GPVTS Teaching

Bhik KotechaConsultant ENT Surgeon

Royal National Throat, Nose & Ear Hospital, London & Queens Hospital, Romford

Topics

• Sleep disorders• Snoring/OSA• Throat problems• ENT Injuries

Throat Problems

• 2 week head & neck referral:• Dyspahagia• Odynophagia• FOSIT• Dysphonia• Aspiration• Weight Loss• Neck lumps• Smoking/Alcohol

Dysphagia

• Duration• Age group• Solids/Liquids• Site• Aspiration• Regurgitation• Coughing/Choking --- Acid reflux

DYSPHAGIA: simple v/s complex

• Clinical history• Clinical examination• Special investigations• Endoscopy – rigid/flexi• Aetiology• Specific treatment

CB: Clinical History

• 59 yr old female• Presented Oct 2002• Dysphagia/choking/occ dyspepsia• Tightness around mouth• No dysphonia• Non-smoker, social drinker• No weight loss• HRT

Clinical Examination

• Inspection - ?Scleroderma• Neck – No lymphadenopathy• Laryngeal crepitus normal• Flexible laryngoscopy• Normal vocal cords• Pooling of saliva left piriform fossa

Special Investigations

• Barium swallow

• FBC, ESR, ACE, ANCA

Results

• Bloods – NAD

• Barium – Cricopharyngeal spasm, no web or pouch. • Cervical spondylosis• Normal Oesophageal peristalsis• No hiatus hernia or reflux

• Rigid Endoscopy

Rigid Endoscopy

• Nov 2002• No mucosal abnormality• Tongue, valleculae, postcricoid & piriform

fossa all normal• Tight cricopharyngeus/spasm• Upper 2cm of oesophagus – NAD• Difficult to visualise lower down• Refer to Gastroenterologist for flexi

Gastroenterologist opinion Dec 2002

• No alarming symptoms and felt better• ?Globus & proximal oesophageal spasm• Gastroscopy not required• ?Manometry to exclude Oes dysmotility• Patient declined• Discharged

Neurologist (1) Nov 2005

• Normal MRI Brain• ? Myasthenia• Normal neurophysiology in peripheral nerves

and muscles• Negative Autoimmune tests• ? Mild Scleroderma• Referred to Rheumatologist• Referred to BK for dysphagia

Rheumatology Opinion – Feb 2006

• Not Scleroderma• ? Sarcoidosis (PMH of ?Rheumatic Heart

disease & ?Erythema Nodusum 20yrs ago)• ? Motor neurone disease• High resolution CT thorax

ENT Jan 2006

• Dysphagia (food sticks in lower oesophagus)• Dysphonia• Flexible laryngoscopy• Pooling of saliva in piriform fossa• Chink on adduction of vocal cords• Refer to Oesophageal Surgeon• Refer to Speech & Language Therapist (SLT)

SLT Jan 2006

2 main problems

• DYSPHAGIA

• SPEECH/VOICE

DysphagiaSYMPTOMS

• Difficulty with solids – effort• Food sticking in pharynx• Increasing time to complete meals/fatigue• Occ regurgitation of food/fluids• Occ coughing/choking episodes• Halitosis

• No history of chest infections but recent weight loss

Swallowing Assessment

Liquids and Solids

• Repeated swallows to clear each bolus• Increased effort with solids• Throat clearing

• No overt signs of aspiration exhibited

Speech/Voice Assessment

• Mildly slurred speech/hyponasal (dysarthric type)

• 100% intelligible but imprecise articulation (labial sounds)

• Decreased volume• Breathy voice quality• Reduced oro-motor function/coordination of

lips/tongue (?oral dyspraxia)

SLT Recommendation

• Speech/voice exercises (dysarthria/dyspraxia)– Oromotor function/coordination– Articulation– Volume

• Videofluoroscopy (modified barium swallow) – objective swallow investigation

Videofluoroscopy

• Oral stage-mildly reduced tongue movement

• Pharyngeal stage-mildly reduced hyo-laryngeal excursion

-no aspiration -?uncoordinated/weak peristalsis

-significant pooling in piriform sinuses-small right PHARYNGEAL POUCH (approx 2cm)

• Upper Oesophageal stage - reduced opening of cricopharyngeus

Definition

Zenker’s diverticulum, otherwise known as

pharyngeal pouch, is a pulsion diverticulum of

the pharyngeal mucosa through Killian’s

dehiscence.

Clinical features

• Dysphagia • Regurgitation• Feeling of food sticking in the

throat • Coughing after eating • Chronic aspiration due to

overspill • Unexplained weight loss and

malnutrition• Halitosis • Hoarseness (less common)• Pain free• Loss of medication in

diverticulum space

Investigations

• Barium swallow• Videofluoroscopy• Manometry• sEMG

Surgical Treatment

Dysphonia

• Hoarseness• Croakiness• Huskiness• Occupational? singer/actor/teacher/preacher• Duration• Intermittent• ?Benign• ?Malignant

Vocal Cord Nodules

Laryngeal Papilloma

Granuloma – Acid reflux

SCC Larynx

Laryngeal Videos

Neck Lumps

• Salivary Glands• Lymph Nodes• Branchial Cyst• Thyroglossal Cyst• Thyroid Swelling

Salivary Glands

• Parotid• Submandibular• Infective• Inflammatory• Calculus• Bimanual palpation• Malignant• VII Nerve

Acute Parotitis

Lymph Nodes

• Reactive• Tuberculous – Posterior

triangle/supraclavicular• Malignant• Lymphoma• Metastatic – PNS, Tongue, Larynx, Pharynx• SCC of skin or scalp

Acute Tonsillitis

Glandular Fever

SCC Metastasis

SCC Lip

SCC Tongue

Branchial Cyst

Thyroglossal Cyst

Thyroid Goitre

Thyroid Gland

• Thyroid status• Compressive symptoms• Bloods – TSH/T4/Thyroid antibodies• Ultra sound scan/FNA• Multinodular goitre• Solitary nodules • Thyroid tumours