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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4440_Библиотеки_им_академика_М_И_Перельмана.pdf
7.3 Colour Atlas ofOropharyngeal Diseases
a b
291
c
e
Fig. 7.3 Clinical picture of oropharyngeal diseases. (a)
Acute tonsillitis; (b) diphtheria; (c) parenchymatous tonsillitis; (d) granular pharyngitis; (e) chronic tonsillitis; (f)
peritonsillar abscess; (g) retropharyngeal abscess; (h) parapharyngeal tumour; (i, j) large tonsillar cleft; (k) tonsillar
debris; (l, m) acute recurrent tonsillitis; (n) oropharyngeal
d
f
isthmus; (o) B/L—chronic tonsillitis; (p) tonsillar debris;
(q) OSMF involving tonsil and anterior tonsillar pillar; (r)
lymphoid hypertrophy of base of tongue; (s) acute tonsillopharyngitis; (t) tonsillolith; (u) tonsillar debris; (v) pharyngitis; (w) U/L tonsillar hypertrophy; (x) grade 3 tonsillar
hypertrophy; and (y) grade 2 tonsillar hypertrophy
292
7 History andExamination ofOropharynx
g
i
k
h
j
l
Fig. 7.3 (continued)
7.3 Colour Atlas ofOropharyngeal Diseases
293
m
a
o
q
n
p
r
Fig. 7.3 (continued)
294
7 History andExamination ofOropharynx
s
a
u
w
t
v
x
y
Fig. 7.3 (continued)
History andExamination
ofLaryngeal andHypopharyngeal
Disorders
8
8.1 Symptomatology/
Presentation ofLarynx
andHypopharynx
The disorders of the larynx range from simple
laryngitis to carcinoma larynx, caused by strain
or injury to the vocal cords through excessive
talking, throat clearing, coughing, smoking,
screaming, singing or speaking too loudly or too
softly. The usual presenting symptoms are change
of voice, dysphonia, dysphagia, etc. The disorders of hypopharynx range from simple reux
disorder to hypopharyngeal cancer. The diseases
of this region presented mainly with dysphagia or
odynophagia.
Usual Symptoms of Carcinoma of Larynx
and Hypopharynx
• Hoarseness or other voice changes that
persists for more than 2weeks.
• An enlarged lymph node or lump in the
neck.
• Airway obstruction, difculty breathing
and noisy breathing.
• Persistent sore throat or a feeling that
something is in the throat.
• Persisting difculty swallowing
(dysphagia).
• Ear pain (referred pain).
8.2 History ofLaryngeal
andHypopharyngeal
Disorders
8.2.1 Presentation/Chief
Complaints/Symptoms
ofLaryngeal Disorder
(a) Change of voice—An impairment or change
in voice quality that affects the ability to
speak or sing. This can range from altered
voice to complete aphonia.
• Type of change of voice (Table8.1)
• Duration of change of voice—The duration of change in voice may be either for
short duration or for long duration.
– Acute—acute laryngitis, laryngotra-
cheal reux, vocal cord paralysis,
iatrogenic.
– Chronic—vocal cord nodule, vocal cord
polyp, vocal cord cyst, vocal cord
benign tumour, laryngeal carcinoma.
• Mode of onset
– Sudden—acute laryngitis, idiopathic,
viral infection, vocal cord paralysis,
iatrogenic.
– Gradual—laryngeal tumour (benign or
malignant), vocal cord polyp, Reinke’s
oedema.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck
Surgery, https://doi.org/10.1007/978-981-96-1765-4_8
295
296
Table 8.1 Types of changes with causes
Type of voice Denition Causes
Hoarseness of voice It is dened as change in voice or rough and
unpleasant voice due to vocal cord lesion
leading to faulty approximation of vocal
cords
Breathy voice It may suggest poor vocal cord function Adductor paralysis
Raspy voice It may indicate vocal cord thickening due to
swelling, inammation
Shaky voice or soft voice It may suggest trouble getting enough
breathing force or air
Hot potato voice It is a term for a defect of resonance in which
the speech has mufed quality, fancifully
likened to a person speaking with a hot
potato in mouth
Table 8.2 Differential diagnosis of hoarseness of voice with other symptoms
Associated symptoms with hoarseness of voice D/D
Pain Acute laryngitis, trauma to larynx
Dysphagia Supraglottic growth, retropharyngeal abscess
Odynophagia, +/− pain, fever
Cough +/− fever
H/o smoking +/−, stridor, dysphagia, neck swelling
8 History andExamination ofLaryngeal andHypopharyngeal Disorders
Carcinoma of voice, vocal cord
polyp, vocal cord paralysis, vocal
cord papilloma, laryngitis
Infection, a chemical irritant, voice
abuse
COPD
Growth over base of tongue
Epiglottitis
Peritonsillar abscess
Acute laryngopharyngitis
Vocal cord paralysis
Carcinoma larynx
Table 8.3 Causes of hoarseness of voice
Inammation/oedema/
infection Structural Neurological Others
Laryngitis
Allergy
Laryngopharyngeal reux
Reinke’s oedema,
epiglottitis
• Associated symptoms and history—pain,
dysphagia, dyspnoea, GERD symptoms,
thyroid surgery, fever, odynophagia, neck
pain, smoking.
