ENT_SORE THROAT.pdf

   

     

 

 

 

 

 

      ENT  1        

Sore  Throat  &  Dysphagia            Dr.  Acuin   17        

References:  Case-­‐based  discussion,  Probst,  Cor  2011  and  2012  (times  new  Roman),  past-­‐E.                                  

 

SORE  THROAT  AND  DYSPHAGIA  

I.  ANATOMY OF THE PHARYNX (PROBST)                   • •

 

• • •

The  pharynx  is  a  tubular,  fibromuscular  space  extending  from  the  skull  base  to  the  inlet  of  the   esophagus(upper    esophageal  sphincter)   The   pharynx   consists   of   a   nasal   part   (nasopharynx),   an   oral   part   (oropharynx),   and   a   laryngeal   part(hypopharynx).   The  primary  function  of  the  pharynx  is  to  coordinate  the  act  of  swallowing.   pharynx  also  contains  the  tonsillar  ring  that  is  important  in  the  immune  response  to  infection   Function  as  a  variable  resonance  chamber  for  modulating  vocal  sounds.  

Nasopharynx:     • This  highest  part  of  the  pharynx  extends  from  the  bony  skull  base  to  an  imaginary  horizontal  line   at  the  level  of  the  velum     • The  nasopharynx  is  bounded  superiorly  by  the  floor  of  the  sphenoid  sinus  and  pharyngeal  roof.     • Also  in  this  region  is  the  pharyngeal  tonsil   • Medial  to  the  Eustachian  tube  orifice,  the  tubal  cartilage  forms  a  projecting  lip  called  the  torus   tubarius.  The  concavity  behind  it  is  termed  the  pharyngeal  recess  (Rosenmuller  fossa)        3  constrictor  muscles  of  the  pharynx:   •

•

•  

Superior   Constrictor   muscle   -­‐   The   elevation   and   contraction   of   the   velum   results   in   the   complete  closure  of  the  velopharyngeal  port,  this  action  is  facilitated  by  the  contraction  of  the   space,  which  narrow  the  pharynx.     Middle   constrictor   muscle   &   Inferior   constrictor   muscle   -­‐   Initiation   of   pharyngeal   peristalsis   occurs.  The  bolus  is  carried  by  sequential  peristaltic  action  of  the  middle  and  inferior  pharyngeal   constrictors  into  and  through  the  pharynx  to  the  cricopharygneal  sphincter.     all  3  are  responsible  for  the  pharyngeal  phase  of  swallowing  

Three  muscular  weak  points  exist  in  the  lower  posterior  wall  of  the  hypopharynx.     • The  first  is  the  Killian  triangle,  located  between  the  constrictor  pharyngis  inferior  and  the   uppermost  fibers  of  the  cricopharyngeus  muscle.     o common  site  for  the  formation  of  hypopharyngeal  diverticula.   • The  second  area  of  weakness  is  the  Killian–Jamieson  region  between  the  oblique  and   transverse  fibers  of  the  constrictor  pharyngis.     • The  third  is  the  Laimer  triangle,  which  is  bounded  above  by  the  cricopharyngeus  and  below  by   the  uppermost  fibers  of  the  esophageal  musculature       II.  ADULT  SWALLOW  PHYSIOLOGY   •

A.  Oral  Phase  (chewing)  –  voluntary   1.  Oral  preparatory   Mastication-­‐  lips,  buccal  muscles,  jaw,  tongue     Salivation   Bolus  formation      Oral Preparatory – happens when the food is first taken in. o Goal: reduce food to a bolus and position it for transport o Initial transport (the bolus Placement) – tongue positions the food to ready it for reduction. o Reduction phase – bolus is chewed & mixed with saliva o Bolus placement – bolus is positioned for transport    Oral Transport o The prepared bolus is transported from anterior to posterior oral cavity for passage to the pharynx.   2.  Initiation  of  the  swallowing  reflex   • Central  recognition  (brainstem  reticular  formation  near  respiratory  center)   • Bolus  propulsion  (tongue  thrust)  to  anterior  faucial  pillars       B.  Pharyngeal  Phase  (swallowing)  –  involuntary     – – –

• • • • •

Reflex  inhibition  of  respiration   Velopharyngeal  closure   Laryngeal  elevation  (by  strap  muscles)  with  closure  (by  epiglottis,   aryepiglottic  folds,  false  vocal  folds,  true  vocal  folds)   Pharyngeal  contraction  (peristalsis)     Relaxation  of  the  cricopharyngeus  and  opening  of  the  upper  esophageal   sphincter  

PAST  TRANX:   1. Complete closure of velopharyngeal opening • If the soft palette does not close, the food contents go to the nose. 2. Hyoid & larynx begin their superior ascent • Hyoid and larynx are elevated because of suprahyoid muscles that pulls the hyoid which suspend the larynx up, to meet the epiglottis) 3. Epiglottis begins to downfold • epiglottis is a stationary object at the base of the tongue so it doesn’t really go down but the edges are the one that close because the muscles pull the edges downward. Epiglottis seals the larynx from entry of food or liquid) 4. Tongue base to posterior pharyngeal wall contact • tongue pushes the epiglottis further down) 5. Top to bottom contraction of constrictors (stripping motion) 6. Continued superior movement of hyoid & larynx

7. 8. 9. 10.

