GPVTS Teaching Bhik Kotecha Consultant 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

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 main problems DYSPHAGIA SPEECH/VOICE

Dysphagia SYMPTOMS 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