43.pharynx,larynx and neck

8/13/2019 43.Pharynx,Larynx and Neck

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43 Pharynx, larynx and neck DAVID J. HOWARD and

VALERIE J. LUND

The pharynx

The pharynx is a fibro ms!"ar #be formin$ #he pper par# of #he respira#ory and

di$es#i%e passa$es. I# ex#ends from #he base of #he s&"" #o #he "e%e" of #he six#h

!er%i!a" %er#ebra a# #he "o'er border of #he !ri!oid !ar#i"a$e 'here i# be!omes

!on#inos 'i#h #he oesopha$s. I# opens an#erior"y in#o #he nose( mo#h and "arynx

from abo%e do'n'ards( and is #herefore di%ided in#o #hree par#s( #he nasopharynx(

oropharynx and hypo pharynx )*i$. +,.-.

Nasopharynx

The nasopharynx "ies an#erior #o #he firs# !er%i!a" %er#ebra and has #he openin$s of #he

es#a!hian #bes in i#s "a#era" 'a""( behind 'hi!h "ie #he pharyn$ea" re!esses( #he

fossae of Rosen /""er. The adenoids are si#a#ed sbm!osa""y a# #he 0n!#ion of #he

roof and pos#erior 'a"" of #he nasopharynx. The nasopharynx is !"osed off from #he

oropharynx drin$ s'a""o'in$ by #he raisin$ of #he sof# pa"a#e and !on#ra!#ion of #hepa"a#opharyn$ea" sphin!#er.

Oropharynx

This is bonded abo%e by #he sof# pa"a#e( be"o' by #he pper srfa!e of #he epi$"o##is

and an#erior"y by #he an#erior fa!ia" pi""ar 'hi!h !on#ains #he pa"a#o$"osss ms!"e.

The oropharynx #herefore !on#ains #he pa"a#ine #onsi"s si#a#ed in #he "a#era" 'a""

be#'een #he an#erior and pos#erior pi""ars of #he fa!es and #he pos#erior #hird of #he

#on$e. These pa"a#ine #onsi"s are par# of #he !omp"e#e rin$ of "ymphoid #isse

)Wa"deyer1s rin$ 'hi!h addi#iona""y !omprises #he adenoids and #he "in$a" #onsi"s

on #he pos#erior #hird of #he #on$e. This rin$ of "ymphoid #isse o!!pyin$ #he en#ry

of #he air and food passa$es is !ons#an#"y exposed #o ne' an#i$eni! s#im"i. I# is an

impor#an# par# of #he m!osa"2asso!ia#ed "ymphoid #isse )/ALT 'hi!h pro!essesan#i$en and presen#s i# #o T2he"per !e""s and 32!e""s. The #onsi""ar #isse prod!es

immno$"obin 4 )I$4( I$A and a sma"" amon# of I$D. These immno$"b"ins are

se!re#ed in#o #he pharynx and #heir o#p# is in!reased in response #o a 'ide %arie#y of

inf"amma#ory pro!esses )*i$. +,.5.

The #isse of Wa"deyer1s rin$ nder$oes physio"o$i!a" hyper#rophy drin$ ear"y

!hi"dhood as #he !hi"d is exposed #o in!reasin$ amon#s of an#i$eni! s#im"i6 #here is

of#en a simi"ar hyper#rophy of #he !er%i!a" "ymph nodes and( indeed( #he abdomina"

"ymph nodes )#he ae#io"o$y of mesen#eri! adeni#is. The #onsi"s !on#ain #or#os !ryp#s

'hi!h !an harbor ps and mi!roor$anisms. 7"o#hin$ #he "a#era" #'o2#hirds of ea!h

#onsi" is #he !aps"e( a 'e""2defined s#r!#re !omposed of fibros and e"as#i! #isse(

and ms!"e fibres. The #onsi" has an ex!ep#iona""y $ood b"ood spp"y. I# is 'e"" #obear in mind #ha# a #or#os fa!ia" ar#ery may be !"ose"y re"a#ed #o #he "o'er po"e. On

#he "a#era" aspe!# of #he #onsi" is a %aryin$ nmber of para#onsi""ar %eins 'hi!h may be

#he sor!e of serios %enos b"eedin$ fo""o'in$ #onsi""e!#omy. This may par#i!"ar"y

o!!r 'hen #he b"eedin$ end re#ra!#s in#o #he pper par# of #he #onsi""ar fossa( and #his

ms# be fond and "i$a#ed before #he pa#ien# "ea%es #he opera#in$ room.

Hypo pharynx

The hypopharynx is bonded abo%e by #he pper border of #he epi$"o##is and

an#erior"y by #he s"opin$ "aryn$ea" in"e#. I#s inferior border is #he "o'er border of #he

!ri!oid !ar#i"a$e 'here i# !on#ines in#o #he oesopha$s. The hypopharynx is

!ommon"y des!ribed ana#omi!a""y of bein$ !omposed of #hree areas8 #he piriform

fossae( #he pos#erior pharyn$ea" 'a"" and #he pos#!ri!oid area. The m!osa of #hese


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areas is in dire!# !on#ini#y 'i#h no dis#in!# barriers( and disease pro!esses( s!h as

ma"i$nan# neop"asms( !an easi"y in%o"%e more #han one area.

9'a""o'in$

9'a""o'in$ is a !omp"ex neroms!"ar a!#. Trama and disease may res"# in

dyspha$ia and a# #imes aspira#ion of food and f"id in#o #he air'ay. In !onsiderin$ #he

diseases 'hi!h in%o"%e #he pharynx and "arynx( i# is impor#an# #o ha%e a basi!nders#andin$ of s'a""o'in$ and #he fn!#ions of #he "arynx. 9'a""o'in$ !onsis#s of

#hree s#a$es8 ora"( pharyn$ea" and oesopha$ea" )*i$. +,.,. :no'"ed$e of #he

physio"o$y of norma" s'a""o'in$ and #he prob"ems as a !onse;en!e of disease has

been enhan!ed in #he "as# #'o de!ades by se of %ideo f"oros!opi! #e!hni;es. This is

#he radio $raphi!a" e%a"a#ion of #he passa$e of a bo"s of radio2opa;e "i;id or so"id

from #he poin# a# 'hi!h i# en#ers #he ora" !a%i#y do'n #o i#s passa$e 'i#hin #he

s#oma!h. This in%es#i$a#ion is !onsiderab"y more a!!ra#e #han #he o"der2fashioned

radio"o$i!a" examina#ion of barim s'a""o'( 'here #he ob0e!# 'as #o !on!en#ra#e on

#he p"ain


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Re#ropharyn$ea" spa!e = #his po#en#ia" spa!e "ies pos#erior #o #he pharynx bonded

an#erior"y by #he pos#erior pharyn$ea" 'a"" and i#s !o%erin$ b!!opharyn$ea" fas!ia

and pos#erior"y by #he !er%i!a" %er#ebrae and #heir !o%erin$ ms!"es and fas!ia. I#

!on#ains #he re#ropharyn$ea" "ymph nodes( 'hi!h are sa""y paired "a#era" nodes( b#

'hi!h are separa#ed by a #o$h median par#i#ion 'hi!h !onne!#s #he pre%er#ebra" 'i#h

#he b!!opharyn$ea" fas!ia. These nodes are more de%e"oped in infan!y and yon$!hi"dren( and i# is a# #his a$e #ha# #hey are mos# "i&e"y #o he in%o"%ed in inf"amma#ory

pro!esses 'hi!h( if se%ere( may affe!# s'a""o'in$ and respira#ion as a !onse;en!e of

$ross s'e""in$ and sppra#ion of #he re#ropharyn$ea" spa!e.

Larynx

The "arynx is #he pro#e!#i%e sphin!#er 'hi!h !"oses off #he air'ay drin$ s'a""o'in$.

In hmans and some o#her mamma"s i# is a"so responsib"e for #he $enera#ion of sond(

'hi!h in hmans is modified by #he pharynx( ora" !a%i#y( nasa" passa$es( sinses(

#on$e( "ips and #ee#h #o prod!e spee!h. The "arynx has a main"y !ar#i"a$inos

frame'or& 'hi!h may ossify in "a#er "ife and 'hi!h !onsis#s of #he hyoid bone abo%e(

#he #hyroid and !ri!oid !ar#i"a$es( and #he in#ri!a#e ary#enoid !ar#i"a$es pos#erior"y.

The !ri!oid !ar#i"a$e is #he on"y !omp"e#e rin$ in #he en#ire air'ay and bonds #he sb$"o##is 'hi!h is #he narro'es# poin# of #he air'ay. This is #he !ommones# si#e for

dama$e from endo#ra!hea" #bes( o!!asiona""y !asin$ "aryn$o#ra!hea" s#enosis.

An ana#omi!a" des!rip#ion of #he "arynx di%ides i# in#o #he spra$"o##is( $"o##is and

sb$"o##is )*i$. +,.>.The #re %o!a" fo"ds )of#en in!orre!#"y !a""ed #he %o!a" !ords

are norma""y 'hi#e in !on#ras# #o #he pin& m!osa of #he res# of #he "arynx and air'ay.

The #re %o!a" fo"ds mee# an#erior"y a# #he mid2"e%e" of #he #hyroid !ar#i"a$e( 'hereas

pos#erior"y #hey are separa#e and a##a!hed #o an ary#enoid !ar#i"a$e. This arran$emen#

prod!es #he ?V1 shape of #he $"o##is )*i$. +,.@.

Ner%e spp"y

The sensory ner%e spp"y #o #he "arynx abo%e #he %o!a" fo"ds is from #he sperior

"aryn$ea" ner%e and be"o' #he %o!a"

fo"ds from #he re!rren# "aryn$ea" ner%e. 3o#h of #hese ner%es are bran!hes of #he

%a$s )


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from #he "n$s b# #he rise in sb$"o##i! pressre for!es #he %o!a" fo"ds apar# s"i$h#"y

for an ins#an# 'i#h a!!ompanyin$ %ibra#ion of #he %o!a" fo"d epi#he"im. The openin$

and !"osin$ o!!rs in rapid se;en!e #o prod!e a %ibra#in$ !o"mn of air 'hi!h is #he

sor!e of sond. The pi#!h of #he sond is !on#ro""ed by #he fre;en!y of #he %o!a"

fo"d epi#he"ia" %ibra#ion( 'hi!h in #rn is de#ermined by #he #hi!&ness( "en$#h and

#ension of #he %o!a" fo"ds !on#ro""ed by #he in#rinsi! ms!"a#re. The "odness orin#ensi#y of #he sond is $o%erned by #he expira#ory air pressre and #he amp"i#de of

#he %o!a" fo"d %ibra#ions.

Bara"ysis or o%er# disease of #he %o!a" fo"ds or !"ose"y asso!ia#ed "aryn$ea" s#r!#res

'i"" $i%e rise #o dis#rban!e of #he sond and !rea#ion of #he symp#om of hoarseness

)Tab"e +,.-.

The ne!&

The ne!& is di%ided in#o an#erior and pos#erior #rian$"es by #he s#erno!"eidomas#oid

ms!"e. The an#erior #rian$"e ex#ends from #he inferior border of #he mandib"e #o #he

s#ernm be"o'( and is bonded by #he mid"ine and #he s#erno!"eidomas#oid ms!"e.

The pos#erior #rian$"e ex#ends ba!&'ards #o #he an#erior border of #rapeis and

inferior"y #o #he !"a%i!"e. The pper par# of #he an#erior #rian$"e is !ommon"ysbdi%ided in#o #he sbmandib"ar #rian$"e abo%e #he di$as#ri! ms!"e and #he

sbmen#a" #rian$"e be"o'. The "ympha#i! draina$e of #he head and ne!& is of

!onsiderab"e !"ini!a" impor#an!e )*i$. +,.. The mos# impor#an# !hain of nodes is #he

deep !er%i!a" nodes 'hi!h rn ad0a!en# #o #he in#erna" 0$"ar %ein. The o#her main

$rops are #he sbmen#a"( sbmandib"ar( preari!"ar and pos#ari!"ar( o!!ipi#a" and

pos#erior #rian$"e nodes.

The pper deep !er%i!a" nodes( 'hi!h !on#ain #he "ar$e 0$"odi$as#ri! node( drain #he

oropharynx( in!"din$ #he #onsi"s( pos#ero"a#era" aspe!#s of #he ora" !a%i#y( sperior

aspe!#s of #he "arynx and piriform fossae( and are #he !ommones# si#e of en"ar$emen#

de #o disease in #hese areas.

The pper deep !er%i!a" nodes may be pa"pa#ed a"on$ #he an#erior border of #he

s#erno!"eidomas#oid ms!"e b# 'hen #he ms!"e is 'e"" de%e"oped or #he ne!& is

obese i# may be diffi!"# #o e%a"a#e #heir #re sie and nder #hese !ir!ms#an!es

!"ini!a" examina#ion may be nre"iab"e.

/e#as#a#i! spread of s;amos !e"" !ar!inoma( 'hi!h a!!on#s for FG per !en# of

ma"i$nan# disease of #he head and ne!&( mos# !ommon"y o!!rs 'i#h #mors of #he

nasopharynx( #on$e base( #onsi"( piriform fossae and spra$"o##i! "arynx. When an

en"ar$ed ne!& node is de#e!#ed and #he possibi"i#y of ma"i$nan# disease sspe!#ed( i# is

#hese fi%e primary si#es 'hi!h ms# re!ei%e !aref" in%es#i$a#ion.

/e#as#a#i! spread #o re$iona" "ymph nodes in #he ne!& is mana$ed sr$i!a""y in many

!ases by rese!#ion of #he ne!& nodes( and a de#ai"ed &no'"ed$e of #heir ana#omy is#hs re;ired. The paro#id and sbmandib"ar sa"i%ary $"ands( and #he #hyroid and

para#hyroid $"ands( are addi#iona" impor#an# ne!& s#r!#res 'hi!h 'i"" be !o%ered

separa#e"y in #heir respe!#i%e !hap#ers.

7"ini!a" examina#ion

Bharynx and "arynx

Brior #o examina#ion of #he pharynx( #he ora" !a%i#y sho"d be examined 'i#h #he aid

of a $ood "i$h# and #on$e depressors )*i$. +,.F.

The ear( nose and #hroa# )ENT sr$eon !s#omari"y ses a ref"e!#in$ mirror on #he

head or a headband2mon#ed fibreop#i! "i$h# sor!e 'hi!h permi#s se of bo#h hands

#o ho"d ins#rmen#s. Inspe!#ion sho"d in!"de #he b!!a" m!osa and "ips( #he pa"a#e(

#he #on$e and f"oor of #he mo#h( a"" srfa!es of #he #ee#h and $ms( openin$ and!"osin$ of #he mo#h( and den#a" o!!"sion. Ba#ien#s sho"d be as&ed #o e"e%a#e #he


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#on$e #o #he roof of #he mo#h and pro#rde #he #on$e #o bo#h #he ri$h# and #he "ef#.

