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Theme 4 - Coggle Diagram

- - - - Acute tonsillitis
        
        General
        Acute bacterial inflammation of the palatine tonsils
        Usually: group A β-hemolytic streptococci
        Rare: staphylococci, Haemophilus influenzae, or pneumococci
        
        Symptoms
        Common in children & adolescents: high fever and severe pain on swallowing, which often radiates to the ear
        Swollen tonsillar lymph nodes
        Muffling of speech (oropharyngeal swelling)
        
        Diagnostics
        Mirror examination → both tonsils are swollen, bright red, and coated
        Inflammatory parameters → leukocytosis, ESR & CRP are elevated
        Bacteriologic testing → 2-3 days! Treatment too late, should have already been initiated
        Rapid immunoassay → 10 minutes
        
        Treatment
        Streptococcal tonsillitis → 10-to 14-day course of penicillin V
        Allergy? Macrolides or oral cephalosporins
        Pain? Analgesics or a single shot of IV corticosteroids
      - Chronic tonsillitis
        
        Symptoms
        Recurrent infections (tonsils & peritonsillar tissue) → permanent structural changes w/scarring
        With or w/o symptoms: pain, lethargy, poor appetite, a bad taste in the mouth, and a bad breath odor
        
        General
        Bacteria grow on cellular debris in poorly drained crypts
        Sustain variety of diseases → rheumatic fever, glomerulonephritis, iritis, psoriasis, inflammatory heart disease, pustulosis palmaris and plantaris, erythema nodosum
        
        Diagnostics
        Mirror examination → small, firm, immobile tonsils with associated peritonsillar redness. (Occasionally, a purulent liquid)
        Tonsillar smears → group A β-hemolytic streptococci (McIsaac scoring system)
        Palpation → Tonsillar lymph nodes may be enlarged
        Laboratory examination → ESR & CRP elevated + left shift in differential blood count
        
        Treatment
        Tonsillectomy if 6+ inflammatory episodes in the past year
    - - General
        Hyperplasia of the pharyngeal tonsil → proliferation of lymphatic tissue
        Children 3-6yrs
      - Treatment
        Treated if causing symptoms
        Adenotomy/adenoidectomy (+ paracentesis, if concomitant middle ear effusion)
      - Symptoms
        Chronic nasal airway obstruction (“mouth breathing”)
        Nasal discharge (“runny nose”)
        Snoring
        Anorexia
        Rhinophonia clausa (“hyponasal voice”)
        Recurring infections of the nose and paranasal sinuses --> Otitis media and chronic impairment of eustachian tube ventilation
        Prolonged conductive hearing loss (esp. first 3-4yrs) → delay speech development
        Chronic mouth breathing → maxillary deformity + dental malalignment
        Enlarged tonsillar lymph nodes
      - Diagnostics
        Rhinoscopy or endoscopy + microscopic examination + pure-tone audiogram
- - - - Peptic stricture
        age 60
        intermittent dysphagia for solids - worsens over a long time
        PPI (mild) or endoscopic dilation + PPI (severe) + surgery (if treatment fails)
      - Barrett's oesophagus
        Normal oesophageal squamous epithelium replased by metaplastic columnar mucosa (segment of columnar-lined oesophagus (CLO))
        Hiatus hernia is almost always present
        Endoscopy
        Prague
        GO junction = depth of endoscope insertion at level of tops of gastric mucosal folds and/or sphincter 'pinch'
        C = depth of endoscopic insertion at the most proximal circumferential extent of suspected columnar metaplasia
        M = depth of endoscopic insertion at the maximum extent of the columnar metaplasia
        C = GO junction - C
        M = GO junction - M
        Radiofrequency ablation (RFA) = treatment of choice (under evaluation)
    - - Achalasia
        Oesophageal aperistalsis and impaired relaxation o/t LOS. LOS pressur is elevated in >50% patients.
        1:100.000 M=F
        Rare in childhood
        Intermittend dysphagia (both liquids & solids from onset)
        Regurgitation (@ night)
        Aspiration pneumonia = complication
        Spontaneous chest pain (spasm) = often misdiagnosed
        Inflammation myenteric plexus (o/t oesophagus) + reduction of ganglion cell nrs.
        Reduction in NO synthase-containing neurones
        DDs: genetic syndromes, infectious diseases, neoplasms, chronic inflammatory diseases
        Chest X-ray = dilation (+ fluid behind heart)
        Barium swallow = lack of peristalsis (synchronous contractions)
        Gastroscopy = exclude carcinoma
        CT scan = exclude distal oesophageal cancer
        Manometry = aperistalsis + failure of relaxation LOS
        Endoscopic (pneumatic balloon) & surgical (Heller's operation - laparoscopically) therapies
        Slight increase in squamous carcinoma
      - Systemic sclerosis
        Diminished peristalsis + oesophageal clearance
        Manometry or barium swallow
        Replacement smooth muscle w/fibrous tissue
        LOS pressure is decreased --> reflux
        Stricutures may develop, dysphagia and heartburn occur later
        Treatment as for GORD + benign stricture
      - Diffuse oesophageal spasm
        Severe form of oesophageal dysmotility
        Retrosternal chest pain + dysphagia
        Can accompany GORD
        Swallowing w/bizarre + marked contractions o/t oesophagus w/o normal peristalsis
        Barium swallow = cocksrew oesophagus
        Asymptomatic oesophageal 'dysmotility' is not infrequent (esp. >60yrs)
        Variant = 'nutcracker' oesophagus = high-amplitude peristalsis. Chest pain > dysphagia
        PPIs may be successful if reflux
        Antispasmodics, nitrates, CCblockers, GABA receptor antagonists
        Balloon dilation or longitudinal oesophageal myotomy may be necessary
      - Miscellaneous motility disorders
        Produce dysphagia
        Elderly, DM, Myotonic dystrophy, oculopharyngeal muscular dystrophy & Myasthenia gravis as well as neurological disorders involving the brain stem
    - - Oesophageal diverticulum
        
