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248
CHAP TER8 Thethroat
loud snoring, chronic mouth breathing, and secondary nocturnal enuresis (bedwetting). Ahistory of apnoeic episodes, hyper- somnolence, frequent night- time awakenings, poor school performance, and a general
failure to thrive are common manifestations of OSAS. Severe cases of
OSAS can lead to pulmonary hypertension, cor pulmonale, and alveolar hypoventilation resulting in chronic CO2 retention. Adenotonsillar
hyper trophy and chronic mouth breathing are associated with craniofacial growth abnormalities with subsequent malocclusion (adenoid facies).
Diagnosis of adenotonsillar hypertrophy is based on the clinical history
and physical examination. Flexible endoscopy is helpful in diagnosing adenoid hypertrophy, adenoid infections, and velopharyngeal insuciency,
as well as ruling out other causes of nasal obstruction. Lateral neck sof t
tissue radiography is rarely indicated.
Management
• For acute upper airway obstruction, consider cor ticosteroids and
antibiotics.
• Medical treatment includes intranasal corticosteroid sprays for
adenoid hyperplasia.
• Tonsillectomy and adenoidectomy may be required as denitive
therapy.
Beware of unilateral tonsillar hyperplasia— it is important to consider the
possibility of neoplasms (carcinoma, lymphoma) or unusual infections
(Mycobacterium tuberculosis, atypical mycobacteria, actinomycosis and
fungal).
Hypopharyngeal/ upper oesophagealrelated problems
bCandidiasis (thrush)
This is discussed in ‘Other types of throat infections’, pp. 246–7.
bPlummer– Vinson syndrome (Patterson– Kelly
syndrome)
This may be secondar y to nutritional deciency (iron). It typically presents in middle- aged women. Symptoms include dysphagia, microcytic
hypochromic anaemia (iron deciency), cervical (pharyngoesophageal)
webs, angular cheilitis, hypothyroidism, hiatus hernia, splenomegaly, and
koilonychia of the nails. Investigations include blood tests (iron levels,
FBC) and oesophagr am or exible endoscopy. These patients have a
higher risk for upper oesophageal and hypopharyngeal carcinoma and
hence careful monitoring is warranted. Treat any iron deciency.
bDiuse oesophageal spasm (beware cardiac
ischaemia)
This is caused by non- peristaltic contraction in oesophageal smooth
muscle. Patients present with sudden- onset, severe odynophagia
and dysphagia to solids and liquids. They may also present with chest
HYPOPHARYNGEAL/UPPER OESOPHAGEAL
pain, mimicking cardiac pain. Both cardiac and oesophageal pain may
be relieved with glyceryl trinitrate, adding to any diagnostic confusion.
Consider ECG/ troponin levels if in doubt . The pain from oesophageal spasm
is sometimes relieved by eructation (belching/ burping). Diagnosis may
also be conrmed by oesophagram and manometry. Treatment is medical (nitrates, calcium channel blockers, anticholinergics). Refractory
cases may be considered for dilation and myotomy.
bGastroesophageal reux disease
GORD is caused by incompetence of the lower oesophageal sphincter
or its transient relaxation. There is also delayed oesophageal clearance
and delayed gastric emptying. Predisposing factors include obesity, alcohol abuse, hiatus hernias, and pregnancy. Typically patients present with
hear tburn, choking spells at night, regurgitation, hoarseness (worse
in the morning), globus, a nocturnal cough, and chronic throat clearing. Diagnosis is often made on the history and response to empirical
anti- reux treatment . Untreated cases can lead to complications such
as Barrett’s oesophagus (gastric metaplasia of the distal oesophagus
which predisposes to malignancy), oesophageal strictures, gastric and
oesophageal ulcerations, aspiration pneumonitis, laryngeal granulomas,
etc. In infants, GORD can cause failure to thr ive and sudden infant death
syndrome. Diagnosis is usually made by careful histor y. Although an antireux regimen may be prescribed based on the history, consider referral
for testing if symptoms don’t resolve, recur, or complications develop.
Investigations
• Nasopharyngoscopy
• Barium swallow
• Oesophagoscopy:this evaluates for oesophagitis and oesophageal
strictures and allows histological conrmation of Barrett’s
oesophagus.