Ba"pa#ion may be re;ired sin$ one or #'o fin$ers $en#"y in#raora""y #o fee" any

s'e""in$s( and #his may be !ombined 'i#h ex#ra ora" pa"pa#ion of #he sbmen#a" and

sbmandib"ar "ymph nodes and sa"i%ary $"ands. 9imp"e per!ssion of #he #ee#h may

re%ea" #enderness indi!a#in$ ad0a!en# pa#ho"o$y in #he maxi""a or

mandib"e.Examina#ion of #he mo#h 'i#ho# ade;a#e i""mina#ion( #he se of a#on$e depressor( and $en#"e pa"pa#ion may fai" #o re%ea" !ommon and impor#an#

pa#ho"o$y.*o""o'in$ examina#ion of #he ora" !a%i#y( #he oropharynx is inspe!#ed 'i#h

#he "i$h# and 'i#h #he #on$e depressor p"a!ed firm"y on #o #he #on$e base #o depress

i# inferior"y.The an#erior and pos#erior fa!ia" pi""ars( #he #onsi"( re#romo"ar #ri$one

and pos#erior pharyn$ea" 'a"" sho"d a"" he inspe!#ed for !o"or !han$es( "!era#ion(

ps( forei$n bodies and s'e""in$s.E%en 'i#h an experien!ed examiner( approxima#e"y

one2#hird of pa#ien#s !anno# #o"era#e #he depression of #he pos#erior base of #on$e

'i#ho# $a$$in$. Bain and #risms as a !onse;en!e of pharyn$o"aryn$ea" or ne!&

pa#ho"o$y may add #o #he diffi!"#y of #he examina#ion. Ho'e%er( if #he pa#ien# is !o2

opera#i%e #he nasopharynx may be fr#her examined by pos#erior rhinos!opy sin$ a

pos#nasa" mirror in#rod!ed a"on$ #he #on$e depressor and mo%ed so #ha# a mirrorima$e is seen of #he nasopharynx. Li&e'ise( fr#her examina#ion of #he inferior

oropharynx( "arynx and piriform fossae !an be ob#ained by indire!# "aryn$os!opy

sin$ "aryn$ea" mirrors. 3o#h of #hese mirror examina#ion #e!hni;es re;ire #he se

of a head"i$h# and bo#h of #he examiner1s hands. Indire!# "aryn$os!opy a""o's

%isa"isa#ion of #he "arynx #o #he "e%e" of #he %o!a" fo"ds( and some#imes addi#iona"

%ie's of #he sb$"o##i! and #ra!hea" air'ay. Vo!a" fo"d mobi"i#y may be assessed.

*ibre2op#i! pharyn$o"aryn$os!opy

The fibre2op#i! nasendos!ope is passed #hro$h #he nose nder #opi!a" anaes#hesia(

and #he en#ire nasopharynx( oropharynx and "arynx !an be seen and demons#ra#ed #o

o#hers. This #e!hni;e a""o's hi$h2;a"i#y %isa"isa#ion in o%er G per !en# of pa#ien#s

)*i$. +,.. /odern fibre2op#i! nasendos!ope ha%e prod!ed #remendos impro%e2

men#s in examina#ion Of #he nasa" !a%i#ies( pharynx and "arynx. They are no' 'ide"y

a%ai"ab"e and sho"d he sed 'hene%er possib"e.

The ne!&

Wi#h #he pa#ien# si##in$( expose #he 'ho"e ne!& so #ha# bo#h !"a%i!"es are !"ear"y seen.

Inspe!# #he ne!& from in fron# and as& #he pa#ien# #o s'a""o'( preferab"y 'i#h #he aid

of a sip of 'a#er. No#e #he mo%emen#s of #he "arynx and any s'e""in$ in #he ne!&. As&

#he pa#ien# #o pro#rde #he #on$e if #here is a mid"ine ne!& s'e""in$. A #hyro$"ossa"

!ys# 'i"" mo%e p'ards 'i#h #he #on$e pro#rsion. Then s#and behind #he sea#ed

pa#ien# 'ho sho"d si# 'i#h #he !hin f"exed s"i$h#"y do'n'ards #o remo%e any nde

#ension in #he s#rap ms!"es( p"as#ysma and s#erno!"eidomas#oid. Ba"pa#e #he ne!&bi"a#era""y sin$ #he p"ps of #he fin$ers( no# #he #ips. I# is impor#an# #o pa"pa#e #he

$rops of "ymph nodes in a defini#e manner !omparin$ #he #'o sides of #he ne!&.

3e$in 'i#h #he sperfi!ia" !hain arond #he pper ne!& and !aref""y pa"pa#e #he en#ire

"en$#h of #he deep !er%i!a" nodes arond #he in#erna" 0$"ar %ein.On examinin$ for a

"mp in #he ne!& i# is of#en he"pf" #o as& #he pa#ien# #o poin# #o #he "mp firs#. As&

#hem 'he#her #he "mp is #ender. A s'e""in$ benea#h #he s#ernomas#oid ms!"e may

be !onsiderab"y "ar$er #han yor e%a"a#ion on pa"pa#ion. If yo are sspi!ios #ha# a

ne!& node is en"ar$ed as a res"# of ma"i$nan!y )i# may be hard( irre$"ar or fixed #o

o%er"yin$ s&in or #o deep s#r!#res #hen i# is manda#ory #o inspe!# #he nasopharynx(

#onsi"s( #on$e base( piriform fossa and spra$"o##i! "arynx )Tab"e +,.5.


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In%es#i$a#ion of diseases in #he pharynx( "arynx and ne!&

B"ain "a#era"


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An examina#ion of #he pharynx( "arynx and ne!& nder $enera" anaes#hesia may be

re;ired as a res"# of prob"ems 'i#h #he ro#ine examina#ion of pa#ien#s. This may be

de #o an inade;a#e %ie' as a !onse;en!e of #risms from pain( poor pa#ien#

!omp"ian!e( or "ar$e obs#r!#i%e pharyn$ea" or "aryn$ea" pa#ho"o$y. These

examina#ions may be fr#her aided by #he se of an opera#in$ mi!ros!ope( or ri$id

#e"es!opes )Hop&in1s rods 'hi!h impro%e #he %isa"isa#ion of #he pharynx and "arynx)*i$. +,.-,.

Diseases of #he pharynx

Nasopharynx

En"ar$ed adenoid

The mos# !ommon !ase of an en"ar$ed adenoid )#here is on"y one nasopharyn$ea"

adenoid( despi#e #he !ommon se of #he #erm ?adenoids1 is physio"o$i!a" hyper#rophy

)*i$. +,.-+. The sie of #he adenoid a"one is no# an indi!a#ion for remo%a". I# is of#en

asso!ia#ed 'i#h hyper#rophy of #he o#her "ymphoid #isses of Wa"deyer1s rin$. If

ex!essi%e hyper#rophy !ases b"o!&a$e of #he nasopharynx in asso!ia#ion 'i#h #onsi"hyper#rophy( #he pper air'ay may be!ome !ompromised drin$ s"eep !asin$

obs#r!#i%e s"eep apnoea. This !ondi#ion is be!omin$ in!reasin$"y dia$nosed( and is

impor#an# be!ase i# !an !ase s"eep depri%a#ion and se!ondary !ardia! !omp"i!a#ions.

I# has been imp"i!a#ed in some !ases of a sdden infan# dea#h syndrome. The mos#

!ommon symp#om is snorin$( 'hi!h is #ypi!a""y irre$"ar( 'i#h #he !hi"d a!#a""y

!easin$ respira#ion )apnoea and #hen res#ar#in$ 'i#h a "od inspira#ory snor#. The

!hi"d is of#en res#"ess and may #a&e p s#ran$e s"eepin$ posi#ions as he or she #ries #o

impro%e #he pharyn$ea" air'ay. 9r$i!a" remo%a" of #he #onsi"s and adenoid is

!ra#i%e( b# i# is impor#an# #o a%oid seda#i%e premedi!a#ions and opia#e ana"$esi!s

pos#opera#i%e"y be!ase #hey may fr#her depress #he !hi"d1s respira#ory dri%e.

Obs#r!#i%e s"eep apnoea may a"so o!!r in ad"#s( 'here #he obs#r!#ion may res"#

from nasa" deformi#y( a hyper#rophi! sof# pa"a#e asso!ia#ed 'i#h an a"#ered

nasopharyn$ea" is#hms( obesi#y and $enera" narro'in$ of #he pharyn$ea" air'ay( or

spra$"o##i! "aryn$ea" pa#ho"o$y. 9r$ery may be indi!a#ed fo""o'in$ in%es#i$a#ion by

means of a s"eep s#dy( drin$ 'hi!h measremen# of #he pa#ien#1s s"eep pa##ern and

ar#eria" oxy$ena#ion is nder#a&en.

Hyper#rophy of adenoid #isse mos# !ommon"y o!!rs be#'een #he a$es of + and -G

years( b# #he adenoid #isse sa""y nder$oes spon#aneos a#rophy drin$ pber#y(

a"#ho$h some remnan#s may persis# in#o ad"# "ife. The re"a#ionship of adenoid

en"ar$emen# #o re!rren# se!re#ory o#i#is media or re!rren# a!#e o#i#is media is no#

en#ire"y !"ear. I# has "on$ been #ho$h# #ha# es#a!hian #be dysfn!#ion res"#s fromei#her inf"amma#ory oedema or in#erferen!e 'i#h pa"a#a" e"e%a#ion 'hi!h opens #he

es#a!hian #be. Ho'e%er( #he exa!# re"a#ionship has no# been de#ermined and many

!hi"dren 'ho ha%e se!re#ory o#i#is media do no# a"'ays benefi# from adenoid remo%a".

Adenoide!#omy

Adenoid #isse !an be remo%ed a"one or in !on0n!#ion 'i#h a #onsi""e!#omy.

Indi!a#ions are8

obs#r!#i%e s"eep apnoea asso!ia#ed 'i#h pos#nasa" obs#r!#ion6

pos#nasa" dis!har$e6

re!rren# a!#e o#i#is media or pro"on$ed seros o#i#is media sa""y "on$er #han ,

mon#hs1 dra#ion6

re!rren# rhinosinsi#is.


8/37

Opera#i%e #e!hni;e. The adenoid #isse is remo%ed 'i#h a $arded !re##e )*i$.

+,.-> pressed a$ains# #he roof of #he nasopharynx and #hen !arried do'n'ards in a

modera#e"y firm s'eepin$ mo%emen# brin$in$ #he ex!ised adenoid in#o #he

oropharynx )*i$. +,.-@. The $ard on #he !re##e se!res #he adenoid and pre%en#s i#

from droppin$ inferior"y in#o #he air'ay. A pos#nasa" s'ab is p"a!ed in#o #he

nasopharynx n#i" a"" haemorrha$e has !eased.Rea!#ionary or se!ondary haemorrha$edrin$ #he re!o%ery period may re;ire #he p"a!in$ of a nasopharyn$ea" pa!& nder a

fr#her anaes#he#i!. This !an o!!asiona""y !ase respira#ory depression in !hi"dren and

ad"#s( and #hey re;ire s#ri!# obser%a#ion 'hi"e #he pa!& is in p"a!e.

Tmorsof #he nasopharynx

3eni$n. There are #'o main #ypes of beni$n #mor of #he nasopharynx8 #he

an$iofibroma and #he an#ro!hoana" po"yp.

An$"o fibroma. This is of#en #ermed ?nasopharyn$ea" an$iofibroma1( b# #his is

in!orre!# as #he #mor arises in #he area of #he sphenopa"a#ine foramen in #he

pos#erior par# of #he nasa" !a%i#y. Ho'e%er( i# readi"y expands in#o #he nasopharynx

and( a"#ho$h #he #mor is no# ma"i$nan# in #ha# i# ne%er me#as#asises( i# does spread

re"en#"ess"y o%er #he s&"" base expandin$ an#erior"y in#o #he nasa" !a%i#ies disp"a!in$#he nasa" sep#m( !ompressin$ #he pos#erior 'a"" of #he maxi""ary an#rm and of#en

en#erin$ i# by bone erosion. Li&e'ise( i# may en#er and expand #he sphenoid sins and

spread "a#era""y #hro$h #he p#ery$opa"a#ine fissre and on'ards in#o #he

infra#empora" fossa o!!asiona""y #o rea!h #he sof# #isses of #he !hee& and orbi# %ia #he

inferior orbi#a" fissre. Inferior"y i# may fi"" #he nasopharynx( depress #he sof# pa"a#e

and e%en#a""y appear 'i#hin #he oropharynx )*i$. +,.-.

/a!ros!opi!a""y #here is a firm reddish2b"e #mor !o%ered 'i#h norma" m!os

membrane( b# "!era#ion may o!!r if #he #mor han$s in#o #he oropharynx or

be!omes exposed an#erior"y a# #he nos#ri". /i!ros!opi!a""y i# is !omposed of imma#re

fibrob"as#s and b"ood %esse"s( and i# remains beni$n e%en in i#s ad%an!ed s#a$es. I#

sho"d probab"y be re$arded as a hamar#oma. 7"ini!a""y #he #mor is !onfined #o

ma"e pa#ien#s !ommon"y be#'een #he a$es of F and 5G years( i.e. arond pber#y. I#

o!!asiona""y o!!rs in #he 5Gs and ,Gs.

I# rare"y re$resses and sa""y !ases pro$ressi%e nasa" obs#r!#ion( re!rren# se%ere

epis#axis( pr"en# rhinorrhoea and o!!asiona""y "oss of %ision de #o !ompression of

#he op#i! ner%e. A"#ho$h #he #mor is rare( #hese symp#oms in a yon$ boy sho"d

a"'ays arose sspi!ion.The #mor o!!rs in many !on#ries arond #he 'or"d b# is

mos# !ommon in nor#hern India. The reasons for #his are n&no'n.

9#andard !"ini!a" examina#ion may easi"y re%ea" #he #mor in #he nasa" !a%i#y or

nasopharynx( b# 7T s!annin$ bes# demons#ra#es #he ex#en# of #he #mor and i#s

a!!ompanyin$ bony erosion. /RI s!annin$ 'i"" fr#her define #he sof#2#isse ex#en#and 'i#h #hese #'o modern in%es#i$a#ions an$io$raphi! e%a"a#ion is rare"y indi!a#ed.

3iopsy sho"d be a%oided n"ess !"ini!a" and radio"o$i!a" examina#ion is no# !"ear.

There sho"d be defini#e reasons for nder#a&in$ biopsy( and ma#!hed b"ood ms# be

in readiness and #he sr$eon prepared #o dea" 'i#h #he haemorrha$e.

