43 Pharynx, larynx and neck

DAVID J. HOWARD and VALERIE J. LUND The pharynx The pharynx is a fibro m s! "ar # be formin$ #he pper par# of #he respira#ory and di$es#i%e passa$es. I# ex#ends from #he base of #he s& "" #o #he "e%e" of #he six#h !er%i!a" %er#ebra a# #he "o'er border of #he !ri!oid !ar#i"a$e 'here i# be!omes !on#in o s 'i#h #he oesopha$ s. I# opens an#erior"y in#o #he nose( mo #h and "arynx from abo%e do'n'ards( and is #herefore di%ided in#o #hree par#s( #he nasopharynx( oropharynx and hypo pharynx )*i$. +,.-.. Nasopharynx The nasopharynx "ies an#erior #o #he firs# !er%i!a" %er#ebra and has #he openin$s of #he e s#a!hian # bes in i#s "a#era" 'a""( behind 'hi!h "ie #he pharyn$ea" re!esses( #he fossae of Rosen / ""er. The adenoids are si# a#ed s bm !osa""y a# #he 0 n!#ion of #he roof and pos#erior 'a"" of #he nasopharynx. The nasopharynx is !"osed off from #he oropharynx d rin$ s'a""o'in$ by #he raisin$ of #he sof# pa"a#e and !on#ra!#ion of #he pa"a#opharyn$ea" sphin!#er. Oropharynx This is bo nded abo%e by #he sof# pa"a#e( be"o' by #he pper s rfa!e of #he epi$"o##is and an#erior"y by #he an#erior fa !ia" pi""ar 'hi!h !on#ains #he pa"a#o$"oss s m s!"e. The oropharynx #herefore !on#ains #he pa"a#ine #onsi"s si# a#ed in #he "a#era" 'a"" be#'een #he an#erior and pos#erior pi""ars of #he fa !es and #he pos#erior #hird of #he #on$ e. These pa"a#ine #onsi"s are par# of #he !omp"e#e rin$ of "ymphoid #iss e )Wa"deyer1s rin$. 'hi!h addi#iona""y !omprises #he adenoids and #he "in$ a" #onsi"s on #he pos#erior #hird of #he #on$ e. This rin$ of "ymphoid #iss e o!! pyin$ #he en#ry of #he air and food passa$es is !ons#an#"y exposed #o ne' an#i$eni! s#im "i. I# is an impor#an# par# of #he m !osa"2asso!ia#ed "ymphoid #iss e )/ALT. 'hi!h pro!esses an#i$en and presen#s i# #o T2he"per !e""s and 32!e""s. The #onsi""ar #iss e prod !es imm no$"obin 4 )I$4.( I$A and a sma"" amo n# of I$D. These imm no$" b"ins are se!re#ed in#o #he pharynx and #heir o #p # is in!reased in response #o a 'ide %arie#y of inf"amma#ory pro!esses )*i$. +,.5.. The #iss e of Wa"deyer1s rin$ nder$oes physio"o$i!a" hyper#rophy d rin$ ear"y !hi"dhood as #he !hi"d is exposed #o in!reasin$ amo n#s of an#i$eni! s#im "i6 #here is of#en a simi"ar hyper#rophy of #he !er%i!a" "ymph nodes and( indeed( #he abdomina" "ymph nodes )#he ae#io"o$y of mesen#eri! adeni#is.. The #onsi"s !on#ain #or# o s !ryp#s 'hi!h !an harbo r p s and mi!roor$anisms. 7"o#hin$ #he "a#era" #'o2#hirds of ea!h #onsi" is #he !aps "e( a 'e""2defined s#r !# re !omposed of fibro s and e"as#i! #iss e( and m s!"e fibres. The #onsi" has an ex!ep#iona""y $ood b"ood s pp"y. I# is 'e"" #o bear in mind #ha# a #or# o s fa!ia" ar#ery may be !"ose"y re"a#ed #o #he "o'er po"e. On #he "a#era" aspe!# of #he #onsi" is a %aryin$ n mber of para#onsi""ar %eins 'hi!h may be #he so r!e of serio s %eno s b"eedin$ fo""o'in$ #onsi""e!#omy. This may par#i! "ar"y o!! r 'hen #he b"eedin$ end re#ra!#s in#o #he pper par# of #he #onsi""ar fossa( and #his m s# be fo nd and "i$a#ed before #he pa#ien# "ea%es #he opera#in$ room. Hypo pharynx The hypopharynx is bo nded abo%e by #he pper border of #he epi$"o##is and an#erior"y by #he s"opin$ "aryn$ea" in"e#. I#s inferior border is #he "o'er border of #he !ri!oid !ar#i"a$e 'here i# !on#in es in#o #he oesopha$ s. The hypopharynx is !ommon"y des!ribed ana#omi!a""y of bein$ !omposed of #hree areas8 #he piriform fossae( #he pos#erior pharyn$ea" 'a"" and #he pos#!ri!oid area. The m !osa of #hese

areas is in dire!# !on#in i#y 'i#h no dis#in!# barriers( and disease pro!esses( s !h as ma"i$nan# neop"asms( !an easi"y in%o"%e more #han one area. 9'a""o'in$ 9'a""o'in$ is a !omp"ex ne rom s! "ar a!#. Tra ma and disease may res "# in dyspha$ia and a# #imes aspira#ion of food and f" id in#o #he air'ay. In !onsiderin$ #he diseases 'hi!h in%o"%e #he pharynx and "arynx( i# is impor#an# #o ha%e a basi! nders#andin$ of s'a""o'in$ and #he f n!#ions of #he "arynx. 9'a""o'in$ !onsis#s of #hree s#a$es8 ora"( pharyn$ea" and oesopha$ea" )*i$. +,.,.. :no'"ed$e of #he physio"o$y of norma" s'a""o'in$ and #he prob"ems as a !onse; en!e of disease has been enhan!ed in #he "as# #'o de!ades by se of %ideo f" oros!opi! #e!hni; es. This is #he radio $raphi!a" e%a" a#ion of #he passa$e of a bo" s of radio2opa; e "i; id or so"id from #he poin# a# 'hi!h i# en#ers #he ora" !a%i#y do'n #o i#s passa$e 'i#hin #he s#oma!h. This in%es#i$a#ion is !onsiderab"y more a!! ra#e #han #he o"der2fashioned radio"o$i!a" examina#ion of bari m s'a""o'( 'here #he ob0e!# 'as #o !on!en#ra#e on #he p"ain <2ray examina#ion of #he oesopha$ s( ra#her #han #he ne' #e!hni; e 'hi!h sho's a !omp"e#e %ideo of a"" s#a$es of s'a""o'in$. This !an be re%ie'ed on many o!!asions( if ne!essary( and $i%es far more de#ai" #han p"ain radio$raph fi"ms. 9'a""o'in$ is media#ed %ia efferen# fibres passin$ #o #he med ""a ob"on$a#a #hro $h #he se!ond di%ision of #he #ri$emina" ner%e )V.( $"ossopharyn$ea" )I<. and %a$ s ner%es )<.. The afferen# pa#h'ay is from #he n !"e s ambi$ o s( and is media#ed %ia #he $"ossopharyn$ea" )I<.( %a$ s )<. and hypo$"ossa" )<II. ner%es. Dama$e #o #hese ma0or !rania" ner%es a# any poin# a"on$ #heir pa#h'ay( by #ra ma or disease( may !a se dyspha$ia 'i#h or 'i#ho # aspira#ion. In #he ora" %o" n#ary phase of s'a""o'in$ #he "ips( !hee&s( #on$ e( f"oor of mo #h( #ee#h and pa"a#e par#i!ipa#e in preparin$ #he food. The food is he"d in #he ora" !a%i#y( "a#era"ised for mas#i!a#ion and #hen formed in#o a bo" s. The #on$ e prope"s #he formed bo" s pos#erior"y in#o #he oropharynx in #he se!ond in%o" n#ary pharyn$ea" phase. The sof# pa"a#e is e"e%a#ed #o pre%en# nasopharyn$ea" es!ape( and #he "a#era" and pos#erior 'a""s !on#ra!# #o prope" #he food do'n'ards. The "arynx mo%es p'ards and for'ards as #he pos#erior #on$ e mo%es ba!&'ards and do'n'ards. The main f n!#ion of #he "arynx is in fa!# no# #he prod !#ion of %oi!e b # #he pro#e!#ion of #he #ra!heobron!hea" air'ay and " n$s. I# is basi!a""y a #hree2#iered sphin!#er me!hanism8 #he firs# #ier !onsis#in$ of #he epi$"o##is( aryepi$"o##i! fo"ds and ary#enoids6 #he se!ond #he fa"se !ords6 and #he #hird "e%e" #he #r e %o!a" fo"ds. The 'ho"e "arynx no# on"y mo%es p'ards and for'ards b # #he #hree2#ier sphin!#er me!hanism !"oses on e%ery o!!asion #ha# s'a""o'in$ o!! rs. As #he food en#ers #he piriform fossa #here is an an#i!ipa#ory re"axa#ion of #he pper oesopha$ea" sphin!#er and #he food en#ers #he oesopha$ s. Oesopha$ea" peris#a"#i! 'a%es #hen !on%ey #he food do'n in#o #he s#oma!h. 4ra%i#y aids bo#h #he in%o" n#ary pharyn$ea" and oesopha$ea" phases of s'a""o'in$. Re"a#ions of #he pharynx )*i$. +,.+. The parapharyn$ea" spa!e = #his po#en#ia" spa!e "ies "a#era" #o #he pharynx and is of impor#an!e 'hen nders#andin$ disease of #he pharynx and ne!&. I# is a po#en#ia" spa!e 'hi!h ex#ends from #he base of #he s& "" abo%e #o #he s perior medias#in m be"o'( and i# is o!! pied by #he !aro#id %esse"s( in#erna" 0 $ "ar %ein( deep !er%i!a" "ymph nodes( #he "as# fo r !rania" ner%es and #he !er%i!a" sympa#he#i! #r n&. Infe!#ion and s pp ra#ion of #he !er%i!a" "ymph node in #he parapharyn$ea" spa!e mos# !ommon"y o!! rs from infe!#ions of #he #onsi"s or #ee#h )par#i! "ar"y #he #hird "o'er mo"ar #oo#h.. I# may #hen spread #hro $ho # #he parapharyn$ea" spa!e p #o #he s& "" base or do'n #o #he paraoesopha$ea" re$ion and s perior medias#in m.

Re#ropharyn$ea" spa!e = #his po#en#ia" spa!e "ies pos#erior #o #he pharynx bo nded an#erior"y by #he pos#erior pharyn$ea" 'a"" and i#s !o%erin$ b !!opharyn$ea" fas!ia and pos#erior"y by #he !er%i!a" %er#ebrae and #heir !o%erin$ m s!"es and fas!ia. I# !on#ains #he re#ropharyn$ea" "ymph nodes( 'hi!h are s a""y paired "a#era" nodes( b # 'hi!h are separa#ed by a #o $h median par#i#ion 'hi!h !onne!#s #he pre%er#ebra" 'i#h #he b !!opharyn$ea" fas!ia. These nodes are more de%e"oped in infan!y and yo n$ !hi"dren( and i# is a# #his a$e #ha# #hey are mos# "i&e"y #o he in%o"%ed in inf"amma#ory pro!esses 'hi!h( if se%ere( may affe!# s'a""o'in$ and respira#ion as a !onse; en!e of $ross s'e""in$ and s pp ra#ion of #he re#ropharyn$ea" spa!e. Larynx The "arynx is #he pro#e!#i%e sphin!#er 'hi!h !"oses off #he air'ay d rin$ s'a""o'in$. In h mans and some o#her mamma"s i# is a"so responsib"e for #he $enera#ion of so nd( 'hi!h in h mans is modified by #he pharynx( ora" !a%i#y( nasa" passa$es( sin ses( #on$ e( "ips and #ee#h #o prod !e spee!h. The "arynx has a main"y !ar#i"a$ino s frame'or& 'hi!h may ossify in "a#er "ife and 'hi!h !onsis#s of #he hyoid bone abo%e( #he #hyroid and !ri!oid !ar#i"a$es( and #he in#ri!a#e ary#enoid !ar#i"a$es pos#erior"y. The !ri!oid !ar#i"a$e is #he on"y !omp"e#e rin$ in #he en#ire air'ay and bo nds #he s b $"o##is 'hi!h is #he narro'es# poin# of #he air'ay. This is #he !ommones# si#e for dama$e from endo#ra!hea" # bes( o!!asiona""y !a sin$ "aryn$o#ra!hea" s#enosis. An ana#omi!a" des!rip#ion of #he "arynx di%ides i# in#o #he s pra$"o##is( $"o##is and s b$"o##is )*i$. +,.>..The #r e %o!a" fo"ds )of#en in!orre!#"y !a""ed #he %o!a" !ords. are norma""y 'hi#e in !on#ras# #o #he pin& m !osa of #he res# of #he "arynx and air'ay. The #r e %o!a" fo"ds mee# an#erior"y a# #he mid2"e%e" of #he #hyroid !ar#i"a$e( 'hereas pos#erior"y #hey are separa#e and a##a!hed #o an ary#enoid !ar#i"a$e. This arran$emen# prod !es #he ?V1 shape of #he $"o##is )*i$. +,.@.. Ner%e s pp"y The sensory ner%e s pp"y #o #he "arynx abo%e #he %o!a" fo"ds is from #he s perior "aryn$ea" ner%e and be"o' #he %o!a" fo"ds from #he re! rren# "aryn$ea" ner%e. 3o#h of #hese ner%es are bran!hes of #he %a$ s )<.. The mo#or ner%es s pp"y #o #he "arynx is from #he re! rren# "aryn$ea" ner%e( 'hi!h is a bran!h of #he %a$ s and 'hi!h s pp"ies a"" in#rinsi! m s!"es. On"y one of #hese in#rinsi! m s!"es( #he pos#erior !ri!oary#enoid( abd !#s #he %o!a" fo"ds d rin$ respira#ion. A"" o#her in#rinsi! m s!"es add !# #he !ords. Lympha#i!s The "ympha#i! draina$e of #he s pra$"o##is abo%e #he %o!a" fo"ds is #o #he pper deep !er%i!a" nodes( 'hi"s# in !on#ras# #ha# of #he s b$"o##is is #o inferior deep !er%i!a" nodes and #o #he para#ra!hea" and medias#ina" nodes. AThe %o!a" fo"ds #hemse"%es ha%e a %ery sparse "ympha#i! draina$e. The !ommones# form of ma"i$nan# disease affe!#in$ #he #r e %o!a" fo"ds is s; amo s !e"" !ar!inoma( and # mo rs !onfined #o #he #r e %o!a" fo"ds do no# me#as#asise #o "ymph nodes n"ess #hey spread in#o s pra$"o##i! or s b$"o##i! #iss e. A"" of #he in#rinsi! m s!"es of #he "arynx are s pp"ied by #he re! rren# "aryn$ea" ner%e( and #herefore dama$e #o #his ner%e or #o #he %a$ s ner%e 'i"" !a se para"ysis of #he %o!a" fo"d on #he side of #he dama$e. Bhona#ionCspee!h D rin$ expira#ion air from #he " n$s passes o # #hro $h #he "arynx nder press re and #he %o!a" fo"ds !hanne" #his in#o a !o" mn of hi$h2speed %ibra#in$ air( #h s prod !in$ so nd. This so nd is !on%er#ed in#o in#e""i$ib"e spee!h by #he remainder of #he %o!a" #ra!#( i.e. #he pharynx( #on$ e( "ips( #ee#h and #he resona#in$ !hambers of #he nose and sin ses. The "arynx f n!#ions by !"osin$ #he %o!a" fo"d a$ains# #he air bein$ exha"ed

from #he " n$s b # #he rise in s b$"o##i! press re for!es #he %o!a" fo"ds apar# s"i$h#"y for an ins#an# 'i#h a!!ompanyin$ %ibra#ion of #he %o!a" fo"d epi#he"i m. The openin$ and !"osin$ o!! rs in rapid se; en!e #o prod !e a %ibra#in$ !o" mn of air 'hi!h is #he so r!e of so nd. The pi#!h of #he so nd is !on#ro""ed by #he fre; en!y of #he %o!a" fo"d epi#he"ia" %ibra#ion( 'hi!h in # rn is de#ermined by #he #hi!&ness( "en$#h and #ension of #he %o!a" fo"ds !on#ro""ed by #he in#rinsi! m s! "a# re. The "o dness or in#ensi#y of #he so nd is $o%erned by #he expira#ory air press re and #he amp"i# de of #he %o!a" fo"d %ibra#ions. Bara"ysis or o%er# disease of #he %o!a" fo"ds or !"ose"y asso!ia#ed "aryn$ea" s#r !# res 'i"" $i%e rise #o dis# rban!e of #he so nd and !rea#ion of #he symp#om of hoarseness )Tab"e +,.-.. The ne!& The ne!& is di%ided in#o an#erior and pos#erior #rian$"es by #he s#erno!"eidomas#oid m s!"e. The an#erior #rian$"e ex#ends from #he inferior border of #he mandib"e #o #he s#ern m be"o'( and is bo nded by #he mid"ine and #he s#erno!"eidomas#oid m s!"e. The pos#erior #rian$"e ex#ends ba!&'ards #o #he an#erior border of #rapeDi s and inferior"y #o #he !"a%i!"e. The pper par# of #he an#erior #rian$"e is !ommon"y s bdi%ided in#o #he s bmandib "ar #rian$"e abo%e #he di$as#ri! m s!"e and #he s bmen#a" #rian$"e be"o'. The "ympha#i! draina$e of #he head and ne!& is of !onsiderab"e !"ini!a" impor#an!e )*i$. +,.E.. The mos# impor#an# !hain of nodes is #he deep !er%i!a" nodes 'hi!h r n ad0a!en# #o #he in#erna" 0 $ "ar %ein. The o#her main $ro ps are #he s bmen#a"( s bmandib "ar( prea ri! "ar and pos#a ri! "ar( o!!ipi#a" and pos#erior #rian$"e nodes. The pper deep !er%i!a" nodes( 'hi!h !on#ain #he "ar$e 0 $ "odi$as#ri! node( drain #he oropharynx( in!" din$ #he #onsi"s( pos#ero"a#era" aspe!#s of #he ora" !a%i#y( s perior aspe!#s of #he "arynx and piriform fossae( and are #he !ommones# si#e of en"ar$emen# d e #o disease in #hese areas. The pper deep !er%i!a" nodes may be pa"pa#ed a"on$ #he an#erior border of #he s#erno!"eidomas#oid m s!"e b # 'hen #he m s!"e is 'e"" de%e"oped or #he ne!& is obese i# may be diffi! "# #o e%a" a#e #heir #r e siDe and nder #hese !ir! ms#an!es !"ini!a" examina#ion may be nre"iab"e. /e#as#a#i! spread of s; amo s !e"" !ar!inoma( 'hi!h a!!o n#s for FG per !en# of ma"i$nan# disease of #he head and ne!&( mos# !ommon"y o!! rs 'i#h # mo rs of #he nasopharynx( #on$ e base( #onsi"( piriform fossae and s pra$"o##i! "arynx. When an en"ar$ed ne!& node is de#e!#ed and #he possibi"i#y of ma"i$nan# disease s spe!#ed( i# is #hese fi%e primary si#es 'hi!h m s# re!ei%e !aref " in%es#i$a#ion. /e#as#a#i! spread #o re$iona" "ymph nodes in #he ne!& is mana$ed s r$i!a""y in many !ases by rese!#ion of #he ne!& nodes( and a de#ai"ed &no'"ed$e of #heir ana#omy is #h s re; ired. The paro#id and s bmandib "ar sa"i%ary $"ands( and #he #hyroid and para#hyroid $"ands( are addi#iona" impor#an# ne!& s#r !# res 'hi!h 'i"" be !o%ered separa#e"y in #heir respe!#i%e !hap#ers. 7"ini!a" examina#ion Bharynx and "arynx Brior #o examina#ion of #he pharynx( #he ora" !a%i#y sho "d be examined 'i#h #he aid of a $ood "i$h# and #on$ e depressors )*i$. +,.F.. The ear( nose and #hroa# )ENT. s r$eon ! s#omari"y ses a ref"e!#in$ mirror on #he head or a headband2mo n#ed fibreop#i! "i$h# so r!e 'hi!h permi#s se of bo#h hands #o ho"d ins#r men#s. Inspe!#ion sho "d in!" de #he b !!a" m !osa and "ips( #he pa"a#e( #he #on$ e and f"oor of #he mo #h( a"" s rfa!es of #he #ee#h and $ ms( openin$ and !"osin$ of #he mo #h( and den#a" o!!" sion. Ba#ien#s sho "d be as&ed #o e"e%a#e #he

