ENT

Sore Throat & Dysphagia

Dr. Acuin
17

References: Case-based discussion, Probst, Cor 2011 and 2012 (times new Roman), past-E.

SORE THROAT AND DYSPHAGIA

I. ANATOMY OF THE PHARYNX (PROBST)

The pharynx is a tubular, fibromuscular space extending from the skull base to the inlet of the
esophagus(upper esophageal sphincter)
The pharynx consists of a nasal part (nasopharynx), an oral part (oropharynx), and a laryngeal
part(hypopharynx).
The primary function of the pharynx is to coordinate the act of swallowing.
pharynx also contains the tonsillar ring that is important in the immune response to infection
Function as a variable resonance chamber for modulating vocal sounds.

Nasopharynx:
This highest part of the pharynx extends from the bony skull base to an imaginary horizontal line
at the level of the velum
The nasopharynx is bounded superiorly by the floor of the sphenoid sinus and pharyngeal roof.
Also in this region is the pharyngeal tonsil
Medial to the Eustachian tube orifice, the tubal cartilage forms a projecting lip called the torus
tubarius. The concavity behind it is termed the pharyngeal recess (Rosenmuller fossa)

3 constrictor muscles of the pharynx:

Superior Constrictor muscle - The elevation and contraction of the velum results in the
complete closure of the velopharyngeal port, this action is facilitated by the contraction of the
space, which narrow the pharynx.

Middle constrictor muscle & Inferior constrictor muscle - Initiation of pharyngeal peristalsis
occurs. The bolus is carried by sequential peristaltic action of the middle and inferior pharyngeal
constrictors into and through the pharynx to the cricopharygneal sphincter.

all 3 are responsible for the pharyngeal phase of swallowing

Three muscular weak points exist in the lower posterior wall of the hypopharynx.
The first is the Killian triangle, located between the constrictor pharyngis inferior and the
uppermost fibers of the cricopharyngeus muscle.
o common site for the formation of hypopharyngeal diverticula.
The second area of weakness is the KillianJamieson region between the oblique and
transverse fibers of the constrictor pharyngis.
The third is the Laimer triangle, which is bounded above by the cricopharyngeus and below by
the uppermost fibers of the esophageal musculature

II. ADULT SWALLOW PHYSIOLOGY

A. Oral Phase (chewing) voluntary

1. Oral preparatory
Mastication- lips, buccal muscles, jaw, tongue
Salivation
Bolus formation

Oral Preparatory happens when the food is first taken in.
o Goal: reduce food to a bolus and position it for transport
o Initial transport (the bolus Placement) tongue positions the food to ready it for reduction.
o Reduction phase bolus is chewed & mixed with saliva
o Bolus placement bolus is positioned for transport

Oral Transport
o The prepared bolus is transported from anterior to posterior oral cavity for passage to the
pharynx.

2. Initiation of the swallowing reflex
Central recognition (brainstem reticular formation near respiratory center)
Bolus propulsion (tongue thrust) to anterior faucial pillars


B. Pharyngeal Phase (swallowing) involuntary

Reflex inhibition of respiration

Velopharyngeal closure
Laryngeal elevation (by strap muscles) with closure (by epiglottis,
aryepiglottic folds, false vocal folds, true vocal folds)
Pharyngeal contraction (peristalsis)
Relaxation of the cricopharyngeus and opening of the upper esophageal
sphincter

PAST TRANX:
1. Complete closure of velopharyngeal opening
If the soft palette does not close, the food contents go to the nose.
2. Hyoid & larynx begin their superior ascent
Hyoid and larynx are elevated because of suprahyoid muscles that pulls the hyoid which
suspend the larynx up, to meet the epiglottis)
3. Epiglottis begins to downfold
epiglottis is a stationary object at the base of the tongue so it doesnt really go down but the
edges are the one that close because the muscles pull the edges downward. Epiglottis seals
the larynx from entry of food or liquid)
4. Tongue base to posterior pharyngeal wall contact
tongue pushes the epiglottis further down)
5. Top to bottom contraction of constrictors (stripping motion)
6. Continued superior movement of hyoid & larynx

7.
8.
9.
10.