Whi"s# radio#herapy has o!!asiona""y been ad%o!a#ed( sr$i!a" rese!#ion is by #he far

!ommones# mana$emen# 'or"d'ide and re;ires an ade;a#e exposre of #he en#ire

re$ion ei#her #hro$h a midfa!ia" de$"o%in$ approa!h or a "a#era" rhino#omy )*i$s

+,.-F and +,.-. 3o#h of #hese approa!hes a""o' "i$a#ion of #he feedin$ maxi""ary

ar#ery. A #ranspa"a#a" approa!h may be sed for #he sma""er #mors b# #his does no#

$i%e f"" !on#ro" of any po#en#ia" b"eedin$.

An#ro!hoana" po"yp. This re"a#i%e"y n!ommon "esion is no# a #mor b# a simp"em!osa" po"yp. I# does no# arise in #he nasopharynx( b# from #he maxi""ary an#rm(


9/37

from 'hi!h i# pro"apses in#o #he nasa" !a%i#y and #hen!e expands ba!&'ards in#o #he

nasopharynx and o!!asiona""y do'n in#o #he oropharynx )*i$s +,.5G and +,.5-. I#

a"so !ommon"y o!!rs in yon$ ma"es( and #herefore may mimi! a #mor of #he

nasa" !a%i#y or nasopharynx. I# is dis#in$ished !"ini!a""y from an an$iofibroma by i#s

a%as!"ari#y( pa"e !o"or( i#s si#e of ori$in on endos!opi! examina#ion and ima$in$( as

i# is a simp"e m!osa" po"yp. Whi"s# i# may be remo%ed in#ra nasa""y by an a%"sionsnare( a por#ion of#en remains in #he an#rm prod!in$ re!rren# symp#oms and i#

re;ires !omp"e#e remo%a" %ia an endos!opi! approa!h #hro$h #he midd"e mea#s or(

o!!asiona""y( a 7a"d'e""=L! pro!edre #o pre%en# re!rren!e.

/a"i$nan#. Nasopharyn$ea" !ar!inoma is an in#eres#in$ s;amos !e"" !ar!inoma 'i#h

a %ery %ariab"e in!iden!e. In mos# par#s of #he 'or"d #he #mor is rare 'i#h an

in!iden!e of "ess #han one person in -GG GGG per year. Ho'e%er( i# is a !ommon

#mor amon$s# so#hern 7hinese( and #his hi$h2ris& pop"a#ion has ra#es of ,G=>G

peop"e per -GG GGG per year. In #he res# of 7hina #here are sbs#an#ia" %aria#ions in #he

in!iden!e b#( in $enera"( #he in!iden!e de!reases from so#h #o nor#h. Hi$her

fre;en!ies of nasopharyn$ea" !ar!inoma are a"so obser%ed in emi$ran# so#hern

7hinese pop"a#ions in so#h2eas# Asia and e"se'here arond #he 'or"d( and i# is a"somore !ommon amon$s# Es&imo( #he :adaans in Eas# /a"aysia and par#s of nor#hern

Afri!a. I# is no' 'e"" a!!ep#ed #ha# me!hanisms "eadin$ #o de%e"opmen# of a !an!er

of#en in%o"%e a m"#i s#ep pro!ess( and #he ae#io"o$y of nasopharyn$ea" !ar!inoma is

mos# "i&e"y #o be m"#ifa!#oria" 'i#h no sin$"e !ase ade;a#e"y exp"ainin$ #he

epidemio"o$y of #he disease. Ho'e%er( i# is a"so !"ear #ha# #hree 'e""2defined ma0or

ae#io"o$i!a" fa!#ors are in%o"%ed in i#s de%e"opmen# )Tab"e +,.,. The exa!#

me!hanism as #o ho' #hese fa!#ors a!# is no# ye# f""y nders#ood. The ma0ori#y of

s;amos !ar!inomas of #he nasopharynx is ndifferen#ia#ed and #he morpho"o$y of

#his #mor is !hara!#eris#i!. On"y a fe' are 'e""2differen#ia#ed s;amos !ar!inomas(

and #hese #'o "esions ma&e p o%er G per !en# of nasopharyn$ea" ma"i$nan!y in

endemi! areas. O#her rare epi#he"ia" #mors are adeno!ar!inoma and adenoid !ys#i!

!ar!inoma. 32 and T2!e"" "ymphomas a"so o!!r in #his re$ion and sho"d no# be

!onfsed 'i#h #he more !ommon ndifferen#ia#ed !ar!inoma.

Nasopharyn$ea" !ar!inoma affe!#s a yon$er a$e $rop of #he pop"a#ion #han a"mos#

any o#her head and ne!& neop"asm. In endemi! re$ions a# "eas# @G per !en# of pa#ien#s

are nder >G years of a$e and #his app"ies #o bo#h sexes.

7"ini!a" fea#res. 9ymp#oms are !"ose"y re"a#ed #o #he posi#ion of #he #mor in #he

nasopharynx and #he de$ree of dis#an# spread 'hi!h may be presen#. Ear"y symp#oms

are of#en minima" in na#re and #hs "iab"e #o be i$nored by bo#h pa#ien# and do!#or.

Approxima#e"y ha"f #he pa#ien#s 'i"" presen# 'i#h a mass in #he ne!&. This

per!en#a$e is e%en hi$her in pa#ien#s nder 5- years of a$e. I# indi!a#es #ha# #he#mor has a"ready rea!hed an ad%an!ed s#a$e. *ine need"e aspira#e or a biopsy of a

ne!& node sho'in$ ndifferen#ia#ed !ar!inoma re;ires immedia#e #horo$h

examina#ion of #he nasopharynx.

The nasopharynx may "oo& norma" or on"y minima""y asymme#ri! b# !on#ain

sbm!osa" nasopharyn$ea" !ar!inoma. Nasa" !omp"ain#s o!!r in one2#hird of

pa#ien#s and ara" symp#oms of ni"a#era" deafness( as a !onse;en!e of es#a!hian

#be obs#r!#ion and se!re#ory o#i#is media( o!!r in approxima#e"y 5G per !en#.

Nero"o$i!a" !omp"i!a#ions 'i#h !rania" ner%e pa"sies de #o disease on #he s&"" base

o!!r re"a#i%e"y "a#e in #he disease b# are a poor pro$nos#i! fa!#or.

A biopsy of #he nasopharynx is manda#ory if #here is sspi!ion of nasopharyn$ea"

ma"i$nan!y.The #radi#iona" me#hod of indire!# examina#ion 'i#h a mirror( a"#ho$hade;a#e in some pa#ien#s( has been sperseded by dire!# inspe!#ion !arried o# by a


10/37

f"exib"e or ri$id nasendos!ope. If #opi!a" anaes#hesia is sed( a biopsy may be #a&en.

9ero"o$i!a" in%es#i$a#ion for Eps#ein=3arr %irs2asso!ia#ed an#i$eni! mar&ers( in

!ombina#ion 'i#h #he !"ini!a" and his#o"o$i!a" examina#ion( is %a"ab"e for #he ear"y

de#e!#ion of disease. Hi$h"y sensi#i%e assays for an#i%ira" an#ibodies( #o$e#her 'i#h #he

ne'"y dis!o%ered %irs2asso!ia#ed sero"o$i!a" mar&ers( are assis#in$ no# on"y in #he

ear"y de#e!#ion b# in #he #rea#men# and !on#ro" of #his disease. I$A an#i%ira" !apsidan#i$en )V7A an#ibody has re!en#"y been e%a"a#ed in mass sr%eys in so#hern

7hina and has been fond #o be an ex!e""en# s!reenin$ me#hod for #he ear"y de#e!#ion

of nasopharyn$ea" !ar!inoma in hi$h2ris& $rops.

Ima$in$.Ima$in$ is essen#ia" #o de#ermine #he ex#en# of #he disease and #o enab"e

!orre!# s#a$in$. In areas 'here 7T and /RI are a%ai"ab"e p"ain fi"m radio$raphy of

#he nasopharynx and o#her an!i""ary me#hods( s!h as xero$raphy and #omo$raphy(

ha%e no' been sperseded. A !hes#


11/37

Trisms !ased by spasm ind!ed in #he p#ery$oid ms!"es from #he spreadin$

infe!#ion may ma&e examina#ion diffi!"#. This may be o%er!ome by #he ins#i""a#ion of

"o!a" anaes#hesia in#o #he pos#erior nasa" !a%i#y )#hereby anaes#he#isin$ #he spheno2

pa"a#ine $an$"ion and dire!#"y in#o #he oropharynx. This simp"e manoe%re aids

sbse;en# examina#ion 'hi!h sho"d be !arried o# 'i#h $ood i""mina#ion and

s!#ion. A diffse s'e""in$ of #he sof# pa"a#e 0s# sperior #o #he in%o"%ed #onsi" is seendisp"a!in$ #he %"a media""y and( in more ad%an!ed !ases( #here may be an area of

ps poin#in$ ndernea#h #he #hin m!osa.

Trea#men#. In #he ear"y s#a$es 'here no dis#in!# abs!ess is poin#in$( in#ra%enos

broad2spe!#rm an#ibio#i!s are indi!a#ed and may prod!e reso"#ion. Ho'e%er( if

#here is fran& abs!ess forma#ion( in!ision and draina$e of #he ps !an be !arried o#

nder "o!a" anaes#hesia )*i$. +,.5+. A sma"" s!a"pe" is bes# modified by 'indin$ a

s#rip of adhesi%e #ape arond #he b"ade so #ha# on"y - !m of #he b"ade pro0e!#s. In

#eena$ers and yon$ ad"#s #he pa#ien# si#s pri$h# and an in!ision is made in #he

posi#ion sho'n in *i$. +,.5+. This is approxima#e"y mid2'ay be#'een #he base of #he

%"a and #he #hird pper mo"ar #oo#h. This may prod!e immedia#e re"ease of ps

b#( if no#( dressin$ for!eps are no' pshed firm"y #hro$h #he in!ision dire!#"yba!&'ards and( on openin$( ps may #hen be en!on#ered. In sma"" !hi"dren $enera"

anaes#hesia may be re;ired.

7hroni! #onsi""i#is

7hroni! #onsi""i#is sa""y res"#s from repea# a##a!&s of a!#e #onsi""i#is in 'hi!h #he

#onsi"s be!ome pro$ressi%e"y dama$ed and pro%ide a reser%oir for infe!#i%e

or$anisms.

Tonsi""e!#omy. Indi!a#ions for #onsi""e!#omy may be di%ided in#o abso"#e or re"a#i%e

)Tab"e +,.>.When #he sie of #he #onsi"s is !on#rib#in$ #o air'ay obs#r!#ion or a

ma"i$nan!y of #he #onsi"s is sspe!#ed( #he de!ision #o perform #onsi""e!#omy is

re"a#i%e"y s#rai$h#for'ard. 7omp"e#e #onsi""e!#omy is preferab"e #o 'ed$e biopsies

'hen s;amos !e"" !ar!inoma is sspe!#ed( and bi"a#era" #onsi""e!#omy is performed

in #he !ase of sspe!#ed "ymphoma as par# of #he s#a$in$ pro!ess.

7onsiderab"e in#eres# no' fo!ses on #he area of s"eep apnoea and re"a#ed prob"ems.

Ba#ien#s sho"d be admi##ed for forma" s"eep s#dies #o es#ab"ish #he exa!# ex#en# and

si#e of #he prob"em fo""o'in$ 'hi!h a %arie#y of medi!a" and sr$i!a" #rea#men#s may

be deemed appropria#e( one of 'hi!h is #onsi""e!#omy.

Re!rren# a!#e #onsi""i#is is #he !ommones# re"a#i%e indi!a#ion for #onsi""e!#omy in

!hi"dren and ado"es!en#s( a"#ho$h i# is impor#an# #ha# #hese a##a!&s are 'e""

do!men#ed and do no# simp"y !ons#i##e a minor sore #hroa# sa""y of %ira" ori$in

and of shor# dra#ion. 7hroni! #onsi""i#is more fre;en#"y affe!#s yon$ ad"#s in

'hom i# is impor#an# #o es#ab"ish #ha# !hroni! mo#h brea#hin$ se!ondary #o nasa"obs#r!#ion is no# #he main prob"em ra#her #han #he #onsi"s #hemse"%es.

Idea""y( #he pro!edre sho"d be nder#a&en 'hen #he #onsi"s are no# a!#e"y infe!#ed(

and i# is impor#an# #o dis!ss fa!#ors 'hi!h may in!rease #he #enden!y #o b"eed. 3"ood

#ransfsion is rare"y re;ired b# i# is norma" pra!#i!e #o perform a ?$rop and sa%e1 in

!hi"dren nder -> &$ in 'ei$h#.

Disse!#ion #onsi""e!#omy is !arried o# nder $enera" anaes#hesia drin$ 'hi!h #he

pa#ien# "ies spine 'i#h #he head ex#ended and 'i#h #he sr$eon si##in$ a# #he end of

#he opera#in$ #ab"e. The m!osa of #he an#erior fa!ia" pi""ar is in!ised and #he #onsi"

!aps"e iden#ified. Usin$ b"n# disse!#ion #he sr$eon separa#es #he #onsi" from i#s bed

n#i" on"y a sma"" inferior pedi!"e is "ef# )*i$. +,.5>. Usa""y a snare is sed #o

separa#e i# from #he "in$a" #onsi". Ribbon $ae is p"a!ed in #he #onsi""ar bed andpressre app"ied for some min#es fo""o'in$ 'hi!h b"eedin$ poin#s may be !on#ro""ed


12/37

by "i$a#re or by bipo"ar dia#hermy. *o""o'in$ sr$ery( #he pa#ien# is &ep# nder !"ose

obser%a#ion for any sys#emi! or "o!a" e%iden!e of b"eedin$ 'i#h re$"ar moni#orin$ of

p"se and b"ood pressre( and obser%a#ion #o see 'he#her #he pa#ien# is s'a""o'in$

ex!essi%e"y )*i$. +,.5@. The pa#ien# is &ep# ni" by mo#h for #he firs# fe' hors in

!ase an immedia#e )or rea!#ionary haemorrha$e sho"d ne!essi#a#e a re#rn #o #hea#re.

Af#er #his period #he pa#ien# is en!ora$ed #o se #he mo#h and a norma" die# rapid"yins#i##ed. Bara!e#amo" is preferred #o aspirin2!on#ainin$ ana"$esi!s. Ba#ien#s are

$enera""y a""o'ed home on #he fo""o'in$ day and are 'arned #ha# #hey may

experien!e o#a"$ia de #o referred pain from #he $"ossopharyn$ea" ner%e and #ha# "a#e

)or se!ondary haemorrha$e may o!!r p #o -G days fo""o'in$ #he sr$ery( 'hi!h

'o"d ne!essi#a#e #heir immedia#e re#rn #o hospi#a".

