laryngeal crepitus
Pharyngeal wall
• Mucosa: – Respiratory in nasopharynx
– Non-keratinizing stratified squamous
• Submucosa– Lymphoid tissue
• Muscular layer– Constrictor and other muscles (striated)
• Pharyngo-basilar fascia
Waldeyar’s ring
• External ring: Cervical lymph nodes
• Intrinsic ring: Submucosal group of lymphoid tissue in the pharynx guarding 2 portals- nose and mouth
• Involved in both humeral and cell mediated immunity
Waldeyer’s ring
Physiology of deglutition
• Process of propulsion of bolus of food from oral cavity to the stomach
• Neuro-muscular activity
• 3 Phases:
– Oral phase: Voluntary
– Pharyngeal phase: Both
– Esophageal phase: Involuntary
Cranial Nerves
• CN V and XII: Chewing & tongue movements
• CN VII: Sensation of oropharynx & taste to anterior 2/3 of tongue
• CN IX: Taste to posterior tongue, sensory and motor functions of the pharynx
• CN X: – Taste to oropharynx, and sensation and motor function to
larynx and laryngopharynx.
– Airway protection
Functions of pharynx
• Deglutition
• Protection from aspiration
• Part of respiratory passage
• Muco-ciliary clearance
• ET to ventilate and drain the middle ear cleft
• Speech- resonance
• Waldeyer’s ring- immunity
• Taste sensation in oropharynx
Diseases of the pharynx
DR KAVITHA ASHOK KUMAR
Chronic adenoiditis/ adenoid hypertrophy/ adenoids
• Chronic inflammation/ enlargement of the adenoids causing obstruction to the nasopharyngeal airway and consequent recurrent naso-sinus infections, otitis media or mal-development of the face (adenoid facies)
Etiology
• Common in children (Immunologically active age)
• Physiological hypertrophy- Peak 2-4 years
• Recurrent upper respiratory tract infections/ allergy
• Low socio-economic status
• Environmental factors- crowding, environmental pollution, etc..
Clinical features
• Nasal (Obstruction/ recurrent naso-sinus infection)– Nasal obstruction, anterior mucoid/ mucopurulent
discharge, mouth breathing, snoring, sleep apnoea, hyponasal speech (Rhinolalia clausa), epistaxis
• Aural (ET dysfunction/AOM/ SOM/ CSOM)– Recurrent otalgia, deafness, ear discharge, etc.
• Throat (Recurrent pharyngitis/ tonsillitis)– Recurrent sore throat, dysphagia, change in voice, poor
eaters, malnutrition
Clinical features (contd)
Facial features (Adenoid facies)
• Pinched nose
• Mouth breathing
• Dribbling of saliva
• Flat nasal arch
• Malar hypoplasia
• Elongated face
• Dull ‘idiotic’ appearance
• Loss of nasolabial fold
• Short protruding upper lip
• Crowding of teeth
• High arched palate
• Deafness-inattentive child
General features
• Growth retardation
• Recurrent LRTI
• Frequent diarrhoea
• Low nutritional status
• Pigeon shaped chest
• Protuberent abdomen
• Enuresis +/-
Investigations
• Clinical diagnosis
• Nasal endoscopy
• Post nasal examination if possible
• X-ray nasopharynx (Lateral view of the head and neck- soft tissue exposure)
• Sleep studies if sleep apnea is suspected
Treatment
• Mild/ infrequent symptoms- medical management
– Control of recurrent respiratory/ aural infections
– Antihistamies and decongestants
– Improve nutritional status
– Breathing exercises
• Moderate-severe/ persistent symptoms
– Adenoidectomy
PALATINE TONSILS
• Epithelium
• Capsule
• Crypts
• Lymphoid tissue
• Tonsillar bed
• Peritonsillar space
Tonsils V/S Lymph node
TONSILS/ Adenoids
• Submucosal
• Efferents only
• No distinct medulla/ cortex
• Capsule +/-
• Crypts/ furrows +
• Age related
• Local and systemic immunity
LYMPH NODE
• Deep
• Both
• Distinct cortex and medulla
• Capsule
• No crypts/ furrows
• Not age related
• Systemic immunity
Blood supply of the tonsils
Blood supply: (FAIL)
• Facial.A (Tonsillar branch and ascending palatine branch)
