JC M ENT

JC M ENT

ENDOSCOPY / VOICE CLINIC
Dr KY Lam

ENT

Thu 24-10-02
PATIENT 1

NPC recurrence + oeso ca

Anteflexed tube, ¯ bore size

Usually just guide through nose, but this Pt oeso ca \ risk perforation

Endoscope ® guide wire ® nasogastric tube

Oeso L = 25 cm (Chinese) - variable

Air to insufflate if oeso collapsed

Tip of guide wire soft \ no perforation

Some Pt (co-operative, no obstructive tumour) - endoscope not needed (Pt swallows nasogastric tube down)

After inserted - stetho to listen to air passed through (hissing)

Confirm positioning with X-ray

Endoscope has 4 channels - instrument, suction, light, camera

PATIENT 2

Physiol of speech: air ® vibration vocal cord ® modulation (paranasal sinuses, tongue, etc)

5 layers vocal cords

Mucosa (epithelium) - most elastic
Lamina propria

Superficial - soft-gelatin, loose fibrous matrix (Reinke's space)

Intermediate (elastic fibres, slightly more mass; if removed, mucosa sticks to vocal ligament ® scarring)

Deep - vocal ligament, dense/ rubberband-like, tensile strength (collagenous fibres). If injured in surgery ® weakening, permanent dysphonia

Vocalis muscle - main body of vocal fold, provides stability and mass

Acid reflux

involved in globus pharyngeus - foreign body sensation, early morning hoarseness

24-pH monitoring (pepsinogen activated in mouth, pharynx no protection ® acid, enzyme injury)

Functional problem

Also can exacerbate ® vocal cord granuloma, polyp

Behavioural mods ® no caffeine, soft drink, fatty foods, meal > 3h before sleeping

Stroboscope - high-speed, out of phase with waveform of pharyngeal mucosa \ gives illusion of slow motion ® good for subtle lesion

Healthy vocal cords have mucus (but not thick and sticky)

Mucus with reflux laryngitis (different condition from reflux oesophagitis) - pepsinogen ® pepsin ® irritate throat ® inflammation ® mucus

PATIENT 3

Previous vocal cord polyp surgery - complicated by granuloma

Previously gave mitomycin-C (anti-ca) which (-) fibroblasts, applied to raw area (eg. immediately after surgery performed)

Note: mitomycin-C also carcinogen \ weight-up possible LT S/E with Tx use (similar to adenoids - previously large benign adenoid were radiated, but Pt's subsequently developed ca from radiation)

Reflux exacerbates vocal polyp

Vocal cord granuloma

Arising from injury to perichondrium of aretynoid cartilage (usually due to intubation)

High recurrence

Case of injury complicated by infection

Also: voice abuse, prolonged intubation

PATIENT 4

Gap in posterior glottis - normal in young females

Altering pitch

Transsexual surgery - scar anterior part vocal cord

Can rotate cricothyroid jt to length and tension

Reinke's oedema: mass of vocal cord \ ¯ pitch

Polyps - usu. junction between anterior 1/3 and posterior 2/3

Difference between polyps and nodules

	Polyps	Nodules
Consistency	Soft	Firm (fibrous)
Behaviour	Vibrate with mucosa
Position	Unilateral*	Bilateral
Tx	Surgery	>70% subside with speech therapy

* Unilateral lesion presses on contralateral side, causes lesion \ eventually bilateral (if remove 1^o lesion, 2^o lesion spontaneously subsides)