Download Clinical Manual of Otolaryngology Clear Scan PDF

TitleClinical Manual of Otolaryngology Clear Scan
TagsSenses Clinical Medicine Auditory System Human Head And Neck Hearing
File Size19.0 MB
Total Pages283
Document Text Contents
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Clinical Manual of


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Clinical Manual of


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


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 (, and in

the Ambulatory Healthcare Pathways (

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


Examination will generally confirm posterior or lateral oropharyngeal

irritation. Laryngeal examination will reveal the edema of the posterior

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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


Cyanosis 25
Retractions 20

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