Laryngeal closure starts from bottom up Continued down-folding of epiglottis to inverted position Anterior movement of hyoid Relaxation of cricopharygeus muscle & opening of upper esophageal sphincter region • patient with cleft palate, the food goes into the nose • laryngeal closure also happens when vocal folds adduct • before the vocal folds abduct (relax), it is very important that the food has entered the esophagus so that nothing is left there in the hypopharynx that can invade the airway.

C.  Esophageal  Phase   • • •

Primary  peristalsis   Relaxation  and  opening  of  the  lower  esophageal  sphincter   Secondary  peristalsis  

                    III.  Cases  

A.  CASE  1                          A  24  year  old  call  center  agent  with  recurrent  sore  throat  and  fever  consulted  you  for  increased  snoring   and  sensation  of  throat  pain  when  swallowing.  He  has  been  feeling  weak  lately  and  fatigues  easily  after  scaling   just  one  flight  of  stairs.  He  has  a  five  year  history  of  purulent  nasal  discharge,  ear  pain  and  dry  cough.  As  a  child  he   has  had  3  to  4  episodes  of  sore  throat  per  year  for  which  he  was  given  antibiotics  by  his  pediatrician.  He  has  been   smoking  one  pack  of  cigarettes  per  day  on  and  off  for  the  past  twenty  years  (he  quitted  smoking  twice)  and  drinks   alcohol  with  his  colleagues  once  or  twice  a  week  after  work.  He  hits  the  gym  once  a  week,  lifting  heavy  weights,   until  he  had  a  rotator  cuff  injury.  He  denies  taking  anabolic  steroids  but  takes  Extra  Joss  and  Red  Bull  before  and   after  workouts.  Despite  this,  he  has  been  steadily  gaining  weight  for  the  past  year.  His  waist:hip  ratio  is  1.2.  He   has  been  taking  Klaricid  OD  for  the  past  3  days  and  asks  you  if  he  needs  to  continue  it.  He  also  wants  to  know  if  he   can  have  his  tonsils  removed  because  he  would  often  get  sore  throat  after  even  just  a  mug  of  iced  mochacinno  at   Starbucks  (he  sticks  to  a  cup  of  espresso  with  every  meal).    

a.  Answers  to  Case  1  (Cor  2012)   1.  How  would  you  approach  the  history  taking  of  this  patient?   • • • •

Ask if patient is currently taking any medications and his past medications Sudden onset is consistent with a GAS pharyngitis. Pharyngitis following several days of coughing or rhinorrhea is more consistent with a viral etiology. Recent exposure to someone with strep throat or any other infection of the throat, nose, or ears Ask if patient has headache, cough or vomiting

• • •

A history of recent orogenital contact suggests the possibility of gonococcal pharyngitis. A history of rheumatic fever is important when considering treatment. And also ask for the common questions like: When did it start? Where did it start (physically)? What does it feel like (characterize pain)? Can you rate pain on scale of 1-10? How often, how long, or how many?

2.  How  would  you  perform  the  physical  exam  in  this  patient?  

• • •

A complete and thorough physical examination should be done. There should be some focus on the inspection of the throat due to its recurrent soreness. Otoscopy should be done in order to assess ear problems and inspection of the nasal cavity should also be included to determine the cause of the discharge. Due to the patient’s smoking history and current complaint of easy fatigability, a complete physical examination of the chest and lungs should be done in order to assess his heart and lungs.

  3.  List  the  likely/possible  clinical  diagnosis  in  this  patient  and  give  the  bases  for  each.  

  V—Vascular Leukemia – patient should present with unilateral enlargement of the tonsils. Symptoms of leukemia include: fever, unexplained weight loss, general discomfort, sore throat, swollen gums, drenching night sweats, headache, vomiting, vision problems, bone or joint pain and painless swelling of the lymph nodes. I—Inflammatory • Streptococcal pharyngitis • Viral pharyngitis • Herpangina (due to Coxsackie virus) • Pharyngoconjunctival fever (due to eight or more viruses) • Infectious mononucleosis • Viral influenza may begin with a sore throat • Tuberculosis N—Neoplasm and carcinomas may include Hodgkin disease and leukemia. D—Degenerative diseases are an unlikely cause of sore throat. I—Intoxication • May include chronic alcoholism and smoker’s throat C—Congenital diseases are an infrequent cause of sore throat • Hiatal hernia with reflux esophagitis may cause recurrent sore throat, because there may be reflux of gastric juice all the way to the posterior pharynx in the recumbent position. • An elongated uvula may also be responsible. A—Allergic diseases • Angioneurotic edema of the pharynx or uvula and allergic rhinitis T—Trauma Foreign bodies such as chicken bones and tonsilloliths E—Endocrine Subacute thyroiditis - although the pain is really in the neck, the patient will report a “sore throat.”  

