Document Text Contents
Page 1
Clinical Manual of
Otolaryngology
Page 2
Clinical Manual of
OTOLARYNGOLOGY
Page 141
The Throat
indicating poor glottal approximation following inhalation. The patient's
voice did not resonate normally and appeared to be primarily tense, with a
strained, strangled quality. There were episodes of breaks into breathiness.
His projection was constricted at the laryngeal level. He had difficulty in
increasing loudness.
The speech therapist's impression was of a long-term voice misuse with
vocal hyperfunction. Therapy consisted of excessive voice reduction and
initiation of a voice therapy program designed to improve the patient's
respiratory/phonatory coordination. The patient underwent several weeks of
intense therapy consisting of two 1-hour sessions a week, with a dramatic
improvement in his voice. Over a period of 3 months, the vocal cord nodules
disappeared and the patient's voice returned to normal.
Unfortunately, the patient presented again a year later after noticing some
voice changes. Consultation was sought with the speech therapist and in two
sessions, the patient's voice was tuned back to its normal state. From that
point, the patient had a consultation with the speech therapist every 6 months,
maintained his teaching load and remained well.
Laryngeal cancers are usually epidermoid neoplasms associated with
tobacco use. The voice has a rough, raspy sound, and the diagnosis is
strongly suspected by the positive history of tobacco use and the insidious
onset of hoarseness. Laryngoscopy confirms the diagnosis. A full work-up
should include complete blood cell count, urinalysis, determination of
creatinine, bilirubin and alkaline phosphatase levels, chest X-ray or CT scan,
and neck examination. A direct laryngoscopy is performed and the tumor is
biopsied. These tumors are best evaluated and treated by head and
neck surgeons. The specific modes of therapy will be discussed in a latter
section.
Another common cause of hoarseness, cough, and a repeated need to
clear ones throat is postnasal drip. The postnasal drip is usually caused by
an indolent chronic rhinosinusitis. This can be an aging rhinitis, an allergic
rhinitis or chronic rhinosinusitis. Descriptions are written in the Handbook
of Nasal Disease (www.drdravidson.ucsd.edu/portals/O/nasal.html), and in
the Ambulatory Healthcare Pathways (www.drdravidson.ucsd.edu/portals/O/
ENT!index.html). The secretions that drain down the posterior and lateral
pharyngeal walls irritate the arytenoids and posterior larynx. This induces
the cough and constant clearing of the throat. With prolonged irritation, the
vocal cords become irritated and edematous and the voice develops a hoarse
quality.
Examination will generally confirm posterior or lateral oropharyngeal
irritation. Laryngeal examination will reveal the edema of the posterior
Page 142
Clinical Manual of Otolaryngology
larynx and vocal cords. Treatment is directed at evaluating, diagnosing and
treating the rhinopathy. GERD may cause the same.
Acute Epiglottitis
Acute epiglottitis, also known as supraglottitis, is an infection of the
supraglottis caused by H. influenzae. Patients are usually between 3 and 5
years old, but the disease does affect younger children and adults as well.
Patients are generally febrile and show toxic symptoms; sometimes they
drool because of the pain when they swallow. The frequency of signs and
symptoms is given in Table 4.1. The supraglottis becomes edematous and
the airway narrows. The patient rapidly develops inspiratory stridor. As the
swelling progresses, the patient has increasing difficulty in swallowing.
Examination commonly reveals a toxic, febrile child, usually with some
degree of inspiratory stridor. Pharyngeal examination may show a red, swollen
epiglottis, but care should be taken when looking for this. Touching the
epiglottis with the tongue blade may induce fatal laryngospasm. The patient
is often most comfortable sitting up. The diagnosis is made by the clinical
picture. Soft tissue lateral X-rays may show the swollen epiglottis and confirm
the diagnosis. However, as airway obstruction may occur at any time in
patients with epiglottitis, a child with any suspicion of epiglottitis should
never be sent to X-ray unless attended by a physician skilled in intubation.
If blood cultures are taken, they often grow H. influenzae.
Treatment must be immediate. Humidified mask oxygen should be started.
Racemic epinephrine inhalation may improve breathing. Dexamethasone or
Frequency o! symptoms and signs of acute epiglottitis
-- ---
Symptoms %
Fever 100
Respiratory distress 100
Sore throat 60
Dysphagia 60
Stridor 50
Irritability or restlessness 50
Drooling 40
Cough 35
Hoarseness 25
Signs
Cyanosis 25
Retractions 20
Clinical Manual of
Otolaryngology
Page 2
Clinical Manual of
OTOLARYNGOLOGY
Page 141
The Throat
indicating poor glottal approximation following inhalation. The patient's
voice did not resonate normally and appeared to be primarily tense, with a
strained, strangled quality. There were episodes of breaks into breathiness.
