diseases of the throat by dr. kavitha ashok kumar msu malaysia
DESCRIPTION
for teachers and studentsTRANSCRIPT
![Page 1: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/1.jpg)
Diseases of the throat
Dr Kavitha Ashokkumar
![Page 2: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/2.jpg)
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
![Page 3: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/3.jpg)
White lesions in the oral cavity
• candidiasis • Median rhomboid glossitis
![Page 4: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/4.jpg)
Lichen planus
• Reticular lichen planus/Wickman’sstriae
• Erosive lichen planus
![Page 5: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/5.jpg)
Oral submucous fibrosis
![Page 6: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/6.jpg)
![Page 7: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/7.jpg)
Red patches in the oral cavity
![Page 8: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/8.jpg)
![Page 9: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/9.jpg)
![Page 10: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/10.jpg)
Lesions of the tongue
• Geographic tongue/benign migratory glossitis
• Hairy tongue
![Page 11: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/11.jpg)
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
![Page 12: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/12.jpg)
ulcers
• Aphthous ulcers • Herpes labialis
![Page 13: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/13.jpg)
Hand,foot and mouth disease
• Low grade fever, oral ulcers,lesions on the palm ,and foot
• Coxsackie virus
![Page 14: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/14.jpg)
Herpes simplex virus infection
• HSV –type 1
• Common in children ,can affect adults too
• Anterior part of the oral cavity affected
• treatment:acylovir
![Page 15: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/15.jpg)
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
![Page 16: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/16.jpg)
Herpangina
• Coxsackie virus
• Contagious
• Symptomatic treatment
![Page 17: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/17.jpg)
Radiation mucositis
• Dosage>5000cGy
• Concomitent chemotherapy
• Direct epithelial injury
• Symptomatic treatment
• Prevention:
• IMRT
• Pentoxifylline,amifostin
![Page 18: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/18.jpg)
![Page 19: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/19.jpg)
![Page 20: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/20.jpg)
Pharynx
• Muscular tube extending from base skull to Lower border of C6/ cricoid cartilage
• Continues as esophagus
• Constrictor muscles+ fascia
![Page 21: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/21.jpg)
• Anteriorly it communicates with
– Nasal cavity
– Oral cavity
– Larynx
![Page 22: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/22.jpg)
3 parts
• Nasopharynx
• Oropharynx
• Laryngopharynx
(Hypopharynx)
![Page 23: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/23.jpg)
Nasopharynx
• Superior: Base skull
• Inferior:– Soft palate in front
– Continues with oropharynx posteriorly
• Anterior- Choanae
• Posterior: posterior pharyngeal wall
• 2 lateral walls
![Page 24: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/24.jpg)
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
![Page 26: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/26.jpg)
Nasopharyngealcarcinoma
Adenoid hypertrophy
![Page 27: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/27.jpg)
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
![Page 28: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/28.jpg)
![Page 29: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/29.jpg)
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
![Page 30: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/30.jpg)
![Page 31: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/31.jpg)
Parts of oropharynx
• Tonsillar fossae with the faucial tonsils the lateral walls
• Posterior 1/3 of tongue (base of tongue)
• Valleculae
• Posterior pharyngeal wall
![Page 32: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/32.jpg)
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
![Page 33: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/33.jpg)
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
![Page 34: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/34.jpg)
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
![Page 35: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/35.jpg)
![Page 36: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/36.jpg)
Pharyngeal wall
• Mucosa: – Respiratory in nasopharynx
– Non-keratinizing stratified squamous
• Submucosa– Lymphoid tissue
• Muscular layer– Constrictor and other muscles (striated)
• Pharyngo-basilar fascia
![Page 37: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/37.jpg)
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
![Page 38: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/38.jpg)
Waldeyer’s ring
![Page 39: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/39.jpg)
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
![Page 40: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/40.jpg)
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
![Page 41: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/41.jpg)
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
![Page 42: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/42.jpg)
Diseases of the pharynx
DR KAVITHA ASHOK KUMAR
![Page 43: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/43.jpg)
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)
![Page 44: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/44.jpg)
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..