        immediately above the UOS = Zenker's diverticulum
        
        Near the middle of the oesophagus = diffuse oesophageal spasm or mediastinal fibrosis
        
        just above LOS = epiphrenic diverticulum (achalasia)
        
        Barium swallow (performed for other reasons)
        Asymptomatic
        Dysphaia + regurgitation (pharyngeal pouch)
        Surgically & endoscopically treated
      - Rings and webs
        Oesophageal web is a thin, membranous tissue flap covered w/squamous epithelium
        May produce dysphagia
        Plummer-Vinson syndrom (Paterson-Brown-Kelly syndrome) = ass. with iron deficiency anaemia, glossitis + angular stomatitis (mainly women)
        LO rings
        
        Mucosal (Schatzki's ring or B ring) = squamocolumnar mucosal junction
        
        Muscular (A ring) = proximal to the mucosal ring
        
        Reassurance + dietary advice (evt. dilation). May respond to PPIs.
      - Benign oesophageal stricture
        Secondary to reflux
        Might occur after ingestion of corrosives, radiotherapy, sclerotherapy of varices & prolonged nasogastric intubaiton.
        Endoscopic dilation (sometimes surgery)
      - Oesophageal infections
        Painful swallowing (in immunosuppressed & debilitated patients)
        
        Candida
        
        Herpes simplex
        
        cytomegalovirus
        
        Mycobacterium tuberculosis
        
        Hard to distinguish
        Smear, culture, biopsy
        Immunosuppressive agents (or antifungal/antiviral)
      - Eosinophilic oesophagitis
        Eosinophils in the oesophageal mucosa (due to allergy or GORD)
        Dysphagia, food impaction, 'heartburn', oesophageal pain (induced inflammation)
        Male>female average 35yrs
        Mucosal furrowing, loss of vascular pattern (thickened mucosa), plaques of eosinophilic surface exudate + prominent circular folds
        Reflux oesophagitis and Schatzki's rings may coexist
        Variation = eosinophilic infiltration due to reflux disease
        1st line = Topical steroids
        2nd line = systemic steroids or empirical elimination diets
      - Oesophageal perforation
        During endoscopic dilation
        Following insertion of a nasogastric tube, gastroscope or transoesophageal echoprobe
        Placement of an expanidng covered oesophageal stent
      - Oesophageal rupture
        "Spontaneous" occurs with violent vomiting (Boerhaave's syndrome) - chest pain + collapse
        May follow alcohol ingestion
        Chest X-ray = hydropneumothorax
        Diagnosis = CT scan = water-soluble contrast swallow
        Mortality rate = 35% w/i 12hrs
        
