Otalgia & Dysphagia in theHead & Neck Cancer 2ww Referral
GP Masterclass Study Evening (27/11/2013)
Mr Taran Tatla BSc, MBBS, DLO, FRCS(Eng)Consultant ENT‐Head & Neck Surgery
North West London Hospitals NHS TrustBMI Clementine Churchill & Bishops Wood Hospitals
Head & Neck Vs Upper GI –2ww Suspected Cancer Referral Forms
Ear Symptoms
• Pain – precipatant (ie URTI),nature, frequency, severity, exacerbating & relieving factors
• Ear Discharge (Otorrhoea) – blood stained / clear / itching
• Hearing Loss (fluctuating, progressive, period)
• Dizziness / Rotational Vertigo
• Tinnitus / Noises in Ear
(?cotton bud use for cleaning ears)
Otalgia : Primary Ear Causes
• Pinna / Ear canal skin: infected sebaceous cyst, furuncle, otitis externa, trauma
• Acute otitis media
• Acute mastoiditis
• Chronic Supparative Otitis Media (CSOM) – Tubotympanic (TM perforation without keratin)
– Squamous (retraction or perforation with keratin)
• Eustachian Tube Dysfunction
Otalgia & Primary Ear Pathology
Eustachian Tube Dysfunction
Eustachian Tube Dysfunction
• Nasal Symptom Enquiry
• Nasal Blockage
• Nasal Discharge (Anterior, Post‐nasal, Blood)
• Nasal Itching & Sneezing
• Facial Pain
• Reduced / Loss of Sense of Smell
• Attempt Valsalva Manoeuvre (forcibly exhale while keeping the mouth and nose closed)
Otalgia: Non‐Ear Conditions
• Referred Pain from:– Parotid gland (inflammation, calculus)
– Teeth (ie impacted wisdom)
– Tonsil / pharynx inflammation & infection
– Laryngo‐pharyngeal reflux
– Oral cavity, oropharynx, nasopharynx, hypopharynx & larynx tumours (>90% = SCC)
– Lymphomas (tonsillar / base of tongue)
– C‐spine pathology (ie degenerative changes)
Oral / Throat Symptom Enquiry
• Tooth pain / sensitivity (recent dental visits?)
• Mouth mucosal ulcers / pain
• Sore throats (frequency / severity /duration / treatments /?refractory etc)
• Tonsillitis (?temp, ?associated difficulty swallowing)
• Swallowing difficulties (to liquids, solids, both, intermittent or progressive)
• Voice change (dysphonia) +/‐ inspiratory noise
Acute Exudative (bacterial) Tonsillitis Vs Infectious Mononucleosis (EBV)
Tonsil Assymetry (?neoplasia)
Laryngo‐pharyngeal Reflux
• +/‐ GORD Symptoms
• Burning / Pains (Throat &/or retro‐sternal) which may be referred to the ear
• Intermittent Change in Voice
• Intermittent Swallowing Change (tightness)
• Throat Clearing
• “Water brash” or bitter taste in mouth
Dietary & Lifestyle History
Laryngopharyngeal Reflux / GORD
-Generalised supraglottic swelling (arytenoids, epiglottis, vocal cord Reinke’s oedema)-Posterior inter-arytenoid granulation tissue-Redundancy of hypertrophied hypopharyngeal mucosa (epiglottic, post-cricoid & posterior pharyngeal wall)
Changes all consistent with GORD
In association:Cervical osteophyte indentation of hypopharynx posteriorly
Head & Neck Cancer
• SCC (>90%) +/‐ Systemic Effects (weight loss)
• Majority =mucosa arising, oral cavity or larynx, followed by oropharynx & hypopharynx
• Link to tobacco smoking/chewing, alcohol, betel nut chewing, Human Papilloma Virus
• Ulcerative / locally destructive or exophytic / expansile
• Unilateral &/or progressive symptoms, particularly referred mouth/throat to ear pain
Oral Cavity SCC
B Cell Lymphoma Left ET Cushion
Oropharynx (Base of Tongue SCC)
Larynx SCC
Hypopharynx SCC
Disposable Flexible Nasendoscopy In Primary Care
Sequential Phases of Normal Swallow
• Oral Phase (preparation) (Voluntary)
Bolus of food / liquid is chewed or manipulated in preparation for swallow
• Oral Phase (propulsion) (Voluntary)
Tongue pushes the bolus into the back of the mouth, beginning the swallow response
• Pharyngeal Phase (Involuntary)
The Bolus passes through the oro/hypopharynx into the oesophagus
• Oesophageal Phase (Involuntary)
The bolus passes through the oesophagus to enter in to the stomach
Sequential Phases of Normal Swallow
• Rapid & precise coordination (numerous muscles & tissues )
• With bolus entry to pharynx, soft palate elevates & hyoid bone /larynx move upward & forward.
• Vocal folds move to midline & epiglottis folds backward, protecting airway.
• Tongue pushes backward & downward into pharynx, pushing bolus down.
• Pharyngeal walls assist by moving inward with a progressive wave of contractions from top to bottom.
• UES relaxes & is pulled open by movement of hyoid bone & larynx, (& thenUES closes after food passes).
• Once in oesophagus, a peristaltic wave moves the bolus downward.
• LES relaxes & allows bolus to move into stomach.
• Once in stomach, the LES closes automatically, preventing gastro‐oesophageal reflux.