4.  Are  there  additional  diagnostic  examinations  needed?  What  are  these  and  give  your  bases  for   each?       a. Throat culture •

•

the use of a throat culture plated on sheep blood agar to confirm the presence of GAS has been a common office practice. The optimal site for throat culture is the surface of the posterior pharynx

b. Rapid antigen detection tests •

These tests all are based upon detection of the carbohydrate antigen of GAS with an antibody tagged reagent which produces a clumping effect or color change after the antigen-antibody interaction.

•

When the rapid GAS antigen test is positive, the result can be deemed reliable and the patient treated appropriately. In contrast, when rapid antigen detection testing produces a negative result, the use of a second swab for confirmatory culture should be considered to avoid missing a positive infection, particularly if there is a high clinical suspicion of GAS or rheumatogenic strains are circulating in the community.

•

Streptococcal antibodies —antibodies to GAS (antistreptolysin O) do not peak until four to five weeks after the onset of pharyngitis. Thus, measurement of streptococcal antibodies is useful only for the retrospective diagnosis of infection

Other tests include:

 

• •

Blood tests—to identify conditions that may be causing the sore throat Mono spot test (if mononucleosis is suspected)  

5.  What  are  the  management  options  for  this  patient  and  the  likely  benefits/risks  for  each?     a)  Discuss  the  basis  for  giving  antibiotics  to  this  patient.  Do  you  agree  with  the  current  antibiotic   therapy  of  this  patient?   •

Antibiotics are usually prescribed if the patient presents with signs and symptoms that support a bacterial etiology, such as fever or the presence of exudates.

•

Antibiotic use also reduces the incidence of acute otitis media and acute sinusitis, which may be present in the patient given his history of ear pain and nasal discharge. T

•

the patient was given Clarithromycin (Klaricid), a macrolide indicated for infections of the lower respiratory tract, skin and soft tissues.

b)  Discuss  the  basis  for  tonsillectomy  in  this  patient.  Would  you  advise  tonsillectomy  to  this  patient?   •

Tonsillectomy  is  indicated  for  individuals  who:   •

have  experienced  3  to  5  bacterial  infections  of  the  tonsils  within  3  to  5  years;  

•

more  than  6  episodes  of  tonsillitis  in  1  year;  

•

chronic  or  recurrent  tonsillitis  unresponsive  to  antibiotics;    

•

enlargement  of  the  tonsils  that  causes  sleep  apnea;    

•

enlargement  of  the  tonsils  that  causes  dysphagia.    

•

In  the  patient's  case,  tonsillectomy  may  be  performed  as  he  fulfills  most  of  the   given  indications.    

c)  What  other  interventions  would  you  consider  in  this  patient  and  provide  the  bases  for  each?   Adenoidectomy  -­‐  Because  adenoid  tissue  has  similar  bacteriology  to  the  pharyngeal  tonsils  and  minimal   additional  morbidity  occurs  with  adenoidectomy  if  tonsillectomy  is  already  being  performed.    

b.  Case  Discussion  (  Dr.  Acuin)   Primary  impression:  Strep.  Pharyngitis.   -­‐   Strep.   Pharyngitis   is   a   condition   predisposing   to   rheumatic   fever,   which   is   mainly   a   disease   due   to   antibodies  against  the  heart.   -­‐   In   this   patient,   he   has   increased   waist-­‐hip   ratio.   Normal   ratio   is   1.   Hi   ratio   of   1.2   can   be   due   to   increased  diet.  It  also  shows  that  his  swallowing  problems  are  not  consistent  with  his  waist  hip  ratio.   -­‐  One  must  elicit  the  patient’s  state  of  nutrition  and  weight  gain.  This  is  seen  in  loud  snorers.  They  have   thicker  necks  and  more  tissues  in  mouth  and  neck  that  vibrate.  This  also  contributes  to  disturbed  sleep.   -­‐  get  history  of  past  medical  consults  and  medical  documentation   -­‐  Attention  must  be  paid  to  the  throat.   Malampati  Scoring  System-­‐  use  to  determine  the  ease  of  intubation  and  space  of  oropharnyx   1-­‐  uvula  fully  visible   2-­‐  uvula  half  visible   3-­‐  Uvula  not  visible,  soft  palate  visible   4-­‐  Hard  palate  only  visible     *  Note  that  the  tongue  obliterates  the  uvula  and  soft  palate  

Random  Egyptian  Fact  1:   The  Titanic  allegedly  sank   because  of  the  Curse  of  the   mummy  of  Princess  of  Amen-­‐ Ra,  whose  mummy  was   allegedly  aboard  the  ship.    