#on$ e #o #he roof of #he mo #h and pro#r de #he #on$ e #o bo#h #he ri$h# and #he "ef#. Ba"pa#ion may be re; ired sin$ one or #'o fin$ers $en#"y in#raora""y #o fee" any s'e""in$s( and #his may be !ombined 'i#h ex#ra ora" pa"pa#ion of #he s bmen#a" and s bmandib "ar "ymph nodes and sa"i%ary $"ands. 9imp"e per! ssion of #he #ee#h may re%ea" #enderness indi!a#in$ ad0a!en# pa#ho"o$y in #he maxi""a or mandib"e.Examina#ion of #he mo #h 'i#ho # ade; a#e i"" mina#ion( #he se of a #on$ e depressor( and $en#"e pa"pa#ion may fai" #o re%ea" !ommon and impor#an# pa#ho"o$y.*o""o'in$ examina#ion of #he ora" !a%i#y( #he oropharynx is inspe!#ed 'i#h #he "i$h# and 'i#h #he #on$ e depressor p"a!ed firm"y on #o #he #on$ e base #o depress i# inferior"y.The an#erior and pos#erior fa !ia" pi""ars( #he #onsi"( re#romo"ar #ri$one and pos#erior pharyn$ea" 'a"" sho "d a"" he inspe!#ed for !o"o r !han$es( "!era#ion( p s( forei$n bodies and s'e""in$s.E%en 'i#h an experien!ed examiner( approxima#e"y one2#hird of pa#ien#s !anno# #o"era#e #he depression of #he pos#erior base of #on$ e 'i#ho # $a$$in$. Bain and #rism s as a !onse; en!e of pharyn$o"aryn$ea" or ne!& pa#ho"o$y may add #o #he diffi! "#y of #he examina#ion. Ho'e%er( if #he pa#ien# is !o2 opera#i%e #he nasopharynx may be f r#her examined by pos#erior rhinos!opy sin$ a pos#nasa" mirror in#rod !ed a"on$ #he #on$ e depressor and mo%ed so #ha# a mirror ima$e is seen of #he nasopharynx. Li&e'ise( f r#her examina#ion of #he inferior oropharynx( "arynx and piriform fossae !an be ob#ained by indire!# "aryn$os!opy sin$ "aryn$ea" mirrors. 3o#h of #hese mirror examina#ion #e!hni; es re; ire #he se of a head"i$h# and bo#h of #he examiner1s hands. Indire!# "aryn$os!opy a""o's %is a"isa#ion of #he "arynx #o #he "e%e" of #he %o!a" fo"ds( and some#imes addi#iona" %ie's of #he s b$"o##i! and #ra!hea" air'ay. Vo!a" fo"d mobi"i#y may be assessed. *ibre2op#i! pharyn$o"aryn$os!opy The fibre2op#i! nasendos!ope is passed #hro $h #he nose nder #opi!a" anaes#hesia( and #he en#ire nasopharynx( oropharynx and "arynx !an be seen and demons#ra#ed #o o#hers. This #e!hni; e a""o's hi$h2; a"i#y %is a"isa#ion in o%er HG per !en# of pa#ien#s )*i$. +,.H.. /odern fibre2op#i! nasendos!ope ha%e prod !ed #remendo s impro%e2 men#s in examina#ion Of #he nasa" !a%i#ies( pharynx and "arynx. They are no' 'ide"y a%ai"ab"e and sho "d he sed 'hene%er possib"e. The ne!& Wi#h #he pa#ien# si##in$( expose #he 'ho"e ne!& so #ha# bo#h !"a%i!"es are !"ear"y seen. Inspe!# #he ne!& from in fron# and as& #he pa#ien# #o s'a""o'( preferab"y 'i#h #he aid of a sip of 'a#er. No#e #he mo%emen#s of #he "arynx and any s'e""in$ in #he ne!&. As& #he pa#ien# #o pro#r de #he #on$ e if #here is a mid"ine ne!& s'e""in$. A #hyro$"ossa" !ys# 'i"" mo%e p'ards 'i#h #he #on$ e pro#r sion. Then s#and behind #he sea#ed pa#ien# 'ho sho "d si# 'i#h #he !hin f"exed s"i$h#"y do'n'ards #o remo%e any nd e #ension in #he s#rap m s!"es( p"as#ysma and s#erno!"eidomas#oid. Ba"pa#e #he ne!& bi"a#era""y sin$ #he p "ps of #he fin$ers( no# #he #ips. I# is impor#an# #o pa"pa#e #he $ro ps of "ymph nodes in a defini#e manner !omparin$ #he #'o sides of #he ne!&. 3e$in 'i#h #he s perfi!ia" !hain aro nd #he pper ne!& and !aref ""y pa"pa#e #he en#ire "en$#h of #he deep !er%i!a" nodes aro nd #he in#erna" 0 $ "ar %ein.On examinin$ for a " mp in #he ne!& i# is of#en he"pf " #o as& #he pa#ien# #o poin# #o #he " mp firs#. As& #hem 'he#her #he " mp is #ender. A s'e""in$ benea#h #he s#ernomas#oid m s!"e may be !onsiderab"y "ar$er #han yo r e%a" a#ion on pa"pa#ion. If yo are s spi!io s #ha# a ne!& node is en"ar$ed as a res "# of ma"i$nan!y )i# may be hard( irre$ "ar or fixed #o o%er"yin$ s&in or #o deep s#r !# res. #hen i# is manda#ory #o inspe!# #he nasopharynx( #onsi"s( #on$ e base( piriform fossa and s pra$"o##i! "arynx )Tab"e +,.5..

In%es#i$a#ion of diseases in #he pharynx( "arynx and ne!& B"ain "a#era" <2rays B"ain "a#era" radio$raphs of #he ne!& and !er%i!a" spine may sho' sof#2#iss e abnorma"i#ies6 of par#i! "ar impor#an!e is #he dep#h and o #"ine of #he pre%er#ebra" sof#2#iss e shado'. The o #"ine of #he "aryn$o#ra!hea" air'ay may be a sef " $ ide #o #he presen!e of disease in #he pharynx and "arynx )*i$. +,.-G.. Radio2opa; e forei$n bodies may be %isib"e( impa!#ed in #he pharynx( "arynx or pper oesopha$ s.There sho "d be no air 'i#hin #he pper oesopha$ s( if #his is seen i# is indi!a#i%e of pa#ho"o$y. 3ari m s'a""o' This <2ray has #radi#iona""y been sed #o assess #he pharynx and oesopha$ s sin$ simp"e bari m "i; id and p"ain <2rays. Ho'e%er( i# has no' been s perseded in many p"a!es by #he se of %ideo f" oros!opi! s# dies 'hi!h re!ord #he mo%in$ ima$es of a sma"" ; an#i#y of radio2opa; e "i; id( enab"in$ e%a" a#ion of #he ora" and pharyn$ea" phases of s'a""o'in$ in m !h more de#ai" )*i$. +,.--.. /anome#ri! ana"ysis and pH re!ordin$s 'i#hin #he pharynx and oesopha$ s are sed in spe!ia"ised ni#s and may be !o p"ed 'i#h sim "#aneo s %ideo f" oros!opy #o assess !han$es in " mina" press re and pH #o define m s! "ar in!o2ordina#ion and #he ro"e of ref" x of "o'2pH $as#ri! !on#en#s. 7omp #erised #omo$raphy )7T. s!annin$ 7T s!annin$ is 'ide"y sed #o assess head and ne!& disorders( and #he in!reasin$ ; a"i#y of #he ima$es pro%ides m !h impro%ed demons#ra#ion of disease in #he pharynx( "arynx and ne!&. In#ra%eno s !on#ras# $i%en a# #he same #ime as #he 7T s!an )dynami! s!annin$. f r#her impro%es #he demons#ra#ion of disease in #hese areas )*i$. +,.-5.. O#her #e!hni; es /a$ne#i! resonan!e ima$in$ )/RI. is bein$ in!reasin$"y sed and may $i%e be##er sof#2#iss e defini#ion of some diseases h # poorer defini#ion of bony and !ar#i"a$ino s s#r !# res. U"#raso nd s!annin$ !an be sef " in differen#ia#in$ so"id "esions( e.$. ma"i$nan# "ymph nodes from !ys#i! "esions s !h as a bran!hia" !ys#. *ine need"e aspira#ion !y#o"o$y This #e!hni; e !an be performed nder "o!a" anaes#hesia ei#her in #he o #2pa#ien# depar#men# or in a !y#o"o$y !"ini!.*ine need"e aspira#ion !y#o"o$y is sef " par#i! "ar"y if a ne!& " mp is #ho $h# #o be ma"i$nan#. In!reasin$"y hi$h ra#es of a!! ra#e his#o"o$i!a" dia$nosis are repor#ed and #here is no e%iden!e of spread of # mo r #hro $h #he s&in #ra!& !a sed by #he fine hyperdermi! need"e sed 'i#h #his #e!hni; e. *ine need"e aspira#ion may be f r#her aided by "#raso nd or 7T $ idan!e. An$io$raphy or di$i#a" s b#ra!#ion %as! "ar ima$in$ These may be indi!a#ed if a %as! "ar "esion s !h as a !aro#id body # mo r is s spe!#ed. An$io$raphy may ha%e a #herape #i! ro"e #o p"ay by fa!i"i#a#in$ embo"isa#ion of #he "esion. Voi!e ana"ysis An in!reasin$ %arie#y of #e!hni; es is no' a%ai"ab"e for #he meas remen# of %o!a" f n!#ion in!" din$ %ideos#robos!opy. This #e!hni; e #i"ises a f"exib"e or ri$id endos!ope !o p"ed #o a %ideo2!amera and a s#robos!opi! "i$h#. This a""o's iden2 #ifi!a#ion of #he fine epi#he"ia" mo%emen#s of #he %o!a" fo"ds and demons#ra#es #his on a moni#or #o #he pa#ien#( do!#or and spee!h #herapis#. This #e!hni; e a""o's %ery sensi#i%e assessmen# of "aryn$ea" %o!a" fo"d pa#ho"o$y. Dire!# pharyn$os!opy and "aryn$os!opy

An examina#ion of #he pharynx( "arynx and ne!& nder $enera" anaes#hesia may be re; ired as a res "# of prob"ems 'i#h #he ro #ine examina#ion of pa#ien#s. This may be d e #o an inade; a#e %ie' as a !onse; en!e of #rism s from pain( poor pa#ien# !omp"ian!e( or "ar$e obs#r !#i%e pharyn$ea" or "aryn$ea" pa#ho"o$y. These examina#ions may be f r#her aided by #he se of an opera#in$ mi!ros!ope( or ri$id #e"es!opes )Hop&in1s rods. 'hi!h impro%e #he %is a"isa#ion of #he pharynx and "arynx )*i$. +,.-,.. Diseases of #he pharynx Nasopharynx En"ar$ed adenoid The mos# !ommon !a se of an en"ar$ed adenoid )#here is on"y one nasopharyn$ea" adenoid( despi#e #he !ommon se of #he #erm ?adenoids1. is physio"o$i!a" hyper#rophy )*i$. +,.-+.. The siDe of #he adenoid a"one is no# an indi!a#ion for remo%a". I# is of#en asso!ia#ed 'i#h hyper#rophy of #he o#her "ymphoid #iss es of Wa"deyer1s rin$. If ex!essi%e hyper#rophy !a ses b"o!&a$e of #he nasopharynx in asso!ia#ion 'i#h #onsi" hyper#rophy( #he pper air'ay may be!ome !ompromised d rin$ s"eep !a sin$ obs#r !#i%e s"eep apnoea. This !ondi#ion is be!omin$ in!reasin$"y dia$nosed( and is impor#an# be!a se i# !an !a se s"eep depri%a#ion and se!ondary !ardia! !omp"i!a#ions. I# has been imp"i!a#ed in some !ases of a s dden infan# dea#h syndrome. The mos# !ommon symp#om is snorin$( 'hi!h is #ypi!a""y irre$ "ar( 'i#h #he !hi"d a!# a""y !easin$ respira#ion )apnoea. and #hen res#ar#in$ 'i#h a "o d inspira#ory snor#. The !hi"d is of#en res#"ess and may #a&e p s#ran$e s"eepin$ posi#ions as he or she #ries #o impro%e #he pharyn$ea" air'ay. 9 r$i!a" remo%a" of #he #onsi"s and adenoid is ! ra#i%e( b # i# is impor#an# #o a%oid seda#i%e premedi!a#ions and opia#e ana"$esi!s pos#opera#i%e"y be!a se #hey may f r#her depress #he !hi"d1s respira#ory dri%e. Obs#r !#i%e s"eep apnoea may a"so o!! r in ad "#s( 'here #he obs#r !#ion may res "# from nasa" deformi#y( a hyper#rophi! sof# pa"a#e asso!ia#ed 'i#h an a"#ered nasopharyn$ea" is#hm s( obesi#y and $enera" narro'in$ of #he pharyn$ea" air'ay( or s pra$"o##i! "aryn$ea" pa#ho"o$y. 9 r$ery may be indi!a#ed fo""o'in$ in%es#i$a#ion by means of a s"eep s# dy( d rin$ 'hi!h meas remen# of #he pa#ien#1s s"eep pa##ern and ar#eria" oxy$ena#ion is nder#a&en. Hyper#rophy of adenoid #iss e mos# !ommon"y o!! rs be#'een #he a$es of + and -G years( b # #he adenoid #iss e s a""y nder$oes spon#aneo s a#rophy d rin$ p ber#y( a"#ho $h some remnan#s may persis# in#o ad "# "ife. The re"a#ionship of adenoid en"ar$emen# #o re! rren# se!re#ory o#i#is media or re! rren# a! #e o#i#is media is no# en#ire"y !"ear. I# has "on$ been #ho $h# #ha# e s#a!hian # be dysf n!#ion res "#s from ei#her inf"amma#ory oedema or in#erferen!e 'i#h pa"a#a" e"e%a#ion 'hi!h opens #he e s#a!hian # be. Ho'e%er( #he exa!# re"a#ionship has no# been de#ermined and many !hi"dren 'ho ha%e se!re#ory o#i#is media do no# a"'ays benefi# from adenoid remo%a". Adenoide!#omy Adenoid #iss e !an be remo%ed a"one or in !on0 n!#ion 'i#h a #onsi""e!#omy. Indi!a#ions are8 A obs#r !#i%e s"eep apnoea asso!ia#ed 'i#h pos#nasa" obs#r !#ion6 A pos#nasa" dis!har$e6 A re! rren# a! #e o#i#is media or pro"on$ed sero s o#i#is media s a""y "on$er #han , mon#hs1 d ra#ion6 A re! rren# rhinosin si#is.

Opera#i%e #e!hni; e. The adenoid #iss e is remo%ed 'i#h a $ arded ! re##e )*i$. +,.->. pressed a$ains# #he roof of #he nasopharynx and #hen !arried do'n'ards in a modera#e"y firm s'eepin$ mo%emen# brin$in$ #he ex!ised adenoid in#o #he oropharynx )*i$. +,.-@.. The $ ard on #he ! re##e se! res #he adenoid and pre%en#s i# from droppin$ inferior"y in#o #he air'ay. A pos#nasa" s'ab is p"a!ed in#o #he nasopharynx n#i" a"" haemorrha$e has !eased.Rea!#ionary or se!ondary haemorrha$e d rin$ #he re!o%ery period may re; ire #he p"a!in$ of a nasopharyn$ea" pa!& nder a f r#her anaes#he#i!. This !an o!!asiona""y !a se respira#ory depression in !hi"dren and ad "#s( and #hey re; ire s#ri!# obser%a#ion 'hi"e #he pa!& is in p"a!e. T mo rsof #he nasopharynx 3eni$n. There are #'o main #ypes of beni$n # mo r of #he nasopharynx8 #he an$iofibroma and #he an#ro!hoana" po"yp. An$"o fibroma. This is of#en #ermed ?nasopharyn$ea" an$iofibroma1( b # #his is in!orre!# as #he # mo r arises in #he area of #he sphenopa"a#ine foramen in #he pos#erior par# of #he nasa" !a%i#y. Ho'e%er( i# readi"y expands in#o #he nasopharynx and( a"#ho $h #he # mo r is no# ma"i$nan# in #ha# i# ne%er me#as#asises( i# does spread re"en#"ess"y o%er #he s& "" base expandin$ an#erior"y in#o #he nasa" !a%i#ies disp"a!in$ #he nasa" sep# m( !ompressin$ #he pos#erior 'a"" of #he maxi""ary an#r m and of#en en#erin$ i# by bone erosion. Li&e'ise( i# may en#er and expand #he sphenoid sin s and spread "a#era""y #hro $h #he p#ery$opa"a#ine fiss re and on'ards in#o #he infra#empora" fossa o!!asiona""y #o rea!h #he sof# #iss es of #he !hee& and orbi# %ia #he inferior orbi#a" fiss re. Inferior"y i# may fi"" #he nasopharynx( depress #he sof# pa"a#e and e%en# a""y appear 'i#hin #he oropharynx )*i$. +,.-E.. /a!ros!opi!a""y #here is a firm reddish2b" e # mo r !o%ered 'i#h norma" m !o s membrane( b # "!era#ion may o!! r if #he # mo r han$s in#o #he oropharynx or be!omes exposed an#erior"y a# #he nos#ri". /i!ros!opi!a""y i# is !omposed of imma# re fibrob"as#s and b"ood %esse"s( and i# remains beni$n e%en in i#s ad%an!ed s#a$es. I# sho "d probab"y be re$arded as a hamar#oma. 7"ini!a""y #he # mo r is !onfined #o ma"e pa#ien#s !ommon"y be#'een #he a$es of F and 5G years( i.e. aro nd p ber#y. I# o!!asiona""y o!! rs in #he 5Gs and ,Gs. I# rare"y re$resses and s a""y !a ses pro$ressi%e nasa" obs#r !#ion( re! rren# se%ere epis#axis( p r "en# rhinorrhoea and o!!asiona""y "oss of %ision d e #o !ompression of #he op#i! ner%e. A"#ho $h #he # mo r is rare( #hese symp#oms in a yo n$ boy sho "d a"'ays aro se s spi!ion.The # mo r o!! rs in many !o n#ries aro nd #he 'or"d b # is mos# !ommon in nor#hern India. The reasons for #his are n&no'n. 9#andard !"ini!a" examina#ion may easi"y re%ea" #he # mo r in #he nasa" !a%i#y or nasopharynx( b # 7T s!annin$ bes# demons#ra#es #he ex#en# of #he # mo r and i#s a!!ompanyin$ bony erosion. /RI s!annin$ 'i"" f r#her define #he sof#2#iss e ex#en# and 'i#h #hese #'o modern in%es#i$a#ions an$io$raphi! e%a" a#ion is rare"y indi!a#ed. 3iopsy sho "d be a%oided n"ess !"ini!a" and radio"o$i!a" examina#ion is no# !"ear. There sho "d be defini#e reasons for nder#a&in$ biopsy( and ma#!hed b"ood m s# be in readiness and #he s r$eon prepared #o dea" 'i#h #he haemorrha$e. Whi"s# radio#herapy has o!!asiona""y been ad%o!a#ed( s r$i!a" rese!#ion is by #he far !ommones# mana$emen# 'or"d'ide and re; ires an ade; a#e expos re of #he en#ire re$ion ei#her #hro $h a midfa!ia" de$"o%in$ approa!h or a "a#era" rhino#omy )*i$s +,.-F and +,.-H.. 3o#h of #hese approa!hes a""o' "i$a#ion of #he feedin$ maxi""ary ar#ery. A #ranspa"a#a" approa!h may be sed for #he sma""er # mo rs b # #his does no# $i%e f "" !on#ro" of any po#en#ia" b"eedin$. An#ro!hoana" po"yp. This re"a#i%e"y n!ommon "esion is no# a # mo r b # a simp"e m !osa" po"yp. I# does no# arise in #he nasopharynx( b # from #he maxi""ary an#r m(

