GPVTS Teaching
Bhik KotechaConsultant ENT Surgeon
Royal National Throat, Nose & Ear Hospital, London & Queens Hospital, Romford
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
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)
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
Dysphonia
• Hoarseness• Croakiness• Huskiness• Occupational? singer/actor/teacher/preacher• Duration• Intermittent• ?Benign• ?Malignant
Salivary Glands
• Parotid• Submandibular• Infective• Inflammatory• Calculus• Bimanual palpation• Malignant• VII Nerve
Lymph Nodes
• Reactive• Tuberculous – Posterior
triangle/supraclavicular• Malignant• Lymphoma• Metastatic – PNS, Tongue, Larynx, Pharynx• SCC of skin or scalp
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