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

• Sleep disorders
• Snoring/OSA
• Throat problems
• ENT Injuries
Topics

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

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)

2 main problems
SLT Jan 2006
• 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