-­‐  Know  the  patient’s  risk  factors:   1.  Second  hand  cigarette  smoke  is  a  risk  factor  for  URTI   2.  Alcohol  and  caffeine  causes  sore  throat       -­‐  irritates  the  mucosa,  due  to  increased  acid     -­‐  relaxes  GE  Sphincter,  causing  reflux  and  leading  to  sore  throat,  snoring  and  obesity.       Past-­‐E:  *  Disclaimer*  Sagot  ko  lang  ung  iba  dito,  pls  research  if  you  doubt  the  answers.  Tnx!     ✭ Acute  bacterial  vs.  Acute  viral  tonsillopharyngitis   Both:     o Present  as  high  grade  fever,  malaise  and  joint  pains   o Tonsils  are  swollen  and  eythematous   o May  be  associated  with  enlarged  lymph  nodes     Bacterial  only:   o May  cause  acute  glomerulopnephritis   o Attacks  heart  muscle,  causing  acute  rheumatic  fever   o Infections  of  deep  fascial  neck  spaces     Neither:   o Definitive  treatment  is  tonsillectomy   o Best  diagnosed  by  culture  and  throat  swab      D/DX:       1.  Malignancy       Dx.  Tests:       -­‐  do    a  histopathologic  study  of  the  oro/hypopharynx  and  larynx       -­‐  Types  of  tumors:  friable,  fungating,  ulcerating,  infiltrating,  -­‐  do  an  oropharynx  biopsy         -­‐  adjacent/local  spread  to  bone-­‐  do  CT  scan       -­‐  spread  to  soft  tissue-­‐  MRI       -­‐  distant  mets-­‐  PET  

  2.  TB   -­‐      TB  culture       -­‐  PCR    can  also  detect  TB       3.  HIV/AIDS       -­‐  HIV  has  increased  prevalence  among  call  center  agents,  thus  elicit  sexual  history.       -­‐  on  PE,  also  do  tests  for  HIV.      Management  Issues       -­‐Antibiotics  (Clindamycin,  Amoxicillin/Clavulanic  acid)       -­‐antibiotics  are  effective,  they  eliminate  the  symptoms  if  the  cause  is  bacterial  and  reduce  the     risk  of  glomerulonephritis  and  fever       -­‐  however,  take  note  of  side  effects:         Clindamycin:  abdominal  pain,  necrotizing  enterocolitis       Amoxcillin:  diarrhea,  dehydration  and  electrolyte  imbalance       -­‐determine  antibiotic  resistance       -­‐  start  1st  with  penicillin/erythromycin/Co-­‐trimoxazole.  Penicillin  is  the  DOC  for  Acute  tonsillitis     ✭ For  Bacterial  Tonsillopharyngitis:     Random  Egyptian  Fact  2:    Dx:  no  throat  swab     -­‐  do  rapid  strep  immunoassay   The  story  of  Cinderella  started  in     Ancient  Egypt,  with  Rhodopis  as    Tx:  oral  penicillin  G  (400-­‐800  k  units)-­‐  4x  a  day  for  10  days   the  name  of  Cinderella.  It  involved                 For  children:  (25-­‐90k  units)-­‐  10-­‐14  days   jealous  servants,  a  lost  slipper  and                  IV  Penicillin  G  (  5-­‐  30  Million  units/kg/day)   a  happy  ending  w/  Pharaoh.              Children:  (  100-­‐250  K  units/kg/day)       -­‐  hydration  and  antipyretics       Note:  Not  all  chronic  tonsillitis  is  an  infection     *  NOT  ALL  CONDITIONS  ARE  VIRAL  OR  INFECTION  ALWAYS!         -­‐  Postnasal  drip  conditions  are  not  resolved  by  antibiotics       Characterized  by:   • Posterior  pharyngeal  discharge   • Hypertrophied  lymphoid  follicles   • Chronic  throat  clearing/  pruritus   • Dry  cough   • Vague  throat  discomfort   • Allergic    Sx       -­‐  Practice  Antibiotic  Stewardship   • To  prevent  reisitance   • Rotate  antibiotics.  Example  Co-­‐trimoxzole  resistance  in  hospital  is  at  70%,  so  give  other   drugs          