Haemorrha$e is ob%ios"y #he mos# !ommon !omp"i!a#ion( o!!rrin$ in #he

immedia#e pos#opera#i%e period )Tab"e +,.@. Lo!a" pressre( hydro$en peroxide(

$ar$"es and $enera" sppor#i%e measres may he"p in mi"d !ases( b# i# is $enera""y

.'ises# #o re#rn #o #hea#re for defini#i%e #rea#men# par#i!"ar"y in yon$er pa#ien#s.

3"ood "oss is rep"a!ed 'i#h !rys#a""oid 'hi"s# a !ross2ma#!h is performed( and

fre;en# obser%a#ions of b"ood pressre( p"se and respira#ory ra#e are made.Ade;a#e ana"$esia is $i%en 'i#ho# !asin$ respira#ory depression. Wi#h #he pa#ien#

sea#ed pri$h# in bed #he mo#h is examined nder reasonab"e i""mina#ion #o

de#ermine #he si#e of b"eedin$ and if possib"e #o s!#ion a'ay !"o#s from #he #onsi""ar

fossa. A s'ab soa&ed in - in -GGG adrena"ine may be he"d a$ains# #he b"eedin$ area in

a !o2opera#i%e pa#ien#( b# if #his is no# possib"e andCor #he b"eedin$ persis#s #hea#re

sho"d be a"er#ed. Under $enera" anaes#hesia i# may be possib"e #o iden#ify a b"eedin$

spo#( b# of#en a more $enera"ised ooe is obser%ed and s#rin$ of #he #onsi" bed

!ombined 'i#h #he app"i!a#ion of 9r$i!e" and bipo"ar dia#hermy is of#en more

s!!essf" #han a##emp#ed p"a!emen# of "i$a#res.

La#e haemorrha$e is $enera""y se!ondary #o infe!#ion and pa#ien#s sho"d be

immedia#e"y !ommen!ed on in#ra%enos an#ibio#i!s 'i#h aerobi! and anaerobi! !o%er.

9i$nifi!an# or persis#en# b"eedin$ may re;ire a fr#her $enera" anaes#he#i! and nder

se'in$ of #he sr$i!a" bed( 'hi!h by #his #ime 'i"" of#en be !o%ered 'i#h s"o$h and

$ran"a#ion #isse. Bos#opera#i%e #onsi""ar haemorrha$e ms# s#i"" be re$arded as a

serios and "ife2#hrea#enin$ !omp"i!a#ion and sho"d no# be nderes#ima#ed(

par#i!"ar"y in #he yon$er pa#ien#.

Barapharyn$ea" and re#ropharyn$ea" abs!ess

Barapharyn$ea" abs!ess. The parapharyn$ea" abs!ess may be !onfsed 'i#h a

peri#onsi""ar abs!ess b# #he maxima" s'e""in$ is behind #he pos#erior fa!ia" pi""ar

and #here may be "i##"e oedema of #he sof# pa"a#e. The pa#ien# is sa""y a yon$ !hi"d

and #here may be a se%ere de$ree of $enera" ma"aise. Wi#h an ob%ios abs!esspoin#in$ in#o #he oropharynx( draina$e may be !arried o# 'i#h a b"n# ins#rmen# or

#he $"o%ed fin$er b# $enera" anaes#hesia is fre;en#"y re;ired and #he exper#ise of a

senior anaes#he#is#( $ood i""mina#ion and $ood s!#ion are abso"#e"y essen#ia". A

"ar$e parapharyn$ea" abs!ess may !ompromise bo#h #he air'ay and s'a""o'in$. In

#he ear"ier !ases admission #o hospi#a" and #he ins#i##ion of f"id rep"a!emen#s

!op"ed 'i#h in#ra%enos an#ibio#i!s may prod!e reso"#ion. The ad%an!ed !ases a"so

re;ire in#ra%enos an#ibio#i!s.

A!#e re#ropharyn$ea" abs!ess

This is #he res"# of sppra#ion of #he pre%er#ebra" "ymph nodes and( a$ain( is mos#

!ommon"y seen in !hi"dren 'i#h mos# of #he !ases o!!rrin$ in #hose nder - year of

a$e. I# is asso!ia#ed 'i#h infe!#ion of #he #onsi"s( nasopharynx or oropharynx( and isfre;en#"y a!!ompanied by se%ere $enera" ma"aise( ne!& ri$idi#y( dyspha$ia( droo"in$(


13/37

a !ropy !o$h( an a"#ered !ry and mar&ed dyspnoea. Indeed( dyspnoea may be #he

prominen# symp#om( and may a"so be a!!ompanied by febri"e !on%"sions and

%omi#in$.

These !hi"dren sho"d a"'ays be !aref""y examined( and an inspe!#ion of #he

pos#erior 'a"" of pharynx may sho' $ross s'e""in$ and an abs!ess poin#in$ benea#h

#he #hinned m!osa. In !on#ries 'here diph#heria s#i"" o!!rs( an a!#ere#ropharyn$ea" abs!ess may be !onfsed 'i#h #his b# #he presen!e of #he $reyish2

$reen membrane aids differen#ia#ion. O!!asiona""y( a forei$n body( mos# !ommon"y a

fish hone 'hi!h has perfora#ed #he pos#erior pharyn$ea" m!osa( 'i"" $i%e rise #o an

abs!ess in #his si#a#ion in o"der !hi"dren and yon$ ad"#s.

These pa#ien#s sho"d be admi##ed #o hospi#a" and in#ra%enos an#ibio#i!s ins#i##ed

immedia#e"y. 9r$i!a" draina$e of #he abs!ess may no# be ne!essary b#( if so(

re;ires experien!ed anaes#hesia as on ind!#ion !are ms# be #a&en #o a%oid

rp#rin$ #he abs!ess. The air'ay is pro#e!#ed by p"a!in$ #he !hi"d in a head2do'n

posi#ion 'hi"s# a pair of dressin$ for!eps $ided by #he fin$er may be #hrs# in#o an

ob%ios abs!ess in #he pos#erior 'a"" 'i#h #he !on#en#s bein$ e%a!a#ed. On o#her

o!!asions an approa!h an#erior and media" #o #he !aro#id shea#h %ia a !er%i!a" in!isionmay he re;ired.

7hroni! re#ropharyn$ea" abs!ess

This !ondi#ion is no' rare and mos# !ommon"y #he res"# of an ex#ension of

#ber!"osis of #he !er%i!a" spine 'hi!h has spread #hro$h #he an#erior "on$i#dina"

"i$amen# #o rea!h #he re#ropharyn$ea" spa!e. In !on#ras# #o #he a!#e re#ropharyn$ea"

abs!ess( #his !ondi#ion o!!rs a"mos# so"e"y in ad"#s and radio"o$y sa""y sho's

e%iden!e of bone des#r!#ion and "oss of #he norma" !r%a#re of #he !er%i!a" spine.

The spine may be ;i#e ns#ab"e and nde manip"a#ion may pre!ipi#a#e a

nero"o$i!a" e%en#. In addi#ion #o #he re#ropharyn$ea" s'e""in$ seen in#raora""y( #here

may be f""ness behind #he s#erno!"eidomas#oid ms!"e on one side. A !hroni!

re#ropharyn$ea" abs!ess ms# no# he opened in#o #he mo#h( as s!h a pro!edre may

"ead #o se!ondary infe!#ion. Draina$e of #he abs!ess may no# be ne!essary if si#ab"e

#rea#men# of #he nder"yin$ #ber!"osis disease is ins#i##ed. If i# is ne!essary #hen i#

sho"d he !arried o# #hro$h a !er%i!a" in!ision an#erior #o #he s#erno!"eidomas#oid

ms!"e 'i#h an approa!h an#erior and media" #o #he !aro#id shea#h #o #he

re#ropharyn$ea" spa!e. The !a%i#y is opened and s!#ioned dry af#er #a&in$ biopsy

ma#eria". O!!asiona""y sr$ery is re;ired #o de!ompress #he spina" !ord if #here is a

pro$ressi%e nero"o$i!a" defi!i#.

4"and"ar fe%er )infe!#ios monon!"eosis

This sys#emi! !ondi#ion is sa""y !ased by Eps#ein=3arr %irs b# simi"ar fea#res

!an be de #o !y#ome$a"o%irs or #oxop"asmosis.7"ini!a" fea#res. The #onsi"s are #ypi!a""y ery#hema#os 'i#h a !reamy2$rey exda#e(

and #hey appear a"mos# !onf"en# and sa""y symme#ri!a" in !on#radis#in!#ion #o a

;insy. In addi#ion #o #he dis!omfor# and dyspha$ia( #he pa#ien# may droo" sa"i%a and

ha%e respira#ory diffi!"#y( par#i!"ar"y on inspira#ion. They !ommon"y ha%e a hi$h

#empera#re and $ross $enera" ma"aise 'i#h o#her no#ab"e !er%i!a" or $enera"ised

"ymphadenopa#hy. O!!asiona""y an en"ar$ed sp"een or "i%er may be de#e!#ed. These

fea#res mos# !ommon"y o!!r in #eena$ers and yon$ ad"#s( and dia$nosis !an be

!onfirmed by sero"o$i!a" #es#in$ sho'in$ a posi#i%e Ba"=3nne"" #es#( an abso"#e

and re"a#i%e "ympho!y#osis( and #he presen!e of a#ypi!a" mono!y#es in #he periphera"

b"ood.

Trea#men#. Ana"$esia and main#enan!e of f"id in#a&e are impor#an#. A sma"" nmberof pa#ien#s re;ires admission #o hospi#a" if #he air'ay is !ompromised and a shor#


14/37

!orse of s#eroids may be he"pf". If #his is ne!essary i# sho"d on"y be !arried o# as

an in2pa#ien# 'here #he air'ay !an be !ons#an#"y moni#ored. An#ibio#i!s are of "i##"e

%a"e and( indeed( ampi!i""in is !on#raindi!a#ed be!ase of #he fre;en# appearan!e of

a 'idespread s&in rash.

Hman immnodefi!ien!y %irs

The hman immnodefi!ien!y %irs )HIV is #he !asa#i%e a$en# of a!;iredimmnodefi!ien!y syndrome )AID9 'hi!h( a"#ho$h i# 'as ini#ia""y asso!ia#ed 'i#h

in#ra%enos dr$ sers and homosexa" ma"es( is no' spreadin$ in many par#s of #he

'or"d #o affe!# #he he#erosexa" !ommni#y. I# !an affe!# a"mos# a"" of #he head and

ne!& s#r!#res a# any poin# drin$ #he disease. The ini#ia" sero!on%ersion may presen#

'i#h #he symp#oms of $"and"ar fe%er 'hi!h is fo""o'ed by an asymp#oma#i! period

of %ariab"e "en$#h. In #he preAID9 period( prior #o #he f""2b"o'n symp#oms of #he

AID92re"a#ed !omp"ex( many pa#ien#s ha%e minor pper respira#ory #ra!# symp#oms

'hi!h are of#en o%er"oo&ed s!h as o#i#is ex#erna( rhinosinsi#is and a nonspe!ifi!

pharyn$i#is. As #he pa#ien# mo%es in#o #he f""2b"o'n AID92re"a#ed !omp"ex a

persis#en# $enera"ised "ymphadenopa#hy is fre;en#"y fond affe!#in$ #he !er%i!a"

nodes 'hi!h is sa""y de #o fo""i!"ar hyperp"asia. Ho'e%er( pa#ien#s may a"sode%e"op #mors s!h as :aposi1s sar!oma( some#imes seen in #he ora" !a%i#y( and

hi$h2$rade ma"i$nan# 32!e"" "ymphoma affe!#in$ #he !er%i!a" "ymph nodes and

nasopharynx. In addi#ion( m"#ip"e "!ers may be fond in #he ora" !a%i#y or pharynx

asso!ia#ed 'i#h herpes infe!#ion. 9e%ere !andida may affe!# #he ora" !a%i#y pharynx or

e%en "arynx( and a hairy "e!op"a&ia may affe!# #he #on$e )*i$. +,.5. There is a"so

an in!reased in!iden!e of s;amos !e"" !ar!inoma of #he ora" !a%i#y.

The $"obs syndrome

A 'ide %arie#y of pa#ien#s has a predominan# symp#om of a fee"in$ of a "mp in #he

#hroa# )La#in8 $"obs "mp. The symp#om mos# !ommon"y affe!#s ad"#s be#'een ,G

and @G years of a$e. This fee"in$ is no# #re dyspha$ia as #here is no diffi!"#y in

s'a""o'in$. /os# pa#ien#s no#i!e #he symp#om more if #hey s'a""o' #heir o'n sa"i%a(

i.e. a for!ed dry s'a""o'( ra#her #han 'hen #hey ea# or drin&. The ae#io"o$y of #his

!ommon symp#om is n&no'n b# some pa#ien#s may ha%e $as#ro2oesopha$ea" ref"x

or spasm of #heir !ri!opharyn$es ms!"e. The symp#om may be asso!ia#ed 'i#h #he

presen!e of a pharyn$ea" po!h( or #mors in #he oropharynx( hypopharynx or pper

oesopha$s.

The ori$ina" name of $"obs hys#eri!s is nhe"pf" and a"#ho$h #hese pa#ien#s may

be anxios and a# #imes in#ro%er#ed( #hey none #he "ess re;ire f"" examina#ion #o

ex!"de "o!a" disease. Radio"o$i!a" and endos!opi! in%es#i$a#ion may be ne!essary #o

ex!"de an nder"yin$ !ase.

Bharyn$ea" po!hThe po!h is a pro#rsion of m!osa #hro$h :i""ian1s dehis!en!e( a 'ea& area of #he

pos#erior pharyn$ea" 'a"" be#'een #he ob"i;e fibres of #hyropharyn$es and #he

#rans%erse fibres of !ri!opharyn$es a# #he "o'er end of #he inferior !ons#ri!#or

ms!"e. These fibres( a"on$ 'i#h #he !ir!"ar fibres of #he pper oesopha$s( form #he

physio"o$i!a" pper oesopha$ea" sphin!#er me!hanism. i#e 'hy #he po!h forms is

no# ye# !"ear e%en 'i#h modern %ideo f"oros!opi! and manome#ri! s#dies. /any

pa#ien#s 'i#h pharyn$ea" po!hes ha%e been demons#ra#ed #o ha%e norma" re"axa#ion

of #he pper oesopha$ea" sphin!#er me!hanism in re"a#ion #o s'a""o'in$( b# o#hers

ha%e been sho'n #o ha%e in!omp"e#e pharyn$ea" re"axa#ion( ear"y !ri!opharyn$ea"

!on#ra!#ion and abnorma"i#ies of #he pharyn$ea" !on#ra!#ion 'a%e. As #he po!h

en"ar$es #he resis#an!e of #he %er#ebra" !o"mn behind sa""y !ases i# #o #rn"a#era""y #o #he "ef# )*i$. +,.5F.


15/37

7"ini!a" fea#res. Ba#ien#s sfferin$ from #his !ondi#ion are !ommon"y more #han @G

years of a$e and i# is #'i!e as !ommon in 'omen as in men.