• Ascending pharyngeal.A
• Int. maxillary.A (Descending palatine branch)
• Lingual.A
Lymphatic:
• Jugulo-digastric nodes
Acute tonsillitis
• Acute inflammation of the faucial tonsils usually secondary to viral infection and seen commonly in children
Etiology
• Common in children
• Usually bacterial infection follows a viral infection
• Environmental factors- exposure to cold weather/ food, pollutants, etc.- reduced local immunity
• Malnutrition
• Metabolic abnormalities
• Immunological status
Microbioloygy
Viral (50%)
• Rhino/ adeno/ entero virus
Bacterial
• B- hemolytic streptococcus- ‘Rheumatic’
• H.Influenzae
• Streptococcus pneumoniae
• Staphylococcus
Pathological types
• Catarrhal
• Follicular
• Parenchymatous
• Membranous
Clinical features- Symptoms
• Systemic– Fever, malaise, lethargy, headache
• Local– Sore throat- ‘raw’ feeling
– Odynophagia, dysphagia
– Refuse feeds
– Referred otalgia
• Usually symptoms resolve in 1-2 weeks
Signs
• Fever: 103-104 F
• Enlarged and congested tonsils
• Odematous mucosa of the tonsils, pillars and uvula
• Yellowish spots (follicles) on the tonsil/ membrane
• Tonsillar squeeze+ and tender
• Tongue coated and congested
• Tender jugulodigastric nodes
Differential diagnosis
• Acute non-specific pharyngitis
• Acute specific pharyngitis– Diphtheria
– Vincent’s angina
– Monocytic angina (Infectious mononucleosis/ glandular fever)
– Agranulocytic angina
– Leukemic angina
Investigations
• Usually treatment is based on clinical diagnosis
• Recurrent acute tonsillitis/ not responding to medical treatment
– FBP
– Throat swab for C/S
• TRO specific causes of acute pharyngitis
Treatment- Medical only
• Rest, light warm nourishing feeds
• Antibiotics– Broad spectrum penicillin group like amoxycillin/ ampicillin
– Erythromycin or other macrolides if penicillin allergy+
– 7-10 days
• Analgesics
• Fluid electrolyte balance
• Antiseptic gargles/ lozenges- soothing
Complications
• Incomplete resolution—microabscess– chronic tonsillitis
• Intra-tonsillar abscess
• Peritonsillar abscess
• Para/ retropharyngeal abscess
• Laryngeal odema
• AOM
• Systemic- Septicemia/ acute rheumatic fever/ acute nephritis
Chronic tonsillitis
• Chronic bacterial infection of the faucial tonsils usually consequent to incompletely resolved acute/ subacute tonsillitis
Etiopathology
• Common in children
• Improper treatment of acute tonsillitis—microabscess– infection flares up whenever local immunity is reduced like viral infection, cold feeds, exposure to pollutants etc.
• Low socio-economic status
• Malnutrition
• Environmental factors
Microbiology
• Same as acute tonsillitis
• B-hemolytic streptococcus- ‘Rheumatic’
• H. Influenzae
• Streptococcus pneumoniae
• Streptococcus viridans
• Staphylococcus
Pathological types
• Chronic follicular tonsillitis
• Chronic parenchymatous tonsillitis
• Chronic fibrotic tonsillitis
Clinical features- Symptoms
• Usually pediatric age group- <14-16 years
• Recurrent episodes of sore throat, fever, dysphagia/ odynophagia
• Recurrent painful upper neck swellings
• Refuse feeds/ poor eaters
• Failure to thrive
• Snoring/ stridor if tonsils are grossly enlarged
Cardinal signs of chronic tonsillitis
• Enlarged and congested tonsils (exception: chronic fibrotic tonsillitis)
• Anterior pillars are congested
• Septic squeeze (tonsillar squeeze) may be positive
• Enlarged, discrete, non-tender, bilateral jugulo-digastric nodes– become tender during acute exacerbations
DD
• Chronic non-specific pharyngitis– Infective- Rule out septic foci in nose/ sinuses/
oral cavity/ LRT
– Reactive- allergy/ reflux pharyngitis/ exposure to irritant chemicals/ smoking, secondary to mouth breathing, etc.