   Surgeries:     1.  Tonsillectomy   – Being  Lymphoid  Tissue,  the  Tonsils  are  expected  to  inflame  DIFFUSELY,  BILATERALLY,  but  NOT   necessarily  symmetrically       -­‐    recurrent  pharyngitis  can  recur  after  tonsillectomy     -­‐  be  careful  on  advising  it.      The  tonsillectomy  dilemma:   • Attack  rate  of  ARF  in  untreated  culture  +  children  =  0.3-­‐0.9%   • Attack  rate  of  RF  in  adults  =  3%   • Attack  rate  of  AGN  =  10-­‐15%,  0  recurrence   • There  is  no  evidence  from  randomised  controlled  trials  to  guide  the  clinician  in  formulating  the   indications  for  surgery  in  adults  or  children.      Indications  for  tonsillectomy:   • Severe  obstruction  to  swallowing  and/or  breathing  due  to  enlarged  tonsils-­‐AN  INDICATION   • Other  so-­‐called  relative  indications  have  no  clear  benefit  and  can  even  be  harmful     • Recurrent,  medically  intractable  middle  ear  effusion  with  hearing  loss        Common  Causes  of  UNILATERAL  Tonsillar  enlargement   • Peritonsillar  Abscess  (‘Quinsy  Throat’)-­‐     • Complication  includes  retropharyngeal  abscess   • Occurs  in  between  tonsillar  fascia  and  superior  constrictor   • Hot  potato  voice   • Primary  Tonsillar  Carcinoma   • Metastatic  cancer  from  a  distant  site   • Lymphoma      Ominous  Signs  in    UNILATERAL  Tonsillar  enlargement   • Weight  loss   • Halitosis   • Massive  /  Rapid  Enlargement   • Painless  Enlargement   • Cranial  Nerve  Involvement   • Lymph  Node  Involvement  /  Hepatosplenomegaly       2.  Adenoidectomy     -­‐    tonsillitis  is  NOT  equal  to  adenoiditis     -­‐  it  does  not  have  same  risks.     -­‐   may   cause   hyponasal   speech,   chronic   rhinitis,   sinusitis,   and   otitis   media   due   to   obstructed     Eustachian  tube  opening     -­‐  bilateral  otitis  media  with  effusion  may  cause  hearing  loss.-­‐  AN  INDICATION  FOR  IT.      Other  interventions:   • Lifestyle  modifications-­‐  diet   • PPI,  (20-­‐40  mg  before  breakfast)   • Antacids  such  as  Mg  and  Al  OH   • H2  blockers                

 

 B.  CASE  2   A  2  year  old  boy  was  brought  by  his  parents  for  recurrent  cough,  fever  and  poor  appetite  since  one  month   ago.   His   cough   sounds   like   a   barking   seal.   He   also   has   been   having   recurrent   right   ear   pain.   On   physical   examination  he  has  low  grade  fever,  alar  flaring  and  enlarged  tonsils.  You  also  note  mild  chest  retractions.  He  is   irritable   and   appears   to   be   hungry.   You   offer   him   some   juice.   He   takes   some   but   refuses   to   finish   the   rest.   He   refuses  to  lie  down  and  prefers  to  sit  hunched  forward  with  his  arms  propping  him  up.  He  points  to  the  toys  you   keep   in   your   clinic   and   selects   your   Lego   construction   set.   His   mother   says   those   are   his   favorite   toys   but   he   tends   to  put  them  in  his  mouth  so  she  took  them  away.   a.  Answers  to  Case  2  (Cor  2012)  

1.  How  would  you  approach  the  history  taking  of  this  patient?   • • •

In HPI, the duration and severity of sore throat should be noted. In the past medical history, history of previous infection should be asked. In the review of systems, other symptoms like difficulty in swallowing, speaking, or breathing should be noted.

2.  How  would  you  perform  the  physical  exam  in  this  patient?   • • • • •

Perform a Mirror Exam - assess if both tonsils are swollen, bright red and coated. Palpate the lymph nodes on along the jaw and on the neck, assess if they are swollen and tender. Examine the nose to check for inflammations, infections and post nasal conditions. Perform an otoscopic examination of the ear to check for any inflammations. In the physical examination, it is important to know if there is fever and if there are signs of respiratory distress such as tachypnea, dyspnea, stridor and tripod positioning which are present in this case.

•

Tripod position consists of sitting upright, leaning forward with neck hyperextended and jaw thrust forward.

