Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4540_Библиотеки_им_академика_М_И_Перельмана.pdf
238
CHAP TER8 Thethroat
Sorethroat
Askabout
• Onset
• Known precipitant
• Unilateral or bilateral
• Symptoms ofURTI
• Discomfort when swallowing
• Contact with other people with similar symptoms
• Fever/ chills/ headache/ photophobia
• Neck stiness.
Lookfor
• Swollen/ displacedtonsil
• Ulceration
• Pus/ quinsy
• Lymphadenopathy/ rash
• Pyrexia
• Neck stiness, photophobia, Kernig’ssign.
Swelling/ lump inthethroat
Askabout
• Onset
• Known precipitant
• Unilateral or bilateral
• Symptoms ofURTI
• Diculty when swallowing.
Lookfor
• Swollen/ displaced tonsil oruvula
• Tonsilloliths
• Lymphadenopathy
• Tumour
• Enlarged thyroid/ parotidgland.
Examination ofthethroat
Thorough clinical examination of the pharynx requires good lighting, a
tongue depressor, and mirror. Ideally it also includes exible breoptic
laryngoscopy. Detailed examination is often car ried out by otolaryngologists. In the emergency department, head light examination using a
tongue depressor and mirror may also reveal useful signs. Clinically the
throat needs to be regarded as more than just the back of themouth.
Nasopharynx
Applied anatomy
The nasopharynx (nasal par t of the phar ynx) is the uppermost par t of
the pharynx. It extends from the base of the skull to the upper surface
EXAMIN ATION OF THETHROAT
of the soft palate. It dier s from the rest of the phar ynx in that its cavity
is always patent. Anteriorly it communicates through the choanae with
the nasal cavities. Laterally the Eustachian tubes open into it. Behind this
opening is a deep recess, the pharyngeal recess (fossa of Rosenmüller)—
a common site for nasopharyngeal malignancy. Posteriorly lies the pharyngeal tonsil.
The location of the na sopharynx makes it very dicult to access and
examine easily. If endoscopy is not available the only way to examine the
nasopharynx is posterior rhinoscopy. Asmall, angled mirror is placed
at the back of the pharynx. Astrong light is then directed towards the
mirror. This is reected upwards, showing the posterior nasal cavity. Unfortunately both the tongue and uvula can hamper the view.
Endoscopic techniques have now considerably improved visualization.
Nasopharyngeal endoscopy may be performed transorally or transnasally and will provide detailed views of the region.
Oropharynx
Applied anatomy
The orophar ynx opens into the mouth. Its later al walls are composed
of the two palatine arches between which is the palatine tonsil. Most
structures of the orophar ynx can be visualized during the examination of
the oral cavity. The palatine tonsils are assessed for symmetr y, mobility,
and for the presence of any coatings or ulceration.
Tonsilloliths may be visible in the cr ypts and crevasses of the tonsils.
They are usually yellow/ white in colour and seen as pale spots. Alaryngeal mirror or lar yngoscope may be used to examine the tongue base
and the lateral walls of the oropharynx. If possible, palpate the tongue
base/ tonsillar region for induration if symptoms raise suspicion of a tumour.
Hypopharynx
Applied anatomy
The hypopharynx (laryngopharynx) lies inferior to the epiglottis, passing
down to diverge into the lar ynx and oesophagus. The oesophagus lies
posteriorly. The hypopharynx is divided into three areas (piriform sinus,
postcricoid area, and the posterior pharyngeal wall). Clinical examination of the hypopharynx (mirror examination, endoscopy) is performed
along with examination of the larynx.
Waldeyer’sring
This refers to a ring- like arrangement of lymphoid tissue in the naso - and
oropharynx. It consistsof:
• Pharyngeal tonsils (or adenoids)
• Tubal tonsil (where each Eustachian tube opens into the
nasopharynx)
• Palatine tonsils (tonsils)
• Lingual tonsils (on the posterior tongue).
