Larynx & Pharynx

·         "TONSILS---/ TONSILITIS / TONSILLECTOMY --- infec.by group A & B streptococcal / strepto.pyogenes-(common org.)-Rxpenicillin for 10 days, pain in the post 1/3 tongue after tonsillectomy is due to injury to / throat pain radiating to the ear following tonsillectomy is due to IX cr. Nerve, tonsil develop embryologically from 2nd.pharyngeal pouch, Hard elongated swelling in the tonsillar fossa after tonsillectomy --elongated styloid process, Tonsillectomy--indications-(1) F.B. tonsil, (2) unilat.enlargement of tonsil with suspected malignancy, (3) atrophic tonsillitis, (4) Recuurent acute tonsillitis , (5) recurrent quincy, postop. complication hemorrhage--Rx antibiotics + saline wash, sec.hemorrhage(5-8hrs)-is due to- infection,& it is the common postop.compli.,hemorrhage after 6hrs --reactionary H., main blood supply to tonsil is facial artery, tonsillectomy is CI in polioepidemic, Palatine tonsil have Efferents but no afferents, After Quincy interval tonsillectomy is done after 6 wks.,commonest L.N. to enlarge in acute tonsillitis is Jugulodiagastric L.N., tonsil reach their max. size by 5yrs.,"

 

·         "VOCAL CORD(S)---is line by stratified sq. epithelium, REINKI'S layer seen, web form'n. post truamatically can be prevented by MC NAUGHT'S KEEL, unilat.V.C. palsy--commonest cause-Idiopathic, left unilat. V.C. palsy-cause-oesophageal ca., Precancerous lesion in V.C.-leukoplakia, localised nodule vocal cord of sq.cell ca. vocal cord-Rx-Excision, earliest symp.of ca.vocal cord--Hoarseness, MOUSE NIBBLED APP.of V.C.--seen in T.B. of V.C., granuloma of V.C.-is due to Intubation, unilat.complete paralysis of V.C. can be corrected by--Teflon inj.,cricoarytenoid arthrodesis,implant procedures, T1N0M0 CA.of V.C.-Rx--radical radiotherapy, Internal tensor lengthening mucosa of V.C. is Cricothyroid, pri.aetiological factor in contact ulcer of larynx--Vocal Abuse, V.C.paralysis--resp.obst., aphonia by adductor paralysis can be overcomed by Arytenoidectomy, 19yrs.old female with aphonia has bilat.abductor paralysis cause is functional,"

·         "CANCER OF LARYNX---Squamous cell cancer of larynx is commonest presentation, it is the commonest cause of Hoarseness of voice in Elderly man of more than 2mths.duration / Laryngeal Stridor in a 60yrs.man, Early fes.of Ca.larynx= Hoarsness of voice, NO neck secondaries-->Rx only Radiation, STAGE-III-->SURGERY+RADIATION,Rx of Glottic cancer-- TOC.-for (T1N0M0)-->EXTRENAL BEAM RADIOTHERPY, Ca larynx with Fully Mobile Cords-TOC.-->RADIOTH.,Rx of Ca.larynx with Stridor-->PLANNED TRACHEOSTOMY,glottic cancer has least chance of Nodal Mets.,Glottic Vocal Cancer has Best Prognosis, Hoarsness Early in Glottic Cancer, INFRAGLOTTIC CA.-->Commonly Spreads to Mediastinal L N'S, Ant.Commissure growth-Rx-->Conservative Laryngectomy, post cricoid growth

·         "ANGIOFIBROMA (NASOPHARYGEAL)---Juvenile angiofibroma is locally enlarging tumour producing destruction of bony structures without producing distal secondaries, Young Males(10 yrs boys), Bilateral Nasal Obstruction, bleeding from nose/ Intermittent profuse Epistaxis, firm pinkish mass in nasopharynx, Inv.=X-ray base of skull, carotid angiography, C.T.SCAN(IOC), Benign but potentially malignant, "

·         "NAOPHARYNGEAL CANCER---EBV is a causative agent, Spreads to Lymph nodes, commonest Presentation--Cervical adenopathy, there is High Incidence of NODAL METASTASIS, "

·         STRIDOR---effect of BILAT. RLN damage, most common cause in adult--malignancy, Rx of congenital laryngeal stridor =reassurance to parents, most common cause pf stridor in newborn—laryngomalacia.

1. Inspiratory stridor reflects airflow impairment above or at the level of the vocal cords. It is generally high pitched when occurring at the vocal cords and may be low pitched when obstruction is above the vocal cords (pharynx or supraglottic larynx).
2. Expiratory stridor is usually produced from airflow limitation in the distal tracheobronchial (intrathoracic) tree. It gives rise to a more prolonged, sonorous sound. This may be confused with wheezing, such as in asthma.
3. Biphasic stridor has both an inspiratory and expiratory component and is localized to the subglottic region.

·         "TRACHEOSTOMY---complication commonly occur in children-is-difficult decannulation, indication--stridor, coma of long duration , diptheria, laryngeal obst.,flail chest, tetanus(cyanotic spells) , It is not used in F.B. / Obst.of post basal lobe /bronchus, commonest compli.of paediatric--Pneumothorax, "--------((6))

·         "RECURRENT LARYNGEAL NERVE---partial RLN palsy produces Vocal cord in PARAMEDIAN position, closely related to Inf.thyroid artery, BILAT.RLN PALSY=ADDUCTED position & stridor, supplies all except cricothyroid( SLN),"----------((5))

·         EPIGLOTTITIS---ACUTE--Commonest Organism causing it is -Hemophilus Influenze, DOC.in children--Ampicillin,commonest cause death-is-Respiratory obstruction, the "tripod" position

·         Bacterial tracheitis (pseudomembranous croup) is a severe form of croup that may occur at any age.