from 'hi!h i# pro"apses in#o #he nasa" !a%i#y and #hen!e expands ba!&'ards in#o #he nasopharynx and o!!asiona""y do'n in#o #he oropharynx )*i$s +,.5G and +,.5-.. I# a"so !ommon"y o!! rs in yo n$ ma"es( and #herefore may mimi! a # mo r of #he nasa" !a%i#y or nasopharynx. I# is dis#in$ ished !"ini!a""y from an an$iofibroma by i#s a%as! "ari#y( pa"e !o"o r( i#s si#e of ori$in on endos!opi! examina#ion and ima$in$( as i# is a simp"e m !osa" po"yp. Whi"s# i# may be remo%ed in#ra nasa""y by an a% "sion snare( a por#ion of#en remains in #he an#r m prod !in$ re! rren# symp#oms and i# re; ires !omp"e#e remo%a" %ia an endos!opi! approa!h #hro $h #he midd"e mea# s or( o!!asiona""y( a 7a"d'e""=L ! pro!ed re #o pre%en# re! rren!e. /a"i$nan#. Nasopharyn$ea" !ar!inoma is an in#eres#in$ s; amo s !e"" !ar!inoma 'i#h a %ery %ariab"e in!iden!e. In mos# par#s of #he 'or"d #he # mo r is rare 'i#h an in!iden!e of "ess #han one person in -GG GGG per year. Ho'e%er( i# is a !ommon # mo r amon$s# so #hern 7hinese( and #his hi$h2ris& pop "a#ion has ra#es of ,G=>G peop"e per -GG GGG per year. In #he res# of 7hina #here are s bs#an#ia" %aria#ions in #he in!iden!e b #( in $enera"( #he in!iden!e de!reases from so #h #o nor#h. Hi$her fre; en!ies of nasopharyn$ea" !ar!inoma are a"so obser%ed in emi$ran# so #hern 7hinese pop "a#ions in so #h2eas# Asia and e"se'here aro nd #he 'or"d( and i# is a"so more !ommon amon$s# Es&imo( #he :adaDans in Eas# /a"aysia and par#s of nor#hern Afri!a. I# is no' 'e"" a!!ep#ed #ha# me!hanisms "eadin$ #o de%e"opmen# of a !an!er of#en in%o"%e a m "#i s#ep pro!ess( and #he ae#io"o$y of nasopharyn$ea" !ar!inoma is mos# "i&e"y #o be m "#ifa!#oria" 'i#h no sin$"e !a se ade; a#e"y exp"ainin$ #he epidemio"o$y of #he disease. Ho'e%er( i# is a"so !"ear #ha# #hree 'e""2defined ma0or ae#io"o$i!a" fa!#ors are in%o"%ed in i#s de%e"opmen# )Tab"e +,.,.. The exa!# me!hanism as #o ho' #hese fa!#ors a!# is no# ye# f ""y nders#ood. The ma0ori#y of s; amo s !ar!inomas of #he nasopharynx is ndifferen#ia#ed and #he morpho"o$y of #his # mo r is !hara!#eris#i!. On"y a fe' are 'e""2differen#ia#ed s; amo s !ar!inomas( and #hese #'o "esions ma&e p o%er HG per !en# of nasopharyn$ea" ma"i$nan!y in endemi! areas. O#her rare epi#he"ia" # mo rs are adeno!ar!inoma and adenoid !ys#i! !ar!inoma. 32 and T2!e"" "ymphomas a"so o!! r in #his re$ion and sho "d no# be !onf sed 'i#h #he more !ommon ndifferen#ia#ed !ar!inoma. Nasopharyn$ea" !ar!inoma affe!#s a yo n$er a$e $ro p of #he pop "a#ion #han a"mos# any o#her head and ne!& neop"asm. In endemi! re$ions a# "eas# @G per !en# of pa#ien#s are nder >G years of a$e and #his app"ies #o bo#h sexes. 7"ini!a" fea# res. 9ymp#oms are !"ose"y re"a#ed #o #he posi#ion of #he # mo r in #he nasopharynx and #he de$ree of dis#an# spread 'hi!h may be presen#. Ear"y symp#oms are of#en minima" in na# re and #h s "iab"e #o be i$nored by bo#h pa#ien# and do!#or. A Approxima#e"y ha"f #he pa#ien#s 'i"" presen# 'i#h a mass in #he ne!&. This per!en#a$e is e%en hi$her in pa#ien#s nder 5- years of a$e. I# indi!a#es #ha# #he # mo r has a"ready rea!hed an ad%an!ed s#a$e. *ine need"e aspira#e or a biopsy of a ne!& node sho'in$ ndifferen#ia#ed !ar!inoma re; ires immedia#e #horo $h examina#ion of #he nasopharynx. A The nasopharynx may "oo& norma" or on"y minima""y asymme#ri! b # !on#ain s bm !osa" nasopharyn$ea" !ar!inoma. Nasa" !omp"ain#s o!! r in one2#hird of pa#ien#s and a ra" symp#oms of ni"a#era" deafness( as a !onse; en!e of e s#a!hian # be obs#r !#ion and se!re#ory o#i#is media( o!! r in approxima#e"y 5G per !en#. Ne ro"o$i!a" !omp"i!a#ions 'i#h !rania" ner%e pa"sies d e #o disease on #he s& "" base o!! r re"a#i%e"y "a#e in #he disease b # are a poor pro$nos#i! fa!#or. A biopsy of #he nasopharynx is manda#ory if #here is s spi!ion of nasopharyn$ea" ma"i$nan!y.The #radi#iona" me#hod of indire!# examina#ion 'i#h a mirror( a"#ho $h ade; a#e in some pa#ien#s( has been s perseded by dire!# inspe!#ion !arried o # by a

f"exib"e or ri$id nasendos!ope. If #opi!a" anaes#hesia is sed( a biopsy may be #a&en. 9ero"o$i!a" in%es#i$a#ion for Eps#ein=3arr %ir s2asso!ia#ed an#i$eni! mar&ers( in !ombina#ion 'i#h #he !"ini!a" and his#o"o$i!a" examina#ion( is %a" ab"e for #he ear"y de#e!#ion of disease. Hi$h"y sensi#i%e assays for an#i%ira" an#ibodies( #o$e#her 'i#h #he ne'"y dis!o%ered %ir s2asso!ia#ed sero"o$i!a" mar&ers( are assis#in$ no# on"y in #he ear"y de#e!#ion b # in #he #rea#men# and !on#ro" of #his disease. I$A an#i%ira" !apsid an#i$en )V7A. an#ibody has re!en#"y been e%a" a#ed in mass s r%eys in so #hern 7hina and has been fo nd #o be an ex!e""en# s!reenin$ me#hod for #he ear"y de#e!#ion of nasopharyn$ea" !ar!inoma in hi$h2ris& $ro ps. Ima$in$.Ima$in$ is essen#ia" #o de#ermine #he ex#en# of #he disease and #o enab"e !orre!# s#a$in$. In areas 'here 7T and /RI are a%ai"ab"e p"ain fi"m radio$raphy of #he nasopharynx and o#her an!i""ary me#hods( s !h as xero$raphy and #omo$raphy( ha%e no' been s perseded. A !hes# <2ray( ho'e%er( sho "d s#i"" be performed. 7T has a ma0or ro"e in de#erminin$ #he siDe and posi#ion of #he # mo r essen#ia" for radio#herapy p"annin$ and assessin$ #he response #o #rea#men#( dia$nosin$ re! rren!e and de#e!#in$ !omp"i!a#ions. Trea#men#.Brimary #rea#men# of nasopharyn$ea" !ar!inoma is radio#herapy. The ma0ori#y of #he # mo rs be"on$s #o #he radiosensi#i%e ndifferen#ia#ed s; amo s !e"" $ro p. Wi#h #he ad%en# of 7T( pre!ise radio#herapy #rea#men# p"annin$ is no' possib"e and bra!hy#herapy )in#ra!a%i#ary and in#ers#i#ia" radio#herapy. and !hemo#herapy are in!reasin$"y added in #he mana$emen# p"an. E"e!#i%e ex#erna" radio#herapy is $i%en #o #he ne!& in a"" !ases( e%en 'hen no ne!& nodes are apparen#. *or ear"y disease( ,2year disease2free s r%i%a" ra#es of more #han E> per !en# are no' !ommon. Ho'e%er( "a#e disease has fi$ res of on"y ,G=>G per !en# for ,2year disease2free s r%i%a". A"#ho $h #he benefi# of modern radio#herapy is beyond do b#( #he %a" e of addi#iona" !hemo#herapy remains deba#ed( b # i# is "i&e"y #ha# a !ombina#ion of !hemo#herapy and radio#herapy 'i"" prod !e be##er "o!o re$iona" !on#ro" of #he # mo r. 9 r$ery is reser%ed for re! rren# disease in ne!& nodes and #he o!!asiona" remo%a" of re! rren# s& "" base disease 'hi!h has no# responded #o addi#iona" radio#herapy or !hemo#herapy. Oropharynx A! #e #onsi""i#is This !ommon !ondi#ion is !hara!#erised by a sore #hroa#( fe%er( $enera" ma"aise( dyspha$ia( en"ar$ed pper !er%i!a" nodes and some#imes referred o#a"$ia. Approxima#e"y ha"f #he !ases are ba!#eria"( #he mos# !ommon !a se bein$ a pyo$eni! $ro p A s#rep#o!o!! s. The remainder is %ira" and a 'ide %arie#y of %ir ses has been imp"i!a#ed6 in par#i! "ar( infe!#io s monon !"eosis may fre; en#"y be mis#a&en for ba!#eria" #onsi""i#is. On examina#ion #he #onsi"s are s'o""en and ery#hema#o s( and ye""o' or 'hi#e p s# "es may be seen on #he pa"a#ine #onsi"s( hen!e #he name ?fo""i! "ar #onsi""i#is1. A #hroa# s'ab sho "d be #a&en a# #he #ime of examina#ion and b"ood for Ba "=3 nne"" #es#in$ )*i$. +,.55.. Trea#men#. Bara!e#amo" or simi"ar ana"$esia may be adminis#ered #o re"ie%e pain and $ar$"es of $"y!ero"=#hymo" are soo#hin$. The !ondi#ion is fre; en#"y sensi#i%e #o benDy" or phenyoxyme#hy"peni!i""in )peni!i""in V. and #hese are $i%en n#i" an#ibio#i! sensi#i%i#ies are &no'n. Ampi!i""in is a%oided as i# may exa!erba#e #he si# a#ion and pre!ipi#a#e a rash in pa#ien#s 'i#h infe!#io s monon !"eosis. /os# !ases reso"%e in a fe' days. I insy This is #he forma#ion of an abs!ess in #he peri#onsi""ar re$ion !a sin$ se%ere pain and #rism s( and mos# s a""y asso!ia#ed 'i#h s#rep#o!o!!a" infe!#ion )see *i$. +,.5,..

Trism s !a sed by spasm ind !ed in #he p#ery$oid m s!"es from #he spreadin$ infe!#ion may ma&e examina#ion diffi! "#. This may be o%er!ome by #he ins#i""a#ion of "o!a" anaes#hesia in#o #he pos#erior nasa" !a%i#y )#hereby anaes#he#isin$ #he spheno2 pa"a#ine $an$"ion. and dire!#"y in#o #he oropharynx. This simp"e manoe %re aids s bse; en# examina#ion 'hi!h sho "d be !arried o # 'i#h $ood i"" mina#ion and s !#ion. A diff se s'e""in$ of #he sof# pa"a#e 0 s# s perior #o #he in%o"%ed #onsi" is seen disp"a!in$ #he % "a media""y and( in more ad%an!ed !ases( #here may be an area of p s poin#in$ ndernea#h #he #hin m !osa. Trea#men#. In #he ear"y s#a$es 'here no dis#in!# abs!ess is poin#in$( in#ra%eno s broad2spe!#r m an#ibio#i!s are indi!a#ed and may prod !e reso" #ion. Ho'e%er( if #here is fran& abs!ess forma#ion( in!ision and draina$e of #he p s !an be !arried o # nder "o!a" anaes#hesia )*i$. +,.5+.. A sma"" s!a"pe" is bes# modified by 'indin$ a s#rip of adhesi%e #ape aro nd #he b"ade so #ha# on"y - !m of #he b"ade pro0e!#s. In #eena$ers and yo n$ ad "#s #he pa#ien# si#s pri$h# and an in!ision is made in #he posi#ion sho'n in *i$. +,.5+. This is approxima#e"y mid2'ay be#'een #he base of #he % "a and #he #hird pper mo"ar #oo#h. This may prod !e immedia#e re"ease of p s b #( if no#( dressin$ for!eps are no' p shed firm"y #hro $h #he in!ision dire!#"y ba!&'ards and( on openin$( p s may #hen be en!o n#ered. In sma"" !hi"dren $enera" anaes#hesia may be re; ired. 7hroni! #onsi""i#is 7hroni! #onsi""i#is s a""y res "#s from repea# a##a!&s of a! #e #onsi""i#is in 'hi!h #he #onsi"s be!ome pro$ressi%e"y dama$ed and pro%ide a reser%oir for infe!#i%e or$anisms. Tonsi""e!#omy. Indi!a#ions for #onsi""e!#omy may be di%ided in#o abso" #e or re"a#i%e )Tab"e +,.>..When #he siDe of #he #onsi"s is !on#rib #in$ #o air'ay obs#r !#ion or a ma"i$nan!y of #he #onsi"s is s spe!#ed( #he de!ision #o perform #onsi""e!#omy is re"a#i%e"y s#rai$h#for'ard. 7omp"e#e #onsi""e!#omy is preferab"e #o 'ed$e biopsies 'hen s; amo s !e"" !ar!inoma is s spe!#ed( and bi"a#era" #onsi""e!#omy is performed in #he !ase of s spe!#ed "ymphoma as par# of #he s#a$in$ pro!ess. 7onsiderab"e in#eres# no' fo! ses on #he area of s"eep apnoea and re"a#ed prob"ems. Ba#ien#s sho "d be admi##ed for forma" s"eep s# dies #o es#ab"ish #he exa!# ex#en# and si#e of #he prob"em fo""o'in$ 'hi!h a %arie#y of medi!a" and s r$i!a" #rea#men#s may be deemed appropria#e( one of 'hi!h is #onsi""e!#omy. Re! rren# a! #e #onsi""i#is is #he !ommones# re"a#i%e indi!a#ion for #onsi""e!#omy in !hi"dren and ado"es!en#s( a"#ho $h i# is impor#an# #ha# #hese a##a!&s are 'e"" do! men#ed and do no# simp"y !ons#i# #e a minor sore #hroa# s a""y of %ira" ori$in and of shor# d ra#ion. 7hroni! #onsi""i#is more fre; en#"y affe!#s yo n$ ad "#s in 'hom i# is impor#an# #o es#ab"ish #ha# !hroni! mo #h brea#hin$ se!ondary #o nasa" obs#r !#ion is no# #he main prob"em ra#her #han #he #onsi"s #hemse"%es. Idea""y( #he pro!ed re sho "d be nder#a&en 'hen #he #onsi"s are no# a! #e"y infe!#ed( and i# is impor#an# #o dis! ss fa!#ors 'hi!h may in!rease #he #enden!y #o b"eed. 3"ood #ransf sion is rare"y re; ired b # i# is norma" pra!#i!e #o perform a ?$ro p and sa%e1 in !hi"dren nder -> &$ in 'ei$h#. Disse!#ion #onsi""e!#omy is !arried o # nder $enera" anaes#hesia d rin$ 'hi!h #he pa#ien# "ies s pine 'i#h #he head ex#ended and 'i#h #he s r$eon si##in$ a# #he end of #he opera#in$ #ab"e. The m !osa of #he an#erior fa !ia" pi""ar is in!ised and #he #onsi" !aps "e iden#ified. Usin$ b" n# disse!#ion #he s r$eon separa#es #he #onsi" from i#s bed n#i" on"y a sma"" inferior pedi!"e is "ef# )*i$. +,.5>.. Us a""y a snare is sed #o separa#e i# from #he "in$ a" #onsi". Ribbon $a De is p"a!ed in #he #onsi""ar bed and press re app"ied for some min #es fo""o'in$ 'hi!h b"eedin$ poin#s may be !on#ro""ed