Laryngeal closure starts from bottom up

Continued down-folding of epiglottis to inverted position
Anterior movement of hyoid
Relaxation of cricopharygeus muscle & opening of upper esophageal sphincter region
patient with cleft palate, the food goes into the nose
laryngeal closure also happens when vocal folds adduct
before the vocal folds abduct (relax), it is very important that the food has entered the
esophagus so that nothing is left there in the hypopharynx that can invade the airway.

C. Esophageal Phase

Primary peristalsis
Relaxation and opening of the lower esophageal sphincter
Secondary peristalsis

III. Cases

A. CASE 1
A 24 year old call center agent with recurrent sore throat and fever consulted you for increased snoring
and sensation of throat pain when swallowing. He has been feeling weak lately and fatigues easily after scaling
just one flight of stairs. He has a five year history of purulent nasal discharge, ear pain and dry cough. As a child he
has had 3 to 4 episodes of sore throat per year for which he was given antibiotics by his pediatrician. He has been
smoking one pack of cigarettes per day on and off for the past twenty years (he quitted smoking twice) and drinks
alcohol with his colleagues once or twice a week after work. He hits the gym once a week, lifting heavy weights,
until he had a rotator cuff injury. He denies taking anabolic steroids but takes Extra Joss and Red Bull before and
after workouts. Despite this, he has been steadily gaining weight for the past year. His waist:hip ratio is 1.2. He
has been taking Klaricid OD for the past 3 days and asks you if he needs to continue it. He also wants to know if he
can have his tonsils removed because he would often get sore throat after even just a mug of iced mochacinno at
Starbucks (he sticks to a cup of espresso with every meal).

a. Answers to Case 1 (Cor 2012)

1. How would you approach the history taking of this patient?

Ask if patient is currently taking any medications and his past medications
Sudden onset is consistent with a GAS pharyngitis. Pharyngitis following several days of
coughing or rhinorrhea is more consistent with a viral etiology.
Recent exposure to someone with strep throat or any other infection of the throat, nose, or ears
Ask if patient has headache, cough or vomiting

A history of recent orogenital contact suggests the possibility of gonococcal pharyngitis.

A history of rheumatic fever is important when considering treatment.
And also ask for the common questions like: When did it start? Where did it start (physically)?
What does it feel like (characterize pain)? Can you rate pain on scale of 1-10? How often, how
long, or how many?

2. How would you perform the physical exam in this patient?

A complete and thorough physical examination should be done. There should be some
focus on the inspection of the throat due to its recurrent soreness.
Otoscopy should be done in order to assess ear problems and inspection of the nasal
cavity should also be included to determine the cause of the discharge.
Due to the patients smoking history and current complaint of easy fatigability, a
complete physical examination of the chest and lungs should be done in order to assess
his heart and lungs.

3. List the likely/possible clinical diagnosis in this patient and give the bases for each.

VVascular
Leukemia patient should present with unilateral enlargement of the tonsils. Symptoms of leukemia
include: fever, unexplained weight loss, general discomfort, sore throat, swollen gums, drenching night
sweats, headache, vomiting, vision problems, bone or joint pain and painless swelling of the lymph nodes.
IInflammatory
Streptococcal pharyngitis
Viral pharyngitis
Herpangina (due to Coxsackie virus)
Pharyngoconjunctival fever (due to eight or more viruses)
Infectious mononucleosis
Viral influenza may begin with a sore throat
Tuberculosis
NNeoplasm and carcinomas may include Hodgkin disease and leukemia.
DDegenerative diseases are an unlikely cause of sore throat.
IIntoxication
May include chronic alcoholism and smokers throat
CCongenital diseases are an infrequent cause of sore throat
Hiatal hernia with reflux esophagitis may cause recurrent sore throat, because there may be reflux
of gastric juice all the way to the posterior pharynx in the recumbent position.
An elongated uvula may also be responsible.
AAllergic diseases
Angioneurotic edema of the pharynx or uvula and allergic rhinitis
TTrauma
Foreign bodies such as chicken bones and tonsilloliths
EEndocrine
Subacute thyroiditis - although the pain is really in the neck, the patient will report a sore throat.

4. Are there additional diagnostic examinations needed? What are these and give your bases for
each?


a. Throat culture

the use of a throat culture plated on sheep blood agar to confirm the presence of GAS has been a
common office practice.
The optimal site for throat culture is the surface of the posterior pharynx

b. Rapid antigen detection tests

These tests all are based upon detection of the carbohydrate antigen of GAS with an antibody
tagged reagent which produces a clumping effect or color change after the antigen-antibody
interaction.