In #he ini#ia" phases 'hen #here is a sma"" di%er#i!"m #he pa#ien#s may presen# 'i#h

$"obs2#ype symp#oms of a fee"in$ of some#hin$ in #he #hroa# or minor diffi!"#ies and

s"i$h# re$r$i#a#ion on s'a""o'in$. A %ideof"oros!opi! or barim s'a""o' s#dy may

sho' abnorma"i#ies of #he pper oesopha$ea" sphin!#er in asso!ia#ion 'i#h #he sma""po!h. As #he di%er#i!"m en"ar$es pa#ien#s may experien!e re$r$i#a#ion of

ndi$es#ed food some#imes hors af#er a mea"( par#i!"ar"y if #hey are bendin$ do'n

or #rnin$ o%er in bed a# ni$h#. They are some#imes a'o&en a# ni$h# 'i#h a fee"in$ of

#i$h#ness in #he #hroa# and a fi# of !o$hin$. O!!asiona""y #hey may presen# 'i#h

re!rren# nexp"ained !hes# infe!#ions as a res"# of sma"" amon#s of "i;id and food

bein$ aspira#ed from #he po!h. As #he po!h in!reases in sie #he pa#ien#s may no#i!e

$r$"in$ noises from #he ne!& on s'a""o'in$ and #he po!h may be!ome "ar$e

eno$h #o form a %isib"e s'e""in$ in #he ne!&. This s'e""in$ may in!rease 'hen #he

pa#ien# drin&s and( indeed( #here may be in!reasin$ diffi!"#y 'i#h s'a""o'in$

asso!ia#ed 'i#h 'ei$h# "oss and !a!hexia.

Radio"o$i!a" examina#ion. If a pharyn$ea" po!h is sspe!#ed( #his is an ex#reme"ysef" examina#ion. A #hin em"sion of barim is $i%en #o #he pa#ien# as a barim

s'a""o' )*i$. +,.5 or( be##er s#i""( as par# of a %ideof"oros!opi! s'a""o'in$ s#dy.

7are sho"d be exer!ised in pa#ien#s 'ho !o$h on s'a""o'in$ indi!a#in$ #hey may

ha%e aspira#ion. Js# a fe' mi""i"i#res of barim is sffi!ien# #o o#"ine #he pharynx

po!h and pper oesopha$s. The %ideof"oros!opi! s#dy $i%es addi#iona"

informa#ion abo# #he pharyn$ea" !on#ra!#ion 'a%es and #he performan!e of #he pper

oesopha$ea" sphin!#er. O!!asiona""y #here is an asso!ia#ed hia#s hernia a# #he "o'er

end of #he oesopha$s and #his sho"d be ex!"ded. A !hes#


16/37

fond and "i$a#ed 'e"" "a#era""y. The re#ropharyn$ea" spa!e is en#ered abo%e #he

inferior !orner of #he #hyroid !ar#i"a$e( #hereby a%oidin$ ris& of dama$e #o #he

re!rren# "aryn$ea" ner%e. The po!h is fond media""y behind #he "o'er pharynx and

is !aref""y iso"a#ed and disse!#ed ba!& #o i#s ori$in a# :i""ian1s dehis!en!e. I# may

#hen be ex!ised and #he pharynx !"osed in #'o "ayers or( if i# is sma""( i# may

in%a$ina#ed in#o #he pharyn$ea" "men before !"osin$ #he ms!"e "ayers. In a"" !ases amyo#omy di%idin$ #he fibres of #he !ri!ophary$es ms!"e and #he pper oesopha$ea"

!ir!"ar ms!"e fibres ms# be performed. The 'ond is sa""y !"osed 'i#h draina$e

and #he pa#ien# fed #hro$h #he naso$as#ri! #be for ,= days.

7omp"i!a#ions. This !"assi! opera#ion has been asso!ia#ed 'i#h 'ond infe!#ion(

medias#ini#is( pharyn$ea" fis#"aforma#ion and s#enosis of #he pper oesopha$s.

Varia#ions ha%e been #ried 'hi!h in!"de simp"y hi#!hin$ p #he po!h in#o a sperior

posi#ion 'i#ho# ex!isin$ i#( #hs a""o'in$ #he fnds and body #o emp#y !on#inos"y

in#o #he oesopha$s. This is nsa#isfa!#ory 'i#h #he "ar$er po!hes. Endos!opi!

di%ision of #he bar of ms!"e formin$ #he an#erior 'a"" of #he po!h and #he pos#erior

aspe!# of #he "men of #he oesopha$s has been ad%o!a#ed for many years sin$

Doh"mann1s ins#rmen#s and( more re!en#"y( a "aser app"ied %ia a spe!ia"pharyn$os!ope. There is in!reasin$ e%iden!e #ha# bo#h #he open opera#i%e in#er%en#ion

and pre%ios endos!opi! #e!hni;es !an be impro%ed by sin$ an endos!opi! s#ap"in$

#e!hni;e( 'hereby a spe!ia"ised s#ap"e $n is passed do'n a modified

pharyn$os!ope 'hi!h safe"y di%ides #he an#erior 'a"" of #he po!h and #he pos#erior

'a"" of #he oesopha$s. This !omp"e#es a f"" myo#omy and a""o's any food and f"id

#o drain from #he po!h dire!#"y do'n #he oesopha$s. The s#ap"es pro%ide an ins#an#

#'o2"ayer !"osre a# #he si#e of di%ision( and #his endos!opi! #e!hni;e is asso!ia#ed

'i#h %ery "o' morbidi#y and a hi$h s!!ess ra#e for #he re"ief of #he pa#ien#1s

symp#oms. Lo' morbidi#y is par#i!"ar"y impor#an# in #his e"der"y $rop of pa#ien#s.

9ideropeni! dyspha$ia

Bro"on$ed iron defi!ien!y anaemia may "ead #o dyspha$ia( par#i!"ar"y in midd"e2a$ed

fema"es. In addi#ion( #hey may ha%e &oi"ony!hia( !hei"osis and an$"ar s#oma#i#is(

#o$e#her 'i#h "assi#de and poor exer!ise #o"eran!e. The dyspha$ia is !ased by a

pos#!ri!oid 'eb( and #hese pa#ien#s ha%e a hi$her in!iden!e of pos#!ri!oid

ma"i$nan!y. Bro$nosis of #hese pos#!ri!oid #mors is %ery poor( re;irin$ radi!a"

#rea#men# 'i#h radio#herapy and ma0or sr$ery( and i# is #herefore impor#an# #o pre%en#

#his prob"em by re!o$ni#ion and #rea#men# of #he anaemia. The syndrome is asso!ia#ed

'i#h #he names of B"mme# and Vinson( and Ba##erson and 3ro'n :e""y.

Tmors of #he oropharynx3eni$n

3eni$n #mors of #he oropharynx are rare( papi""omas bein$ #he mos# !ommon.

These are sa""y in!iden#a" findin$s and are rare"y of any impor#an!e.

/a"i$nan#

The mos# impor#an# epi#he"ia" #mor is s;amos !e"" !ar!inoma( 'hi!h !ons#i##es

ro$h"y G per !en# of a"" epi#he"ia" #mors in #he pper aerodi$es#i%e #ra!# )*i$s

+,.,G and +,.,-. In #he oropharynx #he propor#ion is "ess )G per !en# be!ase of #he

hi$her in!iden!e of "ymphoma )5> per !en# and sa"i%ary $"and #mors )> per !en#.

Ae#io"o$y

9;amos !ar!inomas of #he oropharynx ha%e s#ron$ asso!ia#ions 'i#h !i$are##e

smo&in$ and #he !onsmp#ion of a"!oho"( and #hese #'o fa!#ors !ase %aryin$in!iden!e #hro$ho# #he 'or"d. In !on#ries 'here #he !onsmp#ion of #oba!!o and


17/37

a"!oho" is asso!ia#ed 'i#h poor ora" hy$iene #hese ma"i$nan!ies assme ma0or

impor#an!e. De #o #he ri!h "ympha#i! draina$e of #he oropharynx( !er%i!a" node

me#as#a#ases are !ommon. They may be #he on"y presen#in$ fea#re 'i#h an apparen#

o!!"# primary of#en bein$ nsspe!#ed and missed in #he #onsi" or #on$e base.The

ma0ori#y of "ymph node me#as#ases from oropharyn$ea" s;amos !ar!inomas is #o

#he 0$"odi$as#ri! node. This is #he !ommones# si#e for #he so2!a""ed ?bran!hia" !ys#!ar!inoma1( b# se%era" s#dies in re!en# #imes ha%e sho'n #ha# #his is probab"y an

ex#reme"y rare pa#ho"o$y and #ha# sa""y #he dia$nosis represen#s !ys#i! de$enera#ion

in a 0$"odi$as#ri! node from a sma"" nde#e!#ed primary s;amos !ar!inoma in #he

#onsi" or #on$e base. 9;amos !e"" !ar!inomas are mos# !ommon in #he six#h and

se%en#h de!ades and more fre;en# in men.

Trea#men#

Trea#men# pa##erns %ary 'i#h fa!i"i#ies( h# ear"y #mors may be !red by

radio#herapy( "aser ex!ision or more !on%en#iona" ex!ision. Re!rren# disease

fo""o'in$ radio#herapy is mana$ed sr$i!a""y( and repair of #he oropharynx may

re;ire re$iona""y based myo!#aneos f"aps or free f"aps 'i#h mi!ro%as!"ar

anas#omosis. Ne!& disse!#ion is re;ired in a "ar$e propor#ion of !ases of ad%an!eddisease. Bos#opera#i%e dyspha$ia 'i#h aspira#ion( as a res"# of in#erferen!e in #he

!omp"ex neroms!"ar !on#ro" of #he se!ond phase of s'a""o'in$( is a par#i!"ar

prob"em in #hese pa#ien#s. /ore ad%an!ed #mors may a"so re;ire addi#iona"

rese!#ion of #he mandib"e or an asso!ia#ed #o#a" "aryn$e!#omy( so #his #ype of sr$ery

is bes# !arried o# in a !en#re nder#a&in$ #his 'or& on a re$"ar basis.

Lymphoma of #he head and ne!&

Lymphomas of #he head and ne!& may arise in noda" or ex#ranoda" sires( and bo#h

Hod$&in1s disease and nonHod$&in1s "ymphoma !ommon"y presen# as "ymph node

en"ar$emen# in #he ne!&. Hod$&in1s disease is rare in #he oropharynx( b#

nonHod$&in1s "ymphoma a!!on#s for ->=5G per !en# of #mors a# #his si#e in some

!on#ries. /os# are of #he 32!e"" #ype and ha%e fea#res in !ommon 'i#h o#her

#mors of /ALT sires. /any of #he "ymphomas of #he oropharynx ha%e no

demons#rab"e deposi# e"se'here in #he body 'hen a f"" "ymphoma in%es#i$a#ion is

!arried o#. On o!!asions( ho'e%er( #hey may be se!ondary or !oin!iden# 'i#h

deposi#s a# o#her sires in #he ne!&( #he $as#roin#es#ina" #ra!#( "n$ and #he #es#es.

*r#her e%a"a#ion 'i#h 7T s!annin$ of #he #horax and abdomen( and bone marro'

e%a"a#ion are essen#ia". Radio#herapy is ndob#ed"y #he #rea#men# of !hoi!e for

"o!a"ised nonHod$&in1s "ymphoma and may $i%e !on#ro" ra#es as hi$h as > per !en#

a# > years. *or dissemina#ed nonHod$&in1s "ymphoma #he #rea#men# of !hoi!e is

sys#emi! !hemo#herapy. 7ombina#ion !hemo#herapy is sed in pa#ien#s 'i#h an

nfa%orab"e his#o"o$i!a" #ype.

Tmors of #he hypopharynx

3eni$n

3eni$n #mors of #he hypopharynx are %ery rare( #he mos# !ommon bein$ #he

fibroma and #he "eiomyoma. These are po"ypoid #mors 'hi!h sa""y presen# 'i#h

dyspha$ia and are seen on %ideof"oros!opy or barim s'a""o'. They sho' a smoo#h

!ons#an# mass "yin$ in #he "men of #he hypopharynx or oesopha$s.

/a"i$nan#

/a"i$nan# #mors of #he hypopharynx are a"mos# ex!"si%e"y s;amos !e""

!ar!inoma 'i#h a predominan!e of modera#e and poor differen#ia#ion. The #mors

are sa""y !"assified a!!ordin$ #o #heir ana#omi!a" sire of ori$in from #he piriformfossa( pos#!ri!oid re$ion or pos#erior pharyn$ea" 'a"" b#( as men#ioned in #he se!#ion


18/37

on pharyn$ea" ana#omy( i# !an be diffi!"# #o de#ermine #he sire of ori$in 'hen a

#mor has spread #o in%o"%e one or more of #hese areas. E%en differen#ia#ion be#'een

"aryn$ea" and hypopharyn$ea" #mors !an be diffi!"# in #he ad%an!ed disease 'hen

#he aryepi$"orri! fo"d has been rep"a!ed or !o%ered by #mors. /ar&ed differen!es in

#he in!iden!e of #hese #mors o!!r #hro$ho# #he 'or"d in asso!ia#ion 'i#h fa!#ors

s!h as iron defi!ien!y anaemia )see sbse!#ion on 9ideropeni! dyspha$ia and #heymay be asso!ia#ed 'i#h mar&ed sbm!osa" spread of -G mm or more 'hi!h fr#her

!omp"i!a#es #heir e%a"a#ion. Tmors arisin$ from #he piriform fossa and pos#erior

pharyn$ea" 'a"" may spread #o pper or "o'er !er%i!a" nodes. Tmors arisin$ in #he

pos#!ri!oid area #ypi!a""y me#as#asise #o para#ra!hea" and paraoesopha$ea" nodes

'hi!h may no# be pa"pab"e. As 'i#h oropharyn$ea" #mors( a"!oho" and #oba!!o are

#'o prin!ipa" !ar!ino$ens imp"i!a#ed in #hese #mors. Bos#!ri!oid !ar!inoma(

a"#ho$h essen#ia""y a rare disease( is more !ommon in 'omen #han men. The

dia$nosis of hypopharyn$ea" !ar!inoma sho"d be !onsidered in a"" pa#ien#s

presen#in$ 'i#h dyspha$ia or hoarseness( par#i!"ar"y if #hey ha%e a his#ory of iron

defi!ien!y and anaemia( smo&in$ or si$nifi!an# a"!oho" !onsmp#ion.