Lymphoid tissue in Waldeyer’s ring gradually increases in size from birth
and attains a relatively larger size when the child is around 4year s ofage.
239
240
CHAP TER8 Thethroat
Oesophagus
In experienced hands, the oesophagus can be examined by means of
exible or rigid endoscopy. Flexible oesophagoscopy can be performed
under local anaesthesia. It is generally well tolerated and allows for concomitant examination of the stomach and duodenum. Rigid oesophagoscopy is performed under general anaesthesia and indicated when
looking for foreign bodies, or visualizing the pyriform fossa and postcricoid region.
Steps inexamination
• Ask the patient to remove any dentures.
• If appropriate, examine trunk for rash— a scarlet fever rash gener ally
starts on the chest and spreads to the neck and face. The rash
associated with infectious mononucleosis tends to be generalized.
• Examine the neck for cervical lymphadenopathy. Note any trismus.
• Inspect the tongue and throat. In streptococcal disease there may be
a ‘strawberry tongue’. In cases of infectious mononucleosis there may
be petechiae on the palate.
• Examine the back of tongue and tonsils (press down on the tongue
with a tongue depressor).
• If there is any discharge or loosely adherent plaques/ slough, gently
try to wipe o for microbiology/ pathology.
• Palpate the base of the tongue (feeling for tumours).
• Look at the uvula and palate.
• Examine the nasopharynx and lar ynx with a mirror or exible
breoptic nasendoscope.
Remember— examination of the mouth and throat is not just a case of looking. If possible (without causing excessive gagging) always palpate suspicious
areas. Tumours can easily be missed if this is not routinely undertaken. If one
of the tonsils is displaced medially, examine the associated parotid — tumours
of the deep lobe can displace the tonsil. Not all tumours are obvious to the
nakedeye.
Useful investigations
Laborator ytests
• Complete blood count including dierential count is required for
infective conditions.
• Monospot or Paul – Bunnell test if glandular fever is suspected
• Liver function test if glandular fever is suspected
• Serum biochemistry and renal functions if dehydrated
• Serum ferritin levels and iron prole if Plummer– Vinson syndrome
suspected
• Specic tests for gonococci, syphilis, chlamydia, diphtheria,etc.
• Throat swab for a rapid strep test if streptococcal sore throat is
suspected
• Throat swab for culture if no clinical response to rst- line antibiotics
• Tests for Helicobacter pylori infection (which can predispose to acid
reux andGORD).
THE INFECTEDTHROAT
Plainlms
Conventional radiographs have become largely obsolete in the investigation of diseases of the phar ynx. However, a contrast swallow is still a useful tool in the investigation of some oesophageal disorder s (diver ticula,
tumours, stenoses, and disorders of motility). Various contrast media
can be used (e.g. bar ium, sodium amidotrizoate, iopromide, iotrolan),
depending on the nature of the investigation and any pre- existing disorders. If there is a risk or suspicion of a perforation or aspiration, barium
should not beused.
CT/ M RI
Cross- sectional imaging with CT and MRI is useful in the diagnosis of pharyngeal tumours/ masses and in some inammator y processes (abscess).
Videouoroscopy
This is used mainly to assess swallowing disorders using high- speed cineradiography. This technique evaluates the dierent phases of swallowing
with high- speed image resolution (approximately 50 images per second).
Modied barium swallow is a videouoroscopic study that visualizes oral
and pharyngeal phases of swallowing.
Manometry
This measures duration, amplitude, and velocity of peristalticwaves.
Laryngoscopy and oesophagoscopy
Indicated if suspect malignancy, to remove foreign bodies, and to biopsy
a mass or lesion.
Functional (breoptic) endoscopic evaluation
ofswallowing
This allows bedside evaluation of swallowing function.
241
cThe infectedthroat
Most infected throats are minor infections which will settle quickly with
supportive measures or following a short cause of antibiotics.
