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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4440_Библиотеки_им_академика_М_И_Перельмана.pdf
8.3 History/Presentation ofHypopharyngeal Disease
301
• Duration
– Acute—common cold, u,
supraglottitis.
– Chronic—idiopathic, carcinoma,
GERD, diverticulum.
• Mode of onset
– Sudden—foreign body in cricophar-
ynx or oesophagus, supraglottitis.
– Gradual—idiopathic, carcinoma
hypopharynx, Plummer-Vinson
syndrome (Peterson-Kelly syndrome), oesophageal web.
• Associated symptoms—electric-like
sensation, pain, foreign body sensation, GERD, odynophagia, bitter taste
in mouth.
(b) Regurgitation—This is dened as a mix-
ture of gastric juices, and sometimes,
undigested food rises back to oesophagus
or mouth.
• In adult, this is caused by acid reex,
GERD, rumination syndrome, blockage, pregnancy, smoking and eating
disorder and presented as heartburn or
chest pain, bitter or sour taste in
mouth, trouble swallowing, feeling a
lump in throat.
• In children, it is common in early life;
this is presented as trouble swallowing
which may cause gagging and choking, irritability, back aching, avoidance
of food, frequent cough and pneumonia. Any symptoms of blood or bile in
regurgitation, problem feeding, excessive crying and breathing difculty
indicate the serious problem.
(c) Burning sensation in lower part of neck
(Table8.7).
(d) Foreign body sensation.
(e) Throat pain—Typically, pain is unilateral
and well localized, often radiates to ear,
no response with antibiotic.
(f) Odynophagia—pain in swallowing.
(g) Choking—due to aspiration.
(h) Hoarseness or other voice changes.
(i) Neck swelling—enlarged lymph node or
lump in mid-part of neck/jugulo-
omohyoid area (level III).
(j) Persistent sore throat or a feeling that
something is caught in the throat.
(k) Otalgia—Pain in ear due to laryngeal or
hypopharyngeal disorders is called
referred pain. It is due to Arnold’s nerve
branch of vagus nerve. Invasion of the
laryngeal nerve causes spread of neuro-
pathic impulses to the auricular nerve
(sensory to posterior external auditory
canal and back of pinna).
(l) Chronic bad breath (halitosis)—present/
absent.
(m) Unexplained weight loss—This is due to
dysphagia, loss of appetite.
(n) Dyspnoea (difculty in breathing)—
Dyspnoea is a symptoms of airway
obstruction. The difculty in breathing or
dyspnoea in hypopharyngeal disorders is
most of time due to involvement of lar-
ynx or involvement of RLN, larynx or
trachea.
• Duration—It can be acute if it is present for short duration or chronic.
• Severity—It can be mild, moderate
and severe.
• Associated symptoms—dyspnoea,
change of voice, neck swelling.
(o) Stridor (sound of breathing)—It is
dened as audible sound heard without
stethoscope during inspiratory, or in expi-
Table 8.7 Causes of burning sensation in throat
Causes Presentation with burning sensation
GERD Tasting a sour liquid in the back of your throat, coughing, trouble swallowing, chest
pain, hoarse voice, feeling like food is stuck in your throat
Burning mouth syndrome Increased thirst, a metallic taste or bitter taste in mouth, loss of taste
Carcinoma Persistent burning, dysphagia, hoarseness of voice
Idiopathic
Thermal injury Odynophagia, burning sensation while eating or drinking
302
Table 8.8 Differential diagnosis of carcinoma of larynx and laryngopharynx
Associated symptoms or history Site of lesion
H/o smoking and alcohol or both CA hypopharynx
30- to 50-year-old woman or non-smoker with Plummer-
Vinson or Paterson-Kelly syndrome (dysphagia,
hypopharyngeal and oesophageal webs, weight loss, and iron
deciency anaemia)
Asbestos exposure Hypopharyngeal cancer
Iron and vitamin C deciencies Lower hypopharyngeal tumours
GERD or LPRD Tumours in the posterior cricoid region
Geographical—USA Pyriform sinus CA
Northern European countries who do not smoke Postcricoid squamous cell carcinoma
Previous diagnosis of salivary gland tumour
H/o radiotherapy
USA or Canada CA pyriform fossa> posterior pharyngeal wall>
Hoarseness of voice Tumour involves larynx, RLN
Respiratory distress Tumour invading the larynx or trachea
Thyroid swelling Swelling in lower part of neck
8 History andExamination ofLaryngeal andHypopharyngeal Disorders
Postcricoid CA
postcricoid area
ratory or in both phases of respiration. In
cases of carcinoma of hypopharynx or
mass lesion in hypopharynx, it is inspiratory and due to either direct involvement
of larynx or involvement of recurrent
laryngeal nerve or due to mechanical
obstruction due to mass effect.