• Chronic specific pharyngitis– Granulomatous conditions like TB, syphilis etc.
– Fungal pharyngitis- immunocompromised state
Investigations
• FBP
• Throat swab for culture and sensitivity
• Nasal endoscopy and radiology of PNS/ nasopharynx to rule out septic foci/ associated adenoid hypertrophy if suspected
• If planning for tonsillectomy– Blood grouping and cross matching
– BT/ CT/ PT/ APTT
Treatment
• Medical treatment attempted
– Antibiotics/ analgesics/ improve the nutritional status/ treat associated septic foci, if any.
• Treatment is usually surgical - Tonsillectomy
Complications of chronic tonsillitis
• Local– Peritonsillar abscess
– Para/ retropharyngeal abscess
– Laryngeal odema
– Etc.
• Systemic– Rheumatic fever- carditis, arthritis, acute
glomerulonepritis
– Retarded growth
Tonsillectomy
Types
Dissection and snare method
• Dissection method
• Cryo-surgery
• Cautery- assisted tonsillectomy
• Laser assisted tonsillectomy
• Guillotine tonsillectomy
Indications
• Absolute indications
– Respiratory obstruction
– Peritonsillar abscess (4-6 weeks)
– Chronic tonsillitis
• Suspected case of malignancy
Relative indications
• Acute glomerular nephritis
• Acute rhuematic fever
• Subacute Bacterial endocarditis
• halitosis
• Tumors of tonsils– Benign- papilloma
– Malignant- small tumors confined to tonsils
• Tonsillar cyst, tonsillolith, embedded FB in the tonsils, etc.
• Surgical approach– Elongated styloid process
– Glossopharyngeal neurectomy
– As part of Uvulo-palato-pharyngo-plasty (UPPP)
Contraindications
• Active infection
• Bleeding/ clotting disorders
• Cervical spondylosis
• Diphtheritic tonsillitis
• Endemic of polio
• Failure in controlling systemic diseases like hypertension, diabetes, bronchial asthma, LRTI, etc..
Technique
• GA
• Nasotracheal/ orotracheal intubation
• Rose position
• Boyle-Davis mouth gag
Technique
• Incision at the anterior pillar
• Dissect in the cleavage plane between capsule and bed of the tonsils
• Eve’s tonsillar snare
• Hemostasis
Post-operative care
• Lateral position
• Vital signs
• Look for frequent swallow reflex
• Antibiotics and analgesics
• Cold feeds after 4 hours
• Saline or dilute hydrogen peroxide gargles
Complications
• Hemorrhage
• Aspiration
• Injury to structures- teeth, lips, gums, palate, etc.
• Injury to posterior pillars- speech/ reflux
• Residual tonsils
• Lingual tonsillitis
Tonsillectomy hemorrhage
• Primary
– During surgery
– Poor selection of the case, improper technique
– Ligate/ cauterize the bleeding vessel
Reactionary hemorrhage• Post-operative within 24 hours
• Failure to ligate all vessels or slippage of sutures
• Hypotensive anesthesia- BP returns to normal post-operatively
• Increased arterial or venous pressure during recovery
• Clot in the fossa- prevents contraction and retraction of the vessels
• Remove clot- apply pressure- usually bleeding stops
• If persistant bleeding- shift patient to OT- Ligation of the vessels
Secondary hemorrhage
– Due to sepsis and usually occurs on 5th-7th day post-operative
– Start parenteral antibiotics
– Persistent bleeding- shift patient to OT- interpillar suturing
Adenoidectomy
Indications
• Adenoid facies
• Septic focus- Otitis media, chronic rhinosinusitis
• Snoring
• Sleep apnea syndrome
Technique
• Orotracheal intubation
• Rose position till curettage
• Boyle-Davis mouth gag
• Palpate nasopharynx
• St.Clair Thomson’s adenoid curette with/ without cage
• Insert behind the soft palate till posterior end of septum is felt
• Flex the neck
• Push curette backwards to trap adenoids inside the curette
• Curette with sweeping motion- downwards and forwards
Complications
• Bleeding
• Aspiration
• ET orifice injury– Otitis media
• Injury to soft palate, posterior pharyngeal wall, etc..