by "i$a# re or by bipo"ar dia#hermy. *o""o'in$ s r$ery( #he pa#ien# is &ep# nder !"ose obser%a#ion for any sys#emi! or "o!a" e%iden!e of b"eedin$ 'i#h re$ "ar moni#orin$ of p "se and b"ood press re( and obser%a#ion #o see 'he#her #he pa#ien# is s'a""o'in$ ex!essi%e"y )*i$. +,.5@.. The pa#ien# is &ep# ni" by mo #h for #he firs# fe' ho rs in !ase an immedia#e )or rea!#ionary. haemorrha$e sho "d ne!essi#a#e a re# rn #o #hea#re. Af#er #his period #he pa#ien# is en!o ra$ed #o se #he mo #h and a norma" die# rapid"y ins#i# #ed. Bara!e#amo" is preferred #o aspirin2!on#ainin$ ana"$esi!s. Ba#ien#s are $enera""y a""o'ed home on #he fo""o'in$ day and are 'arned #ha# #hey may experien!e o#a"$ia d e #o referred pain from #he $"ossopharyn$ea" ner%e and #ha# "a#e )or se!ondary. haemorrha$e may o!! r p #o -G days fo""o'in$ #he s r$ery( 'hi!h 'o "d ne!essi#a#e #heir immedia#e re# rn #o hospi#a". Haemorrha$e is ob%io s"y #he mos# !ommon !omp"i!a#ion( o!! rrin$ in #he immedia#e pos#opera#i%e period )Tab"e +,.@.. Lo!a" press re( hydro$en peroxide( $ar$"es and $enera" s ppor#i%e meas res may he"p in mi"d !ases( b # i# is $enera""y .'ises# #o re# rn #o #hea#re for defini#i%e #rea#men# par#i! "ar"y in yo n$er pa#ien#s. 3"ood "oss is rep"a!ed 'i#h !rys#a""oid 'hi"s# a !ross2ma#!h is performed( and fre; en# obser%a#ions of b"ood press re( p "se and respira#ory ra#e are made. Ade; a#e ana"$esia is $i%en 'i#ho # !a sin$ respira#ory depression. Wi#h #he pa#ien# sea#ed pri$h# in bed #he mo #h is examined nder reasonab"e i"" mina#ion #o de#ermine #he si#e of b"eedin$ and if possib"e #o s !#ion a'ay !"o#s from #he #onsi""ar fossa. A s'ab soa&ed in - in -GGG adrena"ine may be he"d a$ains# #he b"eedin$ area in a !o2opera#i%e pa#ien#( b # if #his is no# possib"e andCor #he b"eedin$ persis#s #hea#re sho "d be a"er#ed. Under $enera" anaes#hesia i# may be possib"e #o iden#ify a b"eedin$ spo#( b # of#en a more $enera"ised ooDe is obser%ed and s # rin$ of #he #onsi" bed !ombined 'i#h #he app"i!a#ion of 9 r$i!e" and bipo"ar dia#hermy is of#en more s !!essf " #han a##emp#ed p"a!emen# of "i$a# res. La#e haemorrha$e is $enera""y se!ondary #o infe!#ion and pa#ien#s sho "d be immedia#e"y !ommen!ed on in#ra%eno s an#ibio#i!s 'i#h aerobi! and anaerobi! !o%er. 9i$nifi!an# or persis#en# b"eedin$ may re; ire a f r#her $enera" anaes#he#i! and nder se'in$ of #he s r$i!a" bed( 'hi!h by #his #ime 'i"" of#en be !o%ered 'i#h s"o $h and $ran "a#ion #iss e. Bos#opera#i%e #onsi""ar haemorrha$e m s# s#i"" be re$arded as a serio s and "ife2#hrea#enin$ !omp"i!a#ion and sho "d no# be nderes#ima#ed( par#i! "ar"y in #he yo n$er pa#ien#. Barapharyn$ea" and re#ropharyn$ea" abs!ess Barapharyn$ea" abs!ess. The parapharyn$ea" abs!ess may be !onf sed 'i#h a peri#onsi""ar abs!ess b # #he maxima" s'e""in$ is behind #he pos#erior fa !ia" pi""ar and #here may be "i##"e oedema of #he sof# pa"a#e. The pa#ien# is s a""y a yo n$ !hi"d and #here may be a se%ere de$ree of $enera" ma"aise. Wi#h an ob%io s abs!ess poin#in$ in#o #he oropharynx( draina$e may be !arried o # 'i#h a b" n# ins#r men# or #he $"o%ed fin$er b # $enera" anaes#hesia is fre; en#"y re; ired and #he exper#ise of a senior anaes#he#is#( $ood i"" mina#ion and $ood s !#ion are abso" #e"y essen#ia". A "ar$e parapharyn$ea" abs!ess may !ompromise bo#h #he air'ay and s'a""o'in$. In #he ear"ier !ases admission #o hospi#a" and #he ins#i# #ion of f" id rep"a!emen#s !o p"ed 'i#h in#ra%eno s an#ibio#i!s may prod !e reso" #ion. The ad%an!ed !ases a"so re; ire in#ra%eno s an#ibio#i!s. A! #e re#ropharyn$ea" abs!ess This is #he res "# of s pp ra#ion of #he pre%er#ebra" "ymph nodes and( a$ain( is mos# !ommon"y seen in !hi"dren 'i#h mos# of #he !ases o!! rrin$ in #hose nder - year of a$e. I# is asso!ia#ed 'i#h infe!#ion of #he #onsi"s( nasopharynx or oropharynx( and is fre; en#"y a!!ompanied by se%ere $enera" ma"aise( ne!& ri$idi#y( dyspha$ia( droo"in$(

a !ro py !o $h( an a"#ered !ry and mar&ed dyspnoea. Indeed( dyspnoea may be #he prominen# symp#om( and may a"so be a!!ompanied by febri"e !on% "sions and %omi#in$. These !hi"dren sho "d a"'ays be !aref ""y examined( and an inspe!#ion of #he pos#erior 'a"" of pharynx may sho' $ross s'e""in$ and an abs!ess poin#in$ benea#h #he #hinned m !osa. In !o n#ries 'here diph#heria s#i"" o!! rs( an a! #e re#ropharyn$ea" abs!ess may be !onf sed 'i#h #his b # #he presen!e of #he $reyish2 $reen membrane aids differen#ia#ion. O!!asiona""y( a forei$n body( mos# !ommon"y a fish hone 'hi!h has perfora#ed #he pos#erior pharyn$ea" m !osa( 'i"" $i%e rise #o an abs!ess in #his si# a#ion in o"der !hi"dren and yo n$ ad "#s. These pa#ien#s sho "d be admi##ed #o hospi#a" and in#ra%eno s an#ibio#i!s ins#i# #ed immedia#e"y. 9 r$i!a" draina$e of #he abs!ess may no# be ne!essary b #( if so( re; ires experien!ed anaes#hesia as on ind !#ion !are m s# be #a&en #o a%oid r p# rin$ #he abs!ess. The air'ay is pro#e!#ed by p"a!in$ #he !hi"d in a head2do'n posi#ion 'hi"s# a pair of dressin$ for!eps $ ided by #he fin$er may be #hr s# in#o an ob%io s abs!ess in #he pos#erior 'a"" 'i#h #he !on#en#s bein$ e%a! a#ed. On o#her o!!asions an approa!h an#erior and media" #o #he !aro#id shea#h %ia a !er%i!a" in!ision may he re; ired. 7hroni! re#ropharyn$ea" abs!ess This !ondi#ion is no' rare and mos# !ommon"y #he res "# of an ex#ension of # ber! "osis of #he !er%i!a" spine 'hi!h has spread #hro $h #he an#erior "on$i# dina" "i$amen# #o rea!h #he re#ropharyn$ea" spa!e. In !on#ras# #o #he a! #e re#ropharyn$ea" abs!ess( #his !ondi#ion o!! rs a"mos# so"e"y in ad "#s and radio"o$y s a""y sho's e%iden!e of bone des#r !#ion and "oss of #he norma" ! r%a# re of #he !er%i!a" spine. The spine may be ; i#e ns#ab"e and nd e manip "a#ion may pre!ipi#a#e a ne ro"o$i!a" e%en#. In addi#ion #o #he re#ropharyn$ea" s'e""in$ seen in#raora""y( #here may be f ""ness behind #he s#erno!"eidomas#oid m s!"e on one side. A !hroni! re#ropharyn$ea" abs!ess m s# no# he opened in#o #he mo #h( as s !h a pro!ed re may "ead #o se!ondary infe!#ion. Draina$e of #he abs!ess may no# be ne!essary if s i#ab"e #rea#men# of #he nder"yin$ # ber! "osis disease is ins#i# #ed. If i# is ne!essary #hen i# sho "d he !arried o # #hro $h a !er%i!a" in!ision an#erior #o #he s#erno!"eidomas#oid m s!"e 'i#h an approa!h an#erior and media" #o #he !aro#id shea#h #o #he re#ropharyn$ea" spa!e. The !a%i#y is opened and s !#ioned dry af#er #a&in$ biopsy ma#eria". O!!asiona""y s r$ery is re; ired #o de!ompress #he spina" !ord if #here is a pro$ressi%e ne ro"o$i!a" defi!i#. 4"and "ar fe%er )infe!#io s monon !"eosis. This sys#emi! !ondi#ion is s a""y !a sed by Eps#ein=3arr %ir s b # simi"ar fea# res !an be d e #o !y#ome$a"o%ir s or #oxop"asmosis. 7"ini!a" fea# res. The #onsi"s are #ypi!a""y ery#hema#o s 'i#h a !reamy2$rey ex da#e( and #hey appear a"mos# !onf" en# and s a""y symme#ri!a" in !on#radis#in!#ion #o a ; insy. In addi#ion #o #he dis!omfor# and dyspha$ia( #he pa#ien# may droo" sa"i%a and ha%e respira#ory diffi! "#y( par#i! "ar"y on inspira#ion. They !ommon"y ha%e a hi$h #empera# re and $ross $enera" ma"aise 'i#h o#her no#ab"e !er%i!a" or $enera"ised "ymphadenopa#hy. O!!asiona""y an en"ar$ed sp"een or "i%er may be de#e!#ed. These fea# res mos# !ommon"y o!! r in #eena$ers and yo n$ ad "#s( and dia$nosis !an be !onfirmed by sero"o$i!a" #es#in$ sho'in$ a posi#i%e Ba "=3 nne"" #es#( an abso" #e and re"a#i%e "ympho!y#osis( and #he presen!e of a#ypi!a" mono!y#es in #he periphera" b"ood. Trea#men#. Ana"$esia and main#enan!e of f" id in#a&e are impor#an#. A sma"" n mber of pa#ien#s re; ires admission #o hospi#a" if #he air'ay is !ompromised and a shor#

!o rse of s#eroids may be he"pf ". If #his is ne!essary i# sho "d on"y be !arried o # as an in2pa#ien# 'here #he air'ay !an be !ons#an#"y moni#ored. An#ibio#i!s are of "i##"e %a" e and( indeed( ampi!i""in is !on#raindi!a#ed be!a se of #he fre; en# appearan!e of a 'idespread s&in rash. H man imm nodefi!ien!y %ir s The h man imm nodefi!ien!y %ir s )HIV. is #he !a sa#i%e a$en# of a!; ired imm nodefi!ien!y syndrome )AID9. 'hi!h( a"#ho $h i# 'as ini#ia""y asso!ia#ed 'i#h in#ra%eno s dr $ sers and homosex a" ma"es( is no' spreadin$ in many par#s of #he 'or"d #o affe!# #he he#erosex a" !omm ni#y. I# !an affe!# a"mos# a"" of #he head and ne!& s#r !# res a# any poin# d rin$ #he disease. The ini#ia" sero!on%ersion may presen# 'i#h #he symp#oms of $"and "ar fe%er 'hi!h is fo""o'ed by an asymp#oma#i! period of %ariab"e "en$#h. In #he preAID9 period( prior #o #he f ""2b"o'n symp#oms of #he AID92re"a#ed !omp"ex( many pa#ien#s ha%e minor pper respira#ory #ra!# symp#oms 'hi!h are of#en o%er"oo&ed s !h as o#i#is ex#erna( rhinosin si#is and a nonspe!ifi! pharyn$i#is. As #he pa#ien# mo%es in#o #he f ""2b"o'n AID92re"a#ed !omp"ex a persis#en# $enera"ised "ymphadenopa#hy is fre; en#"y fo nd affe!#in$ #he !er%i!a" nodes 'hi!h is s a""y d e #o fo""i! "ar hyperp"asia. Ho'e%er( pa#ien#s may a"so de%e"op # mo rs s !h as :aposi1s sar!oma( some#imes seen in #he ora" !a%i#y( and hi$h2$rade ma"i$nan# 32!e"" "ymphoma affe!#in$ #he !er%i!a" "ymph nodes and nasopharynx. In addi#ion( m "#ip"e "!ers may be fo nd in #he ora" !a%i#y or pharynx asso!ia#ed 'i#h herpes infe!#ion. 9e%ere !andida may affe!# #he ora" !a%i#y pharynx or e%en "arynx( and a hairy "e !op"a&ia may affe!# #he #on$ e )*i$. +,.5E.. There is a"so an in!reased in!iden!e of s; amo s !e"" !ar!inoma of #he ora" !a%i#y. The $"ob s syndrome A 'ide %arie#y of pa#ien#s has a predominan# symp#om of a fee"in$ of a " mp in #he #hroa# )La#in8 $"ob s " mp.. The symp#om mos# !ommon"y affe!#s ad "#s be#'een ,G and @G years of a$e. This fee"in$ is no# #r e dyspha$ia as #here is no diffi! "#y in s'a""o'in$. /os# pa#ien#s no#i!e #he symp#om more if #hey s'a""o' #heir o'n sa"i%a( i.e. a for!ed dry s'a""o'( ra#her #han 'hen #hey ea# or drin&. The ae#io"o$y of #his !ommon symp#om is n&no'n b # some pa#ien#s may ha%e $as#ro2oesopha$ea" ref" x or spasm of #heir !ri!opharyn$e s m s!"e. The symp#om may be asso!ia#ed 'i#h #he presen!e of a pharyn$ea" po !h( or # mo rs in #he oropharynx( hypopharynx or pper oesopha$ s. The ori$ina" name of $"ob s hys#eri! s is nhe"pf " and a"#ho $h #hese pa#ien#s may be anxio s and a# #imes in#ro%er#ed( #hey none #he "ess re; ire f "" examina#ion #o ex!" de "o!a" disease. Radio"o$i!a" and endos!opi! in%es#i$a#ion may be ne!essary #o ex!" de an nder"yin$ !a se. Bharyn$ea" po !h The po !h is a pro#r sion of m !osa #hro $h :i""ian1s dehis!en!e( a 'ea& area of #he pos#erior pharyn$ea" 'a"" be#'een #he ob"i; e fibres of #hyropharyn$e s and #he #rans%erse fibres of !ri!opharyn$e s a# #he "o'er end of #he inferior !ons#ri!#or m s!"e. These fibres( a"on$ 'i#h #he !ir! "ar fibres of #he pper oesopha$ s( form #he physio"o$i!a" pper oesopha$ea" sphin!#er me!hanism. I i#e 'hy #he po !h forms is no# ye# !"ear e%en 'i#h modern %ideo f" oros!opi! and manome#ri! s# dies. /any pa#ien#s 'i#h pharyn$ea" po !hes ha%e been demons#ra#ed #o ha%e norma" re"axa#ion of #he pper oesopha$ea" sphin!#er me!hanism in re"a#ion #o s'a""o'in$( b # o#hers ha%e been sho'n #o ha%e in!omp"e#e pharyn$ea" re"axa#ion( ear"y !ri!opharyn$ea" !on#ra!#ion and abnorma"i#ies of #he pharyn$ea" !on#ra!#ion 'a%e. As #he po !h en"ar$es #he resis#an!e of #he %er#ebra" !o" mn behind s a""y !a ses i# #o # rn "a#era""y #o #he "ef# )*i$. +,.5F..

7"ini!a" fea# res. Ba#ien#s s fferin$ from #his !ondi#ion are !ommon"y more #han @G years of a$e and i# is #'i!e as !ommon in 'omen as in men. In #he ini#ia" phases 'hen #here is a sma"" di%er#i! " m #he pa#ien#s may presen# 'i#h $"ob s2#ype symp#oms of a fee"in$ of some#hin$ in #he #hroa# or minor diffi! "#ies and s"i$h# re$ r$i#a#ion on s'a""o'in$. A %ideof" oros!opi! or bari m s'a""o' s# dy may sho' abnorma"i#ies of #he pper oesopha$ea" sphin!#er in asso!ia#ion 'i#h #he sma"" po !h. As #he di%er#i! " m en"ar$es pa#ien#s may experien!e re$ r$i#a#ion of ndi$es#ed food some#imes ho rs af#er a mea"( par#i! "ar"y if #hey are bendin$ do'n or # rnin$ o%er in bed a# ni$h#. They are some#imes a'o&en a# ni$h# 'i#h a fee"in$ of #i$h#ness in #he #hroa# and a fi# of !o $hin$. O!!asiona""y #hey may presen# 'i#h re! rren# nexp"ained !hes# infe!#ions as a res "# of sma"" amo n#s of "i; id and food bein$ aspira#ed from #he po !h. As #he po !h in!reases in siDe #he pa#ien#s may no#i!e $ r$"in$ noises from #he ne!& on s'a""o'in$ and #he po !h may be!ome "ar$e eno $h #o form a %isib"e s'e""in$ in #he ne!&. This s'e""in$ may in!rease 'hen #he pa#ien# drin&s and( indeed( #here may be in!reasin$ diffi! "#y 'i#h s'a""o'in$ asso!ia#ed 'i#h 'ei$h# "oss and !a!hexia. Radio"o$i!a" examina#ion. If a pharyn$ea" po !h is s spe!#ed( #his is an ex#reme"y sef " examina#ion. A #hin em "sion of bari m is $i%en #o #he pa#ien# as a bari m s'a""o' )*i$. +,.5H. or( be##er s#i""( as par# of a %ideof" oros!opi! s'a""o'in$ s# dy. 7are sho "d be exer!ised in pa#ien#s 'ho !o $h on s'a""o'in$ indi!a#in$ #hey may ha%e aspira#ion. J s# a fe' mi""i"i#res of bari m is s ffi!ien# #o o #"ine #he pharynx po !h and pper oesopha$ s. The %ideof" oros!opi! s# dy $i%es addi#iona" informa#ion abo # #he pharyn$ea" !on#ra!#ion 'a%es and #he performan!e of #he pper oesopha$ea" sphin!#er. O!!asiona""y #here is an asso!ia#ed hia# s hernia a# #he "o'er end of #he oesopha$ s and #his sho "d be ex!" ded. A !hes# <2ray is impor#an# #o ex!" de aspira#ion pne moni#is. Ri$id oesopha$os!opy or pharyn$os!opy nder $enera" anaes#hesia is nne!essary for dia$nosis and may be dan$ero s. When #he dia$nosis is ns spe!#ed. oesopha$os!opy performed 'i#ho # rea"isin$ #he pa#ho"o$y may be asso!ia#ed 'i#h #he #ip of #he oesopha$os!ope en#erin$ #he po !h and perfora#in$ #he f nd s. 9 bse; en# medias#ini#is is asso!ia#ed 'i#h a hi$h mor#a"i#y. Trea#men#. 9 r$ery is indi!a#ed 'hen #he po !h is asso!ia#ed 'i#h pro$ressi%e symp#oms( and par#i! "ar"y 'hen a prominen# !ri!opharyn$ea" bar of m s!"e asso!ia#ed 'i#h abnorma"i#y of #he pper oesopha$ea" sphin!#er me!hanism !a ses !onsiderab"e dyspha$ia. In %ery e"der"y pa#ien#s a de!ision #o opera#e may be offse# by #he $enera" !ondi#ion of #he pa#ien#. Breopera#i%e physio#herapy and a##en#ion #o #he respira#ory( !ardio%as! "ar and n #ri#iona" aspe!#s of #he pa#ien# are impor#an#. Breopera#i%e !hes# physio#herapy and periopera#i%e an#ibio#i!s are re!ommended. In #he !"assi!a" opera#ion #he openin$ #o #he po !h is firs# iden#ified sin$ a pharyn$os!ope and a naso$as#ri! # be p"a!ed in#o #he oesopha$ea" " men #o a""o' pos#opera#i%e n #ri#ion. This ini#ia" endos!opy is of#en diffi! "# be!a se #he norma" oesopha$ea" openin$ is sma"" !ompared 'i#h #he " men of #he po !h b # i# may be fa!i"i#a#ed by sin$ a Doh"mann1 s ri$id endos!ope 'hi!h a""o's be##er %is a"isa#ion. The naso$as#ri! # be a""o's iden#ifi!a#ion of #he oesopha$ s s bse; en#"y by pa"pa#ion and fa!i"i#a#es #he myo#omy( in addi#ion #o a""o'in$ pos#opera#i%e feedin$. The po !h may be pa!&ed 'i#h ribbon $a De soa&ed in prof"a%in so" #ion #o aid iden#ifi!a#ion of #he ne!& of #he po !h. A "o'er ne!& in!ision a"on$ #he an#erior border of #he "ef# s#erno!"eidomas#oid m s!"e( or a #rans%erse !rease in!ision( is #hen sed and #he s#erno!"eidomas#oid m s!"e and !aro#id shea#h are re#ra!#ed "a#era""y and #he #ra!hea and "arynx media""y. The midd"e #hyroid %ein is di%ided and( if ne!essary( #he inferior #hyroid ar#ery is