Management
• Dietar y changes and smok ing cessation; elevate head of bed at night;
avoid tight tting clothing; avoid overeating, abstain from caeine,
fatt y foods, alcohol and chocolates; avoid aspirin, nitrates, and
calcium channel blockers. Medication includes:
•
Liquid antacids (calcium carbonate, hydroxides of aluminium and
magnesium, sodium bicarbonate). Be careful— overuse may result
in acid – base and other met abolic disturbances
•
H2- blockers (cimetidine, famotidine, ranitidine,
nizatidine):considered for uncomplicated GORD; side eects
include constipation, diarrhoea, confusion, and elevated liver
enzymes.
•
Proton pump inhibitors (omeprazole, lansoprazole):highly
eective, rst- line agents for complicated GORD or failed rst- line
regimens.
•
Prokinetic agents (cisapride, metoclopramide):indicated for
delayed gastric emptying, increases lower oesophageal sphincter
pressure; side eects include tardive dyskinesia and confusion.
• Surgical management is indicated for failed medical regimen;
fundoplication increases tone of the distal oesophagus.
249
250
CHAP TER8 Thethroat
bOesophagitis
Various formsexist:
• Reux oesophagitis.
• Candidal oesophagitis
• Herpes oesophagitis. Multiple ulcerations, most commonly seen in
immunocompromised patients.
• Drug- induced oesophagitis. Typically punctate ulcerations; causative
drugs include tetracycline, quinidine, aspirin, and clindamycin.
• Radiation oesophagitis. May be acute (during therapy) or chronic
(scarring and stenosis 6 – 18months after radiation therapy).
• Eosinophilic oesophagitis. This is an allergic inammatory condition
of the oesophagus, sometimes called allergic oesophagitis. Symptoms
include swallowing diculty, food impaction, and heartburn. It should
be considered if gastroesophageal reux does not respond to high-
dose proton- pump inhibitors or if pH studies rules out GORD. Biopsy
may be required. Treatment includes corticosteroids and other
anti- inammatories. Mechanical dilatation may be considered with
strictures.
bOesophageal diverticulum (pharyngealpouch)
A phar yngeal pouch is created by herniation of mucosa through the
muscular wall. There are three areas of natural weakness in the upper
oesophageal/ hypopharyngeal segment:
• Killian’s triangle:inferior to the cricopharyngeal muscle and superior
to the cr icothyroid muscles
• Killian– Jamieson space:laterally, between cricophar yngeal and
oesophagusmuscle
• Laimer– Haecker mann space:between cricophar yngeus superiorly
and circular bres inferiorly
• Several types of diverticulumexist.
bOesophageal neoplasms
Benign tumours andcysts
These are rare and are less common than malignant tumours. Patients
present with dysphagia, pressure behind the sternum, bleeding, and
weight loss. Diagnosis is by barium swallow and endoscopy (with biopsy),
CT/ MRI. Treatment requires endoscopic or open excision.
Malignant tumours
These typically present in elderly males with a history of tobacco and
alcohol abuse. They are also seen in association with caustic burns, radiation, oesophageal webs, Plummer– Vinson disease, achalasia, pernicious
anaemia, nutritional deciencies, oesophagitis, and GORD. Tumours
may initially result in painless dysphagia which develops later into odynophagia. There may also be haemoptysis, a cough, hoarseness, and weight
loss. Investigations include barium swallow, endoscopy and biopsy and
CT/ MRI. Management is multimodal therapy (surgery, radiation/ chemother apy). Overall there is a poor prognosis.
MISCELLANEOUS CONDITIONS INVOLVING THETHROAT
bOesophageal webs andrings
Webs are asymmetric, thin, membranous projec tion into the lumen,
composed of mucosa and submucosa only. Rings are thicker, composed of mucosa , submucosa, and muscularis mucosa. Upper cervical
webs may be associated with Plummer– Vinson syndrome. Diagnosis is
conrmed with oesophagrams or oesophagoscopy. Treatment options
include dilation and endoscopic laser excision.
eOesophageal rupture and perforation
Aetiology includes iatrogenic instrumentation (most common cause),
blunt and penetrating trauma, neoplasms, inammation, and increased
abdominal pressure:
• Mallory– Weiss syndrome:incomplete tear of oesophageal mucosa
from increased abdominal pressure (vomiting in alcoholics), presents
as an upper GIbleed.
• Boerhaave syndrome:increased abdominal pressure result s in a
full- thickness tear of the lower oesophagus. Symptoms include
bloodstained vomiting, chest pain, dyspnoea, and hypovolaemia.