• Injury to anterior longitudinal ligament--subluxation of the atlanto-occipetal joint--quadriplegia
Peritonsillar space
• Potential space
• Loose areolar tissue
• Between tonsillar capsule and tonsillar bed formed by superior constrictor muscle
7/25/2014 Dr. Kavitha Ashok Kumar
Peritonsillar abscess / Quincy
• Usually consequent to acute tonsillitis
• More common in adults- reason?
• Predisposed by immuno-compromised state, diabetes mellitus
• Tonsillitis—peritonsillitis—peritonsillarabscess
• Streptococcus/ staphylococus, anaerobic bacteriae
7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features-Symptoms
• Any age- common in adults• Acute pain in the throat• Odynophagia- usually more on one side• Referred otalgia• Fever, malaise, lethargy• Dribbling of saliva• Unable to open mouth (trismus)• Difficulty in articulation- ‘hot potato voice’• Painful neck swelling• Laryngeal odema—hoarseness—stridor
7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features-Signs
• Fever, toxic appearance, rapid pulse
• Trismus, Dribbling of saliva
• Tonsil pushed medially and uvula pushed to opposite side
• Tender jugulo-digastric lymph nodes
7/25/2014 Dr. Kavitha Ashok Kumar
Investigations
• Start treatment with clinical diagnosis
• Throat swab for C/S
• Hb., TC/DC, ESR, Peripheral smear
• Blood sugar
• CT scan
7/25/2014 Dr. Kavitha Ashok Kumar
Treatment
• Hospitalize
• IV antibiotics and analgesics
– Penicillin group preferred
• IV fluids- electrolyte/ fluid balance
• I&D
– Site of I&D
• Point where 2 imaginary lines meet- vertical line along anterior pillar and horizontal line at the base of the uvula
– Guarded knife/ quinsy knife- 1 cm. deep
•Tonsillectomy7/25/2014 Dr. Kavitha Ashok Kumar
Complications
• Laryngeal odema- stridor
• Spread to other neck spaces
• Dehydration/ electrolyte imbalance
• Septicemia
7/25/2014 Dr. Kavitha Ashok Kumar
RETROPHARYNGEAL ABSCESS
7/25/2014 Dr. Kavitha Ashok Kumar
Retropharyngeal space(Space of Gillette/ Lincoln’s highway)
7/25/2014 Dr. Kavitha Ashok Kumar
Retropharyngeal abscess
• Inflammation and accumulation of pus in the retropharyngeal space
Types
• Acute (Suppuration of retropharyngeal lymph nodes)
• Chronic (Due to Tuberculosis of the spine)
7/25/2014 Dr. Kavitha Ashok Kumar
Etiopathology
ACUTE
• Common in children (<3years)
– Retropharyngeal lymph nodes-active
– Adenoiditis/ tonsillitis—suppuration of retropharyngeal lymph nodes (Streptococcus usually)
• Adults
– FB
– Immunocompromised
– From other spaces
CHRONIC
• >Middle ages/ adults
• TB of spine
• Abscess posterior to prevertebral fascia
7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features -Symptoms
ACUTE
• Acute onset
• Fever, toxic
• Odynophagia- rapidly progressive- severe
• Hot potato voice/ hoarseness
• Nasal obstruction if at the level of nasopharynx
• Trismus absent usually
• Stridor
CHRONIC
• Insidious onset
• Systemic features of TB +/-
• Painless lump in the throat
• Dysphagia
• Throat symptoms are usually mild
• Cervical pain
7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features- Signs
ACUTE
• Paramedian bulge on the posterior pharyngeal wall
• Signs of acute inflammation +
• Neck: Larynx appears prominent as it is pushed forwards
CHRONIC
• Median bulge on the posterior pharyngeal wall
• No signs of acute inflammation
7/25/2014 Dr. Kavitha Ashok Kumar
Investigations
ACUTE
• Neutrophilia
• Radiology (X-ray lateral view neck/ CT)
– Prevertebral widening
– Larynx and trachea displaced forwards
– Fluid level
– Straightening of spine (Prevertebral muscle spasm)
– Look for FB
CHRONIC
• Lymphocytosis
• Radiology (X-ray lateral view neck/ CT)
– Prevertebral widening
– Destruction of the cervical vertebral bodies