        50% after 24h
        
        90% after 48h
    - - Cancer o/t oesophagus
        6th most common worldwide
        Squamous cancers in middle 1/3rd = 40%, upper 1/3rd = 15%
        Adenocarcinomas in lower 1/3rd = 45%
        SCC
        In the UK 5-10/100.000/year
        High levels of alcohol consumption, tobacco use, obesity, low vegetable/fruit consumption, diets high in saturated fat, cholesterol & refined cereals, red/processed meat --> increased risk
        Diets rich in fibre, carotenoids, folate, vit C, non-starchy vegetables, fish, white meat consumptiom --> decrease risk
        Adenocarcinoma
        Arise in columnar-lined epithelium in LO.
        70% new oesophageal cancer diagnoses
        Aged 60-70
        Progressive dysphagia + unrelenting (first solids - then liquids as well)
        Lesion may be ulcerative, proliferative or scirrhous
        Metastases to lymph nodes
        Weight loss + anorexia
        Obstruction --> difficulty swallowing saliva, coughing, aspiration
        Endoscopy - histological proof
        Barium swallow - differential diagnosis (motility disorder)
        TNM staging
        CT-scan = metastases, volume of tumour
        Endoscopic ultrasound = 90% accuracy for assessing depth o/t tumour, 80% for lymph node involvement
        Laparoscopy = if tumour is at the cardia
        PET = confirm CT scan suspected metastases
        Treatment depends on age & perfornance status & stage o/t disease
        40% OS after 1 year
        
        Surgery if not infiltrated outside o/t oesophageal wall (w/neo-adjuvant and adjuvant treatment)
        
        Neo-adjuvant chemoradiation therapy
        
        Palliative therapy
        
        Chemoradiation alone
        
        Nutritional support
      - Other oesophageal tumours
        GI stromal tumours and leiomyomas
        10% cause dysphagia or bleeding
        Sugical removal if symptomatic or >3cm
        Kaposki's sarcoma is in oesophagus, mouth and hypopharynx in patients w/AIDS
    - - Globus
        