When the rapid GAS antigen test is positive, the result can be deemed reliable and the patient
treated appropriately. In contrast, when rapid antigen detection testing produces a negative result,
the use of a second swab for confirmatory culture should be considered to avoid missing a
positive infection, particularly if there is a high clinical suspicion of GAS or rheumatogenic
strains are circulating in the community.

Streptococcal antibodies antibodies to GAS (antistreptolysin O) do not peak until four to five
weeks after the onset of pharyngitis. Thus, measurement of streptococcal antibodies is useful only
for the retrospective diagnosis of infection

Other tests include:

Blood teststo identify conditions that may be causing the sore throat
Mono spot test (if mononucleosis is suspected)

5. What are the management options for this patient and the likely benefits/risks for each?

a) Discuss the basis for giving antibiotics to this patient. Do you agree with the current antibiotic
therapy of this patient?

Antibiotics are usually prescribed if the patient presents with signs and symptoms that support a
bacterial etiology, such as fever or the presence of exudates.

Antibiotic use also reduces the incidence of acute otitis media and acute sinusitis, which may be
present in the patient given his history of ear pain and nasal discharge. T

the patient was given Clarithromycin (Klaricid), a macrolide indicated for infections of the lower
respiratory tract, skin and soft tissues.

b) Discuss the basis for tonsillectomy in this patient. Would you advise tonsillectomy to this patient?

Tonsillectomy is indicated for individuals who:

have experienced 3 to 5 bacterial infections of the tonsils within 3 to 5 years;

more than 6 episodes of tonsillitis in 1 year;

chronic or recurrent tonsillitis unresponsive to antibiotics;

enlargement of the tonsils that causes sleep apnea;

enlargement of the tonsils that causes dysphagia.

In the patient's case, tonsillectomy may be performed as he fulfills most of the

given indications.

c) What other interventions would you consider in this patient and provide the bases for each?
Adenoidectomy - Because adenoid tissue has similar bacteriology to the pharyngeal tonsils and minimal
additional morbidity occurs with adenoidectomy if tonsillectomy is already being performed.

b. Case Discussion ( Dr. Acuin)

Primary impression: Strep. Pharyngitis.
- Strep. Pharyngitis is a condition predisposing to rheumatic fever, which is mainly a disease due to
antibodies against the heart.
- In this patient, he has increased waist-hip ratio. Normal ratio is 1. Hi ratio of 1.2 can be due to
increased diet. It also shows that his swallowing problems are not consistent with his waist hip ratio.
- One must elicit the patients state of nutrition and weight gain. This is seen in loud snorers. They have
thicker necks and more tissues in mouth and neck that vibrate. This also contributes to disturbed sleep.
- get history of past medical consults and medical documentation
- Attention must be paid to the throat.
Malampati Scoring System- use to determine the ease of intubation and space of oropharnyx
1- uvula fully visible
2- uvula half visible
3- Uvula not visible, soft palate visible
4- Hard palate only visible

* Note that the tongue obliterates the uvula and soft palate

Random Egyptian Fact 1:

The Titanic allegedly sank
because of the Curse of the
mummy of Princess of Amen-
Ra, whose mummy was
allegedly aboard the ship.

- Know the patients risk factors:

1. Second hand cigarette smoke is a risk factor for URTI
2. Alcohol and caffeine causes sore throat

- irritates the mucosa, due to increased acid

- relaxes GE Sphincter, causing reflux and leading to sore throat, snoring and obesity.

Past-E: * Disclaimer* Sagot ko lang ung iba dito, pls research if you doubt the answers. Tnx!

Acute bacterial vs. Acute viral tonsillopharyngitis
Both:
o Present as high grade fever, malaise and joint pains
o Tonsils are swollen and eythematous
o May be associated with enlarged lymph nodes

Bacterial only:
o May cause acute glomerulopnephritis
o Attacks heart muscle, causing acute rheumatic fever
o Infections of deep fascial neck spaces

Neither:
o Definitive treatment is tonsillectomy
o Best diagnosed by culture and throat swab

D/DX:

1. Malignancy


Dx. Tests:


- do a histopathologic study of the oro/hypopharynx and larynx


- Types of tumors: friable, fungating, ulcerating, infiltrating, - do an oropharynx biopsy


- adjacent/local spread to bone- do CT scan


- spread to soft tissue- MRI


- distant mets- PET


2. TB
-

TB culture


- PCR can also detect TB


3. HIV/AIDS


- HIV has increased prevalence among call center agents, thus elicit sexual history.