In children suspected with supraglottitis or epiglottitis, pharyngeal examination should be avoided because it can trigger airway obstruction.   3.  List  the  likely/possible  clinical  diagnosis  in  this  patient  and  give  the  bases  for  each.   •

Tonsillitis – it can be due to viral or bacterial infection. The common symptoms include enlarged tonsils, cough and fever • Tonsillopharyngitis – its symptoms include cough, low grade fever, poor apetite, and enlarged tonsils • Epiglottitis – symptoms include fever, cough and irritability • Infectious mononucleosis – it is a mild upper airway obstruction that presents as an intermittent alar nasal flaring and stridor in supine position. It is common in children less than four years old. • Aspiration – it is the inhalation of foreign objects into the airway. It is common in infants and toddlers.   4.  Are  there  additional  diagnostic  examinations  needed?  What  are  these  and  give  your  bases  for   each?   •

   

• • • • •

Swab culture of throat specimen could confirm the etiologic agent present Serologic tests can confirm presence of infectious mononucleosis Fine needle aspiration evaluates microflora in chronic tonsillitis X-ray can determine presence of aspirated objects Flexible laryngoscopy can assess the size of the tonsil

  5.  What  are  the  management  options  for  this  patient  and  the  likely  benefits/risks  for  each?   • • •

Tonsillitis – pain management, medications, lozenges, gargling solution of warm water and salt Epiglottitis – tracheal intubation to protect the airway and antibiotics (3rd generation cephalosporins) Infectious mononucleosis – no specific treatment is necessary because it is self-limiting. Treatment is directed towards relief of symptoms. Supportive measures are necessary.

  b.  Discussion    (Dr.  Acuin)     -­‐  note  the  patient’s  position.  If  a  patient  is  leaning  forward,  the  tongue  hangs  out,  but  if  leaning  back,  it   falls  back.     -­‐  assess  the  adequacy  of  airway     -­‐  in  swollen  epiglottis,  tell  the  patient  to  open  mouth  and  say  ahh,  use  a  mirror  to  reflect  the  uvula.  This  is   known  as  indirect  larnyngoscopy     -­‐  Laryngeal  spasm  is  dangerous  because  of  no  breathing     -­‐  Do  a  flexible  laryngoscopy  to  the  pharynx   -­‐  Do  an  X-­‐ray  of  the  neck  for  epiglotittis.-­‐  common  among  4-­‐6  year  olds.    -­‐  Note  the  barking  cough  of  the  patient,  this  may  signify  croup.     -­‐  Note  the  dysphagia   • A  large  foreign  body  may  obstruct  the  esophagus-­‐  true  emergency   • May  not  obstruct  airway   • In  the  brobchopulmoanry  segment,  it  may  cause  atelectasis  and  recurrent  pneumonia   • Look  for  draining  sinuses  and  do  X-­‐ray    

• •

odynophagia – pain in swallowing dysphagia – difficulty in swallowing

  c.  Assessment  of  Foreign  Body                                     Break  Quote:  

Question by a Student: “If a single teacher can't teach us all the subjects, then how could you expect a single to student to learn all the subjects?”  

 

 

 

 

 

 

-­‐  Patho  tranx,  PLM  MEDICINE  BATCH  2014  

           

 

 

   

 

   

APPROACH  TO  PATIENT    WITH  FOREIGN  BODY  

C.  Case  III   A   65   year   old   female   is   recovering   from   her   stroke.   Currently   she   is   being   fed   through   a   nasogastric  tube  but  her  attending  physician  is  referring  her  to  you,  the  ENT  physician,  to  determine  if   she  can  be  safely  fed  through  her  mouth.   a.  answers   1.  Describe  the  mechanisms  by  which  stroke  can  lead  to  swallowing  disorders.   •

strokes of the medulla,

•

Cerebral, cerebellar, or brain stem strokes can impair swallowing physiology.

•

Cerebral lesions can interrupt voluntary control of mastication and bolus transport during the oral phase.

•

Cortical lesions involving the precentral gyrus may produce contralateral impairment in facial, lip, and tongue motor control, and contralateral compromise in pharyngeal peristalsis.

•

Brain stem strokes are less common than cortical lesions but result in the largest swallowing compromise. Brain stem lesions can affect sensation of the mouth, tongue, and cheek, timing in the trigger of the pharyngeal swallow, laryngeal elevation, glottic closure, and cricopharyngeal relaxation.

•

In people with neurological problems, it is easier for them to swallow solid because liquids demand greater coordination

•

In stroke patients who might have problem in swallowing water, liquids are thickened to have a more solid consistency, allowing for better control by the weakened musculature involved in swallowing

  2.  What  signs  and  symptoms  would  you  ask  for  to  determine  if  she  is  a  safe  oral  feeder?   •

presence   of   dysphagia.   This   increases   the   risk   for   aspiration   pneumonia   if   the   patient   is   not   able   to  swallow  well.    

•

A   swallowing   test   may   be   performed   to   determine   this.   If   a   patient   is   able   to   swallow   down   small  amounts  of  food  or  liquid,  then  it  is  probably  safe  to  start  oral  feeding,  although  slowly.  