fo nd and "i$a#ed 'e"" "a#era""y. The re#ropharyn$ea" spa!e is en#ered abo%e #he inferior !orner of #he #hyroid !ar#i"a$e( #hereby a%oidin$ ris& of dama$e #o #he re! rren# "aryn$ea" ner%e. The po !h is fo nd media""y behind #he "o'er pharynx and is !aref ""y iso"a#ed and disse!#ed ba!& #o i#s ori$in a# :i""ian1s dehis!en!e. I# may #hen be ex!ised and #he pharynx !"osed in #'o "ayers or( if i# is sma""( i# may in%a$ina#ed in#o #he pharyn$ea" " men before !"osin$ #he m s!"e "ayers. In a"" !ases a myo#omy di%idin$ #he fibres of #he !ri!ophary$e s m s!"e and #he pper oesopha$ea" !ir! "ar m s!"e fibres m s# be performed. The 'o nd is s a""y !"osed 'i#h draina$e and #he pa#ien# fed #hro $h #he naso$as#ri! # be for ,=E days. 7omp"i!a#ions. This !"assi! opera#ion has been asso!ia#ed 'i#h 'o nd infe!#ion( medias#ini#is( pharyn$ea" fis# "aforma#ion and s#enosis of #he pper oesopha$ s. Varia#ions ha%e been #ried 'hi!h in!" de simp"y hi#!hin$ p #he po !h in#o a s perior posi#ion 'i#ho # ex!isin$ i#( #h s a""o'in$ #he f nd s and body #o emp#y !on#in o s"y in#o #he oesopha$ s. This is nsa#isfa!#ory 'i#h #he "ar$er po !hes. Endos!opi! di%ision of #he bar of m s!"e formin$ #he an#erior 'a"" of #he po !h and #he pos#erior aspe!# of #he " men of #he oesopha$ s has been ad%o!a#ed for many years sin$ Doh"mann1s ins#r men#s and( more re!en#"y( a "aser app"ied %ia a spe!ia" pharyn$os!ope. There is in!reasin$ e%iden!e #ha# bo#h #he open opera#i%e in#er%en#ion and pre%io s endos!opi! #e!hni; es !an be impro%ed by sin$ an endos!opi! s#ap"in$ #e!hni; e( 'hereby a spe!ia"ised s#ap"e $ n is passed do'n a modified pharyn$os!ope 'hi!h safe"y di%ides #he an#erior 'a"" of #he po !h and #he pos#erior 'a"" of #he oesopha$ s. This !omp"e#es a f "" myo#omy and a""o's any food and f" id #o drain from #he po !h dire!#"y do'n #he oesopha$ s. The s#ap"es pro%ide an ins#an# #'o2"ayer !"os re a# #he si#e of di%ision( and #his endos!opi! #e!hni; e is asso!ia#ed 'i#h %ery "o' morbidi#y and a hi$h s !!ess ra#e for #he re"ief of #he pa#ien#1s symp#oms. Lo' morbidi#y is par#i! "ar"y impor#an# in #his e"der"y $ro p of pa#ien#s. 9ideropeni! dyspha$ia Bro"on$ed iron defi!ien!y anaemia may "ead #o dyspha$ia( par#i! "ar"y in midd"e2a$ed fema"es. In addi#ion( #hey may ha%e &oi"ony!hia( !hei"osis and an$ "ar s#oma#i#is( #o$e#her 'i#h "assi# de and poor exer!ise #o"eran!e. The dyspha$ia is !a sed by a pos#!ri!oid 'eb( and #hese pa#ien#s ha%e a hi$her in!iden!e of pos#!ri!oid ma"i$nan!y. Bro$nosis of #hese pos#!ri!oid # mo rs is %ery poor( re; irin$ radi!a" #rea#men# 'i#h radio#herapy and ma0or s r$ery( and i# is #herefore impor#an# #o pre%en# #his prob"em by re!o$ni#ion and #rea#men# of #he anaemia. The syndrome is asso!ia#ed 'i#h #he names of B" mme# and Vinson( and Ba##erson and 3ro'n :e""y. T mo rs of #he oropharynx 3eni$n 3eni$n # mo rs of #he oropharynx are rare( papi""omas bein$ #he mos# !ommon. These are s a""y in!iden#a" findin$s and are rare"y of any impor#an!e. /a"i$nan# The mos# impor#an# epi#he"ia" # mo r is s; amo s !e"" !ar!inoma( 'hi!h !ons#i# #es ro $h"y HG per !en# of a"" epi#he"ia" # mo rs in #he pper aerodi$es#i%e #ra!# )*i$s +,.,G and +,.,-.. In #he oropharynx #he propor#ion is "ess )EG per !en#. be!a se of #he hi$her in!iden!e of "ymphoma )5> per !en#. and sa"i%ary $"and # mo rs )> per !en#.. Ae#io"o$y 9; amo s !ar!inomas of #he oropharynx ha%e s#ron$ asso!ia#ions 'i#h !i$are##e smo&in$ and #he !ons mp#ion of a"!oho"( and #hese #'o fa!#ors !a se %aryin$ in!iden!e #hro $ho # #he 'or"d. In !o n#ries 'here #he !ons mp#ion of #oba!!o and

a"!oho" is asso!ia#ed 'i#h poor ora" hy$iene #hese ma"i$nan!ies ass me ma0or impor#an!e. D e #o #he ri!h "ympha#i! draina$e of #he oropharynx( !er%i!a" node me#as#a#ases are !ommon. They may be #he on"y presen#in$ fea# re 'i#h an apparen# o!! "# primary of#en bein$ ns spe!#ed and missed in #he #onsi" or #on$ e base.The ma0ori#y of "ymph node me#as#ases from oropharyn$ea" s; amo s !ar!inomas is #o #he 0 $ "odi$as#ri! node. This is #he !ommones# si#e for #he so2!a""ed ?bran!hia" !ys# !ar!inoma1( b # se%era" s# dies in re!en# #imes ha%e sho'n #ha# #his is probab"y an ex#reme"y rare pa#ho"o$y and #ha# s a""y #he dia$nosis represen#s !ys#i! de$enera#ion in a 0 $ "odi$as#ri! node from a sma"" nde#e!#ed primary s; amo s !ar!inoma in #he #onsi" or #on$ e base. 9; amo s !e"" !ar!inomas are mos# !ommon in #he six#h and se%en#h de!ades and more fre; en# in men. Trea#men# Trea#men# pa##erns %ary 'i#h fa!i"i#ies( h # ear"y # mo rs may be ! red by radio#herapy( "aser ex!ision or more !on%en#iona" ex!ision. Re! rren# disease fo""o'in$ radio#herapy is mana$ed s r$i!a""y( and repair of #he oropharynx may re; ire re$iona""y based myo! #aneo s f"aps or free f"aps 'i#h mi!ro%as! "ar anas#omosis. Ne!& disse!#ion is re; ired in a "ar$e propor#ion of !ases of ad%an!ed disease. Bos#opera#i%e dyspha$ia 'i#h aspira#ion( as a res "# of in#erferen!e in #he !omp"ex ne rom s! "ar !on#ro" of #he se!ond phase of s'a""o'in$( is a par#i! "ar prob"em in #hese pa#ien#s. /ore ad%an!ed # mo rs may a"so re; ire addi#iona" rese!#ion of #he mandib"e or an asso!ia#ed #o#a" "aryn$e!#omy( so #his #ype of s r$ery is bes# !arried o # in a !en#re nder#a&in$ #his 'or& on a re$ "ar basis. Lymphoma of #he head and ne!& Lymphomas of #he head and ne!& may arise in noda" or ex#ranoda" sires( and bo#h Hod$&in1s disease and nonHod$&in1s "ymphoma !ommon"y presen# as "ymph node en"ar$emen# in #he ne!&. Hod$&in1s disease is rare in #he oropharynx( b # nonHod$&in1s "ymphoma a!!o n#s for ->=5G per !en# of # mo rs a# #his si#e in some !o n#ries. /os# are of #he 32!e"" #ype and ha%e fea# res in !ommon 'i#h o#her # mo rs of /ALT sires. /any of #he "ymphomas of #he oropharynx ha%e no demons#rab"e deposi# e"se'here in #he body 'hen a f "" "ymphoma in%es#i$a#ion is !arried o #. On o!!asions( ho'e%er( #hey may be se!ondary or !oin!iden# 'i#h deposi#s a# o#her sires in #he ne!&( #he $as#roin#es#ina" #ra!#( " n$ and #he #es#es. * r#her e%a" a#ion 'i#h 7T s!annin$ of #he #horax and abdomen( and bone marro' e%a" a#ion are essen#ia". Radio#herapy is ndo b#ed"y #he #rea#men# of !hoi!e for "o!a"ised nonHod$&in1s "ymphoma and may $i%e !on#ro" ra#es as hi$h as E> per !en# a# > years. *or dissemina#ed nonHod$&in1s "ymphoma #he #rea#men# of !hoi!e is sys#emi! !hemo#herapy. 7ombina#ion !hemo#herapy is sed in pa#ien#s 'i#h an nfa%o rab"e his#o"o$i!a" #ype. T mo rs of #he hypopharynx 3eni$n 3eni$n # mo rs of #he hypopharynx are %ery rare( #he mos# !ommon bein$ #he fibroma and #he "eiomyoma. These are po"ypoid # mo rs 'hi!h s a""y presen# 'i#h dyspha$ia and are seen on %ideof" oros!opy or bari m s'a""o'. They sho' a smoo#h !ons#an# mass "yin$ in #he " men of #he hypopharynx or oesopha$ s. /a"i$nan# /a"i$nan# # mo rs of #he hypopharynx are a"mos# ex!" si%e"y s; amo s !e"" !ar!inoma 'i#h a predominan!e of modera#e and poor differen#ia#ion. The # mo rs are s a""y !"assified a!!ordin$ #o #heir ana#omi!a" sire of ori$in from #he piriform fossa( pos#!ri!oid re$ion or pos#erior pharyn$ea" 'a"" b #( as men#ioned in #he se!#ion

on pharyn$ea" ana#omy( i# !an be diffi! "# #o de#ermine #he sire of ori$in 'hen a # mo r has spread #o in%o"%e one or more of #hese areas. E%en differen#ia#ion be#'een "aryn$ea" and hypopharyn$ea" # mo rs !an be diffi! "# in #he ad%an!ed disease 'hen #he aryepi$"orri! fo"d has been rep"a!ed or !o%ered by # mo rs. /ar&ed differen!es in #he in!iden!e of #hese # mo rs o!! r #hro $ho # #he 'or"d in asso!ia#ion 'i#h fa!#ors s !h as iron defi!ien!y anaemia )see s bse!#ion on 9ideropeni! dyspha$ia. and #hey may be asso!ia#ed 'i#h mar&ed s bm !osa" spread of -G mm or more 'hi!h f r#her !omp"i!a#es #heir e%a" a#ion. T mo rs arisin$ from #he piriform fossa and pos#erior pharyn$ea" 'a"" may spread #o pper or "o'er !er%i!a" nodes. T mo rs arisin$ in #he pos#!ri!oid area #ypi!a""y me#as#asise #o para#ra!hea" and paraoesopha$ea" nodes 'hi!h may no# be pa"pab"e. As 'i#h oropharyn$ea" # mo rs( a"!oho" and #oba!!o are #'o prin!ipa" !ar!ino$ens imp"i!a#ed in #hese # mo rs. Bos#!ri!oid !ar!inoma( a"#ho $h essen#ia""y a rare disease( is more !ommon in 'omen #han men. The dia$nosis of hypopharyn$ea" !ar!inoma sho "d be !onsidered in a"" pa#ien#s presen#in$ 'i#h dyspha$ia or hoarseness( par#i! "ar"y if #hey ha%e a his#ory of iron defi!ien!y and anaemia( smo&in$ or si$nifi!an# a"!oho" !ons mp#ion. On examina#ion indire!# "aryn$os!opy may sho' on"y s b#"e si$ns of disease s !h as oedema or poo"in$ of sa"i%a ni"a#era""y in a piriform fossa( or dimin #ion of %o!a" fo"d mobi"i#y. A"" re$ions of #he ne!& m s# be assessed in a sys#ema#i! manner. *ine need"e aspira#e is ad%o!a#ed for s spi!io s nodes. A s spe!#ed primary may re; ire %ideof" oros!opy or bari m s'a""o' s# dy( endos!opy and biopsy( and 7T or /RI s!annin$ if a%ai"ab"e. A !hes# <2ray sho "d be #a&en #o de#e!# a se!ond primary or me#as#asis. Trea#men# 9; amo s !ar!inoma of #he hypopharynx !ommon"y presen#s "a#e and !arries a poor pro$nosis. Ear"y "esions may be #rea#ed 'i#h radio#herapy a"one( and s r$ery is $enera""y sed for re! rren!e af#er radio#herapy or as primary ex!ision in ad%an!ed disease. To#a" pharyn$o"aryn$e!#omy is !ommon"y re; ired and( for "esions ex#endin$ in#o #he pper oesopha$ s( oesopha$e!#omy and #o#a" #hyroide!#omy may addi#iona""y be needed. Re!ons#r !#ion of #he ex!ised pharynx andCor oesopha$ s may be nder#a&en by #he se of a myo! #aneo s f"ap( free 0e0 na" #ransfer or $as#ri! #ransposi#ion. These ma0or s r$i!a" #e!hni; es re; ire ex!e""en# preopera#i%e prepara#ion of #he pa#ien# and s r$i!a" #eams 'i#h a hi$h s#andard of exper#ise as #hey ha%e a po#en#ia" mor#a"i#y and a 'ide %arie#y of !omp"i!a#ions. 9'a""o'in$ and %oi!e rehabi"i#a#ion are ne!essary #o s ppor# pa#ien#s af#er #his ma0or s r$ery if #hey are #o ad0 s# #hemse"%es and main#ain some ; a"i#y of "ife. 7y#o#oxi! dr $s ha%e no# been fo nd #o ha%e si$nifi!an# %a" e as an ad0 n!# #o s r$ery or radio#herapy in #he #rea#men# of pa#ien#s 'i#h hypopharyn$ea" s; amo s !ar!inoma. I# is #o be hoped in #he f # re #ha# #hey 'i"" prod !e be##er res "#s so #ha# #he ma0or s r$ery and i#s asso!ia#ed debi"i#y !an be a%oided. 3efore de!idin$ #o $i%e !hemo#herapy in any form of s; amo s !ar!inoma of #he head and ne!& one has #o ba"an!e #he pro$nosis of #he disease a$ains# #he expe!#ed re"ief and possib"e #oxi! side effe!#s. The mos# !ommon"y sed a$en#s are !isp"a#in( >2f" oro ra!i" )>*U. and me#ho#raxa#e. These dr $s are bes# adminis#ered by do!#ors exper# in #heir se and as par# of !on#ro""ed #ria"s n#i" 'e !an e%a" a#e #he mos# s i#ab"e me#hod of adminis#ra#ion and #he bes# !ombina#ion of a$en#s. Diseases of the larynx

Emer$en!ies 9#ridor 9#ridor means noisy brea#hin$. I# may be inspira#ory or expira#ory or o!! rrin$ in bo#h phases of respira#ion. Inspira#ory s#ridor is s a""y d e #o an obs#r !#ion a# or abo%e #he %o!a" fo"ds and mos# !ommon"y is a res "# of an inha"ed forei$n body or a! #e infe!#ion s !h as epi$"o##i#is. Expira#ory s#ridor is s a""y from #he "o'er respira#ory #ra!# and $i%es rise #o a pro"on$ed expira#ory 'heeDe. I# is mos# !ommon"y asso!ia#ed 'i#h a! #e as#hma or a! #e infe!#i%e #ra!heobron!hi#is. 3iphasi! s#ridor is s a""y d e #o obs#r !#ion or disease of #he #ra!heobron!hia" air'ay and dis#a" " n$s. 9#ridor in !hi"dren )Tab"e +,.E. Infan#s and !hi"dren presen#in$ 'i#h s#ridor need assessmen# 'i#h a f "" his#ory and !aref " examina#ion if appropria#e. If on presen#a#ion a !hi"d is !yanosed and se%ere"y n'e"" #he air'ay m s# be se! red as soon as possib"e b # i# is of#en possib"e #o ob#ain a brief his#ory from #he paren#s( 'i#h impor#an# poin#ers. A n rse or !o""ea$ e may be derai"ed #o do #his 'hi"s# #he res s!i#a#ion is #a&in$ p"a!e. His#ory. In infan#s in #he firs# year of "ife i# is impor#an# #o es#ab"ish 'he#her #he s#ridor is asso!ia#ed 'i#h par#i! "ar a!#i%i#ies s !h as s'a""o'in$( !ryin$ or mo%emen#. These may s $$es# !on$eni#a" "aryn$oma"a!ia or s b$"o##i! s#enosis. If #he s#ridor is exa!erba#ed by feedin$( par#i! "ar"y in #he firs# + 'ee&s of "ife( #his s $$es#s a %as! "ar rin$ or #ra!heooesopha$ea" fis# "a. If #he !ry is 'ea& or abnorma" #his 2s $$es#s a %o!a" fo"d pa"sy. If #he prob"em on"y o!! rs in asso!ia#ion 'i#h an pper respira#ory #ra!# infe!#ion and( in par#i! "ar( is biphasi! #his 'o "d s $$es# !on$eni#a" s b$"o##i! s#enosis. In a yo n$ !hi"d inspira#ory s#ridor and droo"in$ s $$es# a! #e epi$"o##i#is( 'hereas biphasi! s#ridor 'i#ho # droo"in$ s $$es#s "aryn$o#ra!heobron!hi#is or !ro p. Examina#ion. Obser%e #he !hi"d !aref ""y a# res#6 do no# a##emp# #o mo%e or hand"e #he !hi"d( par#i! "ar"y if #he s#rid "o s !hi"d is bein$ he"d by i#s mo#her or o#her fami"y member.On!e a baby s#ar#s #o !ry i# may be impossib"e #o s# dy i#s res#in$ respira#ory pa##ern for some #ime. As& #he mo#her( nor a n rse or a !o""ea$ e( #o mo%e a baby or yo n$ !hi"d in#o differen# posi#ions s !h as fa!e do'n and s pine( and 'a#!h for !han$es in i#s respira#ory pa##ern and "e%e" of dis#ress. Obser%e any droo"in$ and 'i#h neona#es and infan#s a"'ays #ry #o 'a#!h #he !hi"d bein$ fed( "is#enin$ #o #he #ra!hea and !hes# 'i#h a s#e#hos!ope if possib"e. A"'ays examine #he 'ho"e !hi"d( "oo&in$ for any e%iden!e of !on$eni#a" abnorma"i#ies before a##emp#in$ any examina#ion of #he #hroa#. If a !hi"d is s#rid "o s and droo"in$ and si##in$ pri$h# in i#s mo#her1s arms or !hair do no# a##emp# #o "ie i# do'n and do no# a##emp# #o "oo& inside #he mo #h.These are po#en#ia""y "ife2#hrea#enin$ !ir! ms#an!es as #he !hi"d may aspira#e a "ar$e ; an#i#y of #hi!& sa"i%a !on#ained 'i#hin i#s ora" !a%i#y. The !hi"d does nor 'ish #o a##emp# s'a""o'in$ in #he !ase of a re#ropharyn$ea" abs!ess( parapharyn$ea" abs!ess or a! #e epi$"o##i#is as #hese !ondi#ions are so painf ". I# is par#i! "ar"y impor#an# in a! #e epi$"o##i#is as #he aspira#ion of #hi!& sa"i%a may be asso!ia#ed 'i#h f r#her "aryn$ea" spasm and a respira#ory arres#. Res#"essness( in!reasin$ #a!hy!ardia and !yanosis are impor#an# si$ns of hypoxia. If #he !hi"d is no# dis#ressed and droo"in$( and nor mar&ed"y s#rid "o s i# may be !o2opera#i%e eno $h for i# #o be possib"e #o "oo& inside #he mo #h and !he!& #he pa"a#e( #on$ e and oropharynx. In s#rid "o s !hi"dren( par#i! "ar"y neona#es and infan#s( a #rans2! #aneo s oxime#er is in%a" ab"e if a%ai"ab"e. I# may be p"a!ed on #he !hi"d before any examina#ion and d rin$ any s bse; en# mana$emen#. A res s!i#a#ion #ro""ey 'i#h #he ne!essary e; ipmen# for emer$en!y