– Collapse of body of vertebrae
– Can extend inferiorly beyond the superior mediastinum
7/25/2014 Dr. Kavitha Ashok Kumar
7/25/2014 Dr. Kavitha Ashok Kumar
Treatment
ACUTE
• Hospitalize
• IV antibiotics, analgesics, fluid-electrolyte balance
• I&D:
– ‘Transoral’ – stab incision on the posterior pharyngeal wall at the most prominent site
– Supine-head end low
– LA usually
– GA- only if awake intubation possible
– Tracheostomy if stridor+
CHRONIC
• ATT
• I&D:
– ‘Transcervical’
– GA
– Lateral neck incision
– Orthopedic/ spine surgeon for further surgical treatment
7/25/2014 Dr. Kavitha Ashok Kumar
Parapharyngeal space
7/25/2014 Dr. Kavitha Ashok Kumar
Parapharyngeal abscess-Etiology
• Common in adults
• >Immuno-compromised state (Diabetes, IV drug abuse)
Septic foci:
• Pharynx: Acute tonsillitis/ adenoiditis, quinsy
• Teeth: Apical abscess of last molar tooth
• Ear: Bezold’s abscess
• Suppurative lymphadenitis
• Spread from other neck spaces
• Trauma- external/ FB7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features-Symptoms
• Acute and rapidly progressive
• Fever, toxic, malaise, lethargy
• Sore throat
• Odynophagia
• Torticolis- muscle spasm
• Painful neck swelling behind the angle of the mandible
7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features-Signs
• Fever, toxic appearance, rapid pulse
• Trismus- if anterior compartment involved
• Neck swelling behind angle of mandible (Anterior and deep to SCM muscle)- signs of acute inflammation +
• Oropharynx:
– Tonsil/ lateral pharyngeal wall pushed medially-depends on the compartment involved
– Look for septic focus-teeth/ tonsils
• Paralysis of IX, X, XI, XII CN/ Jugular venous thrombophelebitis may be present if posterior compartment is involved
7/25/2014 Dr. Kavitha Ashok Kumar
Investigations
• Hb., TC/DC
• Blood sugar
• X-ray neck-AP/ lateral views
• CT scan
–Abscess cavity- site and extent
–Assess airway patency
• Rule out immunodeficiency states if suspected
7/25/2014 Dr. Kavitha Ashok Kumar
Treatment
Medical
• Hospitalize
• IV antibiotics and analgesics
• IV fluids- fluid and electrolyte balance
I&D
• Transcervical’ approach
• If stridor/ difficulty in intubation: Tracheostomy
• Transverse incision about 2-3 cms below the angle of the mandible
• Blunt dissection medial to SCM muscle and carotid sheath and along inner surface of medial pterygoidmuscle
7/25/2014 Dr. Kavitha Ashok Kumar
Diseases of the Larynx
Dr Kavitha Ashokkumar
7/25/2014 Dr. Kavitha Ashok Kumar
Types
• Acute simple laryngitis
• Acute epiglottitis
• Acute laryngo-tracheo-bronchitis (ALTBS)
• Diphtheritic laryngitis
7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features- Symptoms
• Severity variable. In professional voice users even minimal catarrh may give rise to severe symptoms
• Hoarseness usually following URTI or voice abuse
• Complete loss of voice in severe cases (aphonia)
• Dysphonia- difficulty in speaking
• Pain in the throat > on swallowing and speaking
• Voice fatigue (phonesthenia)
• Painful irritant cough with thick expectoration
• Fever +/-
7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features-Signs
• Fever +/-
• Husky-hoarse voice
• Generalized nasal and pharyngeal congestion
• ILS:
– Congestion and edema of epiglottis, ventricular bands and vocal cords
– Thick mucus
7/25/2014 Dr. Kavitha Ashok Kumar
7/25/2014 Dr. Kavitha Ashok Kumar
Treatment
• Voice rest
• Tackle etiological factors, if any. Stop smoking.
• Humidification- medicated steam inhalation (mucolytic and soothing)
• Warm saline gargles
• Mucolytics like Bromhexine
• Irritant and painful cough may be suppressed by linctus codiene, dextromethorphan, etc.