![Page 45: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/45.jpg)
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
![Page 46: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/46.jpg)
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
![Page 47: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/47.jpg)
![Page 48: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/48.jpg)
General features
• Growth retardation
• Recurrent LRTI
• Frequent diarrhoea
• Low nutritional status
• Pigeon shaped chest
• Protuberent abdomen
• Enuresis +/-
![Page 49: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/49.jpg)
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
![Page 50: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/50.jpg)
![Page 51: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/51.jpg)
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
![Page 52: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/52.jpg)
PALATINE TONSILS
• Epithelium
• Capsule
• Crypts
• Lymphoid tissue
• Tonsillar bed
• Peritonsillar space
![Page 53: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/53.jpg)
![Page 54: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/54.jpg)
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
![Page 55: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/55.jpg)
![Page 56: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/56.jpg)
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
![Page 57: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/57.jpg)
Acute tonsillitis
• Acute inflammation of the faucial tonsils usually secondary to viral infection and seen commonly in children
![Page 58: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/58.jpg)
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
![Page 59: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/59.jpg)
Microbioloygy
Viral (50%)
• Rhino/ adeno/ entero virus
Bacterial
• B- hemolytic streptococcus- ‘Rheumatic’
• H.Influenzae
• Streptococcus pneumoniae
• Staphylococcus
![Page 60: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/60.jpg)
Pathological types
• Catarrhal
• Follicular
• Parenchymatous
• Membranous
![Page 61: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/61.jpg)
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
![Page 62: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/62.jpg)
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
![Page 63: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/63.jpg)
Differential diagnosis
• Acute non-specific pharyngitis
• Acute specific pharyngitis– Diphtheria
– Vincent’s angina
– Monocytic angina (Infectious mononucleosis/ glandular fever)
– Agranulocytic angina
– Leukemic angina
![Page 64: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/64.jpg)
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
![Page 65: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/65.jpg)
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
![Page 66: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/66.jpg)
Complications
• Incomplete resolution—microabscess– chronic tonsillitis
• Intra-tonsillar abscess
• Peritonsillar abscess
• Para/ retropharyngeal abscess
• Laryngeal odema
• AOM
• Systemic- Septicemia/ acute rheumatic fever/ acute nephritis
![Page 67: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/67.jpg)
Chronic tonsillitis
• Chronic bacterial infection of the faucial tonsils usually consequent to incompletely resolved acute/ subacute tonsillitis
![Page 68: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/68.jpg)
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
![Page 69: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/69.jpg)
Microbiology
• Same as acute tonsillitis
• B-hemolytic streptococcus- ‘Rheumatic’
• H. Influenzae
• Streptococcus pneumoniae
• Streptococcus viridans
• Staphylococcus
![Page 70: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/70.jpg)
Pathological types
• Chronic follicular tonsillitis
• Chronic parenchymatous tonsillitis
• Chronic fibrotic tonsillitis
![Page 71: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/71.jpg)
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
![Page 72: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/72.jpg)
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
![Page 73: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/73.jpg)
![Page 74: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/74.jpg)
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
![Page 75: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/75.jpg)
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
![Page 76: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/76.jpg)
Treatment
• Medical treatment attempted
– Antibiotics/ analgesics/ improve the nutritional status/ treat associated septic foci, if any.
• Treatment is usually surgical - Tonsillectomy
![Page 77: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/77.jpg)
Complications of chronic tonsillitis
• Local– Peritonsillar abscess
– Para/ retropharyngeal abscess
– Laryngeal odema
– Etc.
• Systemic– Rheumatic fever- carditis, arthritis, acute
glomerulonepritis
– Retarded growth
![Page 78: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/78.jpg)
![Page 79: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/79.jpg)
Tonsillectomy
Types
Dissection and snare method
• Dissection method
• Cryo-surgery
• Cautery- assisted tonsillectomy
• Laser assisted tonsillectomy
• Guillotine tonsillectomy
![Page 80: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/80.jpg)
Indications
• Absolute indications
– Respiratory obstruction
– Peritonsillar abscess (4-6 weeks)
– Chronic tonsillitis
• Suspected case of malignancy
![Page 81: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/81.jpg)
Relative indications
• Acute glomerular nephritis
• Acute rhuematic fever
• Subacute Bacterial endocarditis
• halitosis
![Page 82: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/82.jpg)
• 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)
![Page 83: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/83.jpg)
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..