Examination may reveal tachycardia, fever, respiratory distress, dysphagia, subcutaneous emphysema, Hammer’s sign (crunching sound
over heart from subcutaneous emphysema). Investigations include CXR
(mediastinal widening, pneumothorax) and oesophagram (sodium amidotrizoate). Untreated cases can lead to complications including chemical mediastinitis and septic shock . Usually need ear ly surgical repair and
drainage, antibiotics and anti- reux medication.
bGlobus
Globus is a feeling of a lump in the throat when actually there is no lump
present. It is often associated with anxiety. Usually it is idiopathic in
nature (globus pharyngeus or globus hystericus), but occasionally may
be secondar y to identied patholog y:
• Oesophagealspasm
• GORD
• Neuromuscular disorder s such asmyasthenia gravis, Parkinson’s
disea seandstroke
• Rarely, cancers of the upper GItract.
251
Miscellaneous conditions involving
thethroat
bAphthousulcers
These most commonly occur in the oral cavity but can also present in
oropharynx. They are mostly idiopathic, but can be immunological, hormonal, stress induced, traumatic, or nutritional related.
• Minor aphthous ulcers are the most common. There is burning and
tingling before ulcer formation. Ulcers are <1.0cm in diameter and
painful.
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CHAP TER8 Thethroat
• Major aphthous ulcer. These are more painful and larger (1– 3cm in
diameter), multiple (1– 10), and carr y a risk of scar formation.
• Herpetifor m. These form numerous small ulcers 1– 3mm in diameter.
Treatment includes observation (self- limiting), consider anti- inammatory
agent s, oral and t opical cor ticosteroids. S creen for hae matinic de ciencies .
cSwollen uvula (Quincke’s disease orsign)
An acutely swollen uvula can present with foreign body sensation or
fullness in the throat, mued voice, and gagging. E xamination reveals
the uvula is swollen, pale, and translucent. It may be seen resting on the
tongue, moving in and out with respiration. There may also be an associated rash, history of exposure to aller gens, or a recurrent seasonal
incidence. Consider foods, drugs, physical agents, inhalants, insect bites,
and hereditary angio- oedema. Initial treatment includes parenteral antihistamines. More severe cases may need nebulized adrenaline (epinephrine) and parenter al cor ticosteroids. If there is a histor y of recurrent
episodes or family history, consider checking for C4 complement level
or C1 esterase inhibitor levels to screen for hereditar y angio- oedema.
All patients should be observed for an adequate per iod of time to insure
that there is either improvement or no further worsening.
bEagle syndrome (styloid– carotid artery syndrome)
This is a rare condition in which there is elongation of the st yloid process,
or calcication of the stylohyoid ligament . ‘Classic’ and ‘vascular’ forms
are described. Patient s are usually aged between 30 and 50years and
can present with recurrent sore throat, dysphagia, neck pain, and ot algia.
Blackouts and sudden death due have also been repor ted and are due
to mechanical pressure on the carotid. Consider this when neurological
symptoms occurs upon head rotation. The tip of the st yloid process may
be palpable in the back of the throat. Plain lms and CT conrm the
diagnosis (the enlarged styloid may be visible on an OPT or a lateral soft
tissue X- ray). In both types, treatment is surgical (partial styloidectomy).
bLeucoplakia and erythroplakia
(See also E Chapter 13.) These can also occur in the pharynx.
Leucoplakia anywhere in the oral cavity and pharynx carries a small risk
of malignant change. However, the risk is often site dependent (not ably
oor of mouth) and particularly related to smoking and alcohol abuse.
Ery throplakia has a higher risk of malignancy. All chronic leucoplakia or
ulcer ative lesions that fail to heal af ter 3– 6 weeks should be referred.
bSnoring and obstructive sleepapnoea
Snoring occurs as a result of vibration of the upper respiratory structures (usually the uvula and soft palate) secondary to partial obstr uction
of air movement while sleeping. Intensity and loudness can var y considerably. Associated causes include:
• Intrinsic muscular weakness, causing the throat to rela x duringsleep
• Retruded mandiblejaw
• Enlarged tonsils/ adenoids
• Large collar size/ obesity
DYSPHAGIA AND ASPIRATION
• Obstruction in the nasal passageway
• Obstructive sleepapnoea
• Muscle relaxants including alcohol ordrugs
• Sleeping on one’s back, which may result in the tongue dropping to
the back of themouth.