Dysphagia (Difficulty in Swallow)= Interruption in the natural swallow sequence
Central Motor or Sensory disturbanceOften after CVA , brain trauma, SOLProgressive neurological Disorders ie MND Cranial Neuropathies / InjuryHigher Centres (emotion / stress)
Central Nervous System / Cranial Nerve Effects
Autonomic Impairment /
Neuromuscular / Motility Disorders
Mechanical / LumenalEffects
Dysphagia (Difficulty in Swallow)= Interruption in the natural swallow sequence
Central Motor or Sensory disturbanceOften after CVA , brain trauma, SOLProgressive neurological Disorders ie MND Cranial Neuropathies / InjuryHigher Centres (emotion / stress)
Central Nervous System / Cranial Nerve Effects
Autonomic Impairment / Neuromuscular Motility Disorders
Mechanical / LumenalEffects
Peripheral Motor & / or Sensory disturbanceImpairment of the upper or lower oesophageal sphincter (inflammatory / AI disease ie CTD)Vocal cord / Tongue / Palatal WeaknessGORD / LPR(Common)
Dysphagia (Difficulty in Swallow)= Interruption in the natural swallow sequence
Central Motor or Sensory disturbanceOften after CVA , brain trauma, SOLProgressive neurological Disorders ie MND Cranial Neuropathies / InjuryHigher Centres (emotion / stress)
Central Nervous System / Cranial Nerve Effects
Autonomic Impairment / Neuromuscular Motility Disorders
Mechanical / LumenalEffects
Peripheral Motor & / or Sensory disturbanceImpairment of the upper or lower oesophageal sphincter (inflammatory / AI disease ie CTD)Vocal cord / Tongue / Palatal WeaknessGORD / LPR(Common)
Mechanical impairment (H&N/Thyroid, Oesophagus,other tumour, scar or stricture) – intrinsic / extrinsicImpairment of the upper or lower oesophageal sphincter &/or larynx elevation ie Tracheostomy tube in situSimple Causes (poor teeth, ill‐fitting dentures, URTI)
Clinical Presentation• Depends on causation, duration and severity
• Can be relatively minor symptoms (ie drooling, globus –discomfort /sensation of lump in throat or food sticking, retrosternal discomfort)
• Or more problematic (inadequate nutrition, dehydration, and weight loss when significant dysphagia)
Clinical Presentation• Depends on causation, duration and severity
• Can be relatively minor symptoms (ie drooling, globus –discomfort /sensation of lump in throat or food sticking, retrosternal discomfort)
• Or more problematic (inadequate nutrition, dehydration, and weight loss when significant dysphagia)
• Dysphagia to liquids (suggests central / neurological cause), to solids (suggests mechanical cause ie tumour /pharyngeal pouch) or to both
• Dysphagia may be intermittent (often with LPR and globus) or progressive and worsening in severity (UADT / Oesophageal Malignancy / pharyngeal pouch)
Clinical Presentation• Depends on causation, duration and severity
• Can be relatively minor symptoms (ie drooling, globus –discomfort /sensation of lump in throat or food sticking, retrosternal discomfort)
• Or more problematic (inadequate nutrition, dehydration, and weight loss when significant dysphagia)
• Dysphagia to liquids (suggests central / neurological cause), to solids (suggests mechanical cause ie tumour /pharyngeal pouch) or to both
• Dysphagia may be intermittent (often with LPR and globus) or progressive and worsening in severity (UADT / Oesophageal Malignancy / pharyngeal pouch)
• Aspiration (passage of food /liquid through VCs with sensation of food "going down wrong way"), can be a serious consequence of dysphagia causing chronic coughing, choking, airway obstruction and aspiration pneumonia.
• It may result from pharyngeal obstruction, weakness or incoordination of the pharyngeal muscles, poor opening of the UES, or other impairments
• If sensation or consciousness is impaired, aspiration does not provoke a cough response, which is particularly dangerous (ie post CVA)
Zenker’s Diverticulum (Pharyngeal Pouch)
Herniation of a mucosal sac between the fibres of the inferior constrictor muscle & cricopharyngeus (Killian’s dehiscence)
Zenker’s Diverticulum:Aetiology
• Primary disorder is a motility disorder in cricopharyngeus muscle (the diverticular sac is secondary)
• As sac evolves, the dysphagia worsens (path of least resistance to food bolus is direct into sac)
• The sac distends, exerting pressure on the cervical oesophagus (further increasing resistance to food passage)
• Patient then forced to swallow harder against the obstruction (increasing intraluminal pressure in the inferior hypopharynx, leading to further enlargement of the diverticulum)
• Likely discoordination of UES relaxation (theories include neurologic disease, inflammatory scarring & GORD as triggers)
• Treatment must address the cricopharyngeal spasm as well as the sac
Zenker’s Diverticulum:Presentation
• Zenker’s is an uncommon condition & generally affects the older patient but not exclusively
• Dysphagia is a common complaint & other symptoms include:– Choking
– Weight Loss
– Regurgitation
– Excess mucus & throat clearing
– Aspiration & chest infections
• Symptoms often present for years,
• Progressive dysphagia +/‐ aspiration +/‐ weight loss and debilitation => indication for operative intervention
Zenker’s Diverticulum:Barium Swallow
Endoscopic Diverticulotomy:Diverticuloscope with Staple Division, Diathermy
or Laser (cricopharyngeal myotomy)
NWLH Integrated Care of Swallow (ICoS) Pathway
Clinical Otolaryngology. 30(6) : 547 ‐ 550.
Disposable Flexible Nasendoscopy In Primary Care
-High Resolution CMOS chip-tip-Disposable endoscope-Well tolerated by patients under LA-Clinician (ENT & Gastro) validation & support (MDT integrated swallow service for UADT & Upper GI 2ww referrals)
-Avoidance of endoscope sterilisation costs & high set-up / maintenanace costs of central sterilisation services-Ideal for “one-stop” evaluation & screening of patients with swallow difficulties (dysphagia)-Avoidance of down-stream costs of panendoscopy under GA, Ba swallows, OGD, repeated OPD visits to multiple specialists
ANY QUESTIONS?
Thank You
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