![Page 84: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/84.jpg)
Technique
• GA
• Nasotracheal/ orotracheal intubation
• Rose position
• Boyle-Davis mouth gag
![Page 85: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/85.jpg)
Technique
• Incision at the anterior pillar
• Dissect in the cleavage plane between capsule and bed of the tonsils
• Eve’s tonsillar snare
• Hemostasis
![Page 86: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/86.jpg)
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
![Page 87: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/87.jpg)
Complications
• Hemorrhage
• Aspiration
• Injury to structures- teeth, lips, gums, palate, etc.
• Injury to posterior pillars- speech/ reflux
• Residual tonsils
• Lingual tonsillitis
![Page 88: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/88.jpg)
Tonsillectomy hemorrhage
• Primary
– During surgery
– Poor selection of the case, improper technique
– Ligate/ cauterize the bleeding vessel
![Page 89: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/89.jpg)
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
![Page 90: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/90.jpg)
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
![Page 91: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/91.jpg)
Adenoidectomy
Indications
• Adenoid facies
• Septic focus- Otitis media, chronic rhinosinusitis
• Snoring
• Sleep apnea syndrome
![Page 92: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/92.jpg)
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
![Page 93: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/93.jpg)
![Page 94: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/94.jpg)
![Page 95: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/95.jpg)
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
![Page 96: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/96.jpg)
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
![Page 97: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/97.jpg)
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
![Page 98: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/98.jpg)
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
![Page 99: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/99.jpg)
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
![Page 100: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/100.jpg)
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
![Page 101: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/101.jpg)
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
![Page 102: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/102.jpg)
Complications
• Laryngeal odema- stridor
• Spread to other neck spaces
• Dehydration/ electrolyte imbalance
• Septicemia
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 103: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/103.jpg)
RETROPHARYNGEAL ABSCESS
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 104: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/104.jpg)
Retropharyngeal space(Space of Gillette/ Lincoln’s highway)
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 105: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/105.jpg)
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
![Page 106: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/106.jpg)
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
![Page 107: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/107.jpg)
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
![Page 108: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/108.jpg)
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
![Page 109: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/109.jpg)
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
![Page 110: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/110.jpg)
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 111: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/111.jpg)
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
![Page 112: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/112.jpg)
Parapharyngeal space
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 113: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/113.jpg)
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
![Page 114: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/114.jpg)
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
![Page 115: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/115.jpg)
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
![Page 116: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/116.jpg)
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
![Page 117: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/117.jpg)
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
![Page 118: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/118.jpg)
Diseases of the Larynx
Dr Kavitha Ashokkumar
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 119: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/119.jpg)
Types
• Acute simple laryngitis
• Acute epiglottitis
• Acute laryngo-tracheo-bronchitis (ALTBS)
• Diphtheritic laryngitis
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 120: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/120.jpg)
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
![Page 121: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/121.jpg)
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
![Page 122: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/122.jpg)
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 123: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/123.jpg)
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
![Page 124: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/124.jpg)
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
![Page 125: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/125.jpg)
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 126: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/126.jpg)
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
![Page 127: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/127.jpg)
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
![Page 128: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/128.jpg)
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 129: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/129.jpg)
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
![Page 130: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/130.jpg)
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 131: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/131.jpg)
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
![Page 132: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/132.jpg)
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
![Page 133: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/133.jpg)
• 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
![Page 134: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/134.jpg)
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
![Page 135: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/135.jpg)
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
![Page 136: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/136.jpg)
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 137: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/137.jpg)
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
![Page 138: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/138.jpg)
7/25/2014 Dr. Kavitha Ashok Kumar
![Page 139: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/139.jpg)
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
![Page 140: Diseases of the throat by Dr. Kavitha Ashok Kumar MSU Malaysia](https://reader033.vdocuments.mx/reader033/viewer/2022052412/559430581a28ab4c3d8b474f/html5/thumbnails/140.jpg)
7/25/2014 Dr. Kavitha Ashok Kumar