Snoring may be an early sign of obstructive sleep apnoea (OSA). This
condition is known to cause sleep deprivation resulting in daytime
drowsiness, irritability, lack of concentration, and decreased libido. The
Epwor th sleepiness score is a tool often used to assist with diagnosing
the condition and monitoring its management. The histor y from a partner can be also very useful (do they stop breathing, sleep in another
room, how does it aect lives,etc.)
More recently, studies have shown an increased risk of myocardial infarc-
tion, hypertension (both systemic and pulmonary), and stroke.
Treatment includes management of reversible causes (avoid alcohol,
lose weight, etc.). In some units, respiratory physicians r un OSA clinics and patients may need to be referred there (either directly or from
their own doctor) for assessment. After attending to modiable factors nocturnal nasal continuous positive air way pressure may be tried.
Mandibular advancement devices are also useful. They posture the jaw
forward to prevent the tongue falling into the hypophar ynx. In other
cases tonsillectomy or uvulectomy may increase the air way diameter.
Positive pressure ventilation and jaw advancement surgery are occasionally required in severe ca ses. Tracheostomy is now r arely per formed. Jaw
advancement surgery is eective but car ries risk due to co- morbidities.
bDysphagia and aspiration
Dysphagia is an import ant symptom, which may signify signicant or
sinister pathology. It therefore requires careful assessment and often
urgent referral. On average, people swallow once or twice ever y minute. It takes approximately 1 second. Aspiration is the intrusion of food
or liquid into the unprotected airway below the level of the vocal folds.
This can lead to infec tions of the respiratory system, pneumonitis, and
pneumonia.
bOdynophagia
This is painful swallowing, either in the throat (oropharynx) or oesophagus. It can occur with or without dysphagia. If persistent, it results in
weight loss. Odynophagia can be caused by many conditions
Causes of dysphagia
• Xerostomia (irradiation, salivary glands disease, ordrugs)
• Poor head posture
• Ineective lipseal
• Restricted tongue movement
• Cleft palate or reduced velopharyngealseal
• Delayed or absent swallow reex due to postoperative swelling or
cranial nerveinjur y
253
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CHAP TER8 Thethroat
• Restricted laryngeal elevation results in unsatisfactory closure of
the larynx and aspiration
• Vocal fold paralysis following cranial nerveinjur y
• Reduced pharyngeal motility
• Pharyngeal/ oesophageal pathology (notably strictures and tumours)
• Stroke and other neurological disorders
• The presence of a tracheostomy tube can restrict laryngeal
elevation
• Ineective peristalsis hinders the passage of food to the stomach.
• Incomplete or constricted cricopharyngeal and cardiac sphincters
hinder passage of food to stomach.
• Ingestion of very hot or cold food ordrink
• Drugs
• Mucosalulcers
• URTIs
• Immune disorders
• Epiglottitis
• Tumours
• Motor disorders.
Useful clues inassessment
• Charac ter of dysphagia:solid dysphagia (obstructive) vs liquid
dysphagia (neurological)
• Progressive (tumour, achalasia)
• Odynophagia (suggests acute process, foreign body, pharyngitis,
laryngitis)
• Regurgitation (nasal or gastric regurgitation, timing of
regurgitation), type of regurgitated food (digested or undigested)
• Aspiration (cough after ingestion, recurrent pneumonia, choking)
• Contributing factors:history of GORD, history of foreign body
ingestion ortrauma
• Indicators for potential malignancy (weight loss, family history of
cancer, hoarseness, smoking, alcoholabuse)
• History of neurological, connective tissue, or autoimmune disorders.
Assessment ofdysphagia
The histor y and examination may provide important clues to the
underlyingcause.
Signs ofaspiration
Acute
• Distress
• Coughing, choking, and gasping
• Respiratory diculty— wheezing or gurgling
• Loss of voice or gurgling ‘wet’ soundingvoice
• Change of colour (greyness)
• Tachycardia and sweating.
ASSESSMENT OF DYSPHAGIA
Chronic
• Respiratory problems/ chest infections
• Coughing and choking
• Excess oral secretions
• Loss ofweight
• Hunger
• Refusal toeat.
Silent aspiration
Patients with loss of sensation in the larynx may aspirate without coughing and without awareness of the problem. Nasogastric tubes may also
be easily passed into the trachea without obvioussigns.