in# ba#ion or #ra!heos#omy sho "d be !"ose a# hand( if a# a"" possib"e( before !ommen!in$ examina#ion and in%es#i$a#ion of #hese !hi"dren. Investigation. In addi#ion #o #he oxime#er( p"ain "a#era" <2rays of #he ne!& and a !hes# <2ray !an be ob#ained b # on"y if #he !hi"d1s !ondi#ion permi#s. If #he !hi"d is se%ere"y s#rid "o s #hey sho "d no# be sen# #o an <2ray depar#men# 'i#ho # a!!ess #o medi!a" s#aff or res s!i#a#ion e; ipmen#. The <2rays may !onfirm #he presen!e of a forei$n body or sho' sof#2#iss e shado'in$ !onsis#en# 'i#h a re#ropharyn$ea" or parapharyn$ea" abs!ess( a! #e epi$"o##i#is or !hes# disease. Examination under anaesthesia. Examina#ion nder anaes#hesia is essen#ia" in a"" !hi"dren 'hose dia$nosis remains in do b#. 7y#o#oxi! dr $s ha%e nor been fo nd #o ha%e si$nifi!an# %a" e as an ad0 n!# #o s r$ery or radio#herapy in #he #rea#men# of pa#ien#s 'i#h hypopharyn$ea" s; amo s !ar!inoma. I# is #o be hoped in #he f # re #ha# #hey 'i"" prod !e be##er res "#s so #ha# #he ma0or s r$ery and i#s asso!ia#ed debi"i#y !an be a%oided. 3efore de!idin$ #o $i%e !hemo#herapy in any form of s; amo s !ar!inoma of #he head and ne!& one has #o ba"an!e #he pro$nosis of #he disease a$ains# #he expe!#ed re"ief and possib"e #oxi! side effe!#s. The mos# !ommon"y sed a$en#s are !isp"a#in( >2f" oro ra!i" )>*U. and me#ho#rexa#e. These dr $s are bes# adminis#ered by do!#ors exper# in #heir se and as par# of !on#ro""ed #ria"s n#i" 'e !an e%a" a#e #he mos# s i#ab"e me#hod of adminis#ra#ion and #he bes# !ombina#ion of a$en#s. This re; ires a hi$h "e%e" of s&i"" and !"ose !o2opera#ion be#'een s r$eon and anaes#he#is#( and appropria#e ri$id "aryn$os!opes( bron!hos!opes( endos!opi! Hop&in1s rods and an opera#in$ mi!ros!ope sho "d be made a%ai"ab"e. E; ipmen# sho "d be a%ai"ab"e a# a"" #imes #o nder#a&e an r$en# #ra!heos#omy #o es#ab"ish or main#ain an air'ay. A! #e epi$"o##i#is )Tab"e +,.E. This i""ness may o!! r in ad "#s( a"#ho $h for# na#e"y #he s#ridor rare"y pro$resses as rapid"y as in !hi"dren. In !hi"dren i# is of rapid onse# and #ends #o o!! r in !hi"dren of 5 years of a$e or o%er. 9#ridor is s a""y asso!ia#ed 'i#h droo"in$ of sa"i%a. The !ondi#ion is !a sed by Haemophi" s inf" enDae infe!#ion 'hi!h ini#ia""y !a ses a se%ere pharyn$i#is a# #he 0 n!#ion of #he oropharynx and hypopharynx before pro2 $ressin$ #o prod !e inf"amma#ion and oedema of #he "aryn$ea" in"e#. As i# pro$resses i# a!# a""y in%o"%es #he 'ho"e of #he s pra$"o##i! "arynx( 'i#h se%ere oedema of #he ariepi$"o##ie fo"ds and epi$"o##is bein$ #he mos# no#ab"e !omponen#6 hen!e #he !ommon"y sed #erm ?a! #e epi$"o##i#is1. Examina#ion and in%es#i$a#ion are o #"ined abo%e( b # #hese !hi"dren fre; en#"y re; ire in#ensi%e mana$emen# 'i#h emer$en!y in# ba#ion or #ra!heos#omy fo""o'ed by oxy$ena#ion( h midifi!a#ion( !on#in o s oxime#ry and an#ibio#i!s s !h as ampi!i""in or !h"orampheni!o" #o !omba# #he haemophi" s infe!#ion. This may be asso!ia#ed 'i#h sep#i!aemia and b"ood ! "# res sho "d be ob#ained. 7hi"dren 'i#h a! #e epi$"o##i#is may de%e"op air'ay obs#r !#ion rapid"y. Inser#ion of a spa# "a in#o #he mo #h may pre!ipi#a#e a respira#ory arres# and is bes# a%oided. Infan#s and !hi"dren ha%e sma"" air'ays and hi$h oxy$en demand. I# is ex#reme"y impor#an# #o pre2emp# any respira#ory arres#. Laryngotracheobronchitis (croup) This is s a""y of s"o'er onse# in !on#ras# #o a! #e epi$"o##i#is and o!! rs mos# !ommon"y in !hi"dren nder 5 years of a$e. I# is s a""y %ira" in ori$in and #he !ases of#en o!! r in !" s#ers. The !hi"dren ha%e a biphasi! s#ridor and of#en hoarseness( and a #ypi!a" bar&in$ !o $h. Air'ay in#er%en#ion is re; ired "ess of#en b # admission #o

hospi#a" 'i#h oxy$ena#ion and h midifi!a#ion !o p"ed 'i#h an#ibio#i!s may be ne!essary if #here are si$ns of se!ondary infe!#ion. Foreign bodies 3o#h !hi"dren and ad "#s may inha"e forei$n bodies. Jo n$ !hi"dren 'i"" a##emp# #o s'a""o' a 'ide %arie#y of ob0e!#s( b # !oins( beads and par#s of #oys are par#i! "ar"y !ommon. In ad "#s #he aspira#ion is s a""y of food( par#i! "ar"y inade; a#e"y !he'ed bones and mea#. This is more !ommon in e"der"y eden# "o s ad "#s and o!!asiona""y por#ions of den# res may be inha"ed( par#i! "ar"y in asso!ia#ion 'i#h road #raffi! a!!iden#s. 7"ini!a" fea# res. The his#ory is of#en paramo n# and i# is impor#an# #o a"'ays be"ie%e #he pa#ien#( par#i! "ar"y a paren# 'ho $i%es a his#ory of forei$n body in$es#ion or inha"a#ion in a !hi"d( e%en #ho $h #he pain( dyspha$ia( !o $hin$( e#!.( may ha%e se##"ed. Ad "# pa#ien#s 'i""( on #he 'ho"e( ha%e a !"ear re!a"" and #he dia$nosis is more easy( b # #his may no# a"'ays be #he !ase par#i! "ar"y if #he pa#ien# is s fferin$ from men#a" i""ness. *ish bones may "od$e in #he #onsi"s or base of #on$ e 'i#h minima" symp#oms b # in !er#ain areas of #he 'or"d( no#ab"y Asia( sma"" fish bones may impa!# in #he #onsi"s( oropharynx or hypopharynx and $i%e rise #o parapharyn$ea" and re#ropharyn$ea" abs!ess forma#ion. Examination. Examina#ion may be pre%en#ed by #rism s( pain and anxie#y( b # #he presen!e of a forei$n body may be s spe!#ed by a sa"i%ary poo" 'i#hin #he piriform fossa or ad0a!en# oedema and ery#hema of #he pharyn$o"aryn$ea" m !osa. Radiology. Radio"o$y may be he"pf " b # is no# !ri#i!a". *ish hones are of#en no# %isib"e on p"ain <2rays( and a norma" p"ain <2ray does no# ex!" de a forei$n body 'i#hin #he pharynx( "arynx( oesopha$ s or " n$s.9pe!ia"ised s# dies may he"p in !ases of do b# sin$ #omo$raphy of #he ne!&( 7T s!an or a .$as#ro$raffin s'a""o'in$ s# dy in #he !ase of a s spe!#ed oesopha$ea" forei$n body. reatment. In #he !ase of an inha"ed forei$n body !a sin$ se%ere s#ridor in a neona#e or infan# i# may be remo%ed ei#her by hoo&in$ i# from #he pharynx 'i#h a fin$er or by in%er#in$ #he !hi"d !aref ""y by i#s an&"es and s"appin$ i#s ba!&. In a "ar$er !hi"d i# may be more appropria#e #o bend #hem o%er yo r &nee 'i#h #heir head han$in$ do'n and a$ain s#ri&e #hem firm"y be#'een #he sho "ders. In #he !ase of ad "#s an impa!#ed "aryn$ea" forei$n body may he !o $hed o # in asso!ia#ion 'i#h a Heim"i!h manoe %re. This in%o"%es s#andin$ behind #he pa#ien#( !"aspin$ #he arms aro nd #he "o'er #horax s !h #ha# #he &n !&"es of #he !"asped hands !ome in#o !on#a!# 'i#h #he pa#ien#1s xiphis#ern m( and #hen a brief firm !ompression of #he "o'er #horax may aid ins#an# expira#ion of #he forei$n body. Ifnone of #hese immedia#e emer$en!y meas res remo%es #he forei$n body and #he pa#ien# is !yanosed and se%ere"y s#rid "o s( an immedia#e !ri!o#hyroido#omy or #ra!heos#omy may be ne!essary. If "ess r$en# !ases( if #he radio$raphy is no# sef " b # a forei$n body is s#ron$"y s spe!#ed( #hen de#ai"ed endos!opy nder $enera" anaes#hesia may be indi!a#ed.I# is impor#an# #o remember #ha# #he symp#oms of forei$n body in$es#ion are more re"iab"e #han #he res "#s of spe!ia"is# radio"o$y in%es#i$a#ions. An$ione ro#i! oedema( radio#herapy( "aryn$ea" #ra ma asso!ia#ed 'i#h road #raffi! a!!iden#s( !orrosi%es( s!a"ds and smo&e in$es#ion may a"" !a se si$nifi!an# pharyn$o"aryn$ea" oedema( in addi#ion #o #he a! #e infe!#i%e !ondi#ions men#ioned e"se'here. Hoarseness is #he predomina#e symp#om a"on$ 'i#h dyspha$ia prior #o #he in!rease in dyspnoea. If "aryn$os!opi! examina#ion is possib"e mar&ed oedema of #he s pra$"o##is and pharynx

!an be seen. H midified oxy$en( adrena"ine neb "isers( sys#emi! an#ihis#amines and s#eroids may be %a" ab"e in #hese !ases. /orphine sho "d no# be $i%en #o #hese pa#ien#s #o !omba# #heir dis#ress as i# may !a se respira#ory depression and respira#ory arres#. If #he dyspnoea pro$resses in# barion or #ra!heos#omy 'i"" be ne!essary. This pro!ed re is #o re"ie%e air'ay obs#r !#ion or #o pro#e!# #he air'ay by fashionin$ a dire!# en#ran!e in#o #he #ra!hea #hro $h #he s&in of #he ne!&. Tra!heos#omy may be done as an emer$en!y 'hen #he pa#ien# is in ex#remis and #he "arynx !anno# be in# ba#ed b # i# is no# a"'ays an easy pro!ed re( par#i! "ar"y in #he obese pa#ien#( and sho "d no# be embar&ed pon n"ess abso" #e"y ne!essary. An easier a"#erna#i%e for #he inexperien!ed do!#or is #he inser#ion of a "ar$e in#ra%eno s !ann "a or( a"#erna#i%e"y( a sma"" # be in#o #he !ri!o#hyroid membrane 'hi!h "ies in #he mid"ine immedia#e"y be"o' #he #hyroid !ar#i"a$e. Emer$en!y in# ba#ion is a f r#her op#ion 'hen #he "aryn$o#ra!hea" air'ay is no# obs#r !#ed( and #ra!heos#omy may be performed fo""o'in$ ini#ia" endo#ra!hea" in# barion. 7hoi!e of opera#ion A The de$ree of r$en!y in es#ab"ishin$ #ra!heos#omy 'i"" de#ermine #he me#hod sed( b # preferen!e sho "d a"'ays be for #he e"e!#i%e pro!ed re. One of #he mos# appropria#e pie!es of ad%i!e in s r$ery is ?#he #ime #o do a #ra!heos#omy is 'hen yo firs# #hin& i# may be ne!essary1. A"" of #he po#en#ia" !omp"i!a#ions of #ra!heos#omy are mar&ed"y de!reased if a me#i! "o s e"e!#i%e pro!ed re is performed nder !on#ro""ed !ir! ms#an!es by an experien!ed #eam If #ime a""o's #he fo""o'in$ sho "d be nder#a&en8 A inspe!#ion and pa"pa#ion of #he ne!& #o assess #he "aryn$o#ra!hea" ana#omy in #he indi%id a" pa#ien#6 A indire!# or dire!# "aryn$os!opy6 A #omo$raphy of #he "arynx and pper #ra!hea6 A assessmen# of p "monary f n!#ion. A Whene%er possib"e #he pro!ed re sho "d be ade; a#e"y exp"ained #o #he pa#ien# beforehand( 'i#h par#i! "ar emphasis on #he inabi"i#y #o spea& immedia#e"y fo""o'in$ #he opera#ion and possib"e diffi! "#ies 'i#h s'a""o'in$. Emer$en!y #ra!heos#omy. If a s&i""ed anaes#he#is# is na%ai"ab"e "o!a" anaes#hesia is emp"oyed( b # in despera#e !ases 'here #he pa#ien# is n!ons!io s none is re; ired. The on"y 'ord of 'arnin$ 'o "d be in #hose pa#ien#s 'ho ha%e s ffered se%ere head and ne!& #ra ma( and may ha%e an ns#ab"e !er%i!a" spine fra!# re. 7ri!o#hyroido#omy may be more s i#ab"e nder #hese !ir! ms#an!es. If i# is possib"e #he pa#ien# sho "d he "aid s pine 'i#h paddin$ p"a!ed nder #he sho "ders and #he ex#ended ne!& &ep# as s#eady as possib"e in #he mid"ine. This aids pa"pa#ion of #he #hyroid and !ri!oid !ar#i"a$e be#'een #he #h mb and index fin$er of #he free hand. The mo%emen#s of #he fin$ers of #he free hand are impor#an# in #his #e!hni; e. The opera#ion is more diffi! "# in sma"" !hi"dren and #hi!&2ne!&ed ad "#s as #he "andmar&s are diffi! "# #o pa"pa#e. A %er#i!a" mid"ine in!ision sho "d be made from #he inferior aspe!# of #he #hyroid !ar#i"a$e #o #he s pras#erna" no#!h and !on#in ed do'n be#'een #he infrahyoid m s!"es )*i$. +,.,5.. There may he hea%y b"eedin$ from #he 'o nd a# #his poin#( par#i! "ar"y if #he ne!& is !on$es#ed as a res "# of #he pa#ien#1s effor# #o brea#he aro nd an a! #e pper air'ay obs#r !#ion. No s#eps sho "d be #a&en #o !on#ro" #his haemorrha$e( a"#ho $h an assis#an# and s !#ion appara# s are %a" ab"e if a%ai"ab"e. The opera#or sho "d fee" !aref ""y( and 'i#ho # nd e has#e( for #he !ri!oid !ar#i"a$e sin$ #he index fin$er of #he free hand 'hi"s# re#ra!#in$ #he s&in ed$es by press re app"ied by #he #h mb and midd"e fin$er. If #he si# a#ion is one of ex#reme r$en!y a

f r#her %er#i!a" in!ision s#rai$h# in#o #he #ra!hea a# #he "e%e" of #he se!ond( #hird and fo r#h rin$ sho "d be made immedia#e"y 'i#ho # re$ard #o #he presen!e of #he #hyroid is#hm s )*i$. +,.,,.. The &nife b"ade is ro#a#ed #hro $h HGG #h s openin$ #he #ra!hea. A# #his poin# #he pa#ien# may !o $h %io"en#"y as b"ood en#ers #he air'ay. The opera#or sho "d be a'are of #his possibi"i#y and a%oid "osin$ #he posi#ion of #he s!a"pe" in #he open #ra!hea. Any form of a%ai"ab"e # be sho "d be inser#ed in#o #he #ra!hea as soon as possib"e and b"ood and se!re#ion s !&ed o r. On!e an air'ay has been es#ab"ished haemos#asis is #hense! red. Wi#h #he emer$en!y nder !on#ro" #he #ra!heos#omy sho "d be refashioned as soon as possib"e. 9ho "d addi#iona" e; ipmen# and more #ime be a%ai"ab"e on!e #he !ri!oid !ar#i"a$e has been iden#ified( b" n# fin$er disse!#ion inferior"y !an be sed #o mobi"ise #he #hyroid is#hm s 'hi!h sho "d be di%ided be#'een haemos#a#s( !"earin$ #he #ra!hea before ma&in$ a %er#i!a" in!ision #hro $h #he se!ond=fo r#h rin$s. A #ra!hea" di"a#or sho "d be inser#ed #hro $h #he #ra!hea" in!ision and #he ed$es of #he #ra!hea" 'o nd separa#ed $en#"y. In !ases of s spe!#ed HIV infe!#ion or diph#heria #he s r$eon sho "d p"a!e a s'ab o%er #he 'o nd so #ha# #he %io"en# expira#ory effor#s 'hi!h may fo""o' do nor !on#amina#e #he opera#or)s. 'i#h infe!#ed m ! s and b"ood. When respira#ory effor#s ha%e be!ome "ess %io"en# a #ra!heos#omy # be sho "d be inser#ed in#o #he #ra!hea and #he di"a#or remo%ed. I# is impor#an# #ha# #he s r$eon &eeps a fin$er on #he # be 'hi"e #he assis#an# #ies #he a##a!hed rapes ro nd #he pa#ien#1s ne!&. E"e!#i%e #ra!heos#omy. The ad%an#a$e of an e"e!#i%e pro!ed re is #ha# #here is !omp"e#e air'ay !on#ro" a# a"" #imes( nh rried disse!#ion and !aref " p"a!emen# of an appropria#e # be. 7"ose !o2opera#ion be#'een #he s r$eon( anaes#he#is# and s!r b n rse is essen#ia"( and a##en#ion #o #he de#ai"s 'i""mar&ed"y red !e possib"e !omp"i!a#ions and morbidi#y from #he pro!ed re. *o""o'in$ ind !#ion of $enera" anaes#hesia and endo#ra!hea" in# ba#ion( #he pa#ien# is posi#ioned 'i#h a !ombina#ion of head ex#ension and p"a!emen# of an appropria#e sandba$ nder #he sho "ders )*i$. +,.,+.. There sho "d be no ro#a#ion of #he head. 7hi"dren1s heads sho "d nor be o%er2ex#ended as i# is possib"e #o en#er #he #ra!hea in #he fif#h or six#h rin$s nder #hese !ir! ms#an!es. The inexperien!ed s r$eon may find #he inser#ion of a bron!hos!ope in #he #ra!hea of $rea# he"p 'hen performin$ #ra!heos#omy in yo n$ !hi"dren. A #rans%erse in!ision may be sed in #he e"e!#i%e si# a#ion. The #hyroid is#hm s is di%ided !aref ""y and o%erse'n( and #ension s # res are p"a!ed ei#her side of #he #ra!hea" fenes#ra#ion in !hi"dren )*i$s +,.,+2+,.,F.. A 30or& f"ap may be sed in ad "#s. The ad%an#a$es of #he 30Kr& me#hod far o #'ei$h #he po#en#ia" disad%an#a$es( and #he me#hod is par#i! "ar"y sef " for #hose s r$eons 'ho nder#a&e o!!asiona" #ra!heos#omy or 'here #he "e%e" of s&i"" and experien!e of #he n rsin$ s#aff are "imi#ed. Berformed !orre!#"y i# is safe and a""o's rein#rod !#ion of a disp"a!ed# be 'i#h #he minim m of diffi! "#y. The inferior"y based f"ap is be$ n a# i#s apex 'i#h an in!ision on #he s perior aspe!#s of #he se!ond rin$ and ex#ended do'n ei#her side #hro $h #he se!ond and #hird rin$s. The #ip of #he f"ap sho "d be s#i#!hed #o #he inferior ed$e of #he #rans%erse s&in in!ision sin$ horiDon#a" ma##ress s # res #hro $h #he s#r !# re of #he se!ond rin$. These s # res sho "d be $enero s eno $h so #ha# #hey 'i"" nor ! r o r. The firs# #ra!hea" rin$ sho "d no# be %io"a#ed nder any !ir! ms#an!es. Tra!heos#omy # bes. These are basi!a""y made of #'o ma#eria"s( si"%er or p"as#i! )*i$. +,.,H.. 3o#h ma#eria"s ha%e been sed #o ma&e # bes of %ario s siDes 'i#h %aryin$ ! r%es( an$"es( ! ffs( inner # bes and spea&in$ %a"%es. A ! ffed # be is sed ini#ia""y( 'hi!h may be !han$ed af#er ,=+ days #o a non! ffed p"as#i! or si"%er # be. The press re 'i#hin #he # be ! ff sho "d be !aref ""y moni#ored and sho "d be "o' eno $h

