1. GPVTS Teaching Bhik Kotecha Consultant ENT Surgeon Royal National Throat, Nose & Ear Hospital, London & Queens Hospital, Romford

2. Topics Sleep disorders Snoring/OSA Throat problems ENT Injuries

3. Throat Problems 2 week head & neck referral: Dyspahagia Odynophagia FOSIT Dysphonia Aspiration Weight Loss Neck lumps Smoking/Alcohol

4. Dysphagia Duration Age group Solids/Liquids Site Aspiration Regurgitation Coughing/Choking --- Acid reflux

5. DYSPHAGIA: simple v/s complex Clinical history Clinical examination Special investigations Endoscopy – rigid/flexi Aetiology Specific treatment

6. 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

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

8. Special Investigations Barium swallow FBC, ESR, ACE, ANCA

9. Results Bloods – NAD Barium – Cricopharyngeal spasm, no web or pouch. Cervical spondylosis Normal Oesophageal peristalsis No hiatus hernia or reflux Rigid Endoscopy

10. 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

11. 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

12. 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

13. Rheumatology Opinion – Feb 2006 Not Scleroderma ? Sarcoidosis (PMH of ?Rheumatic Heart disease & ?Erythema Nodusum 20yrs ago) ? Motor neurone disease High resolution CT thorax

14. 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)

15. SLT Jan 2006 2 main problems DYSPHAGIA SPEECH/VOICE

16. 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

17. Swallowing Assessment Liquids and Solids Repeated swallows to clear each bolus Increased effort with solids Throat clearing No overt signs of aspiration exhibited

18. 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)

19. SLT Recommendation Speech/voice exercises (dysarthria/dyspraxia) – Oromotor function/coordination – Articulation – Volume Videofluoroscopy (modified barium swallow) – objective swallow investigation

20. 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

21. Definition Zenker’s diverticulum, otherwise known as pharyngeal pouch, is a pulsion diverticulum of the pharyngeal mucosa through Killian’s dehiscence.

22. 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

23. Investigations Barium swallow Videofluoroscopy Manometry sEMG

24. Surgical Treatment

25. Dysphonia Hoarseness Croakiness Huskiness Occupational? singer/actor/teacher/preacher Duration Intermittent ?Benign ?Malignant

26. Vocal Cord Nodules

27. Laryngeal Papilloma

28. Granuloma – Acid reflux

29. SCC Larynx

30. Laryngeal Videos

31. Neck Lumps Salivary Glands Lymph Nodes Branchial Cyst Thyroglossal Cyst Thyroid Swelling

32. Salivary Glands Parotid Submandibular Infective Inflammatory Calculus Bimanual palpation Malignant VII Nerve

33. Acute Parotitis

34. Lymph Nodes Reactive Tuberculous – Posterior triangle/supraclavicular Malignant Lymphoma Metastatic – PNS, Tongue, Larynx, Pharynx SCC of skin or scalp

35. Acute Tonsillitis

36. Glandular Fever

37. SCC Metastasis

38. SCC Lip

39. SCC Tongue

40. Branchial Cyst

41. Thyroglossal Cyst

42. Thyroid Goitre

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