Investigations
These are tailored according to the suspected pathology:
• Modied barium swallow.
• Manometry:measures duration, amplitude, and velocity of
peristalticwaves.
• CXR:reveals pneumonitis, pneumonia, masses, or a displaced
ai r wa y.
• Laryngoscopy and oesophagoscopy:indicated if suspect malignancy,
to remove foreign bodies, and to biopsy a mass or lesion.
• Functional (breoptic) endoscopic evaluation of
swallowing:outpatient evaluation of swallowing function.
• Videostroboscopy:evaluates vocal fold motion, pooled secretions,
and anatomical defects (masses, glot tal chinks,etc.).
• CT/ MRI:may be considered to evaluate masses.
Management ofdysphagia
Medical management ofdysphagia
• Address underlying cause (e.g. iron supplementation for Plummer–
Vinson, pyridostigmine for myasthenia gravis, benztropine for
Parkinson’s disease, antibiotics for acute bacterial pharyngitis).
• Utilize an alternative tempor ary route of nutrition (nasogastric tube
feeds, parenteral nutrition).
• Anti- reux regimen forGORD.
• Address aspiration pneumonia if any (hold oral feeds, antibiotic
regimen, and aggressive pulmonary toilet).
• Botulinum toxin injections:considered for cricopharyngeal spasms.
• Refer to speech and language therapy for swallowing rehabilitation.
Surgical management ofdysphagia
• Oesophageal dilation:may be considered for phar yngeal or
oesophageal strictures, webs, postoperative scarring, and postradiation strictures.
• Cr icopharyngeal myotomy:may be considered for cricopharyngeal
spasms.
• Gastric or jejunal feeding tube:temporary or permanent enteric
feeding.
255
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CHAP TER8 Thethroat
• Tracheostomy (cued):indicated for severe pulmonary
complications, prevents aspiration pneumonia by allowing easier
pulmonary toilet and preventing gross aspiration (but does not
prevent micro- aspiration).
• Lar yngeal suspension:indicated for severe aspiration from
supraglottic and pharyngeal dysfunction; suspends larynx anteriorly
by positioning thyroid cartilage under mandible, may improve voicing
and swallowing.
• Laryngeal diver sion or separ ation:indicated for severe aspiration,
creates a permanent tracheostomy with proximal tracheal segment
diver ted back to the oesophagus.
• Laryngectomy:r arely indicated. It is under taken for life- threatening
complications.
• Bilateral submandibular excision and parotid duct ligation:may be
considered in patients who aspirate saliva.
cCancers ofthethroat
This is a non- specic term. It generally refers to a varied group of cancers
including cancer s ofthe:
• Tonsil
• Upper oesophagus
• Nasopharynx
• Posterior oropharynx
• Larynx.
These are described in the relevant anatomical chapter s.
cTonsil tumours
Malignancy of the tonsils is an uncommon entity. More than 70% of
malignancies are squamous cell carcinoma followed by lymphomas.
Squamous cell carcinomas are about three to four times more common
in men than in women, and seen typically in advanced age. Other more
uncommon malignancies include minor salivary gland tumours and metastatic lesions. Risk factor s include smoking and ethanol abuse and more
recently association with human papilloma virus (HPV). Recent studies
have identied HPV presence in approximately 60% of tonsillar carcinomas. Typically they present with unilateral tonsillar enlargement with or
without cervical lymphadenopathy. Treatment is mutimodal (surgery and
or radiotherapy), depending on the type and stage of the tumour.
cSquamous cell carcinoma
Squamous cell carcinoma is more commonly seen in the oropharynx (see
E Chapter 13). Posterior orophar yngeal tumours can ex tend pass the
fauces and involve the throat. The usual presentation is that of a painless
ulcer and trismus. Patients are usually emaciated. It is commonly seen in
smokers and alcoholics. Prognosis is generallypoor.
Any ulcer that has been present for >3 weeks, without an obvious cause,
should be referred urgently as a possible cancer.
Chapter9
257
The cheek andorbit
Common presentations 258
Common problems and their causes 258
Useful questions and what to look for 259
Examination of the cheek and orbit 262
Useful investigations 266
Orbital fractures (isolated) 267
Zygomatic (malar) fractures 270
The bulging eye (proptosis/ exophthalmos) 273
Trauma- related proptosis 274
Orbital cellulitis 277
Sinusitis 278
Thyroid eye disease 280
Diplopia (double vision) 280