The initial clinical presentation is similar to that of viral croup, but patients subsequently develop high fever, toxicity, pneumonia (up to 60%), and progressive upper airway obstruction that is unresponsive to conventional croup treatment. Localized bacterial invasion of the tracheal mucosa results in edema, purulent secretions, and pseudomembranes.

Management of bacterial tracheitis includes DL&B with removal of secretions. For significant airway compromise the child should remain intubated, and repeated endoscopies are performed for recurrent plugging and crusting. Intravenous antibiotics should follow culture and sensitivity results but should initially cover Staphylococcus aureus.

·         "PLUMMER VINSON'S SYND.---ass. With oesophageal ca., post cricoid growth, IDA, females, premalignant ( for hypopharyngeal ca., "---------((4))

·         "QUINSY---PERITONSILLAR ABSCESS---org.-streptococcus, quinsy+trimus--> Rx for 48 hrs. antibiotics only & then oral drainage,"----------((4))

·         "PATCH IN THROAT--- / MEMBRANE IN THROAT --- (1) vincents angina, Black colour patch in mouth, (2) candida , (3) diptheria, (4) streptococcus, & IN THROAT OF ADULT----> Hemophilus, streptococcus, Neisseria, organism are seen but not E-Coli, "----------((4))

·         "ADENOIDECTOMY--- Indication--Recurrent Otitis Media, Sleep Apnoea synd., Middle ear infec. With deafness, C I --Submucous Cleft Palate, control of Hemorrhage--by Post.Nasal PACK, " ---------((3))

·         "ARNOLD'S NERVE---is a Branch of VAGUS Nerve, Irritation of this causes Ear Cough, Cough response caused while cleaning ear canal is mediated by stimulation of X Cr.N."----------(3)

·         "MULTIPLE PAPILLOMA OF LARYNX---Rx Excision with Laser, common in Infants & Children, Laryngeal papilloma are usaually Multiple & VIRAL in origin, usual site of papilloma is larynx, Rx of single P.= Removal by Direct Laryngoscopy, "---------((3))

·         "TUBERCULOSIS OF LARYNX/TUBERCULOUS LARYNGITIS--- KISS ULCER of Larynx, common site of T.B. Larynx is POST.COMMISSURE OF L."-------((3))

·         "VOCAL FOLDS---& VOCAL FOLD CA.---Vocal folds are abducted by post.cricoarytenoid, in CA. L.N.'Smets never seen,,has good prog.,"----------((3))

·         laryngeal conditions that may present with aspiration during feeds: Unilateral vocal fold paralysis and laryngeal cleft.

·         Benjamin classification for laryngeal tracheal cleft:

I. Dehiscence in interarytenoid muscle

II.Cleft extends into cricoid

III.Extends through cricoid into cervical esophagus

IV.Extension into the thoracic esophagus

·         triad for foreign body presentation: The diagnostic triad of cough, wheeze, and unilaterally diminished breath sounds is present in fewer than 50% of cases. The most sensitive factor is a history of witnessed choking.

·         TONSILLECTOMY:

In "cold" dissection, a superior mucosal incision is created with a knife, then blunt dissection separates the tonsil from the tonsillar bed. The tonsil is then amputated at its inferior aspect, often using a snare.

The "hot" technique employs electrocautery to cut and coagulate simultaneously. Some studies suggest that "cold" dissection may lead to less postoperative pain; however, there may be less intraoperative blood loss with electrocautery.

·         Velopharyngeal insufficiency (VPI) :

VPI occurs when there is incomplete closure of the soft palate against the posterior pharyngeal wall during speech and swallowing. VPI results in hypernasal speech and nasopharyngeal regurgitation. In children, adenoid tissue significantly adds to the bulk of the posterior pharyngeal wall. An adenoidectomy reduces this bulk and can lead to incomplete closure. Most cases are temporary, but persistent or severe cases may require speech therapy and/or surgical treatment.

The incidence of VPI after adenoidectomy ranges from 1/1500 to 1/10,000 in healthy patients.

The incidence is much higher in patients with palatal disorders.A submucous cleft palate is associated with a higher incidence of postadenoidectomy VPI. Signs of a submucous cleft include a bifid uvula, zona pellucida, and notching of the posterior hard palate. In the presence of these findings, a superior pole adenoidectomy is recommended. This procedure removes obstructing tissue from the choanal area but preserves bulk in the posterior pharyngeal wall.

·         The long-term obstruction by adenotonsillar tissue produces a state of increased positive end-expiratory pressure (PEEP). With removal of the obstructing tissue, the excess PEEP is suddenly relieved, and fluid moves into the interstitial and alveolar spaces, resulting in pulmonary edema with decreased blood oxygen saturation. This can occur intraoperatively or a few hours later. Treatment involves diuresis for mild cases, or intubation with reestablishment of increased PEEP in severe cases.

·         COMMON LARYNGEAL ABNORMALITIES

Supraglottic: laryngomalacia, cystic hygroma

Glottic: vocal fold paralysis, web and atresia, posterior laryngeal cleft

Subglottic: congenital subglottic stenosis, subglottic hemangioma

·         Although a rare source of primary pathology, Parapharyngeal space is extremely important as a radiographic landmark because the fat makes it readily visible on MR and CT images of the suprahyoid neck. Due to its central anatomic position, the origin of pathologic processes within the deep fascial spaces of the neck can be identified by the specific displacement pattern of the parapharyngeal space. The parapharyngeal space may provide a path for pathology to extend superiorly to the skull base.

Pleomorphic adenomas of ectopic salivary gland tissue are the most frequently encountered benign tumors of the parapharyngeal space.

·         Diplophonia describes a sound made by vibrating cords at two different frequencies. It indicates that the vocal folds are being affected differently.