• Duration
– Acute—carcinoma of hypophar-
ynx direct invasion.
– Chronic—involvement of recur-
rent laryngeal nerve.
• Mode of onset
– Sudden onset—carcinoma of
hypopharynx.
– Gradual onset—due to mass lesion,
benign tumour.
• Associated symptoms
– Hoarseness of voice—carcinoma
larynx, benign tumour of larynx.
– Odynophagia—epiglottitis, supra-
glottitis.
– Cough with/without expectora-
tion—tuberculosis larynx,
tuberculosis.
– Dysphagia—carcinoma hypophar-
ynx, CA cervical oesophagus.
– H/o alcohol intake and
smoking—carcinoma.
– Anaemia—Peterson-Kelly syn-
drome or Plummer-Vinson syndrome.
(p) Fatigue—This is due to poor nutrition
due to carcinoma hypopharynx.
(q) Halitosis-Fetid breath is due to sapro-
phytic bacterial overgrowth in fungating
necrotic tumours.
2. Associated Symptoms and History (Table8.8).
8.4 Examination ofLarynx
andHypopharynx
8.4.1 Examination ofLarynx
Clinical Anatomy
The larynx is located between c3 and c6
cervical vertebra. It has three parts: supraglottis, glottis and subglottis. Superiorly, it
is continuous with oropharynx at the level
of vallecula and inferiorly with trachea.
Posteriorly, it is related to pyriform fossa,
hypopharynx.
8.4 Examination ofLarynx andHypopharynx
How to Examine
The exterior of larynx is examined in direct
vision and interior with indirect laryngoscopy mirror.
Instruments
Indirect laryngoscopy mirror (Fig.8.1).
1. Examination of exterior of larynx
(a) Inspection
• Widening—growth of pyriform fossa,
extralaryngeal spread of laryngeal carcinoma, transglottic carcinoma.
• Swelling—laryngocoele.
• Movement on swallowing—normal,
restricted.
• Indrawing of suprasternal notch.
(b) Palpation
• Tenderness—perichondritis, postradiation.
• Laryngeal crepitation—This is a normal crepitation sound produced by the
movement of laryngeal cartilage
against cervical spine.
Boca’s sign—Laryngeal crepitus is absent
in carcinoma postcricoid region, retropharyngeal abscess, Ryle’s tube in situ. The
absence of laryngeal crepitus is known as
Boca’s sign.
303
2. Examination of interior of larynx
(a) Indirect laryngoscopy—It is initial
clinical procedure used to visualize the
larynx with help of indirect laryngoscopy mirror and bull’s headlight.
• Technique—This procedure works
best in a brightly lit room. The patient
should be sitting in front of examiner,
upright with a straight back, leaning
slightly towards examiner with chin
pointing upwards (‘snifng position’).
Use a headlight or mirror light to direct
headlight parallel to your eld of
vision. Warm the mirror over an alcohol lamp or with warm water or dip in
Savlon to prevent fogging. Apply
anaesthetic agent (xylocaine spray), if
required to the patient’s pharynx, and
ask patient not to swallow and spit if
required. Test the temperature of the
mirror before commencing the procedure to ensure it is not dangerously hot.
Ask the patient to relax and to protrude
out his or her tongue. Cover the tongue
in gauze and pull it with the thumb and
middle nger of your non-dominant
hand. With the patient breathing in and
out, direct the mirror into the mouth
and towards the back of the throat,
making sure the glass side is downward. At the back of the throat, press
the mirror upwards, against the uvula
and soft palate. Avoid the gag reex by
not touching the posterior pharyngeal
wall or tongue base. Slightly alter the
Fig. 8.1 Indirect
laryngoscopy mirror
Indirect laryngoscopy mirror
304
8 History andExamination ofLaryngeal andHypopharyngeal Disorders
mirror and try various angles to visualize the desired structures. Now ask the
patient to say ee to visualize the vocal
cord movement and pyriform sinus
(Fig.8.2a, b).
• Indications
– Change in voice
– FB sensation
– Dysphagia
– Dysphonia
– Throat pain
– Stridor
– Odynophagia
• Structures seen on indirect laryngos-
copy (Fig. 8.3)
– Base of tongue—This is posterior
1/3 of tongue
– Vallecula—This is space between
tongue and epiglottis
– Median glossoepiglottic fold
– Lateral glossoepiglottic fold
– Epiglottis
– Aryepiglottic fold
– Arytenoid
– False cords
– True cords
– Anterior commissure
– Posterior commissure
– Pyriform fossa
• Structure not seen in indirect
laryngoscopy
– Postcricoid area
– Apex of pyriform fossa.
– Ventricle
– Under surface of vocal cord and
adjoining subglottic area.
