Throat Specific Disorders

Introduction

Disorders of the throat (pharynx) and voice box (larynx) may represent short-lived (acute) inflammation and infections, persistent (chronic) inflammation, or abnormal growths. Specific disorders include vocal cord polyps and nodules, contact ulcers, vocal cord paralysis, laryngoceles, laryngeal papillomasand cancer.

 

Throat infections (pharyngitis) are particularly common among children, although adults may be affected as well. Causes, symptoms, and treatment are similar in both groups, except that in adults (and sexually abused children), gonorrhea, a sexually transmitted disease, may affect the throat.

Epiglottitis is a bacterial infection of the epiglottis.

  • Epiglottitis may block the windpipe (trachea) and be fatal
  • The main symptoms are severe sore throat and noisy, difficult breathing.
  • Doctors make the diagnosis by looking at the epiglottis in the operating room with a flexible light.
  • The Haemophilus influenzae type B (Hib) vaccine can prevent epiglottitis caused by these bacteria.
  • Antibiotics are given to eliminate the infection, and a breathing tube is inserted to keep the airway from swelling shut.

The epiglottis is a small flap of stiff tissue that closes the entrance to the voice box (larynx) and trachea during swallowing. Sometimes, the epiglottis becomes infected with bacteria, usually Haemophilus influenzae type B. Haemophilus influenzae-related epiglottitis was most common among children, but routine vaccination against Haemophilus has almost eliminated this infection in children. Now more cases of epiglottitis occur in adults. However, children may get epiglottitis from other bacteria, and unvaccinated children can be infected by Haemophilus.

 

The swelling caused by this infection may block the airway and lead to difficulty breathing and death. Because children have a smaller airway than adults, epiglottitis is more dangerous in children but can also be fatal in adults.

 

Symptoms are severe throat pain, difficulty swallowing, fever, drooling, and a muffled voice. Because the infection is in the epiglottis, the back of the throat often does not appear infected. As swelling of the epiglottis starts to narrow the airway, the person first begins to make a squeaking noise when breathing in (stridor) and then has progressively worse trouble breathing. The condition progresses rapidly.

 

A doctor suspects the diagnosis based on the person's symptoms. If an adult is not having stridor or any trouble breathing, the doctor may look down the throat with a mirror or take x-rays, which often show the swollen epiglottis. Sometimes the doctor looks down the throat with a thin, flexible viewing tube inserted through the nose (nasopharyngeal laryngoscopy). Children are more likely to have sudden, complete blockage of their airway, particularly when their throat is examined. To minimize this danger, doctors usually examine the throat and epiglottis only in the operating room and do not send children for x-rays.

 

Epiglottitis caused by Haemophilus influenzae type B can be effectively prevented with the Haemophilus influenzae type B (Hib) vaccine.

 

A person without difficulty breathing is given antibiotics and is hospitalized and closely observed in an intensive care unit. If the person has difficulty breathing, doctors insert a plastic breathing tube through the mouth or nose into the trachea (endotracheal intubation). The tube keeps the airway from swelling shut. Sometimes the airway is so swollen that the doctor cannot insert a tube this way and must cut open the front of the neck and insert the tube directly into the trachea (tracheotomy or cricothyroidotomy).

Laryngitis is inflammation of the voice box (larynx).

  • A virus is usually what causes the inflammation.
  • Typical symptoms include hoarseness and loss of voice.
  • The diagnosis is based on symptoms and changes of the voice.
  • Usually, resting the voice and avoiding any irritants are adequate treatment.

The most common cause of short-lived (acute) laryngitis is a viral infection of the upper airways, such as the common cold. Laryngitis also may accompany bronchitis or any other inflammation or infection of the upper airways. Excessive use of the voice, an allergic reaction, and inhalation of irritants such as cigarette smoke can cause acute or persistent (chronic) laryngitis. Bacterial infections of the vocal cords are extremely rare.

 

Chronic laryngitis, in which symptoms last longer than 3 weeks, may be caused by gastroesophageal reflux, and less commonly by lingering bronchitis. People with bulimia who vomit frequently may develop laryngitis.

 

Symptoms are an unnatural change of voice, such as hoarseness, or even loss of voice that develops within hours to a day or so. The throat may tickle or feel raw, and a person may have a constant urge to clear the throat. Symptoms vary with the severity of the inflammation. Fever, a general feeling of illness (malaise), difficulty in swallowing, and a sore throat may occur in severe infections.