However, some sore throats are caused by or ganisms which can result
in serious consequences if overlooked or inadequately treated.
Some causes ofthe infected throat and important sequelae
• Non- specic viral pharyngitis
• Mumps
• Herpangina
• Inuenza
• Bacterial pharyngitis (strep throat)
• Scarletfever
• Rheumaticfever
• Post- streptococcal glomerulonephritis
• Tonsillitis
• Quinsy
242
CHAP TER8 Thethroat
• Infective mononucleosis (glandularfever)
• Epiglottitis
• Uvulitis
• Diphtheria
• Gonorrhoea
• Chlamydia
• HIV (candidiasis)
• Dental infections
• Deep neck infections.
Usually the diagnosis can be made following a careful history and examination. Salient points include:
• Contact history (including sexual contact if suspected sexually
transmitted disease)
• Any known epidemic
• Symptoms of meningism
• Jointpains
• Cardiac symptoms
• Neurological symptoms (Sydenham’s chorea/ St. Vitus’dance)
• Airway compromise
• Ver y highfever
• Lethargy
• Presence ofarash
• Skin nodules
• Pericardialrub
• Appear ances of thethroat
• Drooling
• Haematuria.
The presence (or absence) of these features should help you identify the
more serious infections from the more common, minorones.
cPharyngeal infections
cAcute pharyngitis
This i s a common condi tion. It is mo stly vira l in aetiolo gy but can de velop a
secondary bacterial infection. Pathogens include adenovirus, rhinovirus,
and enterovirus with secondary bacterial infection from Streptococcus,
Pneumococcus, and Haemophilus inuenzae. Patients present with sore
throat, odynophagia, malaise, and fever. On examination, there is diuse
erythema and a granular appearance of the posterior pharyngeal wall.
There is also cervical lymphadenopathy. Treatment is generally supportive (hydration, lozenges, antipyretics). Gargling aspirin or applying benzydamine (Diam®) spray may sooth symptoms. Antibiotics are rarely
indicated (as most infections are viral). Take a throat swab if suspicious of
bacterial infection and consider the more serious infections in your dierential
diagnosis (discussed later).
Non- infective pharyngitis can also occur secondary to sinonasal disease, acid reux, air pollution, or chronic allergy. Symptoms are similar
although the patient is usually systemicallywell.
PHARYNGEAL INFECTIONS
bChronic pharyngitis
This is often associated with postnasal drip (chronic rhinosinusitis), irritants (dust, dry heat, chemicals, smoking, alcohol), acid reux, chronic
mouth breathing (adenoid hypertrophy), allergy, and granulomatous diseases. There is frequent throat clearing with a dry throat, thickened and
granular pharyngeal wall, and pharyngeal crusting
Treatment is supportive, but it is impor tant to address underlying aeti-
ology and avoid contributing factors.
bChronic adenoiditis
Typically a polymicrobial infection, this may be related to GORD, especially in children. It may be dicult to distinguish from sinusitis. Patients
present with persistent nasal discharge, malodorous breath, and nasal
obstruction (snoring). Consider the possibility of a foreign body in the
nose in children. Treatment is initially conser vative but if symptoms persist, refer to ENT for consideration of adenoidectomy.
cInfectious mononucleosis (glandularfever)
The Epstein– Barr virus causes an acute phar yngitis as a part of the infectious mononucleosis syndrome. This is common in children and young
adult s and is transmit ted by oral contact (hence its other name— ‘kisser’s disease’). Patients present with fever, generalized malaise, lymphadenopathy, hepatosplenomegaly, and pharyngitis. On examination
there are massively enlarged tonsils and nasophar yngeal lymphoid tissue,
covered with greyish- white exudates and petechiae at the junction of the
soft and hard palates.
Investigations include a complete blood count. This may show lym-
phocytosis with atypical lymphocytes (activated T cells) on peripheral
smear. The monospot test or Paul – Bunnell test are often diagnostic but
non- specic (heterophile antibody test). They can be negative in 10– 15%
of patients in the rst week of illness. Treatment is largely suppor tive.