Vocal cord nodule,
Polyp, cyst, papilloma
Vocal cord benign tumour
Laryngeal carcinoma,
thyroid carcinoma,
hypopharyngeal
carcinoma
U/L vocal cords paralysis,
B/L vocal cord paralysis
Scarring of vocal cords
Injury to vocal cord
Injury to RLN
(c) Dysphonia (difculty in phonation)
• Types of dysphonia
– Muscle tension dysphonia—Muscle
tension dysphonia is a ‘functional dysphonia’, whereby a pattern of muscle
Differential Diagnosis of Hoarseness of Voice
with Associated Symptoms (Table8.2)
use develops from irritants, laryngitis
or even stress, and among other conditions. The voice changes may be dif-
Causes of Hoarseness of Voice (Table8.3)
ferent in different individuals
(Table8.4).
(b) Aphonia (total loss of voice)—It is pre-
sented as unable to speak or unable to speak
above whisper. It may be either hysterical or
organic (B/L vocal cord paralysis, paralysis
of respiratory muscles, glottic spasm).
– Puberphonia (mutational Falsetto, func-
tional falsetto, incomplete falsetto, adolescent falsetto, pubescent falsetto)—It
is functional voice disorder characterized by habitual use of high pitch voice
8.2 History ofLaryngeal andHypopharyngeal Disorders
Table 8.4 Symptoms of muscle tension dysphonia
• Voice that sounds rough, hoarse, gravelly or raspy.
• Voice that sounds weak, breathy, airy or is only a whisper.
• Voice that sounds strained, pressed, squeezed, tight or tense.
• Voice that suddenly cuts out, breaks off, changes pitch or fades away.
• Voice that ‘gives out’ or becomes weaker the longer the voice is used.
• Pitch that is too high or too low.
• Difculty singing notes that used to be easy.
• Pain or tension in the throat when speaking or singing.
• Feeling like the throat is tired when speaking or singing.
Table 8.5 Types of spasmodic dysphonia
Type of spasmodic dysphonia Denition
Adductor spasmodic dysphonia This is the most common type of spasmodic dysphonia. In this type of
dysphonia, words are often cut off or are difcult to start because of muscle
spasm. Therefore, speech may be choppy, strained, or strangled and full of
effort. If the spasm is absent, voice sounds normal while laughing, crying or
shouting. Stress often makes spasm more severe
Abductor spasmodic dysphonia The voice often sounds weak and breathy. The spasm is usually absent during
laughing, crying and shouting
Mixed spasmodic dysphonia This is usually rare and mixed of both types
297
after puberty. The voice may be breathy,
rough and lacking in power. It is presented with complaint of inability to
shout or compete with background noise
and vocal fatigue. Male has mutational
falsetto, and female has adolescent transitional dysphonia.
– Spasmodic dysphonia—It causes voice
breaks and can give the voice a tight,
strained quality, occasional breaks in
their voice that occur once every few
sentences. Usually, however, the disorder is more severe and spasms may
occur on every other word, making a
person’s speech very difcult for others
to understand. Symptoms of spasmodic
dysphonia range from mild to severe
and become more frequent over time
(Table8.5).
• Duration of dysphonia
– Acute—psychological, neurological,
aphonia.
– Chronic—spasmodic dysphonia.
• Time of onset
– Puberty—puberphonia.
– Adult onset—muscle tension dyspho-
nia, spasmodic dysphonia.
• Mode of onset of dysphonia
– Sudden—psychological, neurological.
– Gradual—spasmodic.
• Associated symptoms/history of neuro-
logical disorder, psychological disorder,
vocal misuse or overuse, throat
dehydration.
(d) Pain in throat—This is an unpleasant sen-
sory and emotional experience associated
with actual or potential tissue damage, or
described in terms of such damage.
• Type of pain
– Burning/stabbing/shooting—neuro-
pathic pain—chronic laryngopharyngeal neuropathy, superior laryngeal
neuralgia, carcinoma larynx.
– Inammatory pain—laryngitis, epiglot-
titis, supraglottitis.
– Pain with no obvious organic origin—
functional pain.