On examina#ion indire!# "aryn$os!opy may sho' on"y sb#"e si$ns of disease s!h asoedema or poo"in$ of sa"i%a ni"a#era""y in a piriform fossa( or dimin#ion of %o!a"

fo"d mobi"i#y. A"" re$ions of #he ne!& ms# be assessed in a sys#ema#i! manner. *ine

need"e aspira#e is ad%o!a#ed for sspi!ios nodes. A sspe!#ed primary may re;ire

%ideof"oros!opy or barim s'a""o' s#dy( endos!opy and biopsy( and 7T or /RI

s!annin$ if a%ai"ab"e. A !hes#


19/37

Emer$en!ies

9#ridor

9#ridor means noisy brea#hin$. I# may be inspira#ory or expira#ory or o!!rrin$ in bo#h

phases of respira#ion. Inspira#ory s#ridor is sa""y de #o an obs#r!#ion a# or abo%e

#he %o!a" fo"ds and mos# !ommon"y is a res"# of an inha"ed forei$n body or a!#e

infe!#ion s!h as epi$"o##i#is. Expira#ory s#ridor is sa""y from #he "o'er respira#ory#ra!# and $i%es rise #o a pro"on$ed expira#ory 'heee. I# is mos# !ommon"y asso!ia#ed

'i#h a!#e as#hma or a!#e infe!#i%e #ra!heobron!hi#is. 3iphasi! s#ridor is sa""y de

#o obs#r!#ion or disease of #he #ra!heobron!hia" air'ay and dis#a" "n$s.

9#ridor in !hi"dren )Tab"e +,.

Infan#s and !hi"dren presen#in$ 'i#h s#ridor need assessmen# 'i#h a f"" his#ory and

!aref" examina#ion if appropria#e. If on presen#a#ion a !hi"d is !yanosed and se%ere"y

n'e"" #he air'ay ms# be se!red as soon as possib"e b# i# is of#en possib"e #o ob#ain

a brief his#ory from #he paren#s( 'i#h impor#an# poin#ers. A nrse or !o""ea$e may be

derai"ed #o do #his 'hi"s# #he ress!i#a#ion is #a&in$ p"a!e.

His#ory. In infan#s in #he firs# year of "ife i# is impor#an# #o es#ab"ish 'he#her #he

s#ridor is asso!ia#ed 'i#h par#i!"ar a!#i%i#ies s!h as s'a""o'in$( !ryin$ ormo%emen#. These may s$$es# !on$eni#a" "aryn$oma"a!ia or sb$"o##i! s#enosis. If #he

s#ridor is exa!erba#ed by feedin$( par#i!"ar"y in #he firs# + 'ee&s of "ife( #his s$$es#s

a %as!"ar rin$ or #ra!heooesopha$ea" fis#"a. If #he !ry is 'ea& or abnorma" #his

2s$$es#s a %o!a" fo"d pa"sy. If #he prob"em on"y o!!rs in asso!ia#ion 'i#h an pper

respira#ory #ra!# infe!#ion and( in par#i!"ar( is biphasi! #his 'o"d s$$es# !on$eni#a"

sb$"o##i! s#enosis. In a yon$ !hi"d inspira#ory s#ridor and droo"in$ s$$es# a!#e

epi$"o##i#is( 'hereas biphasi! s#ridor 'i#ho# droo"in$ s$$es#s

"aryn$o#ra!heobron!hi#is or !rop.

Examina#ion.

Obser%e #he !hi"d !aref""y a# res#6 do no# a##emp# #o mo%e or hand"e #he !hi"d(

par#i!"ar"y if #he s#rid"os !hi"d is bein$ he"d by i#s mo#her or o#her fami"y

member.On!e a baby s#ar#s #o !ry i# may be impossib"e #o s#dy i#s res#in$ respira#ory

pa##ern for some #ime. As& #he mo#her( nor a nrse or a !o""ea$e( #o mo%e a baby or

yon$ !hi"d in#o differen# posi#ions s!h as fa!e do'n and spine( and 'a#!h for

!han$es in i#s respira#ory pa##ern and "e%e" of dis#ress. Obser%e any droo"in$ and 'i#h

neona#es and infan#s a"'ays #ry #o 'a#!h #he !hi"d bein$ fed( "is#enin$ #o #he #ra!hea

and !hes# 'i#h a s#e#hos!ope if possib"e. A"'ays examine #he 'ho"e !hi"d( "oo&in$ for

any e%iden!e of !on$eni#a" abnorma"i#ies before a##emp#in$ any examina#ion of #he

#hroa#.

If a !hi"d is s#rid"os and droo"in$ and si##in$ pri$h# in i#s mo#her1s arms or !hair do

no# a##emp# #o "ie i# do'n and do no# a##emp# #o "oo& inside #he mo#h.These arepo#en#ia""y "ife2#hrea#enin$ !ir!ms#an!es as #he !hi"d may aspira#e a "ar$e ;an#i#y of

#hi!& sa"i%a !on#ained 'i#hin i#s ora" !a%i#y. The !hi"d does nor 'ish #o a##emp#

s'a""o'in$ in #he !ase of a re#ropharyn$ea" abs!ess( parapharyn$ea" abs!ess or a!#e

epi$"o##i#is as #hese !ondi#ions are so painf". I# is par#i!"ar"y impor#an# in a!#e

epi$"o##i#is as #he aspira#ion of #hi!& sa"i%a may be asso!ia#ed 'i#h fr#her "aryn$ea"

spasm and a respira#ory arres#. Res#"essness( in!reasin$ #a!hy!ardia and !yanosis are

impor#an# si$ns of hypoxia. If #he !hi"d is no# dis#ressed and droo"in$( and nor

mar&ed"y s#rid"os i# may be !o2opera#i%e eno$h for i# #o be possib"e #o "oo& inside

#he mo#h and !he!& #he pa"a#e( #on$e and oropharynx. In s#rid"os !hi"dren(

par#i!"ar"y neona#es and infan#s( a #rans2!#aneos oxime#er is in%a"ab"e if a%ai"ab"e.

I# may be p"a!ed on #he !hi"d before any examina#ion and drin$ any sbse;en#mana$emen#. A ress!i#a#ion #ro""ey 'i#h #he ne!essary e;ipmen# for emer$en!y


20/37

in#ba#ion or #ra!heos#omy sho"d be !"ose a# hand( if a# a"" possib"e( before

!ommen!in$ examina#ion and in%es#i$a#ion of #hese !hi"dren.

Investigation.In addi#ion #o #he oxime#er( p"ain "a#era"


21/37

hospi#a" 'i#h oxy$ena#ion and hmidifi!a#ion !op"ed 'i#h an#ibio#i!s may be

ne!essary if #here are si$ns of se!ondary infe!#ion.

Foreign bodies

3o#h !hi"dren and ad"#s may inha"e forei$n bodies. on$ !hi"dren 'i"" a##emp# #o

s'a""o' a 'ide %arie#y of ob0e!#s( b# !oins( beads and par#s of #oys are par#i!"ar"y

!ommon. In ad"#s #he aspira#ion is sa""y of food( par#i!"ar"y inade;a#e"y !he'edbones and mea#. This is more !ommon in e"der"y eden#"os ad"#s and o!!asiona""y

por#ions of den#res may be inha"ed( par#i!"ar"y in asso!ia#ion 'i#h road #raffi!

a!!iden#s.

7"ini!a" fea#res. The his#ory is of#en paramon# and i# is impor#an# #o a"'ays be"ie%e

#he pa#ien#( par#i!"ar"y a paren# 'ho $i%es a his#ory of forei$n body in$es#ion or

inha"a#ion in a !hi"d( e%en #ho$h #he pain( dyspha$ia( !o$hin$( e#!.( may ha%e

se##"ed. Ad"# pa#ien#s 'i""( on #he 'ho"e( ha%e a !"ear re!a"" and #he dia$nosis is more

easy( b# #his may no# a"'ays be #he !ase par#i!"ar"y if #he pa#ien# is sfferin$ from

men#a" i""ness. *ish bones may "od$e in #he #onsi"s or base of #on$e 'i#h minima"

symp#oms b# in !er#ain areas of #he 'or"d( no#ab"y Asia( sma"" fish bones may impa!#

in #he #onsi"s( oropharynx or hypopharynx and $i%e rise #o parapharyn$ea" andre#ropharyn$ea" abs!ess forma#ion.

Examination.

Examina#ion may be pre%en#ed by #risms( pain and anxie#y( b# #he presen!e of a

forei$n body may be sspe!#ed by a sa"i%ary poo" 'i#hin #he piriform fossa or

ad0a!en# oedema and ery#hema of #he pharyn$o"aryn$ea" m!osa.

Radiology.

Radio"o$y may be he"pf" b# is no# !ri#i!a". *ish hones are of#en no# %isib"e on p"ain


22/37

!an be seen. Hmidified oxy$en( adrena"ine neb"isers( sys#emi! an#ihis#amines and

s#eroids may be %a"ab"e in #hese !ases. /orphine sho"d no# be $i%en #o #hese

pa#ien#s #o !omba# #heir dis#ress as i# may !ase respira#ory depression and respira#ory

arres#. If #he dyspnoea pro$resses in#barion or #ra!heos#omy 'i"" be ne!essary. This

pro!edre is #o re"ie%e air'ay obs#r!#ion or #o pro#e!# #he air'ay by fashionin$ a

dire!# en#ran!e in#o #he #ra!hea #hro$h #he s&in of #he ne!&. Tra!heos#omy may bedone as an emer$en!y 'hen #he pa#ien# is in ex#remis and #he "arynx !anno# be

in#ba#ed b# i# is no# a"'ays an easy pro!edre( par#i!"ar"y in #he obese pa#ien#( and

sho"d no# be embar&ed pon n"ess abso"#e"y ne!essary. An easier a"#erna#i%e for

#he inexperien!ed do!#or is #he inser#ion of a "ar$e in#ra%enos !ann"a or(

a"#erna#i%e"y( a sma"" #be in#o #he !ri!o#hyroid membrane 'hi!h "ies in #he mid"ine

immedia#e"y be"o' #he #hyroid !ar#i"a$e. Emer$en!y in#ba#ion is a fr#her op#ion

'hen #he "aryn$o#ra!hea" air'ay is no# obs#r!#ed( and #ra!heos#omy may be

performed fo""o'in$ ini#ia" endo#ra!hea" in#barion.

7hoi!e of opera#ion

The de$ree of r$en!y in es#ab"ishin$ #ra!heos#omy 'i"" de#ermine #he me#hod sed(

b# preferen!e sho"d a"'ays be for #he e"e!#i%e pro!edre. One of #he mos#appropria#e pie!es of ad%i!e in sr$ery is ?#he #ime #o do a #ra!heos#omy is 'hen yo

firs# #hin& i# may be ne!essary1. A"" of #he po#en#ia" !omp"i!a#ions of #ra!heos#omy are

mar&ed"y de!reased if a me#i!"os e"e!#i%e pro!edre is performed nder !on#ro""ed

!ir!ms#an!es by an experien!ed #eam

If #ime a""o's #he fo""o'in$ sho"d be nder#a&en8

inspe!#ion and pa"pa#ion of #he ne!& #o assess #he "aryn$o#ra!hea" ana#omy in #he

indi%ida" pa#ien#6

indire!# or dire!# "aryn$os!opy6

#omo$raphy of #he "arynx and pper #ra!hea6

assessmen# of p"monary fn!#ion.

Whene%er possib"e #he pro!edre sho"d be ade;a#e"y exp"ained #o #he pa#ien#

beforehand( 'i#h par#i!"ar emphasis on #he inabi"i#y #o spea& immedia#e"y fo""o'in$

#he opera#ion and possib"e diffi!"#ies 'i#h s'a""o'in$.

Emer$en!y #ra!heos#omy. If a s&i""ed anaes#he#is# is na%ai"ab"e "o!a" anaes#hesia is

emp"oyed( b# in despera#e !ases 'here #he pa#ien# is n!ons!ios none is re;ired.

The on"y 'ord of 'arnin$ 'o"d be in #hose pa#ien#s 'ho ha%e sffered se%ere head

and ne!& #rama( and may ha%e an ns#ab"e !er%i!a" spine fra!#re.

7ri!o#hyroido#omy may be more si#ab"e nder #hese !ir!ms#an!es.

If i# is possib"e #he pa#ien# sho"d he "aid spine 'i#h paddin$ p"a!ed nder #he

sho"ders and #he ex#ended ne!& &ep# as s#eady as possib"e in #he mid"ine. This aids

pa"pa#ion of #he #hyroid and !ri!oid !ar#i"a$e be#'een #he #hmb and index fin$er of#he free hand. The mo%emen#s of #he fin$ers of #he free hand are impor#an# in #his

#e!hni;e. The opera#ion is more diffi!"# in sma"" !hi"dren and #hi!&2ne!&ed ad"#s as

#he "andmar&s are diffi!"# #o pa"pa#e.

A %er#i!a" mid"ine in!ision sho"d be made from #he inferior aspe!# of #he #hyroid

!ar#i"a$e #o #he spras#erna" no#!h and !on#ined do'n be#'een #he infrahyoid

ms!"es )*i$. +,.,5. There may he hea%y b"eedin$ from #he 'ond a# #his poin#(

par#i!"ar"y if #he ne!& is !on$es#ed as a res"# of #he pa#ien#1s effor# #o brea#he arond

an a!#e pper air'ay obs#r!#ion. No s#eps sho"d be #a&en #o !on#ro" #his

haemorrha$e( a"#ho$h an assis#an# and s!#ion appara#s are %a"ab"e if a%ai"ab"e.

The opera#or sho"d fee" !aref""y( and 'i#ho# nde has#e( for #he !ri!oid !ar#i"a$e

sin$ #he index fin$er of #he free hand 'hi"s# re#ra!#in$ #he s&in ed$es by pressreapp"ied by #he #hmb and midd"e fin$er. If #he si#a#ion is one of ex#reme r$en!y a


23/37

fr#her %er#i!a" in!ision s#rai$h# in#o #he #ra!hea a# #he "e%e" of #he se!ond( #hird and

for#h rin$ sho"d be made immedia#e"y 'i#ho# re$ard #o #he presen!e of #he #hyroid

is#hms )*i$. +,.,,. The &nife b"ade is ro#a#ed #hro$h GG #hs openin$ #he #ra!hea.

A# #his poin# #he pa#ien# may !o$h %io"en#"y as b"ood en#ers #he air'ay. The opera#or

sho"d be a'are of #his possibi"i#y and a%oid "osin$ #he posi#ion of #he s!a"pe" in #he

open #ra!hea. Any form of a%ai"ab"e #be sho"d be inser#ed in#o #he #ra!hea as soonas possib"e and b"ood and se!re#ion s!&ed or. On!e an air'ay has been es#ab"ished

haemos#asis is #hense!red. Wi#h #he emer$en!y nder !on#ro" #he #ra!heos#omy

sho"d be refashioned as soon as possib"e.