– Laryngeal surface of epiglottis.
• Pitfalls of indirect laryngoscopy
examination
– There is anterior and posterior
reversal of structure in mirror
image.
– Overhanging of epiglottis may
obscure vision.
– The anterior commissure is poorly
visualized.
– Depth perception is poor.
– Procedure is difcult in poor.
– The tongue may rise on phonation
and may obscure the view of
larynx.
– Procedure is difcult in short neck.
a
Fig. 8.2 (a, b) Technique of indirect laryngoscopy
b
ds
8.4 Examination ofLarynx andHypopharynx
Trachea
Rima glottis
305
Base of tongue
Vallecula
Epiglottis
False vocal cor
Ventricle
Tr ue vocal cord
Aryepiglottic fold
Pyriform fossa
Post cricoid area
Arytenoid
Fig. 8.3 Labelled diagram of indirect laryngoscopy. BOT
base of tongue, GEF glossoepiglottic fold, V vallecula,
FVC false vocal cords, TVC true vocal cords, AEF
– Vocal cords appear short and at in
the mirror.
– The vocal cords appear white due to
the reection of the greater amount
of light from vocal cords than rest of
larynx.
(b) Rigid Telescopic Indirect Laryngos-
copy (Fig.8.4)—It is an OPD procedure.
Rigid direct laryngoscopy is a useful
technique to accurately assess vocal fold
function.
• Indications—to conrm the ndings
of indirect laryngoscopy.
• Preoperative evaluation—No spe-
cic evaluations are required for rigid
indirect laryngoscopy.
• Technique
– This technique utilizes the same
preparation as mentioned above.
– The anterior tongue is grasped with
a gauze sponge.
– A defogged telescopic rod with a
70-degree or 90-degree viewing
angle is inserted over the surface of
the tongue, taking care not to touch
the posterior tongue or posterior
pharyngeal wall.
– Visualization of the laryngeal and
hypopharyngeal structures is
obtained in the same manner as
described for the mirror.
aryepiglottic fold, IAA interarytenoid area, rima glottidis,
PCA postcricoid area, A arytenoid, PS pyriform sinus
– If the child begins to gag with the
instrument in place, he/she is
asked to pant like a puppy. This
tends to relax the palate and
allows completion of the
examination.
• Limitations
– Failure to accurately diagnose
pathology.
(c) Findings
• Appearance of larynx
– Normal larynx—A normal larynx
appears pinkish in colour, and vocal
cords appear white on indirect
laryngoscopy.
– Abnormal
Rat-bitten appearance
White discoloration
Red discoloration
Shape of epiglottis
Movement of vocal cords
• Examination of supraglottis—The
supraglottis includes vallecula, epiglottis, false vocal cords, aryepiglottic
folds, arytenoid, interarytenoid area
and ventricle.
• Epiglottis
– Normal
– Abnormal
Omega-shaped epiglottis—This is
a sign of laryngomalacia.
306
Fig. 8.4 Rigid telescopic indirect laryngoscopy
8 History andExamination ofLaryngeal andHypopharyngeal Disorders
Swollen epiglottis—This is a sign
of epiglottitis.
Rat-bitten appearance—This is a
sign of tuberculosis larynx.
Congested epiglottis—supraglot-
titis.
– False vocal cords
– Aryepiglottic folds
– Arytenoid
– Interarytenoid area
– Congestion of vocal cords
– Swelling/mass
– Growth
(d) Additional area to be examined
• Examination of neck—The neck
should be examined for lymph node
involvement.
• Examination for evaluation of speech
disorders—They will also examine
how a person moves their lips, jaw
and tongue and may inspect the muscles of the mouth and throat.
Denver’s articulation screening
examination. This test evaluates the clarity
of a person’s pronunciation.
Prosody-voice screening prole. SLPs use
this test to examine multiple aspects of a
person’s speech, including pitch, phrasing,
speech patterns and speaking volume.
Dynamic evaluation of motor speech skills
(DEMSS) manual. The DEMSS is a
comprehensive guide for helping SLPs
diagnose speech disorders.
8.4.2 Examination ofHypopharynx
Assessment begins in the ofce with a thorough
head and neck examination, including inspection,
palpation, and indirect or endoscopic
examination.
• Examination of exterior of hypopharynx/
Neck—The neck should be examined in a systematic fashion.
– Any lymph nodes should be assessed with
regard to size, location and mobility.
– Laryngeal crepitus—Loss of the grating
sensation (laryngeal crepitus) of the laryngeal cartilages over the prevertebral tissues
may indicate deep pharyngeal wall
involvement.
– The patient who puffs out his or her cheeks
or performs a Valsalva manoeuvre may distend the pyriform fossae for inspection.