no# #o o!!" de !ir! "a#ion in #he m !osa" !api""aries. When in posi#ion #he # be sho "d be re#ained by do b"e #apes passed aro nd #he pa#ien#1s ne!& 'i#h a reef &no# on ei#her side. I# is impor#an# #ha# #he pa#ien#1s head is f"exed 'hen #he #apes are #ied o#her'ise #hey may be!ome s"a!& 'hen #he pa#ien# is mo%ed from #he posi#ion of ex#ension( #hereby res "#in$ in a possib"e disp"a!emen# of #he # be if #he pa#ien# !o $hs. A"#erna#i%e"y( #he f"an$es of #he p"as#i! # be may be s#i#!hed dire!#"y #o #he nder"yin$ ne!& s&in. :no'"ed$e of #he physio"o$i!a" !han$es ind !ed by #ra!heos#omy is an essen#ia" re; iremen# for #he nders#andin$ of pos#opera#i%e mana$emen#. A"" forms of #ra!heos#omy and !ri!o#hyroido#omy bypass #he pper air'ay and ha%e #he fo""o'in$ ad%an#a$es8 A #he ana#omi!a" dead spa!e is red !ed by approxima#e"y >G per !en#6 A #he 'or& of brea#hin$ is red !ed6 A a"%eo"ar %en#i"a#ion is in!reased6 A #he "e%e" of seda#ion needed for pa#ien# !omfor# is de!reased and( n"i&e endo#ra!hea" in# barion( #he pa#ien# may be ab"e #a"& and ea# 'i#h a # be in p"a!e.Ho'e%er( #here are se%era" disad%an#a$es8 A "oss of hea# and mois# re ex!han$e performed in #he pper respira#ory #ra!#6 A desi!!a#ion of #ra!hea" epi#he"i m( "oss of !i"ia#ed !e""s and me#ap"asia6 A#he presen!e of a forei$n body in #he #ra!hea s#im "a#es m ! s prod !#ion. Where no !i"ia are presen# #hism !o!i"iary s#ream is arres#ed6 A#he in!reased m ! s is more %is!id( and #hi!& !r s#s may form and b"o!& #he # be( par#i! "ar"y in !hi"dren6 A'hi"s# many pa#ien#s 'i#h a #ra!heos#omy !an feed sa#isfa!#ori"y( #here is some sp"in#in$ of #he "arynx 'hi!h may pre%en# norma" s'a""o'in$ and "ead #o aspira#ion. This aspira#ion may he ?si"en#1( i.e. nor apparen#. Bos#opera#i%e #rea#men# is desi$ned #o !o n#era!# #hese effe!#s( and fre; en# s !#ion and h midifi!a#ion are mos# impor#an# )Tab"e +,.H.. A #ro""ey m s# be p"a!ed by #he bed !on#ainin$ a #ra!hea" di"a#or( d p"i!a#e robes and in#rod !ers( re#ra!#ors and dressin$s. Oxy$en sho "d be a# hand and( in #he ini#ia" period( a n rse m s# be in !ons#an# a##endan!e. H midifi!a#ion 'i"" render #he se!re#ions "ess %is!id6 a s !&er 'i#h a !a#he#er a##a!hed sho "d be on hand #o &eep #he #ra!heobron!hia" #ree free from se!re#ions. The !a#he#er m s# be &ep# in a s#eri"e ho"der and in#rod !ed 'i#h asep#i! pre!a #ions by a"" !on!erned. When m ! s is %ery #ena!io s and !onse; en#"y diffi! "# #o aspira#e( iso#oni! sa"ine or a m !o"y#i! a$en# may be adminis#ered #hro $h #he #ra!heos#omy r be by a fine neb "iser. If #here is an inner r be i# sho "d be remo%ed and 'ashed in sodi m bi!arbona#e so" #ion e%ery + ho rs or more if ne!essary. A n mber of !omp"i!a#ions is asso!ia#ed 'i#h #ra!heos#omy b # a"" !an be a%oided 'i#h !are and a##en#ion #o opera#i%e and pos#opera#i%e derai" )Tab"e +,.-G. .O#her emer$en!y air'ay pro!ed res. *ibre2op#i! endo#ra!hea" in# ba#ion. In mos# emer$en!y si# a#ions endo#ra!hea" in# ba#ion is #he mos# dire!# and sa#isfa!#ory me#hod of se! rin$ #he air'ay. Naso#ra!hea" in# ba#ion in exper# hands is a"so a 'e""2es#ab"ished #e!hni; e and is par#i! "ar"y sef " if #he pa#ien# has #rism s( se%ere mandib "ar in0 ries( !er%i!a" spine ri$idi#y or an obs#r !#in$ mass 'i#hin #he ora" !a%i#y. 3o#h of #hese forms of in# ba#ion !an be aided in diffi! "# pa#ien#s by passin$ a modern fibre2op#i! endos!ope #hro $h #he !en#re of an endo#ra!hea" # be( hen!e $ idin$ i# in#o #he "arynx and #ra!hea nder dire!# %ision )*i$. +,.+G.. Trans#ra!hea" %en#i"a#ion. This #e!hni; e has been in!reasin$"y ad%o!a#ed in #he "as# de!ade and( a"#ho $h some spe!ia"is# e; ipmen# is re; ired( #he a!# a" #e!hni; e is

simp"e and effe!#i%e. I# 'i"" a""o' %en#i"a#ion of #he pa#ien# for periods in ex!ess of ho r and 'i"" of#en $i%e amp"e #ime #o The !ri!o#hyroid membrane is "o!a#ed by pa"pa#ion of #he ne!& 'i#h #he index fin$er( and a -+4 or -@4 p"as#i!2shea#hed in#ra%as! "ar need"e and a -G2m" syrin$e !on#ainin$ a fe' mi""i"i#res of "i$no!aine are in#rod !ed in #he mid"ine and dire!#ed do'n'ards and ba!&'ards in#o #he #ra!hea" " men )*i$. +,.+-.. The need"e is ad%an!ed s#eadi"y and ne$a#i%e press re is p"a!ed on #he syrin$e n#i" b bb"es of air are !"ear"y seen. The #iss es of #he ne!& may be infi"#ra#ed 'i#h #he anaes#he#i! if desired and #he #ra!hea" m !osa "i&e'ise par#"y anaes#he#ised by #he in#rod !#ion of =5 m" af#er $ainin$ #he " men. The need"e is remo%ed and #he p"as#i!2shea#h !ann "a remains in #he #ra!hea. I# is a##a!hed by means of a L er !onne!#ion #o #he hi$h2 press re oxy$en s pp"y. Ven#i"a#ion may be nder#a&en in a !on#ro""ed manner 'i#h a 0e##in$ de%i!e 'i#h #he !hes# bein$ obser%ed for appropria#e mo%emen#s. If #here is se%ere obs#r !#ion of #he "aryn$opharynx by #he forei$n body or # mo r( #he exha"ed o #f"o' of $ases !an be aided by p"a!emen# of one or #'o f r#her !ann "ae as exha"a#ion por#s. This pro!ed re $ains ex#reme"y rapid !on#ro" of %en#i"a#ion and re; ires a minim m of #e!hni!a" exper#ise. 7iri!o#hyroido#omy.7ri!o#hyroido#omy has $ained in!reasin$ s ppor# in some !en#res and is ad%o!a#ed 'hen endo#ra!hea" in# ba#ion is no# possib"e. I# has #he ad%an#a$es of speed and ease re; irin$ "i##"e e; ipmen# and s r$i!a" exper#ise. Ho'e%er( i#s se for a"" b # #he briefes# a!!ess #o #he air'ay remains !on#ro%ersia"( and #here are !onf"i!#in$ repor#s 'i#h re$ard #o #he s bse; en# in!iden!e of !omp"i!a#ions( par#i!2 "ar"y #hose of s b$"o##i! s#enosis and "on$2#erm %oi!e !han$es. The pa#ien#1s ne!& is ex#ended and #he area be#'een #he prominen!e of #he #hyroid !ar#i"a$e and #he !ri!oid !ar#i"a$e be"o' is pa"pa#ed 'i#h #he index fin$er of #he free hand. In #he emer$en!y si# a#ion a %er#i!a" s&in in!ision is re!ommended 'i#h disse!#ion rapid"y !arried do'n #o #he!ri!o#hyroid membrane. A -!m #rans%erse in!ision is made #hro $h #he membrane immedia#e"y abo%e #he !ri!oid !ar#i"a$e and #he s!a"pe" #'is#ed #hro $h a ri$h# an$"e #o $ain a!!ess #o #he air'ay )*i$s +,.+5.. If a%ai"ab"e ar#ery for!eps( di"a#or or #ra!hea" hoo& 'i"" aid impro%in$ #he aper# re and #he inser#ion of an a%ai"ab"e # be )*i$+,.+,.. Dependin$ on #he de$ree of emer$en!y i# may be ne!essary for #he s r$eon #o assess #he res "#s of #he pro!ed re by dire!# "aryn$os!opy( and #he a #hors re!ommend #ha# !aref " !onsidera#ion sho "d be $i%en #o !on%ersion of #he !ri!o#hyroido#omy #o a #ra!heos#omy. A"#ho $h #here is deba#e abo # #he fre; en!y of s b$"o##i! s#enosis fo""o'in$ #his pro!ed re( #here is $enera" a$reemen# #ha# i# is m !h in!reased if any "on$2#erm %en#i"a#ion is nder#a&en %ia e%en a modes# siDe #ra!heos#omy # be #hro $h #he !ri!o#hyroid membrane. Laryngeal disease causing voice disorders !ocal nodules These are &no'n as sin$ers1 nod "es in ad "#s and s!reamers nod "es in !hi"dren )*i$. +,.++.. They are fibro s #hi!&enin$s of #he %o!a" fo"ds a# #he 0 n!#ion of #he midd"e and an#erior #hird( and are #he res "# of %o!a" ab se. 9pee!h #herapy is #herefore #he preferred #rea#men# and #he "esions 'i"" reso"%e spon#aneo s"y in mos# !ases. O!!asiona""y #he nod "es 'i"" need #o be s r$i!a""y remo%ed sin$ modern mi!ro"aryn$os!opi! disse!#ion or "aser #e!hni; es. *o""o'2 p by #he spee!h #herapis# is ne!essary n#i" a"" of #he nder"yin$ errors in %oi!e prod !#ion are o%er!ome. !ocal fold polyps

These are s a""y ni"a#era" and may be asso!ia#ed 'i#h an a! #e infe!#i%e episode( !i$are##e smo&in$ and %o!a" ab se Laryngeal papillomata These o!! r main"y in !hi"dren b # !an a"so presen# in ad "#s. They are mos# !ommon"y fo nd on #he %o!a" fo"ds b # may spread #hro $ho # #he "arynx and #ra!heobron!hia" air'ay )*i$. +,.+@.. They are !a sed by papi""oma %ir ses and need remo%a" by "aser s r$ery in order #o main#ain a reasonab"e %oi!e and air'ay. An#i%ira" #rea#men# by s !h dr $s as in#erferon remains of do b#f " %a" e a# presen#. Endo2 s!opi! "aser s r$ery is #he "eas# #ra ma#i! 'ay of remo%in$ #hese "esions and sho "d no# prod !e s!arrin$ or !a se imp"an#a#ion of #he papi""oma#a e"se'here in #he air'ay. "cute laryngitis This of#en o!! rs in asso!ia#ion 'i#h pper respira#ory #ra!# infe!#ions in asso!ia#ion 'i#h a !o $h and pharyn$i#is. I# may( ho'e%er( be "o!a"ised #o #he "arynx( is s a""y %ira" and se##"es ; i!&"y if #he pa#ien# res#s #he %oi!e d rin$ #he a!#i%e inf"amma#ion. 9#eam inha"a#ions are soo#hin$ a"on$ 'i#h mi"d ana"$esi!s b # an#ibio#i!s are nne!essary. The !ondi#ion sho "d reso"%e in 5=, 'ee&s 'i#h %oi!e !are. Hoarseness "as#in$ for ,=+ 'ee&s sho "d a"'ays be referred for an ENT opinion( par#i! "ar"y in smo&ers. #hronic laryngitis 7hroni! "aryn$i#is may be spe!ifi! and !an be !a sed by my!oba!#eria( syphi"is and f n$i. Trea#men# is dire!#ed #o'ards #he !a sa#i%e or$anism. Nonspe!ifi! "aryn$i#is is !ommon( and #he main predisposin$ fa!#ors are smo&in$( !hroni! pper and "o'er respira#ory sepsis and %oi!e ab se. In some !ases #he "aryn$ea" m !osa may be!ome dysp"as#i!(par#i! "ar"y o%er #he #r e %o!a" fo"ds( and is a prema"i$nan# !ondi#ion. I# may re; ire mi!ro"aryn$os!opi! examina#ion and biopsy. Trea#men# is by #he e"imina#ion of any predisposin$ fa!#ors( par#i! "ar"y smo&in$( and a##en#ion #o any %o!a" ab se nder #he $ idan!e of a spee!h #herapis#. Dia$nosis of !hroni! "aryn$i#is sho "d no# he made n"ess #he "arynx has been f ""y e%a" a#ed by a "aryn$o"o$is#. Vo!a" fo"d pa"sy This may be ni"a#era" or bi"a#era"( b # a ni"a#era" "ef# %o!a" fo"d pa"sy is #he !ommones# as a !onse; en!e of #he "on$ in#ra#hora!i! !o rse of #he "ef# re! rren# "aryn$ea" ner%e 'hi!h ar!hes aro nd #he aor#a and may be !ommon"y in%o"%ed in inf"amma#ory and neop"as#i! !ondi#ions in%o"%in$ #he "ef# hi" m )*i$. +,.+E.. L n$ !an!er is #he !ommones# sin$"e !an!er in many par#s of #he 'or"d and a "ef# %o!a" fo"d pa"sy sho "d be !onsidered #o be d e #o a !ar!inoma of #he " n$ n#i" pro%ed o#her'ise.O#her ma"i$nan# "esions !an !a se a simi"ar effe!# and may arise in #he nasopharynx( #hyroid $"and or oesopha$ s. 3i"a#era" %o!a" fo"d para"ysis is n!ommon and #ends #o o!! r af#er #hyroid s r$ery or head in0 ries )Tab"e +,.-5.. 7"ini!a" fea# res Uni"a#era" re! rren# "aryn$ea" ner%e pa"sy of s dden onse# prod !es hoarseness 'hi!h is mos# no#ab"e for "a!& of %o" me #o #he %oi!e and o!!asiona""y may be asso!ia#ed 'i#h diffi! "#y in s'a""o'in$ "i; ids and 'ea&enin$ of #he !o $h. These symp#oms may be shor# "i%ed and #he %oi!e may re# rn #o norma" 'i#hin a fe' 'ee&s as #he m s!"es in #he opposi#e %o!a" fo"d !ompensa#e and mo%e i# a!ross #he mid"ine #o mee# #he para"ysed %o!a" fo"d 'hi!h s a""y "ies in #he paramedian posi#ion. O'in$ #o #his effi!ien# !ompensa#ion( in s"o'"y pro$ressi%e "esions #he pa#ien# may on"y experien!e s"i$h# 'ea&ness of #he %oi!e 'i#h pro"on$ed se. 3i"a#era" re! rren# "aryn$ea" ner%e pa"sy is an o!!asiona" and %ery serio s !omp"i!a#ion of #hyroide!#omy. A! #e dyspnoea o!! rs as a res "# of #he paramedian posi#ion of bo#h %o!a" fo"ds 'hi!h red !e #he air'ay #o 5=, mm and 'hi!h #end #o

$e# s !&ed #o$e#her on inspira#ion. In se%ere !ases #ra!heos#omy or in# ba#ion is ne!essary immedia#e"y o#her'ise dea#h o!! rs from asphyxia. In%es#i$a#ion of %o!a" fo"d para"ysis is mos# easi"y en!ompassed no'adays by a 7T s!an from s& "" base #o diaphra$m. This #e!hni; e has rep"a!ed #he m "#ip"e pre%io s in%es#i$a#ions 'hi!h 'ere ne!essary and re%ea"s mos# of #he pa#ho"o$y 'hi!h may $i%e rise #o an ndia$nosed %o!a" fo"d pa"sy. Approxima#e"y 5G=5> per !en# of !ases of %o!a" fo"d para"ysis o!! rs 'i#ho # &no'n pa#ho"o$y and spon#aneo s re!o%ery may o!! r. In ni"a#era" %o!a" fo"d para"ysis( 'here !ompensa#ion does nor o!! r( #he para"ysed fo"d may be media"ised by in0e!#in$ Tef"on pas#e "a#era" #o #he %o!a" fo"d and disp"a!in$ i# media""y. A"#erna#i%e"y( a sma"" ex#erna" opera#ion on #he #hyroid !ar#i"a$e may be nder#a&en in order #o en#er #he para$"o#ri! spa!e and disp"a!e #he fo"d media""y )#hyrop"as#y.. These s r$i!a" pro!ed res sho "d be performed ear"y if #he !a se is !ar!inoma of #he bron!h s and #he o #"oo& of #he pa#ien# is poor. When #he pa#ho"o$y is n&no'n i# may be be##er #o 'ai# for a period of - year #o see 'he#her spon#aneo s impro%emen# o!! rs and #o a""o' f r#her re!o%ery 'i#h #he he"p of spee!h #herapy. In bi"a#era" %o!a" fo"d para"ysis #he pa#ien#s fre; en#"y re; ire #ra!heos#omy( b # s r$ery may be !arried o # #o remo%e a sma"" por#ion of #he pos#erior aspe!# of one %o!a" fo"d or a por#ion of one ary#enoid !ar#i"a$e. These pro!ed res are mos# easi"y performed endos!opi!a""y 'i#h a !arbon dioxide "aser. They in!rease #he siDe of #he pos#erior $"o##i! air'ay a""o'in$ #he pa#ien# #o be de!ann "a#ed or e%en #o a%oid a #ra!heos#omy in #he firs# p"a!e. 9ome "aryn$o"o$is#s ha%e ad%o!a#ed reinner%a#ion pro!ed res for #he para"ysed "arynx by ro#a#in$ a ner%e m s!"e !ombina#ion in#o #he "arynx from #he ne!&. Ho'e%er( #hese #e!hni; es ha%e no# ye# fo nd 'idespread a!!ep#an!e. T mo rs of #he "arynx 3eni$n # mo rs of #he "arynx are ex#reme"y rare and s; amo s !ar!inoma of #he "arynx predomina#es o%er a"" o#hers( bein$ responsib"e for more #han HG per !en# of # mo rs 'i#hin #he "arynx. I# is #he !ommones# head and ne!& !an!er and a"mos# a"'ays o!! rs in e"der"y ma"e smo&ers. Ho'e%er( o%er #he pas# #'o de!ades #he sex in!iden!e has !han$ed as a !onse; en!e of in!reasin$ smo&in$ amon$s# 'omen( and in some areas #hey no' ma&e p more #han 5G per !en# of #he pa#ien#s. The s; amo s epi#he"i m of #he %o!a" fo"ds and #he respira#ory epi#he"i m of #he s pra$"o##is nder$o dysp"as#i! !han$e s#im "a#ed by !i$are##e smo&in$ and o#her fa!#ors. The in!iden!e of "aryn$ea" !an!er in #he #hree !ompar#men#s s pra$"o##is( $"o##is and s b$"o##is %aries aro nd #he 'or"d6 #he $"o##is is $enera""y #he !ommones# si#e fo""o'ed by #he s pra$"o##is )*i$. +,.+F.. Tr e !ar!inomas of #he s b$"o##is are %ery rare and mos# are a !onse; en!e of inferior spread from #he $"o##is. 7"ini!a" fea# res The fre; en# $"o##i! ori$in means #ha# pa#ien#s a"mos# a"'ays presen# 'i#h hoarseness. This is of $rea# impor#an!e be!a se if a dia$nosis !an be made 'hi"e #he # mo r is in #he firs# s#a$e( i.e. !onfined on"y #o one %o!a" fo"d( #hese !an!ers ha%e more #han a HG per !en# >2year disease2free ! re rare 'hen #rea#ed 'i#h radio#herapy a"one. The ! re rare drops drama#i!a""y on!e #he "ympha#i!a""y ri!h s pra$"o##is or s b$"o##is is in%o"%ed( o'in$ #o spread #o ne!& nodes. The appearan!e of more #han one ne!& $"and ha"%es #he o%era"" pro$nosis of #he pa#ien#. In%es#i$a#ions Dire!# "aryn$os!opy( preferab"y a mi!ro"aryn$os!opy( #o$e#her 'i#h Hop&in1s rod examina#ion a""o's pre!ise de#ermina#ion of #he ex#en# of #he # mo r and biopsy !on2 firms an exa!# his#o"o$y )Tab"e +,.-,.. 7T and /RI s!annin$ $i%e f r#her de#ai"s of