Antibiotics may be indicated to treat or prevent super- added bacterial infection. Avoid ampicillin— this can cause skin rashes in patients with
glandularfever.
eDiphtheria
Despite widespread use of universal childhood immunization, several
hundred cases of pharyngeal infection with Corynebacterium diphtheriae
are seen annually, even in the developed countries. These occur mostly
in non- immunized persons. Diphtheriae is characterized by a grey,
rmly adherent pseudo - membrane covering the pharynx and tonsils.
When scraped (with diculty), the underlying surface usually bleeds.
Usually the disease is localized to the phar ynx but rarely may spread to
the larynx causing potential air way compromise. Some bacterial strains
can produce a lethal exotoxin. Toxins can result in cardiac arrhythmias,
myocarditis, and peripheral nerve palsies. The disease should be immediately reported and treatment commenced even before conr mation with culture. Treatment includes antitoxin therapy (administered
within 48 hours of the onset of symptoms) and high- dose penicillin.
Diphtheria is a notiable disease (see http:// www.hpa.org.uk/ Topics/
InfectiousDiseases/ InfectionsAZ/ NoticationsOfInfectiousDiseases/
ListOfNotiableDiseases).
243
244
CHAP TER8 Thethroat
cTonsil (adenotonsil) infections
In most cases, tonsillitis is a ‘strep throat’ caused by a streptococcal infection. The oropharynx is normally colonized by Staphylococcus,
Streptococcus, Lactobacillus, Bacteroides, and Actinomyces (plus many
other organisms). Viral tonsillitis presents with fever and oropharyngeal erythema without a tonsillar exudate and is usually self- limiting. It
requires only symptomatic treatment.
cAcute streptococcal tonsillitis
Group A beta- haemolytic Streptococcus is the most common pathogen causing acute bacterial pharyngotonsillitis. It is commonly seen
in children and is characterized by fever, sore throat, cervical lymphadenopathy, dysphagia, and odynophagia. Examination reveals tonsillar
and pharyngeal ery thema which is covered with purulent exudates. The
tongue may also be involved (‘strawberr y tongue’). Take aswab.
The main consideration in treating group A beta- haemolytic
Streptococcus is preventing its complications (notably acute rheumatic
fever and post- streptococcal glomerulonephritis). The primary antibiotic
of choice is penicillin. Consider second- line therapy with co- amoxiclav
(ideally following discussion with a microbiologist), if no response is evident within 48 hour s. Consider antibiotic therapy for at least 7– 10days
to decrease the recurrencerates.
bRecurrent acute tonsillitis
In most cases, an episode of acute tonsillitis is followed by complete
recovery. However, the tonsils with their numerous crypts and crevices,
can harbour bacteria and persistent or recurrent infection may occur.
Aggressive medical therapy for recurrent acute tonsillitis may not always
prevent these infections. Many otolaryngologists and primar y care physicians agree that tonsillectomy is indicated in recurrent acute tonsillitis.
Therefore refer toENT.
Current NICE and SIGN guidelines recommend surgery if there are more
than six or seven episodes of acute tonsillitis in 1year, ve episodes/ year for
2 consecutive years, or three episodes/ year for 3 consecutiveyears.
Complications ofacute tonsillitis
cScarletfever
This t ypically presents with fever, severe dysphagia, exudates covering the tonsils and pharynx, a diuse erythematous rash, red inamed
tongue (‘strawberry tongue’), facial ush, and petechial rashes. The
eruptions are followed by desquamation caused by er ythrogenic exotoxin which is pathognomonic. Treatment is with penicillin and supportive care. Scarlet fever is a notiable disease.