• Duration
– Acute—acute laryngitis, supraglottitis,
acute epiglottitis.
– Chronic—rheumatoid arthritis, laryn-
geal carcinoma, perichondritis.
• Severity
– Mild—acute laryngitis.
298
H/o alcohol intake and
8 History andExamination ofLaryngeal andHypopharyngeal Disorders
– Moderate—acute supraglottitis, rheu-
matoid arthritis.
– Severe—acute epiglottitis, laryngeal
carcinoma.
• Mode of onset
– Sudden—acute laryngitis, trauma, acute
supraglottitis, acute epiglottitis.
– Gradual—rheumatoid arthritis, laryn-
geal carcinoma, perichondritis.
• Time of pain—pain during phonation,
pain after phonation, pain at the initiation
of swallowing, after swallowing.
• Associated symptoms with pain are
hoarseness of voice, dysphagia, dyspnoea, GERD odynophagia, hoarseness
of voice.
Rare causes of throat pain
Superior laryngeal neuralgia—It presents as
pain paroxysms, lasting for minutes or hours,
triggered by swallowing, straining voice or head
turning. A trigger point is present on the lateral
aspect of the throat overlying the thyrohyoid
membrane.
Chronic laryngopharyngeal neuropathy—
Laryngeal irritation such as throat irritation,
dysphonia, foreign body sensation in the throat,
stridor and especially chronic cough.
Superior cornu syndrome—It is abnormal
indentation of superior cornu of thyroid cartilage
that causes dysphagia, odynophagia or throat pain.
(e) Dysphagia (difculty in deglutition)
• Duration
– Acute—acute epiglottitis, acute supra-
glottitis, ALTB.
– Chronic—supraglottic tumour, neuro-
logical.
• Mode of onset
– Sudden—infection, stroke (neurologi-
cal).
– Gradual—supraglottic growth.
• Progression
– Progressive—supraglottic growth.
– Non-progressive—stroke.
• Associated symptoms and history of pain,
smoking, alcohol + smoking, FB ingestion, GERD.
(f) Dyspnoea (difculty in breathing)—The
difculty in breathing or dyspnoea in laryngeal disorder or tumour disorders is most of
time due to involvement of larynx or involvement of RLN.
• Duration—It can be acute if it is present
for short duration or chronic.
– Acute—Acute dyspnoea is caused by
acute epiglottitis, acute supraglottitis,
angioneurotic oedema.
– Chronic—laryngeal papillomatosis,
vocal cord polyp, growth, Reinke’s
oedema.
• Severity—It can be mild, moderate and
severe.
• Associated symptoms—change of voice,
neck swelling, dysphagia, odynophagia,
throat pain, drug or food allergy.
(g) Stridor (Sound of Breathing)—It is dened
as audible sound heard without stethoscope
during either in inspiration, expiration or in
both phases of respiration. In cases of carcinoma of larynx or mass lesion in larynx, it is
inspiratory.
• Duration
– Acute—acute epiglottitis, acute
supraglottitis.
– Chronic—laryngeal papillomatosis, vocal
cord polyp, benign tumour of larynx.
• Mode of onset
– Sudden onset—acute epiglottitis.
– Gradual onset—benign tumour of lar-
ynx, vocal cords oedema.
• Associated symptoms
– Hoarseness of voice—carcinoma lar-
ynx, benign tumour of larynx.
– Odynophagia—epiglottitis, supraglotti-
tis.
– Cough
– Cough with expectoration—tuberculo-
sis larynx, tuberculosis.
– Dysphagia—carcinoma hypopharynx,
CA cervical oesophagus.
–
smoking—carcinoma.
– Associated symptoms.
(h) Cough—The dry cough is common in laryn-
geal disorders.
• Dry cough, wheezing, throat tightness
and hoarseness—vocal cord dysfunction,
asthma.
8.2 History ofLaryngeal andHypopharyngeal Disorders
299
• Cough triggers by talking—muscle tension dysphonia.
• Cough during swallowing—vocal cords
paralysis.
• Chronic persisting cough with paradoxical vocal fold movement and extrathoracic airway hyperresponsiveness.
• Chronic cough, throat clearing, FB sensation in throat—irritable larynx syndrome
(Table8.6).
• Associated symptoms with cough h/o
ACE inhibitor, bronchitis, GERD, postnasal drip.
(i) Neck swelling
• Site—larynx and lymph node enlargement
in levels 3, 4, 5 and 6.
• Mode of onset—it can be gradual or
sudden.
• Progression
– Progressive—nodal metastasis, tubercu-
lar lymphadenitis, acute lymphadenitis.
– Non-progressive.
• Associated symptoms—dysphagia,
change of voice.