- on PE, also do tests for HIV.

Management Issues


-Antibiotics (Clindamycin, Amoxicillin/Clavulanic acid)


-antibiotics are effective, they eliminate the symptoms if the cause is bacterial and reduce the

risk of glomerulonephritis and fever


- however, take note of side effects:



Clindamycin: abdominal pain, necrotizing enterocolitis


Amoxcillin: diarrhea, dehydration and electrolyte imbalance


-determine antibiotic resistance


- start 1st with penicillin/erythromycin/Co-trimoxazole. Penicillin is the DOC for Acute tonsillitis

For Bacterial Tonsillopharyngitis:

Random Egyptian Fact 2:
Dx: no throat swab

- do rapid strep immunoassay
The story of Cinderella started in

Ancient Egypt, with Rhodopis as
Tx: oral penicillin G (400-800 k units)- 4x a day for 10 days
the name of Cinderella. It involved

For children: (25-90k units)- 10-14 days
jealous servants, a lost slipper and


IV Penicillin G ( 5- 30 Million units/kg/day)
a happy ending w/ Pharaoh.

Children: ( 100-250 K units/kg/day)


- hydration and antipyretics


Note: Not all chronic tonsillitis is an infection

* NOT ALL CONDITIONS ARE VIRAL OR INFECTION ALWAYS!


- Postnasal drip conditions are not resolved by antibiotics


Characterized by:
Posterior pharyngeal discharge
Hypertrophied lymphoid follicles
Chronic throat clearing/ pruritus
Dry cough
Vague throat discomfort
Allergic Sx


- Practice Antibiotic Stewardship
To prevent reisitance
Rotate antibiotics. Example Co-trimoxzole resistance in hospital is at 70%, so give other
drugs


Surgeries:

1. Tonsillectomy
Being Lymphoid Tissue, the Tonsils are expected to inflame DIFFUSELY, BILATERALLY, but NOT
necessarily symmetrically


- recurrent pharyngitis can recur after tonsillectomy

- be careful on advising it.

The tonsillectomy dilemma:
Attack rate of ARF in untreated culture + children = 0.3-0.9%
Attack rate of RF in adults = 3%
Attack rate of AGN = 10-15%, 0 recurrence
There is no evidence from randomised controlled trials to guide the clinician in formulating the
indications for surgery in adults or children.

Indications for tonsillectomy:
Severe obstruction to swallowing and/or breathing due to enlarged tonsils-AN INDICATION
Other so-called relative indications have no clear benefit and can even be harmful
Recurrent, medically intractable middle ear effusion with hearing loss

Common Causes of UNILATERAL Tonsillar enlargement
Peritonsillar Abscess (Quinsy Throat)-
Complication includes retropharyngeal abscess
Occurs in between tonsillar fascia and superior constrictor
Hot potato voice
Primary Tonsillar Carcinoma
Metastatic cancer from a distant site
Lymphoma

Ominous Signs in UNILATERAL Tonsillar enlargement
Weight loss
Halitosis
Massive / Rapid Enlargement
Painless Enlargement
Cranial Nerve Involvement
Lymph Node Involvement / Hepatosplenomegaly

2. Adenoidectomy

- tonsillitis is NOT equal to adenoiditis

- it does not have same risks.

- may cause hyponasal speech, chronic rhinitis, sinusitis, and otitis media due to obstructed

Eustachian tube opening

- bilateral otitis media with effusion may cause hearing loss.- AN INDICATION FOR IT.

Other interventions:
Lifestyle modifications- diet
PPI, (20-40 mg before breakfast)
Antacids such as Mg and Al OH
H2 blockers

B. CASE 2
A 2 year old boy was brought by his parents for recurrent cough, fever and poor appetite since one month
ago. His cough sounds like a barking seal. He also has been having recurrent right ear pain. On physical
examination he has low grade fever, alar flaring and enlarged tonsils. You also note mild chest retractions. He is
irritable and appears to be hungry. You offer him some juice. He takes some but refuses to finish the rest. He
refuses to lie down and prefers to sit hunched forward with his arms propping him up. He points to the toys you
keep in your clinic and selects your Lego construction set. His mother says those are his favorite toys but he tends
to put them in his mouth so she took them away.
a. Answers to Case 2 (Cor 2012)

1. How would you approach the history taking of this patient?

In HPI, the duration and severity of sore throat should be noted.