        persistent or intermittent sensation of a lump or foreign body i/t throat
        
        occurrence o/t sensation between meals
        
        absence of dysphagia and pain on swallowing (odynophagia)
        Trial of anti-reflux therapy (and antidepressants?)
      - Functional chest pain of presumed oesophageal origin
        Midline chest pain, not burning
        In the absence of a cardiological cause, gastro-oesophageal reflux, and achalasia
        Most respond to high-dose acid suppression therapy or nitrates and CC blockers
        Antidepressant therapy has also been effective
- - - - Symptoms
        Hoarseness
        No respiratory distress
      - Diagnostics
        Telescopic laryngoscopy → unilateral vocal cord immobility is noted during respiration (fixed paramedian position)
        Ultrasonography → examination of the thyroid gland and neck
        CT or MRI → the mediastinum
        Serologic tests + possible exposure
        Electromyography (EMG) → rare conditions of arytenoid dislocation, which is usually caused by intubation trauma, and arytenoid fixation by scar tissue
      - Treatment
        Treatment depends on the cause
        An unsevered nerve can regenerate
        Muscular atrophy → vocal dysfunction → voice therapy
        Augmentation of the paralyzed (injection of Teflon or autologous collagen)
        Medialization procedure → improve vocal cord position
    - - Symptoms
        Dyspnea - resting dyspnea to dyspnea on exertion (paralyzed vocal cords assume an almost closed position) - residual glottic gap
        Intubation - additional mucosal swelling
      - Diagnostics
        Telescopic laryngoscopy → vocal cords fixed in a paramedian position (passive motion in response to airflow)
        Examination methods explained @ unilateral
      - Treatment
        Treatment is based on the cause
        Post surgery? → immediate revision procedure
        Wait and see (if one recovers) Surgery (after 6 months) → suturing portions of one vocal cord in a lateralized position (laterofixation**)
  - - - General
        Bacterial inflammation of the pharynx and laryngeal inlet
        2-8yrs
        Incidence declined since H. influenzae type b vaccine
        Other causes: pneumococci and β-hemolytic streptococci
        Mortality rate 5-10%, 50% develop bacteremia
        Recurrence is rare
      - Symptoms
        Swift onset: high fever, a loud inspiratory stridor, and severe respiratory distress
        Hoarseness and cough may be absent
        Very painful swallowing
        A muffled “hot potato” voice
        Progression → increasing inspiratory retraction in the jugular, sternal, and intercostal areas
        Progressing dyspnea (increasing inflammatory obstruction of the laryngeal inlet)
        Death from asphyxia may occur within minutes - few hours
      - Diagnostics
        Posterior pharyngeal is bright red + epiglottis is swollen and erythematous (“cherry red epiglottis”) - abscess formation is possible
      - Treatment
        Intubation under controlled conditions (extubation usually after 1-3 days if treated)
        Tracheotomy is unnecessary.
        Antibiotic therapy + sedation
        For adults: Early initiation of treatment with IV antibiotics and anti-inflammatory agents can frequently avoid the ne
  - - - General
        Viral disease → pseudocroup → 90% croup syndrome
        6 months to 3 yrs (5%)
        Seasonal peak incidence: spring & fall
        Gradual onset 1-3 days - resolution in 3-5 days (may recur)
        Generally milder course than acute epiglottitis
        Parainfluenza I–III, influenza, respiratory syncytial (RS) viruses (droplet)
      - Symptoms
        Hoarse voice (vocal cord involvement)
        Dry, harsh, barking cough
        Stridor during the evening hours or at night after a few hours’ sleep (loudest @ inspiration) → severe respiratory distress (w/cyanosis)
      - Diagnostics
        Laryngoscopy → inflammatory swelling below the vocal cords and in the upper part of the cervical trachea (luminal narrowing later)
        Normal/slightly elevated temp. + no leukocytosis.
      - Treatment
        Airway humidification + adequate fluid intake
        No need for antibiotics.
        Steroids if increasing stridor (not proven).
        If pronounced stridor and dyspnea inhalation therapy with epinephrine derivatives → regression of inflammatory swelling.
        Intubation only in exceptional cases
  - - - Cyst = pocket of membranous tissue that contains fluid, air, or other substances
        Vocal cord cysts originate in the small mucosal glands of the laryngeal mucosa
      - Symptoms
        Depends on size and location of the lesion and may consist of hoarseness, globus sensation and rarely dyspnoea
      - Treatment
        Removal by endolaryngeal microsurgery
    - - Polyp = growth of tissue usually protruding from a mucous membrane
        Caused by vocal overuse and chronic inflammation
      - Symptoms
        breathy, harsh voice/hoarseness
        If polyp is ‘floating’ → diplophoia
        https://laryngopedia.com/diplophonia/
      - Treatment
        Surgery + voice therapy
    - - Collection of tissue fluid in the subepithelial layer of the vocal cord often due to irritation
      - Symptoms
        Hoarseness
        Frequent throat clearing
        Decrease in voice pitch
      - Treatment
        Removing the irritation + surgery
- - - - CN V, VII, IX, X, XII
        Motor innervation - hypoglossal nerve
        Terminal sulcus - lingual nerve (3rd div. trigeminal nerve)
        Tongue base region - glossopharyngeal + superior laryngeal nerves (CN X)
        Taste buds anterior 2/3rds o/t tongue - chorda tympani (CN VII)
        Taste buds posterior 1/3rd o/t tongue - glossopharyngeal nerve