 

A diagnosis is based on the typical symptoms and voice changes. Sometimes a doctor looks down the throat with a mirror or a thin, flexible viewing tube, which shows some reddening and sometimes some swelling of the lining of the larynx. Because cancer of the larynx may cause hoarseness, a person whose symptoms persist more than a few weeks should be evaluated for cancer.

 

Treatment of viral laryngitis depends on the symptoms. Resting the voice (by not speaking), taking cough suppressants, drinking extra fluids, and inhaling steam relieve symptoms and help healing. Whispering, however, may irritate the larynx even more. Stopping smoking and treating bronchitis, if present, may alleviate laryngitis. An antibiotic is given only for infection caused by bacteria. Depending on the possible cause, specific treatments to control gastroesophageal reflux, bulimia, or drug-induced laryngitis may be helpful.

Laryngoceles are outpouchings of the mucous membrane of a part of the voice box (larynx).

 

Laryngoceles may bulge inward, resulting in hoarseness and airway obstruction, or outward, causing a visible lump in the neck. Laryngoceles are filled with air and can be expanded when a person breathes out forcefully with the mouth closed and the nostrils pinched shut. Laryngoceles tend to occur in musicians who play wind instruments.

 

On a computed tomography (CT) scan, laryngoceles appear smooth and egg-shaped. They may become infected or filled with mucus-like fluid and are usually removed surgically.

Tonsillar cellulitis is a bacterial infection of the tissues around the tonsils. A tonsillar abscess is a collection of pus behind the tonsils.

  • Sometimes, bacteria that infect the throat spread deep into surrounding tissues.
  • Typical symptoms include sore throat, pain when swallowing, fever, swelling, and redness.
  • The diagnosis is based on examination of the throat and sometimes the results of imaging studies.
  • Antibiotics help eliminate the infection.
  • An abscess is drained with a needle or through a small incision.

Sometimes, bacteria (usually streptococci and staphylococci) that infect the throat can spread deeper into the surrounding tissues. This condition is called cellulitis. If the bacteria grow unchecked, a collection of pus (abscess) may form. Abscesses may form next to the tonsils (peritonsillar) or in the side of the throat (parapharyngeal). Tonsillar cellulitis and tonsillar abscesses are most common among adolescents and young adults.

 

Symptoms

With tonsillar cellulitis or a tonsillar abscess, swallowing causes severe pain that often radiates into the ear. People have a severe sore throat, feel ill, have a fever, and may tilt their head toward the side of the abscess to help relieve pain. Spasms of the chewing muscles make opening the mouth difficult (trismus). Cellulitis causes general redness and swelling above the tonsil and on the soft palate. An abscess pushes the tonsil forward, and the uvula (the small, soft projection that hangs down at the back of the throat) is swollen and can be pushed to the side opposite the abscess. Other common symptoms include a "hot potato" voice (speaking as if a hot object is in the mouth), drooling, and severe bad breath (halitosis).

 

Diagnosis and Treatment

A doctor makes the diagnosis by viewing the throat. Tests are not usually performed, but if the doctor is not sure whether an abscess is present, computed tomography (CT) or ultrasonography can be used to identify one. Sometimes if an abscess is suspected, the doctor inserts a needle into the area and tries to draw out pus.

 

Antibiotics, such as penicillin or clindamycin, are given by vein. If no abscess is present, the antibiotic usually starts to clear the infection within 48 hours. If an abscess is present, a doctor must insert a needle in it or cut into it to drain the pus. The area is first numbed with an anesthetic spray or injection. Treatment with antibiotics is continued by mouth.

 

Peritonsillar abscesses tend to recur. Recurrences can be prevented by removing the tonsils, which is usually performed 4 to 6 weeks after the infection has subsided or earlier if the infection is not controlled with antibiotics.

Contact ulcers are raw sores on the mucous membrane covering the cartilage to which the vocal cords are attached.

 

Contact ulcers are usually caused by abusing the voice with forceful speech, particularly as a person starts to speak. These ulcers typically occur in singers, teachers, preachers, sales representatives, lawyers, and other people whose occupation requires them to talk or otherwise use their voice a lot. Backflow (gastroesophageal reflux) of stomach acid also may cause contact ulcers.