In the past medical history, history of previous infection should be asked.
In the review of systems, other symptoms like difficulty in swallowing, speaking, or breathing
should be noted.

2. How would you perform the physical exam in this patient?

Perform a Mirror Exam - assess if both tonsils are swollen, bright red and coated.
Palpate the lymph nodes on along the jaw and on the neck, assess if they are swollen and tender.
Examine the nose to check for inflammations, infections and post nasal conditions.
Perform an otoscopic examination of the ear to check for any inflammations.
In the physical examination, it is important to know if there is fever and if there are signs of
respiratory distress such as tachypnea, dyspnea, stridor and tripod positioning which are present
in this case.

Tripod position consists of sitting upright, leaning forward with neck hyperextended and jaw
thrust forward.

In children suspected with supraglottitis or epiglottitis, pharyngeal examination should be avoided

because it can trigger airway obstruction.

3. List the likely/possible clinical diagnosis in this patient and give the bases for each.

Tonsillitis it can be due to viral or bacterial infection. The common symptoms include enlarged
tonsils, cough and fever
Tonsillopharyngitis its symptoms include cough, low grade fever, poor apetite, and enlarged
tonsils
Epiglottitis symptoms include fever, cough and irritability
Infectious mononucleosis it is a mild upper airway obstruction that presents as an intermittent
alar nasal flaring and stridor in supine position. It is common in children less than four years old.
Aspiration it is the inhalation of foreign objects into the airway. It is common in infants and
toddlers.

4. Are there additional diagnostic examinations needed? What are these and give your bases for
each?

Swab culture of throat specimen could confirm the etiologic agent present
Serologic tests can confirm presence of infectious mononucleosis
Fine needle aspiration evaluates microflora in chronic tonsillitis
X-ray can determine presence of aspirated objects
Flexible laryngoscopy can assess the size of the tonsil


5. What are the management options for this patient and the likely benefits/risks for each?

Tonsillitis pain management, medications, lozenges, gargling solution of warm water and salt
Epiglottitis tracheal intubation to protect the airway and antibiotics (3rd generation
cephalosporins)
Infectious mononucleosis no specific treatment is necessary because it is self-limiting.
Treatment is directed towards relief of symptoms. Supportive measures are necessary.

b. Discussion (Dr. Acuin)

- note the patients position. If a patient is leaning forward, the tongue hangs out, but if leaning back, it
falls back.

- assess the adequacy of airway

- in swollen epiglottis, tell the patient to open mouth and say ahh, use a mirror to reflect the uvula. This is
known as indirect larnyngoscopy

- Laryngeal spasm is dangerous because of no breathing

- Do a flexible laryngoscopy to the pharynx
- Do an X-ray of the neck for epiglotittis.- common among 4-6 year olds.
- Note the barking cough of the patient, this may signify croup.

- Note the dysphagia
A large foreign body may obstruct the esophagus- true emergency
May not obstruct airway
In the brobchopulmoanry segment, it may cause atelectasis and recurrent pneumonia
Look for draining sinuses and do X-ray

odynophagia pain in swallowing

dysphagia difficulty in swallowing

c. Assessment of Foreign Body

















Break Quote:

Question by a Student:
If a single teacher can't teach us all the subjects,
then how could you expect a single to student to learn all the subjects?

- Patho tranx, PLM MEDICINE BATCH 2014

APPROACH TO PATIENT WITH FOREIGN BODY

C. Case III
A 65 year old female is recovering from her stroke. Currently she is being fed through a
nasogastric tube but her attending physician is referring her to you, the ENT physician, to determine if
she can be safely fed through her mouth.
a. answers
1. Describe the mechanisms by which stroke can lead to swallowing disorders.

strokes of the medulla,

Cerebral, cerebellar, or brain stem strokes can impair swallowing physiology.

Cerebral lesions can interrupt voluntary control of mastication and bolus transport during the oral
phase.

Cortical lesions involving the precentral gyrus may produce contralateral impairment in facial,
lip, and tongue motor control, and contralateral compromise in pharyngeal peristalsis.