9ho"d addi#iona" e;ipmen# and more #ime be a%ai"ab"e on!e #he !ri!oid !ar#i"a$e has

been iden#ified( b"n# fin$er disse!#ion inferior"y !an be sed #o mobi"ise #he #hyroid

is#hms 'hi!h sho"d be di%ided be#'een haemos#a#s( !"earin$ #he #ra!hea before

ma&in$ a %er#i!a" in!ision #hro$h #he se!ond=for#h rin$s. A #ra!hea" di"a#or sho"d

be inser#ed #hro$h #he #ra!hea" in!ision and #he ed$es of #he #ra!hea" 'ond

separa#ed $en#"y. In !ases of sspe!#ed HIV infe!#ion or diph#heria #he sr$eon sho"d

p"a!e a s'ab o%er #he 'ond so #ha# #he %io"en# expira#ory effor#s 'hi!h may fo""o'

do nor !on#amina#e #he opera#or)s 'i#h infe!#ed m!s and b"ood. When respira#oryeffor#s ha%e be!ome "ess %io"en# a #ra!heos#omy #be sho"d be inser#ed in#o #he

#ra!hea and #he di"a#or remo%ed. I# is impor#an# #ha# #he sr$eon &eeps a fin$er on #he

#be 'hi"e #he assis#an# #ies #he a##a!hed rapes rond #he pa#ien#1s ne!&.

E"e!#i%e #ra!heos#omy.

The ad%an#a$e of an e"e!#i%e pro!edre is #ha# #here is !omp"e#e air'ay !on#ro" a# a""

#imes( nhrried disse!#ion and !aref" p"a!emen# of an appropria#e #be.

7"ose !o2opera#ion be#'een #he sr$eon( anaes#he#is# and s!rb nrse is essen#ia"( and

a##en#ion #o #he de#ai"s 'i""mar&ed"y red!e possib"e !omp"i!a#ions and morbidi#y

from #he pro!edre. *o""o'in$ ind!#ion of $enera" anaes#hesia and endo#ra!hea"

in#ba#ion( #he pa#ien# is posi#ioned 'i#h a !ombina#ion of head ex#ension and

p"a!emen# of an appropria#e sandba$ nder #he sho"ders )*i$. +,.,+. There sho"d

be no ro#a#ion of #he head. 7hi"dren1s heads sho"d nor be o%er2ex#ended as i# is

possib"e #o en#er #he #ra!hea in #he fif#h or six#h rin$s nder #hese !ir!ms#an!es. The

inexperien!ed sr$eon may find #he inser#ion of a bron!hos!ope in #he #ra!hea of

$rea# he"p 'hen performin$ #ra!heos#omy in yon$ !hi"dren. A #rans%erse in!ision

may be sed in #he e"e!#i%e si#a#ion. The #hyroid is#hms is di%ided !aref""y and

o%erse'n( and #ension s#res are p"a!ed ei#her side of #he #ra!hea" fenes#ra#ion in

!hi"dren )*i$s +,.,+2+,.,F. A 30or& f"ap may be sed in ad"#s. The ad%an#a$es of

#he 30Kr& me#hod far o#'ei$h #he po#en#ia" disad%an#a$es( and #he me#hod is

par#i!"ar"y sef" for #hose sr$eons 'ho nder#a&e o!!asiona" #ra!heos#omy or

'here #he "e%e" of s&i"" and experien!e of #he nrsin$ s#aff are "imi#ed. Berformed!orre!#"y i# is safe and a""o's rein#rod!#ion of a disp"a!ed#be 'i#h #he minimm of

diffi!"#y. The inferior"y based f"ap is be$n a# i#s apex 'i#h an in!ision on #he

sperior aspe!#s of #he se!ond rin$ and ex#ended do'n ei#her side #hro$h #he se!ond

and #hird rin$s. The #ip of #he f"ap sho"d be s#i#!hed #o #he inferior ed$e of #he

#rans%erse s&in in!ision sin$ horion#a" ma##ress s#res #hro$h #he s#r!#re of #he

se!ond rin$. These s#res sho"d be $eneros eno$h so #ha# #hey 'i"" nor !r or.

The firs# #ra!hea" rin$ sho"d no# be %io"a#ed nder any !ir!ms#an!es.

Tra!heos#omy #bes. These are basi!a""y made of #'o ma#eria"s( si"%er or p"as#i! )*i$.

+,.,. 3o#h ma#eria"s ha%e been sed #o ma&e #bes of %arios sies 'i#h %aryin$

!r%es( an$"es( !ffs( inner #bes and spea&in$ %a"%es. A !ffed #be is sed ini#ia""y(

'hi!h may be !han$ed af#er ,=+ days #o a non!ffed p"as#i! or si"%er #be. Thepressre 'i#hin #he #be !ff sho"d be !aref""y moni#ored and sho"d be "o' eno$h


24/37

no# #o o!!"de !ir!"a#ion in #he m!osa" !api""aries. When in posi#ion #he #be sho"d

be re#ained by dob"e #apes passed arond #he pa#ien#1s ne!& 'i#h a reef &no# on ei#her

side. I# is impor#an# #ha# #he pa#ien#1s head is f"exed 'hen #he #apes are #ied o#her'ise

#hey may be!ome s"a!& 'hen #he pa#ien# is mo%ed from #he posi#ion of ex#ension(

#hereby res"#in$ in a possib"e disp"a!emen# of #he #be if #he pa#ien# !o$hs.

A"#erna#i%e"y( #he f"an$es of #he p"as#i! #be may be s#i#!hed dire!#"y #o #he nder"yin$ne!& s&in.

:no'"ed$e of #he physio"o$i!a" !han$es ind!ed by #ra!heos#omy is an essen#ia"

re;iremen# for #he nders#andin$ of pos#opera#i%e mana$emen#. A"" forms of

#ra!heos#omy and !ri!o#hyroido#omy bypass #he pper air'ay and ha%e #he fo""o'in$

ad%an#a$es8

#he ana#omi!a" dead spa!e is red!ed by approxima#e"y >G per !en#6

#he 'or& of brea#hin$ is red!ed6

a"%eo"ar %en#i"a#ion is in!reased6

#he "e%e" of seda#ion needed for pa#ien# !omfor# is de!reased and( n"i&e

endo#ra!hea" in#barion( #he pa#ien# may be ab"e #a"& and ea# 'i#h a #be in

p"a!e.Ho'e%er( #here are se%era" disad%an#a$es8 "oss of hea# and mois#re ex!han$e performed in #he pper respira#ory #ra!#6

desi!!a#ion of #ra!hea" epi#he"im( "oss of !i"ia#ed !e""s and me#ap"asia6

#he presen!e of a forei$n body in #he #ra!hea s#im"a#es m!s prod!#ion. Where no

!i"ia are presen# #hism!o!i"iary s#ream is arres#ed6

#he in!reased m!s is more %is!id( and #hi!& !rs#s may form and b"o!& #he #be(

par#i!"ar"y in !hi"dren6

'hi"s# many pa#ien#s 'i#h a #ra!heos#omy !an feed sa#isfa!#ori"y( #here is some

sp"in#in$ of #he "arynx 'hi!h may pre%en# norma" s'a""o'in$ and "ead #o aspira#ion.

This aspira#ion may he ?si"en#1( i.e. nor apparen#.

Bos#opera#i%e #rea#men# is desi$ned #o !on#era!# #hese effe!#s( and fre;en# s!#ion

and hmidifi!a#ion are mos# impor#an# )Tab"e +,.. A #ro""ey ms# be p"a!ed by #he

bed !on#ainin$ a #ra!hea" di"a#or( dp"i!a#e robes and in#rod!ers( re#ra!#ors and

dressin$s. Oxy$en sho"d be a# hand and( in #he ini#ia" period( a nrse ms# be in

!ons#an# a##endan!e. Hmidifi!a#ion 'i"" render #he se!re#ions "ess %is!id6 a s!&er

'i#h a !a#he#er a##a!hed sho"d be on hand #o &eep #he #ra!heobron!hia" #ree free from

se!re#ions. The !a#he#er ms# be &ep# in a s#eri"e ho"der and in#rod!ed 'i#h asep#i!

pre!a#ions by a"" !on!erned. When m!s is %ery #ena!ios and !onse;en#"y

diffi!"# #o aspira#e( iso#oni! sa"ine or a m!o"y#i! a$en# may be adminis#ered #hro$h

#he #ra!heos#omy rbe by a fine neb"iser. If #here is an inner rbe i# sho"d be

remo%ed and 'ashed in sodim bi!arbona#e so"#ion e%ery + hors or more if

ne!essary. A nmber of !omp"i!a#ions is asso!ia#ed 'i#h #ra!heos#omy b# a"" !an bea%oided 'i#h !are and a##en#ion #o opera#i%e and pos#opera#i%e derai" )Tab"e +,.-G

.O#her emer$en!y air'ay pro!edres.

*ibre2op#i! endo#ra!hea" in#ba#ion. In mos# emer$en!y si#a#ions endo#ra!hea"

in#ba#ion is #he mos# dire!# and sa#isfa!#ory me#hod of se!rin$ #he air'ay.

Naso#ra!hea" in#ba#ion in exper# hands is a"so a 'e""2es#ab"ished #e!hni;e and is

par#i!"ar"y sef" if #he pa#ien# has #risms( se%ere mandib"ar in0ries( !er%i!a" spine

ri$idi#y or an obs#r!#in$ mass 'i#hin #he ora" !a%i#y. 3o#h of #hese forms of

in#ba#ion !an be aided in diffi!"# pa#ien#s by passin$ a modern fibre2op#i! endos!ope

#hro$h #he !en#re of an endo#ra!hea" #be( hen!e $idin$ i# in#o #he "arynx and

#ra!hea nder dire!# %ision )*i$. +,.+G.

Trans#ra!hea" %en#i"a#ion. This #e!hni;e has been in!reasin$"y ad%o!a#ed in #he "as#de!ade and( a"#ho$h some spe!ia"is# e;ipmen# is re;ired( #he a!#a" #e!hni;e is


25/37

simp"e and effe!#i%e. I# 'i"" a""o' %en#i"a#ion of #he pa#ien# for periods in ex!ess of -

hor and 'i"" of#en $i%e amp"e #ime #o

The !ri!o#hyroid membrane is "o!a#ed by pa"pa#ion of #he ne!& 'i#h #he index fin$er(

and a -+4 or -@4 p"as#i!2shea#hed in#ra%as!"ar need"e and a -G2m" syrin$e

!on#ainin$ a fe' mi""i"i#res of "i$no!aine are in#rod!ed in #he mid"ine and dire!#ed

do'n'ards and ba!&'ards in#o #he #ra!hea" "men )*i$. +,.+-. The need"e isad%an!ed s#eadi"y and ne$a#i%e pressre is p"a!ed on #he syrin$e n#i" bbb"es of air

are !"ear"y seen. The #isses of #he ne!& may be infi"#ra#ed 'i#h #he anaes#he#i! if

desired and #he #ra!hea" m!osa "i&e'ise par#"y anaes#he#ised by #he in#rod!#ion of -

=5 m" af#er $ainin$ #he "men. The need"e is remo%ed and #he p"as#i!2shea#h !ann"a

remains in #he #ra!hea. I# is a##a!hed by means of a Ler !onne!#ion #o #he hi$h2

pressre oxy$en spp"y. Ven#i"a#ion may be nder#a&en in a !on#ro""ed manner 'i#h a

0e##in$ de%i!e 'i#h #he !hes# bein$ obser%ed for appropria#e mo%emen#s. If #here is

se%ere obs#r!#ion of #he "aryn$opharynx by #he forei$n body or #mor( #he exha"ed

o#f"o' of $ases !an be aided by p"a!emen# of one or #'o fr#her !ann"ae as

exha"a#ion por#s. This pro!edre $ains ex#reme"y rapid !on#ro" of %en#i"a#ion and

re;ires a minimm of #e!hni!a" exper#ise.7iri!o#hyroido#omy.7ri!o#hyroido#omy has $ained in!reasin$ sppor# in some !en#res

and is ad%o!a#ed 'hen endo#ra!hea" in#ba#ion is no# possib"e. I# has #he ad%an#a$es

of speed and ease re;irin$ "i##"e e;ipmen# and sr$i!a" exper#ise. Ho'e%er( i#s se

for a"" b# #he briefes# a!!ess #o #he air'ay remains !on#ro%ersia"( and #here are

!onf"i!#in$ repor#s 'i#h re$ard #o #he sbse;en# in!iden!e of !omp"i!a#ions( par#i!2

"ar"y #hose of sb$"o##i! s#enosis and "on$2#erm %oi!e !han$es.

The pa#ien#1s ne!& is ex#ended and #he area be#'een #he prominen!e of #he #hyroid

!ar#i"a$e and #he !ri!oid !ar#i"a$e be"o' is pa"pa#ed 'i#h #he index fin$er of #he free

hand. In #he emer$en!y si#a#ion a %er#i!a" s&in in!ision is re!ommended 'i#h

disse!#ion rapid"y !arried do'n #o #he!ri!o#hyroid membrane. A -!m #rans%erse

in!ision is made #hro$h #he membrane immedia#e"y abo%e #he !ri!oid !ar#i"a$e and

#he s!a"pe" #'is#ed #hro$h a ri$h# an$"e #o $ain a!!ess #o #he air'ay )*i$s +,.+5. If

a%ai"ab"e ar#ery for!eps( di"a#or or #ra!hea" hoo& 'i"" aid impro%in$ #he aper#re and

#he inser#ion of an a%ai"ab"e #be )*i$+,.+,.

Dependin$ on #he de$ree of emer$en!y i# may be ne!essary for #he sr$eon #o assess

#he res"#s of #he pro!edre by dire!# "aryn$os!opy( and #he a#hors re!ommend #ha#

!aref" !onsidera#ion sho"d be $i%en #o !on%ersion of #he !ri!o#hyroido#omy #o a

#ra!heos#omy. A"#ho$h #here is deba#e abo# #he fre;en!y of sb$"o##i! s#enosis

fo""o'in$ #his pro!edre( #here is $enera" a$reemen# #ha# i# is m!h in!reased if any

"on$2#erm %en#i"a#ion is nder#a&en %ia e%en a modes# sie #ra!heos#omy #be #hro$h

#he !ri!o#hyroid membrane.

Laryngeal disease causing voice disorders

!ocal nodules

These are &no'n as sin$ers1 nod"es in ad"#s and s!reamers nod"es in !hi"dren )*i$.

+,.++. They are fibros #hi!&enin$s of #he %o!a" fo"ds a# #he 0n!#ion of #he midd"e

and an#erior #hird( and are #he res"# of %o!a" abse. 9pee!h #herapy is #herefore #he

preferred #rea#men# and #he "esions 'i"" reso"%e spon#aneos"y in mos# !ases.