• Examination of interior of hypopharynx—
Indirect laryngoscopy and exible breoptic
endoscopic examination are important to visualize the hypopharynx. Because of the
patient’s gag reex, a exible breoptic examination is the preferred examination technique
and often allows the mucosa of the hypopharynx to be well examined. The usual ndings
of hypopharyngeal disorders are submucosal
fullness or unilateral pooling of saliva, mucosal ulceration, pooling of the saliva in the pyriform fossa, oedema of the arytenoids, or
8.4 Examination ofLarynx andHypopharynx
307
Fig. 8.5 (a, b)
Anatomical sites of
hypopharynx
a b
xation of the cricoarytenoid joint, true vocal
cords or both.
Anatomical landmarks of hypopharynx
(Fig.8.5)
– Postcricoid area
– Pyriform fossa
– Posterior pharyngeal wall
• Additional area to be examined
– Oral examination
The hypopharynx is not visible directly, but
other regional pathologies, including the
synchronous oral cavity or oropharyngeal
tumours, might be seen.
Asymmetry of tonsillar pillars can be a
clue to a tumour invading the palatopharyngeus muscle at insertion to the inferior
constrictor muscle.
– Larynx and pharynx examinations
The mirror examination is the quickest and
simplest screening tool, and other ndings
include mass lesions, hyperkeratotic or
erythematous mucosal lesions, ulcerations
and vocal cord paralysis.
– Neck examination
Examine and document the size, location
and number of palpable lymph nodes in all
cervical and supraclavicular node-bearing
areas.
Palpate for laryngeal crepitus—Tenderness
suggests invasion, while loss of normal
tracheal crepitus suggests invasion of prevertebral tissue or a large postcricoid
tumour.
– Head examination
Pyriform fossa
Post cricold area
Posterior
hypopharyngeal wall
Assess cranial nerve function.
Assess jaw mobility—Trismus suggests
invasion of pterygoid muscles.
Areas of mass lesions or tenderness are
suggestive of regional metastases.
– General examination for distant metastases
and comorbidities
Examination of the lungs may reveal any
metastasis.
Examination of the extremities may reveal
peripheral vascular disease or clubbing
suggestive of advanced lung disease or
synchronous lung cancer.
Hepatomegaly with a hard irregular contour suggests metastatic disease.
General neurological examination may
show toxic or metabolic encephalopathy or
neuropathy. Focal neurological ndings
suggest brain metastases or prior cerebrovascular accident (CVA).
Perform a peripheral lymph node examination to assess for possible distant lymph
node metastases.
Direct laryngoscopy view (Comack and
Lehane grade)
Grade Denition
Grade 1 Visualization of entire laryngeal aperture
Grade 2 Visualization of posterior part of the
laryngeal aperture
Grade 3 Visualization of epiglottis only
Grade 4 Not even the epiglottis is visible
308
8.5 Clinical Atlas
ofHypopharyngeal
andLaryngeal Disease
8.5.1 Colour Atlas
ofHypopharyngeal Disorder
(Fig.8.6a–i)
8 History andExamination ofLaryngeal andHypopharyngeal Disorders
a
c
Anatomy of hypopharynx
e
b
d
Pharyngeal diverticulum
f
Fig. 8.6 Common diseases of hypopharynx. (a–c) Normal anatomy of hypopharynx; (d) pharyngeal diverticulum; (e,
f) pooling of saliva in B/L pyriform fossa; and (g–i) carcinoma of pyriform fossa
8.5 Clinical Atlas ofHypopharyngeal andLaryngeal Disease
309
g
i
Fig. 8.6 (continued)
h
310
8 History andExamination ofLaryngeal andHypopharyngeal Disorders
8.5.2 Colour Atlas ofLaryngeal
Diseases (Fig.8.7, 1 to36)
a
d
g
b c
e f
h
i
j
Fig. 8.7 Disease of larynx and its diseases. (a–c) Normal
anatomy of larynx; (d) adducted vocal cords; (e) abducted
vocal cords; (f) phonatory gap; (g) oedema of VC; (h) cyst
over arytenoid; (i) B/L vocal cord paralysis; (j–l) chronic
laryngitis; (m–o) omega-shaped epiglottis (laryngomalacia); (p) pharyngitis; (q, r) angioneurotic oedema; (s, t)
k l
vocal cord polyp; (u) vocal cord nodule; (v–x) haemorrhagic vocal polyp; (y, z) mass in interarytenoid area; (aa)
rat-bitten appearance; (ab, ac) endophytic growth in vallecula; (ad) ulcero-proliferative growth in vallecula; (ae–
ag) growth in pyriform fossa; (ah, ai) growth in
aryepiglottic fold; and (aj) leucoplakia vocal cords