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GPVTS Teaching

GPVTS Teaching. Bhik Kotecha Consultant ENT Surgeon Royal National Throat, Nose & Ear Hospital, London & Queens Hospital, Romford. Topics. Sleep disorders Snoring/OSA Throat problems ENT Injuries. Throat Problems. 2 week head & neck referral: Dyspahagia Odynophagia FOSIT Dysphonia

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GPVTS Teaching

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

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

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

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

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

  6. CB: Clinical History • 59 yr old female • Presented Oct 2002 • Dysphagia/choking/occ dyspepsia • Tightness around mouth • No dysphonia • Non-smoker, social drinker • No weight loss • HRT

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

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

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

  10. 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

  11. Gastroenterologist opinion Dec 2002 • No alarming symptoms and felt better • ?Globus & proximal oesophageal spasm • Gastroscopy not required • ?Manometry to exclude Oes dysmotility • Patient declined • Discharged

  12. Neurologist (1) Nov 2005 • Normal MRI Brain • ? Myasthenia • Normal neurophysiology in peripheral nerves and muscles • Negative Autoimmune tests • ? Mild Scleroderma • Referred to Rheumatologist • Referred to BK for dysphagia

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

  14. ENT Jan 2006 • Dysphagia (food sticks in lower oesophagus) • Dysphonia • Flexible laryngoscopy • Pooling of saliva in piriform fossa • Chink on adduction of vocal cords • Refer to Oesophageal Surgeon • Refer to Speech & Language Therapist (SLT)

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

  16. Dysphagia SYMPTOMS • Difficulty with solids – effort • Food sticking in pharynx • Increasing time to complete meals/fatigue • Occ regurgitation of food/fluids • Occ coughing/choking episodes • Halitosis • No history of chest infections but recent weight loss

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

  18. Speech/Voice Assessment • Mildly slurred speech/hyponasal (dysarthric type) • 100% intelligible but imprecise articulation (labial sounds) • Decreased volume • Breathy voice quality • Reduced oro-motor function/coordination of lips/tongue (?oral dyspraxia)

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

  20. Videofluoroscopy • Oral stage -mildly reduced tongue movement • Pharyngeal stage -mildly reduced hyo-laryngeal excursion -no aspiration -?uncoordinated/weak peristalsis -significant pooling in piriform sinuses -small right PHARYNGEAL POUCH (approx 2cm) • Upper Oesophageal stage - reduced opening of cricopharyngeus

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

  22. Clinical features • Dysphagia • Regurgitation • Feeling of food sticking in the throat • Coughing after eating • Chronic aspiration due to overspill • Unexplained weight loss and malnutrition • Halitosis • Hoarseness (less common) • Pain free • Loss of medication in diverticulum space

  23. Investigations • Barium swallow • Videofluoroscopy • Manometry • sEMG

  24. Surgical Treatment

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

  26. Vocal Cord Nodules

  27. Laryngeal Papilloma

  28. Granuloma – Acid reflux

  29. SCC Larynx

  30. Laryngeal Videos

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

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

  33. Acute Parotitis

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

  35. Acute Tonsillitis

  36. Glandular Fever

  37. SCC Metastasis

  38. SCC Lip

  39. SCC Tongue

  40. Branchial Cyst

  41. Thyroglossal Cyst

  42. Thyroid Goitre

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

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