eAcute rheumaticfever
Acute rheumatic fever occurs 2– 3 weeks af ter infection with group
Abeta- haemolytic Streptococcus. This infection produces cross- reactive
antibodies, leading to damage of the heart tissues with subsequent
TONSIL (ADENOTONSIL) INFECTIONS
endocarditis, myocarditis, or pericarditis. Preventing rheumatic fever
requires eradication of Streptococcus from the throat which may include
long term antibiotics and tonsillectomy. You may need to discuss this
with ENT and/ or cardiology.
cPost- streptococcal glomerulonephritis
Post- streptococcal glomerulonephritis usually occurs as an acute nephritic
syndrome around 10days after a pharyngotonsillar infection (10– 25%
incidence) by group Abeta- haemolytic Streptococcus. The disease is now
on the decline in developed countr ies, while it continues to occur in developing countries. Pathogenesis involves deposition of immune complexes
and circulating autoantibodies in the glomeruli. Antibiotic treatment has
not been shown to aect the incidence of the disease.
cPeritonsillar abscess (quinsy)
This is caused by the spread of infection beyond the tonsillar capsule
into the peritonsillar space. Patients usually present with a relentless
sore throat, unilateral otalgia, dysphagia, and odynophagia. They may
be dehydrated. On examination there is a unilateral tonsillar/ peritonsillar bulge with uvular deviation. Patients often have trismus, restricting access for incision and drainage. Untreated, this can lead to potential
airway compromise, parapharyngeal or retropharyngeal abscess, aspiration
pneumonia or sepsis. Urgent CT may be required if a para- pharyngeal
abscess is suspected. Management includes needle aspiration or (preferably) incision and drainage under local anaesthesia if not too extensive. Antibiotics and analgesics are prescr ibed. Drainage can often be
performed in the emergency department, or alternatively patients can
be referred urgently to ENT. Some patients may need admission for IV
uids and antibiotics if oral intake is poor. ‘Quinsy tonsillectomy’ (tonsillectomy at time of infection) may be considered for younger children or
unresponsivecases.
eDeep neck infections
(See also E Chapter 5.) Deep neck infections can occur as a complication of any bacterial tonsillitis or pharyngitis. However, with widespread
antibiotics usage, the incidence of these complications has dramatically
decreased. Para- pharyngeal abscesses may present with asymmetric
pharyngeal wall swelling, extending inferiorly into the hypopharynx.
Denitive diagnosis requires a CT scan of the neck. Management includes
control of the airway, IV antibiotics and uids, and urgent surgical drainage of the abscess. Refer urgently a s patients can rapidly deteriorate.
245
246
CHAP TER8 Thethroat
Other types ofthroat infections
cCoxsackievirus (herpangina)
This presents as ulcerative vesicles over the tonsils, pharynx, and palate.
It is often seen in children and presents with generalized symptoms of
headache, fever, anorexia, and odynophagia. Treatment is mostly sup portive, but antibiotics may be needed if bacterial super- infection.
cSexually transmitted disease infection
Patients with exposure to sexually transmitted diseases can develop
tonsillar infections with Neisseria gonorrhoeae (gonococcal), Chlamydia,
or Treponema pallidum (syphilis). Gonococcal infections present as exudative tonsillitis and pharyngitis. Chlamydial infections can infect the eyes
(conjunctivitis) and throat following unprotected oral sex. Infection in the
throat isless common and usually causes minimal symptoms. Syphilitic
infections result in oral chancres (with primar y infections) and exudative
lesions (with secondary syphilis).
eEpiglottitis (supraglottitis)
Acute epiglottitis is a potentially life- threatening disorder due to the risk
of lar yngospa sm and loss of t he airway. It is c haracte rized by in ammator y
oedema of the ary tenoids, aryepiglottic folds, and the epiglottis. Acute
epiglottitis can occur at any age. It is typically caused by Haemophilus inu-
enzae type B, but infection with group Abeta- haemolytic Streptococcus
has become more frequent after the widespread use of Haemophilus
inuenzae vaccination. Non- infectious causes of epiglottitis include
trauma, inhalation injur y, and chemical burns. It can also be associated
with systemic disease. Typical presentation includes:
• Acute high fever/ malaise
• Severe sorethroat
• Diculty in swallowing
• Patient s often sit up and lean for ward in order to improve air ow
(tripodsign).
