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3 stages of swallowing
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• Voluntary
• Anterior tongue moves the bolus of food posteriorly against the hard palate
• Primarily controlled by the suprahyoid muscles |
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• Involuntary
• Bolus enters OP
• NP is sealed
• Lx is elevated and protected
• Pharyngeal constrictors move bolus inferiorly |
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• Esophageal phase, primarily controlled by peristalsis
• Often deteriorates with age |
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Parotid Glands
• Largest salivary glands
• Predominantly serous- secreting cells
• Facial nerve divides it into superficial and deep components
• Stensen’s duct pierces the oral cavity opposite the second molar |
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• Second largest glands
• Contain mucous and serous-secreting cells
• Wharton’s duct pierces the floor of the mouth and exits lateral to the lingual frenulum |
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• Smallestofthemajor salivary glands
• Contain mucous- secreting cells
• Empty through approximately 12 ducts of Rivinus into the floor of mouth |
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- 1st line of immunologic defense
- Diffuselymphatic tissue
• Palatine tonsils (tonsils)
• Pharyngeal tonsils (adenoids)
• Lingual tonsils |
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• Symptoms include: snoring, respiratory pauses, daytime sleepiness
• Typical patient is overweight
• Thick neck contributes to pharyngeal musculature collapse during sleep |
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| Sleep Apnea: Adults diagnosis and treatment |
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- Diagnose with sleep study
• Measures apneas and hypopneas
• Abnormal is AHI > 5, Saturation < 90%
- Treatment options include:
• Weight loss (2% effective)
• CPAP/BiPAP
• Dental Devices
• Uvulopalatopharyngop lasty (UPPP)
• Tracheotomy |
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- Spectrum of sleep disordered breathing
• Benign snoring
• Upper Airway Resistance Syndrome
• Sleep apnea
-Symptoms
• mouth breathing
• snorting and gasping for air while sleeping • Behavior and concentration problems |
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| Sleep Apnea: Children diagnosis and treatment |
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-Diagnosis • History!
• Sleep studies not helpful in routine cases
-Treatment
• Tonsillectomy and adenoidectomy
• Relieves upper airway obstruction
• Rarely spend one night in hospital for observation |
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• Symptoms
• Sore throat, dysphagia, odynophagia
• Signs
• Red, edematous mucosa and/or tonsils, fever, cervical adenitis, elevated WBC |
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| Pharyngitis/Tonsillitis diagnosis and treatment |
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• Differential Diagnosis
• Viral, group A strep, EBV (palate micropetechiae), diptheria (thick grey membrane)
• Treatment
• Viral: supportive
• EBV: consider steroids if obstructing • Bacterial: antibiotics |
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-Indications:
• 7 infections in 1 year
• 5/year x 2 years
• 3/year x 3 years
• SleepApnea
- Avoidif<2y.o.
- Post-op bleeding in 3- 5%, usually 7-10 days post-op |
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• Severe bacterial infection
• Cellulitis can progress to abscess
• Sxs:drooling,trismus, muffled voice, lymphadenitis
• Usually no CT
• Rx=I&D,Abx
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- “Deep neck space” infection
- Torticollis,neckmass, can appear toxic
- Treatment
• ?Airwayevaluation
• CT scan with contrast
• Surgical drainage in operating room
• IV antibiotics
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• Harsh sound produced by turbulent airflow through upper airway
- Inspiratory = above or at larynx
- Expiratory = trachea
- Biphasic = larynx or just inferior
• Multiple causes
• Different from wheeze |
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• New onset requires prompt evaluation by ENT
• Watch pt, respiratory effort and rate
• Offer sitting position, oxygen, heliox
• Good oxygen saturation gives false sense of security
• Common causes to follow |
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• Viral – typically parainfluenza
• Usually children < 5
• Sx: febrile URI, then barky dry cough
• Dx: history, “steeple sign” on neck XR
• Tx: humidify (usually self limited), epi, steroids, intubate if severe |
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• Adults > Children after HiB vaccine
• Progresses rapidly, often within 6 hours
• Sx:pain,drooling,muffledvoice,“sniffing” position
• Dx: based on above, “thumb sign” and ENT scope
• Tx:
• Acute: oxygen, heliox, racemic epi
• ASAP: steroids, abx, secure airway (often with tracheotomy) |
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• Typically viral and self-limited
• Can progress to secondary bacterial infection
• Stridor, tachypnea, fever, drooling
• Tx: broad spectrum abx, airway support |
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• Common causes: surgery, cancer, trauma, idiopathic
• Dx: hoarse/breathy, dysphagia, stridor
• w/u: laryngoscopy, CT skull base through aortic arch, serology
• Tx: follow vs. speech therapy vs. medialization of vocal cord |
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• 10 to 30% of Americans have GERD
• Reflux disease may produce 2 different constellations of symptoms
• Gastroenterology patients with esophagitis
• Extraesophageal symptoms
• Otolaryngology patients with throat complaints, many of whom do not complain of heartburn or esophagitis |
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| Layngopharyngeal Reflux (LPR) |
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• Esophageal dysmotility - significantly prolonged esophageal acid clearance times
• LES dysfunction |
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• Good esophageal function - near normal esophageal acid clearance
• UES dysfunction |
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| LPR patient, reflux disease |
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• Larynx is far more susceptible to acid injury than esophagus
• No acid clearing mechanisms (peristalsis)
• Mucosa is thin, fragile and poorly adapted to protect against reflux
• Up to 50 esophageal reflux events per day is normal. Most last several seconds.
• As few as 3 reflux events per week can cause laryngeal injury |
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• Heartburn
• Regurgitation • Dysphagia |
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| Symptoms of LPR (laryngopharyngeal reflux) |
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• Hoarseness - 71%
• Chronic Cough - 51%
• Globus - 47%
• Heartburn or Regurg – 43% • Throat Clearing - 42%
• Dysphagia – 35%
• Laryngeal Stenosis – Rare
• Laryngeal CA - Controversial |
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| LPR (laryngopharyngeal reflux) |
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• Diet (reduce fat, spice, EtOH, caffeine)
• Lifestyle (lose weight, no late snacks)
• PPIs are superior to H2RAs and other therapies
• Months of therapy are required
• Monitoring LPR requires special equipment |
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• Fastest growing cancer in U.S.
• 6-fold increase in cases in past 20 years (ACS 2008)
• Fewer than 1 in 5 patients survive 5 years
• 15,000 expected to die this year |
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• Office-based procedure to evaluate LPR refractory to standard PPI therapy
• No Sedation
• Scope is a longer and slightly wider version of the standard ENT fiberoptic laryngoscope
• Ports are available for suction, air insufflation and biopsy |
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• Account for over 30,000 new cancer cases and 7,000 deaths per year (ACS)
• Tumors and treatment can cause significant functional and cosmetic deformities
• Most common cancer is Squamous Cell Carcinoma (over 90%), but other cancers can occur in the OC and OP |
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• Risk factors of smoking and alcohol are individual risk factors that are additive in people who do both.
• Treatment is surgery or radiation for small lesions and surgery and radiation for large lesions.
• Chemotherapy is useful for pharynx/larynx and for metastatic disease |
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| oral cavity lecture Conclusions |
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• Anatomy is complicated.
• Oral cavity and pharynx lesions can impair function and cosmesis
• LPR usually requires PPI for months
• Stridor requires prompt ENT evaluation
• Cancers are usually caused by smoking and EtOH and are treated with radiation, surgery and increasingly chemo |
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