His projection was constricted at the laryngeal level. He had difficulty in
increasing loudness.
The speech therapist's impression was of a long-term voice misuse with
vocal hyperfunction. Therapy consisted of excessive voice reduction and
initiation of a voice therapy program designed to improve the patient's
respiratory/phonatory coordination. The patient underwent several weeks of
intense therapy consisting of two 1-hour sessions a week, with a dramatic
improvement in his voice. Over a period of 3 months, the vocal cord nodules
disappeared and the patient's voice returned to normal.
Unfortunately, the patient presented again a year later after noticing some
voice changes. Consultation was sought with the speech therapist and in two
sessions, the patient's voice was tuned back to its normal state. From that
point, the patient had a consultation with the speech therapist every 6 months,
maintained his teaching load and remained well.
Laryngeal cancers are usually epidermoid neoplasms associated with
tobacco use. The voice has a rough, raspy sound, and the diagnosis is
strongly suspected by the positive history of tobacco use and the insidious
onset of hoarseness. Laryngoscopy confirms the diagnosis. A full work-up
should include complete blood cell count, urinalysis, determination of
creatinine, bilirubin and alkaline phosphatase levels, chest X-ray or CT scan,
and neck examination. A direct laryngoscopy is performed and the tumor is
biopsied. These tumors are best evaluated and treated by head and
neck surgeons. The specific modes of therapy will be discussed in a latter
section.
Another common cause of hoarseness, cough, and a repeated need to
clear ones throat is postnasal drip. The postnasal drip is usually caused by
an indolent chronic rhinosinusitis. This can be an aging rhinitis, an allergic
rhinitis or chronic rhinosinusitis. Descriptions are written in the Handbook
of Nasal Disease (www.drdravidson.ucsd.edu/portals/O/nasal.html), and in
the Ambulatory Healthcare Pathways (www.drdravidson.ucsd.edu/portals/O/
ENT!index.html). The secretions that drain down the posterior and lateral
pharyngeal walls irritate the arytenoids and posterior larynx. This induces
the cough and constant clearing of the throat. With prolonged irritation, the
vocal cords become irritated and edematous and the voice develops a hoarse
quality.
Examination will generally confirm posterior or lateral oropharyngeal
irritation. Laryngeal examination will reveal the edema of the posterior
Page 142
Clinical Manual of Otolaryngology
larynx and vocal cords. Treatment is directed at evaluating, diagnosing and
treating the rhinopathy. GERD may cause the same.
Acute Epiglottitis
Acute epiglottitis, also known as supraglottitis, is an infection of the
supraglottis caused by H. influenzae. Patients are usually between 3 and 5
years old, but the disease does affect younger children and adults as well.
Patients are generally febrile and show toxic symptoms; sometimes they
drool because of the pain when they swallow. The frequency of signs and
symptoms is given in Table 4.1. The supraglottis becomes edematous and
the airway narrows. The patient rapidly develops inspiratory stridor. As the
swelling progresses, the patient has increasing difficulty in swallowing.
Examination commonly reveals a toxic, febrile child, usually with some
degree of inspiratory stridor. Pharyngeal examination may show a red, swollen
epiglottis, but care should be taken when looking for this. Touching the
epiglottis with the tongue blade may induce fatal laryngospasm. The patient
is often most comfortable sitting up. The diagnosis is made by the clinical
picture. Soft tissue lateral X-rays may show the swollen epiglottis and confirm
the diagnosis. However, as airway obstruction may occur at any time in
patients with epiglottitis, a child with any suspicion of epiglottitis should
never be sent to X-ray unless attended by a physician skilled in intubation.
If blood cultures are taken, they often grow H. influenzae.
Treatment must be immediate. Humidified mask oxygen should be started.
Racemic epinephrine inhalation may improve breathing. Dexamethasone or
Frequency o! symptoms and signs of acute epiglottitis
-- ---
Symptoms %
Fever 100
Respiratory distress 100
Sore throat 60
Dysphagia 60
Stridor 50
Irritability or restlessness 50
Drooling 40
Cough 35
Hoarseness 25
Signs
Cyanosis 25
Retractions 20