• NSAIDS
• Usually resolves in 1-2 weeks
• If secondary infection present- broad spectrum 7/25/2014 Dr. Kavitha Ashok Kumar
Acute epiglottitis(Acute supraglottitis)
• Acute inflammation of the supraglottis, common in children, usually caused by Hemophilusinfluenzae-type B and may lead to fatal respiratory obstruction
7/25/2014 Dr. Kavitha Ashok Kumar
7/25/2014 Dr. Kavitha Ashok Kumar
Clinical features- Symptoms
• Pediatric age group (> 2-7 years)
• Usually starts as an URTI- sore throat, fever, dysphagia/ odynophagia
• Acute onset and rapidly progressive—may lead to respiratory obstruction within few hours
• ‘Hot potato voice’/ FB sensation in the throat
• Stridor- Inspiratory, increases on supine position—patient tends to sit up leaning forward supporting on upper limbs ‘Tripod sign’
7/25/2014 Dr. Kavitha Ashok Kumar
Signs
• Fever, toxic appearance and flushed skin
• Tripod sign
• Dribbling saliva
• On depressing the tongue or on protrusion of tongue—may see red and edematous epiglottis popping up— ‘Cherry red epiglottis’
‘Sun-rise sign’
• Examination of the throat may precipitate respiratory obstruction due to laryngospasm
• Inspiratory stridor- intercostal retraction, active accessory respiratory muscles, perioral cyanosis +/-
7/25/2014 Dr. Kavitha Ashok Kumar
7/25/2014 Dr. Kavitha Ashok Kumar
Investigations
• Clinical diagnosis
• Flexible scopy may precipitate or increase stridor
• Throat swab/ blood culture
• X-ray lateral view neck (soft tissue exposure)
– ‘Thumb sign’- grossly edematous epiglottis
– Narrowed supraglottic airway
• TC/DC- leucocytosis
7/25/2014 Dr. Kavitha Ashok Kumar
7/25/2014 Dr. Kavitha Ashok Kumar
Vocal nodules
• Syn: Singer’s nodules, teacher’s nodules, screamer’s nodules, juggler’s nodules, etc.
• Defined as disorder of voice abuse commonly seen in professional voice users, characterized by hoarseness, vocal fatigue and presence of pin head sized raised lesions on both the vocal cords at the junction of its anterior I/3 and posterior 2/3.
7/25/2014 Dr. Kavitha Ashok Kumar
Etiopathology
‘Hyperkinetic voice’
• Voice abuse- ‘professional voice users’
– Increased intensity
– Altered pitch
– Long duration
• Chronic cough
• Reflux laryngitis (GERD)
7/25/2014 Dr. Kavitha Ashok Kumar
• Hyperkinetic voice
• Maximum vibration at the junction of anterior 1/3 and posterior 2/3
• Trauma leading to odema and submucosal microhaemorrhage
• Epithelial hyperplasia and subepithelial hyalinization and fibrosis
• Bilateral vocal nodules in the free edge of the cords
7/25/2014 Dr. Kavitha Ashok Kumar
Symptoms
• Professional voice users
• Hoarseness
• Improves initially with voice rest
• Voice fatigue (Phonesthenia)
• Strained speech- pain in the neck/ throat
7/25/2014 Dr. Kavitha Ashok Kumar
Signs
Indirect laryngoscopy
• Pin-head sized pearly white projections on the free edge of the vocal cords at the junction of anterior 1/3 and posterior 2/3
• Vocal cord movements are normal
• Congestion of the cords +/-
7/25/2014 Dr. Kavitha Ashok Kumar
7/25/2014 Dr. Kavitha Ashok Kumar
Investigations
• Diagnosis usually made clinically
• If ILS is difficult
– Flexible laryngoscopy
– Rigid angled laryngeal endoscopy (70°/ 90°)
– Stroboscopy
7/25/2014 Dr. Kavitha Ashok Kumar
7/25/2014 Dr. Kavitha Ashok Kumar
Treatment- Conservative
• Voice rest- ‘Absolute’
• Treatment of local sepsis, cough, reflux, etc.
• Speech therapy
– Vocal hygiene
– Relaxing exercises
• Early lesions may disappear
7/25/2014 Dr. Kavitha Ashok Kumar
7/25/2014 Dr. Kavitha Ashok Kumar