(j) Evaluation of speech and its disorders
Speech—Speech is the process of producing specic sounds that convey meaning to
the listener. Speech is one of the main ways
in which people communicate their
thoughts, feelings and ideas with others.
The act of speaking requires the precise
coordination of multiple body parts, including the head, neck, chest and abdomen.
• Types of speech disorder include stuttering, apraxia and dysarthria.
– Stuttering—Stuttering refers to a
speech disorder that interrupts the
flow of speech, whereas some people
may also find that certain words or
sounds can make a stutter more pronounced. People who stutter can
experience the following types of
disruption.
Repetitions occur when people
involuntarily repeat sounds, vowels
or words.
Blocks happen when people know
what they want to say but have difculty making the necessary speech
sounds. Blocks may cause someone
to feel as though their words are
stuck.
Prolongations refer to the stretching
or drawing out of particular sound.
Types of Stuttering
Developmental stuttering affects
young children who are still learning
speech and language skills. Genetic factors signicantly increase a person’s
likelihood of developing this type of
stutter.
Neurogenic stuttering occurs when
damage to the brain prevents proper
coordination between the different
regions of the brain that play a role in
speech.
Speech disorders—A speech disorder
refers to any condition that affects a person’s ability to produce sounds that create
words. It can affect a person’s self-esteem
and their overall quality of life. There are
many possible causes of speech disorders,
including muscle weakness, brain injuries, degenerative diseases, autism and
hearing loss.
Associated symptoms/history—Stuttering can cause both behavioural and
physical symptoms that occur at the
same time like tension in the face and
shoulders, rapid blinking, lip tremors,
clenched sts, sudden head movements,
h/o aggravating factors (stress, excitement or frustration).
– Verbal apraxia (acquired apraxia of
speech, dyspraxia)—It is motor speech
300
Table 8.6 Different laryngeal causes of dry cough
Irritable larynx syndrome Vocal cord paralysis Muscle tension dysphonia
Upper respiratory infection with cough
Reux
Postnasal drainage
Allergens (e.g. tree, mould, pollen, pet dander)
Cigarette smoke or other kinds of smoke
Odours (e.g. perfume, hairspray)
Food sensitivities
Harsh chemicals/cleaners
Cold air or hot/humid air
Strong emotions (e.g. anxiety, stress)
Hyperfunction of the muscles of the vocal mechanism
8 History andExamination ofLaryngeal andHypopharyngeal Disorders
Change of voice
H/o trauma
H/o thyroid surgery
Dysphonia
Pain while phonation
disorder. It refers specically to the
impairment of motor skills that affect
an individual’s ability to form the
sounds of speech correctly, even when
they know which words they want to
say. Verbal apraxia can be presented
with these symptoms.
Have trouble imitating and saying
sounds on your own. Patient may add
new sounds, leave sounds out or say
sounds the wrong way.
Patient is able to say something the right
way one time but the wrong way the
next time.
Patient moves his tongue and lips to get
them into the right place as he tries to
say sounds. This is called groping.
Speak more slowly.
Be able to say things that person said all
the time—like ‘Hello’ or ‘How are
you?’—without much trouble. This is
called automatic speech.
Not be able to say any sounds at all.
This may happen in severe cases.
– Dysarthria—It occurs when damage to
the brain causes muscle weakness in a
person’s face, lips, tongue, throat or
chest. Muscle weakness in these parts
of the body can make speaking very
difcult. It is presented with slurred
speech, mumbling, speaking too slowly
or too quickly, soft or quiet speech, dif-
culty moving the mouth or tongue.
• Presentation of speech disorders—The
symptoms of speech disorders vary widely
depending on the cause and severity of the
disorder. People can develop multiple
speech disorders with different symptoms.
– Repeating or prolonging sounds
– Distorting sounds
– Adding sounds or syllables to words
– Rearranging syllables
– Having difculty pronouncing words
correctly
– Struggling to say the correct word or
sound
– Speaking with a hoarse or raspy voice
– Speaking very softly
• Duration—it can be short duration or long
duration.
• Mode of onset—sudden or insidious.
• Associated symptoms and past h/o stroke,
head injury, neck injury, dementia,
autism, Down syndrome, head & neck
cancer, hearing loss, ear infection,
Huntington’s disease, Parkinson’s disease
or amyotrophic lateral sclerosis.
Premature baby and low birth weight
should be ruled out.
8.3 History/Presentation
ofHypopharyngeal Disease
1. Chief Complaints/Symptoms of Hypopharyn-
geal Disorders
(a) Dysphagia (difculty in swallowing)—
Patients frequently report food sticking
in the upper oesophagus or upper throat.
This is because the hypopharynx is
involved in the coordination of the swallowing function around the larynx.