Brain stem strokes are less common than cortical lesions but result in the largest swallowing
compromise. Brain stem lesions can affect sensation of the mouth, tongue, and cheek, timing in
the trigger of the pharyngeal swallow, laryngeal elevation, glottic closure, and cricopharyngeal
relaxation.

In people with neurological problems, it is easier for them to swallow solid because liquids
demand greater coordination

In stroke patients who might have problem in swallowing water, liquids are thickened to have a
more solid consistency, allowing for better control by the weakened musculature involved in
swallowing

2. What signs and symptoms would you ask for to determine if she is a safe oral feeder?

presence of dysphagia. This increases the risk for aspiration pneumonia if the patient is not able
to swallow well.

A swallowing test may be performed to determine this. If a patient is able to swallow down
small amounts of food or liquid, then it is probably safe to start oral feeding, although slowly.

. A psychiatric consult may be needed to assess a patient before oral feeding is instituted.

*Definition of safe oral feeder- only 1 attempt to swallow liquid and solids foods (with no residual fluid left)

3. How would you physically assess the different phases of her swallowing function?
Oral phase
If there is a problem
during this phase, the
patient may find it
difficult to chew solids
and to contain the liquid
in the oral cavity before
swallowing. She may
also have a hard time to
initiate swallowing.

Pharyngeal phase
After swallowing, the
patient
may
retain
excessive amounts of food
in the pharynx if there is
weakness in or lack of
coordination
of
the
pharyngeal muscles or if
there is a poor opening of
the
upper
esophageal
sphincter.

Esophageal phase
After swallowing, the patient
may retain food and liquid in
the esophagus after swallowing
if there is a mechanical
obstruction, a motility disorder,
or an impairment of the
opening
of
the
lower
esophageal sphincter.
Trouble swallowing saliva but
no difficulty swallowing food
globus hystericus

4. What diagnostic examinations can be performed to further evaluate her swallowing function?
Barium Swallow Exam - Modified
Cervical Auscultation
Double Contrast Barium Enema
Double Contrast Upper GI
Electrogastrography
Spectral Analysis on EMG
Endoscopy
Fiberoptic Endoscopic Examination of Swallowing
FEEST - Flexible Endoscopic Evaluation of Swallowing with Sensory Testing
Gastroscopy
Manometry
pH probe
Ultrasound
Upper GI for GERD

5. What interventions can be done to help her swallow safely?

Rehabilitation therapy is the main stay of dysphagia management and allows for safe swallowing
Oral feeding with consistency modification thickened liquids increase oropharyngeal control,
while a diet of shopped or pureed foods decreases difficulties with mastication. It consists of 8
varieties of diet.
Compensatory strategies to reduce the risk of aspiration
Chin tuck decrease air diameter
Head rotation ipsilateral pharynx is closed forcing bolus to contralateral pharynx
Head tilt guide bolus to ipsilateral pharynx
Supraglottic swallow simultaneous swallowing and breath holding, closing vocal cords
Mendeleon maneuver form of supraglottic swallow in which the patient mimics the
upward movement of larynx by voluntary holding of larynx
Exercise and facilitation techniques
Exercise is used to increase muscle tone and alignment pharyngeal swallow
Biofeedback techniques are used to reeducate muscle affected in facial palsy and
disorders of articulation
Thermal stimulations in the form of icing of the anterior facial muscles can be performed
to help decrease delay of pharyngeal swallow
Medical interventions Diltiazem aid in esophageal contractions and motility
Endoscopic and surgical interventions
Microsurgical techniques to help in swallowing
Laryngectomy or laryngotracheal diversion
Tracheostomy is often performed as a permanent palliative measure when all else fails
Non-oral feedings
Parenteral alimentation and IV fluid replacement
Nasogastric tubes are convenient for short term but has many complications
jejunostomy

b. Discussion (Dr. Acuin)

How to determine if patient is a safe oral feeder?

S/Sx- listen to patients voice- if gurgly or bubbly= cannot swallow

- swallows spit and aspirates

- afferent arm of reflex not activated

- note that swallowing reflex in pharynx and larynx is involuntary

Dx. Exam
barium swallow- trace the pathway of swallowing but subject to radiation
flexible eval. Of swallowing- valecula, pyriform sinus, vocal fold at risk of aspiration
o done at bedside, no radiation
o does not directly evaluate strength of swallow.