O!!asiona""y #he nod"es 'i"" need #o be sr$i!a""y remo%ed sin$ modern

mi!ro"aryn$os!opi! disse!#ion or "aser #e!hni;es. *o""o'2p by #he spee!h #herapis#

is ne!essary n#i" a"" of #he nder"yin$ errors in %oi!e prod!#ion are o%er!ome.!ocal fold polyps


26/37

These are sa""y ni"a#era" and may be asso!ia#ed 'i#h an a!#e infe!#i%e episode(

!i$are##e smo&in$ and %o!a" abse

Laryngeal papillomata

These o!!r main"y in !hi"dren b# !an a"so presen# in ad"#s. They are mos#

!ommon"y fond on #he %o!a" fo"ds b# may spread #hro$ho# #he "arynx and

#ra!heobron!hia" air'ay )*i$. +,.+@. They are !ased by papi""oma %irses and needremo%a" by "aser sr$ery in order #o main#ain a reasonab"e %oi!e and air'ay. An#i%ira"

#rea#men# by s!h dr$s as in#erferon remains of dob#f" %a"e a# presen#. Endo2

s!opi! "aser sr$ery is #he "eas# #rama#i! 'ay of remo%in$ #hese "esions and sho"d

no# prod!e s!arrin$ or !ase imp"an#a#ion of #he papi""oma#a e"se'here in #he air'ay.

"cute laryngitis

This of#en o!!rs in asso!ia#ion 'i#h pper respira#ory #ra!# infe!#ions in asso!ia#ion

'i#h a !o$h and pharyn$i#is. I# may( ho'e%er( be "o!a"ised #o #he "arynx( is sa""y

%ira" and se##"es ;i!&"y if #he pa#ien# res#s #he %oi!e drin$ #he a!#i%e inf"amma#ion.

9#eam inha"a#ions are soo#hin$ a"on$ 'i#h mi"d ana"$esi!s b# an#ibio#i!s are

nne!essary. The !ondi#ion sho"d reso"%e in 5=, 'ee&s 'i#h %oi!e !are. Hoarseness

"as#in$ for ,=+ 'ee&s sho"d a"'ays be referred for an ENT opinion( par#i!"ar"y insmo&ers.

#hronic laryngitis

7hroni! "aryn$i#is may be spe!ifi! and !an be !ased by my!oba!#eria( syphi"is and

fn$i. Trea#men# is dire!#ed #o'ards #he !asa#i%e or$anism. Nonspe!ifi! "aryn$i#is is

!ommon( and #he main predisposin$ fa!#ors are smo&in$( !hroni! pper and "o'er

respira#ory sepsis and %oi!e abse. In some !ases #he "aryn$ea" m!osa may be!ome

dysp"as#i!(par#i!"ar"y o%er #he #re %o!a" fo"ds( and is a prema"i$nan# !ondi#ion. I#

may re;ire mi!ro"aryn$os!opi! examina#ion and biopsy. Trea#men# is by #he

e"imina#ion of any predisposin$ fa!#ors( par#i!"ar"y smo&in$( and a##en#ion #o any

%o!a" abse nder #he $idan!e of a spee!h #herapis#. Dia$nosis of !hroni! "aryn$i#is

sho"d no# he made n"ess #he "arynx has been f""y e%a"a#ed by a "aryn$o"o$is#.

Vo!a" fo"d pa"sy

This may be ni"a#era" or bi"a#era"( b# a ni"a#era" "ef# %o!a" fo"d pa"sy is #he

!ommones# as a !onse;en!e of #he "on$ in#ra#hora!i! !orse of #he "ef# re!rren#

"aryn$ea" ner%e 'hi!h ar!hes arond #he aor#a and may be !ommon"y in%o"%ed in

inf"amma#ory and neop"as#i! !ondi#ions in%o"%in$ #he "ef# hi"m )*i$. +,.+. Ln$

!an!er is #he !ommones# sin$"e !an!er in many par#s of #he 'or"d and a "ef# %o!a" fo"d

pa"sy sho"d be !onsidered #o be de #o a !ar!inoma of #he "n$ n#i" pro%ed

o#her'ise.O#her ma"i$nan# "esions !an !ase a simi"ar effe!# and may arise in #he

nasopharynx( #hyroid $"and or oesopha$s. 3i"a#era" %o!a" fo"d para"ysis is

n!ommon and #ends #o o!!r af#er #hyroid sr$ery or head in0ries )Tab"e +,.-5.7"ini!a" fea#res

Uni"a#era" re!rren# "aryn$ea" ner%e pa"sy of sdden onse# prod!es hoarseness 'hi!h

is mos# no#ab"e for "a!& of %o"me #o #he %oi!e and o!!asiona""y may be asso!ia#ed

'i#h diffi!"#y in s'a""o'in$ "i;ids and 'ea&enin$ of #he !o$h. These symp#oms

may be shor# "i%ed and #he %oi!e may re#rn #o norma" 'i#hin a fe' 'ee&s as #he

ms!"es in #he opposi#e %o!a" fo"d !ompensa#e and mo%e i# a!ross #he mid"ine #o mee#

#he para"ysed %o!a" fo"d 'hi!h sa""y "ies in #he paramedian posi#ion. O'in$ #o #his

effi!ien# !ompensa#ion( in s"o'"y pro$ressi%e "esions #he pa#ien# may on"y experien!e

s"i$h# 'ea&ness of #he %oi!e 'i#h pro"on$ed se.

3i"a#era" re!rren# "aryn$ea" ner%e pa"sy is an o!!asiona" and %ery serios

!omp"i!a#ion of #hyroide!#omy. A!#e dyspnoea o!!rs as a res"# of #he paramedianposi#ion of bo#h %o!a" fo"ds 'hi!h red!e #he air'ay #o 5=, mm and 'hi!h #end #o


27/37

$e# s!&ed #o$e#her on inspira#ion. In se%ere !ases #ra!heos#omy or in#ba#ion is

ne!essary immedia#e"y o#her'ise dea#h o!!rs from asphyxia.

In%es#i$a#ion of %o!a" fo"d para"ysis is mos# easi"y en!ompassed no'adays by a 7T

s!an from s&"" base #o diaphra$m. This #e!hni;e has rep"a!ed #he m"#ip"e pre%ios

in%es#i$a#ions 'hi!h 'ere ne!essary and re%ea"s mos# of #he pa#ho"o$y 'hi!h may

$i%e rise #o an ndia$nosed %o!a" fo"d pa"sy. Approxima#e"y 5G=5> per !en# of !asesof %o!a" fo"d para"ysis o!!rs 'i#ho# &no'n pa#ho"o$y and spon#aneos re!o%ery

may o!!r. In ni"a#era" %o!a" fo"d para"ysis( 'here !ompensa#ion does nor o!!r( #he

para"ysed fo"d may be media"ised by in0e!#in$ Tef"on pas#e "a#era" #o #he %o!a" fo"d

and disp"a!in$ i# media""y. A"#erna#i%e"y( a sma"" ex#erna" opera#ion on #he #hyroid

!ar#i"a$e may be nder#a&en in order #o en#er #he para$"o#ri! spa!e and disp"a!e #he

fo"d media""y )#hyrop"as#y. These sr$i!a" pro!edres sho"d be performed ear"y if

#he !ase is !ar!inoma of #he bron!hs and #he o#"oo& of #he pa#ien# is poor. When

#he pa#ho"o$y is n&no'n i# may be be##er #o 'ai# for a period of - year #o see 'he#her

spon#aneos impro%emen# o!!rs and #o a""o' fr#her re!o%ery 'i#h #he he"p of

spee!h #herapy.

In bi"a#era" %o!a" fo"d para"ysis #he pa#ien#s fre;en#"y re;ire #ra!heos#omy( b#sr$ery may be !arried o# #o remo%e a sma"" por#ion of #he pos#erior aspe!# of one

%o!a" fo"d or a por#ion of one ary#enoid !ar#i"a$e. These pro!edres are mos# easi"y

performed endos!opi!a""y 'i#h a !arbon dioxide "aser. They in!rease #he sie of #he

pos#erior $"o##i! air'ay a""o'in$ #he pa#ien# #o be de!ann"a#ed or e%en #o a%oid a

#ra!heos#omy in #he firs# p"a!e. 9ome "aryn$o"o$is#s ha%e ad%o!a#ed reinner%a#ion

pro!edres for #he para"ysed "arynx by ro#a#in$ a ner%e ms!"e !ombina#ion in#o #he

"arynx from #he ne!&. Ho'e%er( #hese #e!hni;es ha%e no# ye# fond 'idespread

a!!ep#an!e.

Tmors of #he "arynx

3eni$n #mors of #he "arynx are ex#reme"y rare and s;amos !ar!inoma of #he

"arynx predomina#es o%er a"" o#hers( bein$ responsib"e for more #han G per !en# of

#mors 'i#hin #he "arynx. I# is #he !ommones# head and ne!& !an!er and a"mos#

a"'ays o!!rs in e"der"y ma"e smo&ers. Ho'e%er( o%er #he pas# #'o de!ades #he sex

in!iden!e has !han$ed as a !onse;en!e of in!reasin$ smo&in$ amon$s# 'omen( and

in some areas #hey no' ma&e p more #han 5G per !en# of #he pa#ien#s. The s;amos

epi#he"im of #he %o!a" fo"ds and #he respira#ory epi#he"im of #he spra$"o##is

nder$o dysp"as#i! !han$e s#im"a#ed by !i$are##e smo&in$ and o#her fa!#ors. The

in!iden!e of "aryn$ea" !an!er in #he #hree !ompar#men#s spra$"o##is( $"o##is and

sb$"o##is %aries arond #he 'or"d6 #he $"o##is is $enera""y #he !ommones# si#e

fo""o'ed by #he spra$"o##is )*i$. +,.+F. Tre !ar!inomas of #he sb$"o##is are %ery

rare and mos# are a !onse;en!e of inferior spread from #he $"o##is.7"ini!a" fea#res

The fre;en# $"o##i! ori$in means #ha# pa#ien#s a"mos# a"'ays presen# 'i#h hoarseness.

This is of $rea# impor#an!e be!ase if a dia$nosis !an be made 'hi"e #he #mor is in

#he firs# s#a$e( i.e. !onfined on"y #o one %o!a" fo"d( #hese !an!ers ha%e more #han a G

per !en# >2year disease2free !re rare 'hen #rea#ed 'i#h radio#herapy a"one. The !re

rare drops drama#i!a""y on!e #he "ympha#i!a""y ri!h spra$"o##is or sb$"o##is is

in%o"%ed( o'in$ #o spread #o ne!& nodes. The appearan!e of more #han one ne!& $"and

ha"%es #he o%era"" pro$nosis of #he pa#ien#.

In%es#i$a#ions

Dire!# "aryn$os!opy( preferab"y a mi!ro"aryn$os!opy( #o$e#her 'i#h Hop&in1s rod

examina#ion a""o's pre!ise de#ermina#ion of #he ex#en# of #he #mor and biopsy !on2firms an exa!# his#o"o$y )Tab"e +,.-,. 7T and /RI s!annin$ $i%e fr#her de#ai"s of


28/37

#he ex#en# of "ar$er #mors demons#ra#in$ es!ape of #he #mor o#side #he "arynx

and sspi!ios noda" in%o"%emen# 'i#hin #he ne!& 'hi!h may nor be de#ermined on

!"ini!a" examina#ion.

Trea#men#

Ear"y spra$"o##i! and $"o##i! #mors s#a$es I and II are op#ima""y #rea#ed 'i#h

me$a%o"#a$e radio#herapy 'here #hese fa!i"i#ies exis#. *i%e2year !re ra#es for s#a$es Iand II are approxima#e"y G and G per !en#( respe!#i%e"y( and #he pa#ien# has an

ex!e""en# %oi!e fo""o'in$ #his #ype of #rea#men#. If modern me$a%o"#a$e radio#herapy

is no# a%ai"ab"e #hen ear"y #mors may be ex!ised by means of endos!opi! "aser

sr$ery or open par#ia" "aryn$ea" sr$ery. This "a##er may be in #he form of a

"aryn$ofissre 'hen #he #hyroid !ar#i"a$e is opened an#erior"y in #he mid"ine and #he

s;amos !ar!inoma ex!ised nder dire!# %ision from #he %o!a" fo"d or spra$"o##is

or( in #he !ase of more ex#ensi%e ni"a#era" $"o##i! and spra$"o##i! $ro'#hs( a %er#i!a"

hemi"aryn$e!#omy may be nder#a&en. This "ea%es a defe!# on one side of #he "arynx

'hi!h is sa""y re!ons#r!#ed 'i#h ad0a!en# s#rap ms!"es. Wi#h ear"y bi"a#era"

spra$"o##i! #mors a horion#a" "aryn$e!#omy may be nder#a&en ex!isin$ #he

spra$"o##i! $ro'#h and #he remainder of #he $"o##is. The sb$"o##i! par# of #he "arynxis #hen s#i#!hed #o #he #on$e base #o pro%ide !on#ini#y. In mos# pa#ien#s nder$oin$

par#ia" "aryn$ea" sr$ery of #his #ype #he %oi!e res"# is no# as sa#isfa!#ory as #ha# 'i#h

radio#herapy( a"#ho$h #he !re ra#es are of#en !omparab"e.

Ad%an!ed "aryn$ea" disease

On!e #he s;amos !ar!inoma has !ased fixa#ion of #he %o!a" fo"d or has infi"#ra#ed

o#side #he "arynx in#o ad0a!en# s#r!#res s!h as #he #hyroid $"and and s#rap ms!"es(

some form of sb#o#a" or #o#a" "aryn$e!#omy is re;ired #o a##emp# #o !re #he disease.

To#a" "aryn$e!#omy is fre;en#"y re;ired 'hen radio#herapy fai"s )*i$s +,.+2

+,.>-.Af#er #he "arynx has been remo%ed( #he remainin$ #ra!hea is bro$h# o# on #o

#he "o'er par# of #he ne!& as a permanen# #ra!hea" s#oma and #he hypopharynx( 'hi!h

is opened a# #he rime of #he opera#ion( is !"osed #o res#ore #he !on#ini#y for

s'a""o'in$. Ths( #he pper aerodi$es#i%e and di$es#i%e #ra!#s are permanen#"y

dis!onne!#ed. Bar# or a"" of #he #hyroid $"and and asso!ia#ed para#hyroid $"ands may

a"so need #o be remo%ed dependin$ on #he ex#en# of #he disease( so pa#ien#s af#er #his

#ype of radi!a" sr$ery may re;ire ora" #hyroxine and !a"!im spp"emen#s for #he

remainder of #heir "i%es. Laryn$e!#omy pa#ien#s ms# ob%ios"y a%oid immersion in

'a#er as #his 'o"d f"o' s#rai$h# in#o #heir #ra!hea" s#oma. Ho'e%er( a ra#her !omp"ex

form of snor&"e de%i!e has been de%e"oped #o a""o' "aryn$e!#omy pa#ien#s #o $o

s'immin$ and simp"e pro#e!#ion of #he s#oma 'i#h a #o'e" may a""o' #hem #o #a&e a

!aref" sho'er.

Vo!a" rehabi"i#a#ionThe "oss of #he "a

43.pharynx,larynx and neck

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