•

.  A  psychiatric  consult  may  be  needed  to  assess  a  patient  before  oral  feeding  is  instituted.  

*Definition  of  safe  oral  feeder-­‐  only  1  attempt  to  swallow  liquid  and  solids  foods  (with  no  residual  fluid  left)  

3.  How  would  you  physically  assess  the  different  phases  of  her  swallowing  function?   Oral phase • If there is a problem during this phase, the patient may find it difficult to chew solids and to contain the liquid in the oral cavity before swallowing. She may also have a hard time to initiate swallowing.

Pharyngeal phase • After swallowing, the patient may retain excessive amounts of food in the pharynx if there is weakness in or lack of coordination of the pharyngeal muscles or if there is a poor opening of the upper esophageal sphincter.

Esophageal phase • After swallowing, the patient may retain food and liquid in the esophagus after swallowing if there is a mechanical obstruction, a motility disorder, or an impairment of the opening of the lower esophageal sphincter. • Trouble swallowing saliva but no difficulty swallowing food – globus hystericus

4.  What  diagnostic  examinations  can  be  performed  to  further  evaluate  her  swallowing  function?   Barium Swallow Exam - Modified Cervical Auscultation Double Contrast Barium Enema Double Contrast Upper GI Electrogastrography Spectral Analysis on EMG Endoscopy Fiberoptic Endoscopic Examination of Swallowing FEEST - Flexible Endoscopic Evaluation of Swallowing with Sensory Testing Gastroscopy Manometry pH probe Ultrasound Upper GI for GERD   5.  What  interventions  can  be  done  to  help  her  swallow  safely?   • • • • • • • • • • • • • •

• •

•

•

• •

•

Rehabilitation therapy is the main stay of dysphagia management and allows for safe swallowing Oral feeding with consistency modification – thickened liquids increase oropharyngeal control, while a diet of shopped or pureed foods decreases difficulties with mastication. It consists of 8 varieties of diet. Compensatory strategies to reduce the risk of aspiration • Chin tuck – decrease air diameter • Head rotation – ipsilateral pharynx is closed forcing bolus to contralateral pharynx • Head tilt – guide bolus to ipsilateral pharynx • Supraglottic swallow – simultaneous swallowing and breath holding, closing vocal cords • Mendeleon maneuver – form of supraglottic swallow in which the patient mimics the upward movement of larynx by voluntary holding of larynx Exercise and facilitation techniques • Exercise is used to increase muscle tone and alignment pharyngeal swallow • Biofeedback techniques are used to reeducate muscle affected in facial palsy and disorders of articulation • Thermal stimulations in the form of icing of the anterior facial muscles can be performed to help decrease delay of pharyngeal swallow Medical interventions – Diltiazem aid in esophageal contractions and motility Endoscopic and surgical interventions • Microsurgical techniques to help in swallowing • Laryngectomy or laryngotracheal diversion • Tracheostomy is often performed as a permanent palliative measure when all else fails Non-oral feedings • Parenteral alimentation and IV fluid replacement • Nasogastric tubes are convenient for short term but has many complications • jejunostomy

  b.  Discussion  (Dr.  Acuin)     How  to  determine  if  patient  is  a  safe  oral  feeder?     S/Sx-­‐  listen  to  patient’s  voice-­‐  if  gurgly  or  bubbly=  cannot  swallow     -­‐  swallows  spit  and  aspirates     -­‐  afferent  arm  of  reflex  not  activated     -­‐  note  that  swallowing  reflex  in  pharynx  and  larynx  is  involuntary     Dx.  Exam   • barium  swallow-­‐  trace  the  pathway  of  swallowing  but  subject  to  radiation   • flexible  eval.  Of  swallowing-­‐  valecula,  pyriform  sinus,  vocal  fold  at  risk  of  aspiration   o done  at  bedside,  no  radiation   o does  not  directly  evaluate  strength  of  swallow.    

IV.  Approach  to  dysphagia  management  

  ✭ Assessing  the  Possible  Problem  Site  :   Oropharynx     – Pharyngotonsilitis     Random  Egyptian  fact  3:     – Vincent’s  angina   – Inf.  mononucleosis   Cleopatra  VII  was  the  last  ruler  of   – Diphtheria   ancient  Egypt.  Her  beauty  and  charm   – TB   won  the  love  of  an  emperor  and  a   – Aphthous  ulcers   – Fungal  pharyngitis     soldier.   – Neoplasm     • Hypopharynx     – Epiglotitis     – Supraglotitis     – Valleculitis     – Neoplasm    Larynx    Laryngitis  -­‐  involved  vocal  folds  itself,  may  have  referred  pain    Neoplasm    Esophagus    Cervical  Esophagitis  –  referred  pain    Neoplasm    Cervical  Fascia    Lymphadenitis    Thyroiditis    Neoplasm    Deep  neck  fascitis      Cellulitis   •