The most common dierential diagnosis in the paediatric age group is croup
and a foreign body in the airway (s ee E Chapter 5). Croup has a more
gradual onset than acute epiglottitis, and is commonly associated with lowgrade fever, bark ing cough, and absence of drooling and dysphagia. In acute
epiglottitis, a r adiological ‘thumb sign’ is indicative of severe inammation
of the epiglottis. Conrmation is by exible breoptic laryngoscopy in a
controlled clinical setting.
Because of the risk of inducing laryngeal spasm and/ or total airway obstruction, examination should only be attempted by experienced clinicians and in
an area with adequate equipment and sta prepared to intervene should
upper airway obstruction develop, ideally, in the operatingroom.
Patients with signs of an advancing upper airway obstruction from acute
epiglottitis should be treated as a medical emergency and as an airway emergency. Tracheal intubation is potentially dicult and the team should have
a surgeon capable of performing an immediate tracheotomy if necessary.
Muscle relaxants are avoided and spontaneous ventilation should be maintained during inhalational induction.
CHRONIC ADENOTONSILLAR HYPERTROPHY
Do not send a child with suspected epiglottitis for X- ray alone and do not
perform examination in uncontrolled setting due to the risk of inducing laryngospasm. Try not to distress thechild
bTonsilloliths
Food and secretions may stagnate in deep tonsillar cr ypt s (usually in
the upper pole of the tonsil), leading to bac terial overgrow th and localized infection. Some patients may have a foreign body sensation in the
throat, halitosis, and express out white debris from the tonsils (tonsilloliths). Treatment is initially conservative (ag gressive mouth care, which
includes irrigation or cleaning with cotton swab, hydrogen peroxide
gargles, antiseptic mouth rinse, etc.). Tonsillectomy may be considered
in recalcitrantcases.
bFungal infections
Fungal infection in the throat is a serious condition that is more com monly seen in immunocompromised individuals. Candidiasis (oral
thrush) is relatively common (see E Chapter 13); however, extension
of the infection into the throat is more worrying. At- risk groups include:
• Newborn babies (especially premature)
• Immune deciency (diabetes andAIDS)
• Patients on long- term antibiotics, chemotherapy, or steroids
• Self- neglect (alcoholics, drugabuse)
• Malnourished.
Treatment for a candidal throat infection is more intense than for oral
thrush. Any predisposing cause should be managed. An intense course
of topical and systemic antifungal drugs is required and should be discussed with a microbiologist. Infections in patients with AIDS are dicult
to eradicate, due to their compromised immunity and the high chance
of recurrence. Certain home remedies (eating garlic) are reported to
reduce further infection. Intestinal candidiasis and systemic candidiasis
are rare but serious complications. Patients with fungal throat infections
should be screened for high- risk groups. HIV testing may be necessary
(see http:// www.bashh.org/ documents/ 1838.pdf).
cTuberculosis
TB more commonly infects the lungs, but it can infect the throat as well.
Patients may present with hoarseness, if the organism involves the vocal
cords. TB is a notiable disease.
247
bChronic adenotonsillar hypertrophy
Chronic adenotonsillar hypertrophy is the most common cause of sleepdisordered breathing in children, with symptoms ranging from upper
airway obstruction to obstructive sleep apnoea syndrome (OSAS).
Hypertrophy of the lymphoid tissue occurs in response to colonization
with normal ora or pathogenic microorganisms. Nasal obstruction, rhinorr hoea , and a hypo- nasal voice are the usual presenting symptoms of
adenoid hypertrophy, whereas tonsillar enlargement can cause snoring,
dysphagia, and mued voice. Upper airway obstr uction can manifest as