 

Symptoms include mild pain while speaking or swallowing and varying degrees of hoarseness. A doctor makes the diagnosis by examining the vocal cords with a thin, flexible viewing tube. Occasionally, a small tissue sample is removed and examined under a microscope (biopsy) to make sure that the ulcers are not cancerous and are not caused by tuberculosis.

 

Treatment involves resting the voice by talking as little as possible for at least 6 weeks so that the ulcers can heal. To avoid recurrences, people who develop contact ulcers need voice therapy to learn how to use the voice properly. A speech therapist can provide such instruction. If the person has gastroesophageal reflux, treatment includes taking antacids, not eating within 2 hours of retiring for the night, and keeping the head elevated while sleeping. Antibiotics also can help prevent bacterial infections while the ulcers are healing.

Vocal cord nodules and polyps are noncancerous (benign) growths that cause hoarseness and a breathy voice.

 

Vocal cord polyps are often the result of an acute injury (such as from shouting at a football game) and typically occur on only one vocal cord. Vocal cord nodules occur on both vocal cords and result mainly from abuse of the voice (habitual yelling, singing, or shouting or using an unnaturally low frequency).

 

Symptoms include chronic hoarseness and a breathy voice, which tend to develop over days to weeks. A doctor makes the diagnosis by examining the vocal cords with a thin, flexible viewing tube. Sometimes the doctor removes a small piece of tissue for examination under a microscope (biopsy) to make sure the growth is not cancerous (malignant).

 

Treatment is to avoid whatever is irritating the larynx and rest the voice. If abuse of the voice is the cause, voice therapy conducted by a speech therapist may be needed to teach the person how to speak or sing without straining the vocal cords. Most nodules go away with this treatment, but most polyps must be surgically removed to restore the person's normal voice.

Vocal cord paralysis is the inability to move the muscles that control the vocal cords.

  • Paralysis can be caused by tumors, injuries, or nerve damage caused by infection or toxins.
  • Typical symptoms include voice changes and possible difficulty breathing.
  • The diagnosis is based on examination of the voice box (larynx), bronchial tubes, or esophagus.
  • Several procedures can help keep the airway from closing.

Vocal cord paralysis may affect one or both vocal cords. Females are affected more often than males. Paralysis can result from brain disorders, such as brain tumors, strokes, and demyelinating diseases, or damage to the nerves that lead to the larynx. Nerve damage may be caused by noncancerous (benign) and cancerous (malignant) tumors; injury; a viral infection of the nerves; Lyme disease; or neurotoxins (substances that poison or destroy nerve tissue), such as lead, mercury, arsenic, or the toxins produced in diphtheria.

 

Symptoms and Diagnosis

Vocal cord paralysis may affect speaking, breathing, and swallowing. Paralysis may allow food and fluids to be inhaled into the windpipe (trachea) and lungs. If only one vocal cord is paralyzed, the voice is hoarse and breathy. Usually, the airway is not obstructed because the normal cord on the other side opens sufficiently. When both vocal cords are paralyzed, the voice is reduced in strength but otherwise sounds normal. However, the space between the paralyzed cords is very small, and the airway is inadequate so that even moderate exercise causes difficulty in breathing and a harsh, high-pitched sound with each breath.

 

A doctor tries to find the cause of the paralysis. Examination of the larynx, bronchial tubes, or esophagus with a thin, flexible viewing tube may be performed. Magnetic resonance imaging (MRI) or computed tomography (CT) of the head, neck, chest, and thyroid gland and x-rays of the esophagus also may be needed.

 

Treatment

If only one side is paralyzed, an operation can be done to move the paralyzed vocal cord to the best position for more normal speech. The operation may involve inserting an adjustable spacer near the paralyzed cord or injecting a substance into the paralyzed cord to move the cords closer together.

 

When both sides are paralyzed, keeping the airway open adequately is difficult. A tracheostomy (surgery to create an opening into the trachea through the neck) may be needed. The tracheostomy opening may be permanent or may be used only when the person has an upper respiratory tract infection. In another procedure, called an arytenoidectomy, the vocal cords are permanently separated, thus widening the airway. However, this procedure may worsen voice quality. Laser removal of part of one or both vocal cords is preferred to arytenoidectomy and helps widen the airway. If performed correctly, laser removal can preserve satisfactory voice quality and eliminate the need for a tracheostomy.