✭ DIFFERENTIALS Non-­‐infectious    Inflammation  Allergy  /  Hypersensitivity    Chemical  /  irritative  

•

   

Systemic  Diseases       

HIV   Leukemia   Lymphoma   Tuberculosis   Connective  Tissue  Disease  

Neoplasm    Benign    Primary  Malignancy    Metastatic  Cancer    

V.  Sleep  disordered  breathing     A.  Signs  that  suggest  sleep  apnea   • Loud,  irregular  snoring   • Witnessed  periods  of  apnea   • Daytime  sleepiness   • Restless  sleep   • Intellectual  deterioration   • Personality  changes   • Enuresis    

                                           

                                                                             

(+) Muller’s is an indication for uvulopalatopharyngoplasty (a surgical procedure used to remove tissue in the throat. It involves the removal of tissues which may or may not include the uvula, soft palate, tonsils, and adenoids.)

•                                    

Polysomnography  is  the  best  way  to  assess  sleep  apnea  

•

Velopharyngeal  competence   o The  velopharynx  a  particularly  narrow  segment  of  the  upper  airway,  is  especially   predisposed  to  obstruction  in  such  settings.   o  In  particular,  obese  patients  with  large  necks  often  have  a  more  collapsible  velopharynx   that  predisposes  to  upper  airway  obstruction.     o In  many  patients  with  OSA  collapse  of  the  velopharynx  can  be  induced  by  having  the   patient  perform  Muller's  manoeuvre  during  nasopharyngoscopy     o In  Muller's  manoeuvre  the  patient  is  asked  to  take  a  breath  while  the  mouth  is  closed   and  the  nose  is  pinched  shut.     o This  generates  a  negative  pressure  in  the  upper  airway.  In  patients  who  just  snore,  there   may   be   slight   inward   movement   of   the   soft   palate   and   the   back   of   the   throat   but   the   glottis  remains  visible.   o  Patients   who   have   OSA   show   varying   degrees   of   collapse   in   the   side   walls   of   the   velopharynx,  at  the  base  of  the  tongue,  and  at  the  back  of  the  throat,  which  narrows  the   airway  by  more  than  25%.     o Patients  with  the  degree  of  collapse  seen  here  usually  have  moderately  severe  OSA  or   worse.    

  Sleep  apnea  treatments   o Modify  sleep  position?   o Weight  reduction?   o Respiratory  stimulants  –  tricyclic  antidepressants,  L-­‐tryptophan,  etc?   o CPAP?   o Oral  appliances?   o Surgery  (nose,  throat,  oral  cavity,  face)?     -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐END  OF  TRANSWINTION-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐       Akala  ko  madugo  gumawa  ng  tranx  ng  ophtha,  meron  plang  mas  basag  na  lecture.  Ang  ENT,  bow.  Sorry  kung  magulo   •

format.  Medyo  maraming  refs  din  ang  ginamit  ko  dito,  3  years  worth  of  knowledge…hehe.  Baka  huli  ko  na  to.  Nakakatamad   nang  gumawa.  Hehe.     Pabati!  Hi  sa  mga  bumili  ng  tickets  sa  akin:  Si  Jela  (unang  biktima),  Owis,  JC,  Mariel,  juxy,  Gabriela(  este  Jen  pala  ),   Yeji,  Gelli,  Betty,  HAC,  Franz,  Bei,  Carine,  Ana,  Bern,  Menchai,  Kathee,  Nepo,  Lyreen,  Nicole  O,  Kat  Y.,  Maika  at  finale…Homer!   Good  luck  guys!  Hope  to  see  you  din  sa  “Scholaroyale”  2012.   Kudos  din  to  all  the  subject  heads  and  editors  for  this  set  of  tranx.  Just  2  rounds  of  evals  and  1  set  of  finals,  and  we  will   now  be  called  “Junior  interns”.  

                                               “The  underworld  would  be  a  very  lonely  place  without  you,  my  goddess  of  light”    

 

           RANDOM  EGYPTIAN  FACT  4:  The  story  of  Isis  and  Osiris  is  the  greatest  love  story  of  ancient  Egypt.    

The  jealous  Seth,  God  of  the  desert,  cut  Osiris  into  14  pieces  across  Egypt.  But  Isis  searched  for  all  pieces  for  many  years,  and   with  after  completing  the  parts,  used  love  to  bring  him  back  to  life  for  a  final  embrace.    

     

   

       MALIGAYANG  PASKO  AT  MANIGONG  BAGONG  TAON  BATCH  2013!