IV. Approach to dysphagia management

Assessing the Possible Problem Site :
Oropharynx
Pharyngotonsilitis
Random Egyptian fact 3:
Vincents angina
Inf. mononucleosis
Cleopatra VII was the last ruler of
Diphtheria
ancient Egypt. Her beauty and charm
TB
won the love of an emperor and a
Aphthous ulcers
Fungal pharyngitis
soldier.
Neoplasm
Hypopharynx
Epiglotitis
Supraglotitis
Valleculitis
Neoplasm
Larynx
Laryngitis - involved vocal folds itself, may have referred pain
Neoplasm
Esophagus
Cervical Esophagitis referred pain
Neoplasm
Cervical Fascia
Lymphadenitis
Thyroiditis
Neoplasm
Deep neck fascitis
Cellulitis

DIFFERENTIALS
Non-infectious Inflammation
Allergy / Hypersensitivity
Chemical / irritative

Systemic Diseases

HIV
Leukemia
Lymphoma
Tuberculosis
Connective Tissue Disease

Neoplasm
Benign
Primary Malignancy
Metastatic Cancer

V. Sleep disordered breathing

A. Signs that suggest sleep apnea
Loud, irregular snoring
Witnessed periods of apnea
Daytime sleepiness
Restless sleep
Intellectual deterioration
Personality changes
Enuresis

(+) Mullers is an indication for

uvulopalatopharyngoplasty (a
surgical procedure used to remove
tissue in the throat. It involves the
removal of tissues which may or
may not include the uvula, soft
palate, tonsils, and adenoids.)

Polysomnography is the best way to assess sleep apnea

Velopharyngeal competence
o The velopharynx a particularly narrow segment of the upper airway, is especially
predisposed to obstruction in such settings.
o In particular, obese patients with large necks often have a more collapsible velopharynx
that predisposes to upper airway obstruction.
o In many patients with OSA collapse of the velopharynx can be induced by having the
patient perform Muller's manoeuvre during nasopharyngoscopy
o In Muller's manoeuvre the patient is asked to take a breath while the mouth is closed
and the nose is pinched shut.
o This generates a negative pressure in the upper airway. In patients who just snore, there
may be slight inward movement of the soft palate and the back of the throat but the
glottis remains visible.
o Patients who have OSA show varying degrees of collapse in the side walls of the
velopharynx, at the base of the tongue, and at the back of the throat, which narrows the
airway by more than 25%.
o Patients with the degree of collapse seen here usually have moderately severe OSA or
worse.

Sleep apnea treatments
o Modify sleep position?
o Weight reduction?
o Respiratory stimulants tricyclic antidepressants, L-tryptophan, etc?
o CPAP?
o Oral appliances?
o Surgery (nose, throat, oral cavity, face)?

-------------------------------------------------------END OF TRANSWINTION--------------------------------------------------


Akala ko madugo gumawa ng tranx ng ophtha, meron plang mas basag na lecture. Ang ENT, bow. Sorry kung magulo

format. Medyo maraming refs din ang ginamit ko dito, 3 years worth of knowledgehehe. Baka huli ko na to. Nakakatamad
nang gumawa. Hehe.

Pabati! Hi sa mga bumili ng tickets sa akin: Si Jela (unang biktima), Owis, JC, Mariel, juxy, Gabriela( este Jen pala ),
Yeji, Gelli, Betty, HAC, Franz, Bei, Carine, Ana, Bern, Menchai, Kathee, Nepo, Lyreen, Nicole O, Kat Y., Maika at finaleHomer!
Good luck guys! Hope to see you din sa Scholaroyale 2012.
Kudos din to all the subject heads and editors for this set of tranx. Just 2 rounds of evals and 1 set of finals, and we will
now be called Junior interns.

The underworld would be a very lonely place without you, my goddess of light

RANDOM EGYPTIAN FACT 4: The story of Isis and Osiris is the greatest love story of ancient Egypt.

The jealous Seth, God of the desert, cut Osiris into 14 pieces across Egypt. But Isis searched for all pieces for many years, and
with after completing the parts, used love to bring him back to life for a final embrace.

MALIGAYANG PASKO AT MANIGONG BAGONG TAON BATCH 2013!