#he ex#en# of "ar$er # mo rs demons#ra#in$ es!ape of #he # mo r o #side #he "arynx and s spi!io s noda" in%o"%emen# 'i#hin #he ne!& 'hi!h may nor be de#ermined on !"ini!a" examina#ion. Trea#men# Ear"y s pra$"o##i! and $"o##i! # mo rs s#a$es I and II are op#ima""y #rea#ed 'i#h me$a%o"#a$e radio#herapy 'here #hese fa!i"i#ies exis#. *i%e2year ! re ra#es for s#a$es I and II are approxima#e"y HG and EG per !en#( respe!#i%e"y( and #he pa#ien# has an ex!e""en# %oi!e fo""o'in$ #his #ype of #rea#men#. If modern me$a%o"#a$e radio#herapy is no# a%ai"ab"e #hen ear"y # mo rs may be ex!ised by means of endos!opi! "aser s r$ery or open par#ia" "aryn$ea" s r$ery. This "a##er may be in #he form of a "aryn$ofiss re 'hen #he #hyroid !ar#i"a$e is opened an#erior"y in #he mid"ine and #he s; amo s !ar!inoma ex!ised nder dire!# %ision from #he %o!a" fo"d or s pra$"o##is or( in #he !ase of more ex#ensi%e ni"a#era" $"o##i! and s pra$"o##i! $ro'#hs( a %er#i!a" hemi"aryn$e!#omy may be nder#a&en. This "ea%es a defe!# on one side of #he "arynx 'hi!h is s a""y re!ons#r !#ed 'i#h ad0a!en# s#rap m s!"es. Wi#h ear"y bi"a#era" s pra$"o##i! # mo rs a horiDon#a" "aryn$e!#omy may be nder#a&en ex!isin$ #he s pra$"o##i! $ro'#h and #he remainder of #he $"o##is. The s b$"o##i! par# of #he "arynx is #hen s#i#!hed #o #he #on$ e base #o pro%ide !on#in i#y. In mos# pa#ien#s nder$oin$ par#ia" "aryn$ea" s r$ery of #his #ype #he %oi!e res "# is no# as sa#isfa!#ory as #ha# 'i#h radio#herapy( a"#ho $h #he ! re ra#es are of#en !omparab"e. Ad%an!ed "aryn$ea" disease On!e #he s; amo s !ar!inoma has !a sed fixa#ion of #he %o!a" fo"d or has infi"#ra#ed o #side #he "arynx in#o ad0a!en# s#r !# res s !h as #he #hyroid $"and and s#rap m s!"es( some form of s b#o#a" or #o#a" "aryn$e!#omy is re; ired #o a##emp# #o ! re #he disease. To#a" "aryn$e!#omy is fre; en#"y re; ired 'hen radio#herapy fai"s )*i$s +,.+H2 +,.>-..Af#er #he "arynx has been remo%ed( #he remainin$ #ra!hea is bro $h# o # on #o #he "o'er par# of #he ne!& as a permanen# #ra!hea" s#oma and #he hypopharynx( 'hi!h is opened a# #he rime of #he opera#ion( is !"osed #o res#ore #he !on#in i#y for s'a""o'in$. Th s( #he pper aerodi$es#i%e and di$es#i%e #ra!#s are permanen#"y dis!onne!#ed. Bar# or a"" of #he #hyroid $"and and asso!ia#ed para#hyroid $"ands may a"so need #o be remo%ed dependin$ on #he ex#en# of #he disease( so pa#ien#s af#er #his #ype of radi!a" s r$ery may re; ire ora" #hyroxine and !a"!i m s pp"emen#s for #he remainder of #heir "i%es. Laryn$e!#omy pa#ien#s m s# ob%io s"y a%oid immersion in 'a#er as #his 'o "d f"o' s#rai$h# in#o #heir #ra!hea" s#oma. Ho'e%er( a ra#her !omp"ex form of snor&"e de%i!e has been de%e"oped #o a""o' "aryn$e!#omy pa#ien#s #o $o s'immin$ and simp"e pro#e!#ion of #he s#oma 'i#h a #o'e" may a""o' #hem #o #a&e a !aref " sho'er. Vo!a" rehabi"i#a#ion The "oss of #he "arynx as a $enera#or of so nd does no# pre%en# pa#ien#s spea&in$ as "on$ as an a"#erna#i%e so r!e of %ibra#in$ !an be !rea#ed in #he pharynx. There are basi!a""y #hree 'ays of a!hie%in$ #his. A An ar#ifi!ia" de%i!e 'hi!h prod !es so nd 'hen app"ied #o #he sof# #iss es of #he ne!& 'hi!h is # rned in#o spee!h by #he %o!a" #ra!# !omprisin$ #he #on$ e( #he pharynx( ora" !a%i#y( "ips( #ee#h and nasa" sin ses. These de%i!es are s a""y ba##ery po'ered. A Voi!e prod !#ion may be res#ored in some pa#ien#s by "earnin$ #o s'a""o' air in#o #he pharynx and pper oesopha$ s. On re$ r$i#a#in$ #he air( a se$men# of #he pharyn$o2oesopha$ea" m !osa %ibra#es #o prod !e so nd 'hi!h is on!e a$ain modified by #he %o!a" #ra!# in#o spee!h )*i$. +,.>5..

A The mos# modern me#hod is #o $ain se of #he expired air from #he " n$s #o po'er spee!h 'hi!h is a!hie%ed by p"a!in$ a sma"" %a"%e #hro $h #he ba!& 'a"" of #he #ra!hea" s#oma in#o #he pharynx. This is a one2'ay %a"%e a""o'in$ air from #he #ra!hea #o pass in#o #he pharynx b # i# does no# a""o' food and "i; id #o pass in#o #he air'ay )*i$. +,.>,.. There is a %arie#y of #hese #ype of %a"%es( #he bes# &no'n bein$ #he 3"om=9in$er %a"%e 'hi!h 'as de%e"oped in #he U9A. Wi#h #he res#ora#ion of expired air passin$ in#o #he pharynx( #he se$men# of %ibra#in$ pharyn$ea" m !osa has a m !h $rea#er ; an#i#y of air #han 'hen i# is simp"y s'a""o'ed in#o #he pharynx and oesopha$ s( and #his $i%es an impro%ed f"o' and ; a"i#y #o #he spee!h of #o#a" "aryn$e!#omy pa#ien#s. These %a"%es are !ommon no'adays in "aryn$e!#omy pa#ien#s in many !o n#ries and #hey m s# no# be !onf sed 'i#h #ra!heos#omy # bes. Li&e a"" forei$n bodies( #he spea&in$ %a"%es are asso!ia#ed 'i#h minor !omp"i!a#ions s !h as #he forma#ion of $ran "a#ions( b"eedin$ or "ea&a$e of pharyn$ea" !on#en#s.

The ne!& Lump in the nec$ The !orre!# dia$nosis of a " mp in #he ne!& !an of#en be made 'i#h a !aref " his#ory and examina#ion. The !"ini!a" si$ns of siDe( si#e( shape( !onsis#en!y( fixa#ion #o s&in or deep s#r !# res( p "sa#i"i#y( !ompressabi"iry( #ransi"" mina#ion or #he presen!e of a br i# s#i"" remain as impor#an# as e%er. %ranchial cyst In #he fif#h 'ee& of foe#a" de%e"opmen# fo r $roo%es !an be seen on ea!h side of #he ne!&. These are #he bran!hia" !"ef#s and #he in#er%enin$ bars are #he bran!hia" ar!hes. Ea!h ar!h !on#ains a !en#ra" !ar#i"a$e and ea!h !"ef# is !omposed of a $roo%e on #he o #side and a po !h on #he inside. The firs# !"ef# persis#s as #he ex#erna" a di#ory mea# s( b # #he se!ond( #hird and fo r#h norma""y disappear. A bran!hia" !ys# de%e"ops from #he %es#i$ia" remnan#s of #he se!ond bran!hia" !"ef#( is s a""y "ined by s; amo s epi#he"i m and !on#ains #hi!& # rbid f" id f "" of !ho"es#ero" !rys#a"s )*i$. +,.>+.. The bran!hia" !ys# s a""y presen#s in #he pper ne!& in ear"y or midd"e ad "#hood and is fo nd a# #he 0 n!#ion of #he pper #hird and midd"e #hird of #he s#ernomas#oid m s!"e a# irs an#erior border. I# is a f" !# an# s'e""in$ 'hi!h may #ransi"" mina#e and is of#en sof# in i#s ear"y s#a$es so #ha# i# may be diffi! "# #o pa"pa#e. If infe!#ion o!! rs i# may be!ome mar&ed"y ery#hema#o s and #ender( and on o!!asions i# may be diffi! "# #o differen#ia#e from a # ber! "o s abs!ess. U"#raso nd and fine need"e aspira#ion bo#h aid 'i#h dia$nosis( and #rea#men# is by !omp"e#e ex!ision. This is bes# nder#a&en 'hen #he "esion is ; ies!en# as a##emp#ed ex!ision of an a! #e"y inf"ammed !ys# may !on%er# i# in#o a bran!hia" sin s 'hi!h may be more #ro b"esome. A"#ho $h #he an#erior aspe!# of #he !ys# is easy #o disse!#( i# may pass ba!&'ards and p'ards #hro $h #he for& of #he !ommon !aro#id ar#ery as far as #he pharyn$ea" !ons#ri!#ors. I# passes s perfi!ia" #o #he hypo$"ossa" and $"ossopharyn$ea" ner%es b # deep #o #he pos#erior be""y of #he dia$as#ri!. The hypo$"ossa" and spina" a!!essory ner%e are en!o n#ered in #he opera#i%e fie"d and m s# be posi#i%e"y iden#ified #o a%oid dama$e. /i!ros!opi! examina#ion of #hese !ys#s !ommon"y sho's a "ayer of "ymphoid #iss e s $$es#in$ #ha# #hese !ys#s may arise as a res "# of bran!hia" epi#he"i m en#rapped 'i#hin a "ymph node. %ranchial fistula

A bran!hia" fis# "a )*i$. +,.>>. may be ni"a#era" or bi"a#era" and are #ho $h# #o represen# a persis#en# se!ond bran!hia" !"ef#. Their ex#erna" orifi!e is near"y a"'ays si# a#ed in #he "o'er #hird of #he ne!& near #he an#erior border of #he s#erno!"eidomas#oid( 'hi"s# #he in#erna" orifi!e is "o!a#ed on #he an#erior aspe!# of #he pos#erior fa !ia" pi""ar 0 s# behind #he #onsi". Ho'e%er( #he in#erna" aspe!# of #he #ra!# may 'e"" end b"ind"y a# or !"ose #o #he "a#era" pharyn$ea" 'a""( !ons#i# #in$ a sin s ra#her #han a fis# "a. The #ra!# is "ined by !i"ia#ed !o" mnar epi#he"i m and as s !h #here may be a sma"" amo n# of re! rren# m !o s or m !op r "en# dis!har$e on #o #he ne!&. The #ra!# fo""o's #he same pa#h as a bran!hia" !ys# and re; ires !omp"e#e ex!ision of#en by more #han one #rans%erse in!ision in #he ne!&. %ranchogenic carcinoma I# is do b#f " 'he#her a primary !ar!inoma o!! rs in asso!ia#ion 'i#h a bran!hia" !ys# and i# is a"mos# !er#ain"y d e #o !ys#i! de$enera#ion in a "ymph node !on#ainin$ a deposi# of s; amo s !ar!inoma. The primary fo! s $i%in$ rise #o #he s; amo s !ar!inoma may no# be apparen#( b # is s a""y in #he nasopharynx( #onsi"( #on$ e base( piriform fossa or s pra$"o##i! "arynx. * "" examina#ion( s!annin$ and biopsy of #hese areas is ne!essary #o ex!" de #he o!! "# primary. #ystic hygroma (cavernous lymphangioma) Aro nd #he six#h 'ee& of embryoni! "ife( #he primi#i%e "ymph sa!s de%e"op in #he mesob"as#( #he prin!ipa" pair bein$ si# a#ed in #he ne!& be#'een #he 0 $ "ar and s b!"a%ian %eins6 #hese( 'hi!h !orrespond #o #he "ymph par#s of "o'er anima"s( are &no'n as #he 0 $ "ar "ymph sa!s. 9e; es#ra#ion of a por#ion of #he 0 $ "ar "ymph sa! from #he "ympha#i! sys#em a!!o n#s for #he appearan!e of #hese s'e""in$s )*i$. +,.>@..7ys#i! hy$roma s a""y manifes#s i#se"f in #he neona#e or in ear"y infan!y( and o!!asiona""y may be presen# a# bir#h and be so "ar$e as #o obs#r !# "abo r. 9'e""in$ s a""y o!! rs in #he "o'er #hird of #he ne!& and as i# en"ar$es i# passes p'ards #o'ards #he ear. Of#en #he pos#erior #rian$"e of #he ne!& is main"y in%o"%ed. As a res "# of #he in#er!omm ni!a#ion of i#s many !ompar#men#s( #he s'e""in$ is sof# and par#ia""y !ompressib"e( i# %isib"y in!reases in siDe 'hen #he !hi"d !o $hs or !ries( b # #he !hara!#eris#i! #ha# dis#in$ ishes i# from a"" o#her ne!& s'e""in$s is #ha# i# is bri""ian#"y #rans" !en#. The !hee&( axi""a( $roin and medias#in m are o#her( a"#ho $h "ess fre; en#( si#es for a !ys#i! hy$roma. 7ys#i! hy$romas of #he ne!& !an on rare o!!asions be asso!ia#ed 'i#h "ymphan$ioma#o s "esions of #he #on$ e. The beha%io r of !ys#i! hy$romas d rin$ infan!y is so n!er#ain #ha# i#is impossib"e a# #ha# a$e #o predi!# 'ha# 'i"" happen. They some#imes expand rapid"y and o!!asiona""y respira#ory diffi! "#y ens es demandin$ immedia#e aspira#ion of m !h of #he !ys#1s !on#en#s and e%en( on o!!asion( a #ra!heos#omy. The "esion may be!ome infe!#ed 'hen i#be!omes inf"amed and painf ". 9pon#aneo s re$ression may o!! r. The !ys#s are fi""ed 'i#h !"ear "ymph and "ined by a sin$"e "ayer of epi#he"i m 'i#h a mosai! appearan!e. Defini#i%e #rea#men# is ex!ision of a"" of #he !ys# a# an ear"y s#a$e. This re; ires a me#i! "o s !onser%a#i%e ne!& disse!#ion 'i#h ex!ision of a"" "ympha#i!2bearin$ #iss es 'hi"s# preser%in$ #he norma" ne ro%as! "ar s#r !# res if possib"e. A pre"iminary in0e!#ion of s!"erosin$ a$en#s is no# ad%isab"e as i#des#roys norma" #iss e p"anes ma&in$ #he ! ra#i%e s r$ery more diffi! "#. Thyro$"ossa" d !# !ys#s Embryo"o$y. The #hyroid $"and des!ends ear"y in foe#a" "ife from #he base of #he #on$ e #o'ards i#s posi#ion in #he "o'er ne!& 'i#h #he is#hm s "yin$ o%er #he se!ond and #hird #ra!hea" rin$. A# #he #ime of i#s des!en# #he hyoid bone has no# been formed and #he #ra!& of #he des!en# of #he #hyroid $"and is %ariab"e passin$ in fron#( #hro $h

or behind #he e%en# a" posi#ion of #he hyoid body. Thyro$"ossa" d !# !ys#s represen# a persis#en!e of #his #ra!& and may #herefore be fo nd any'here in or ad0a!en# #o #he mid"ine from #he #on$ e base #o #he #hyroid is#hm s. Rare"y( a #hyro$"ossa" !ys# may be #he on"y f n!#ionin$ #hyroid #iss e in #he body. 7"ini!a" fea# res. The !ys#s a"mos# a"'ays arise in #he mid"ine b # 'hen #hey are ad0a!en# #o #he #hyroid !ar#i"a$e #hey may "ie s"i$h#"y #o one side of #he mid"ine )*i$. +,.>E..7"assi!a""y( #he !ys# mo%es p'ards on s'a""o'in$ and no#ab"y 'i#h #on$ e pro#r sion b # #his may o!! r 'i#h o#her mid"ine !ys#s( s !h as dermoid !ys#s( as i#mere"y indi!a#es a##a!hmen# #o #he hyoid bone. Thyro$"ossa" !ys#s may be!ome infe!#ed and r p# re on #o #he s&in of #he ne!& presen#in$ as a dis!har$in$ sin s. Whi"s# #hey of#en o!! r in !hi"dren #hey may a"so presen# in ad "#s e%en as "a#e as #he six#h or se%en#h de!ade of "ife. Trea#men#. Trea#men# m s# in!" de ex!ision of #he 'ho"e #hryo$"ossa" #ra!# 'hi!h in%o"%es remo%a" of #he body of #he hyoid bone and #he s prahyoid #ra!# #hro $h #he #on$ e base #o #he %a""e! "a a# #he si#e of #he primi#i%e foramen !ae! m #o$e#her 'i#h a !ore of #iss e on ei#her side. This opera#ion is &no'n as 9is#r n&1s opera#ion and pre%en#s re! rren!e( mos# no#ab"y from sma"" side bran!hes of #he #hyro$"ossa" #ra!#. 7er%i!a" rib and #he s!a"ene syndrome Approxima#e"y G.> per !en# of peop"e ha%e a se%en#h !er%i!a" rib( of 'hi!h approxima#e"y ha"f are ni"a#era" and more !ommon"y fo nd on #he ri$h# side. The !er%i!a" rib may $i%e rise #o ner%e press re symp#oms and *i$. +,.>F sho's #he fo r main %arie#ies of !er%i!a" rib. A# #heir exi# from #he ne!&( #he bra!hia" p"ex s and s b!"a%ian ar#ery pass #hro $h a narro' #rian$"e and( if #he base of #he #rian$"e is raised by #he hei$h# of one %er#ebra d e #o #he in#erposi#ion of a !er%i!a" rib( #he s b!"a%ian ar#ery and #he fo r#h firs# dorsa" ner%e are bo nd #o be an$ "a#ed or !ompressed. The ar#ery may be!ome !ons#ri!#ed 'i#h a f siform di"a#ion of #he firs# 5 =+ !m dis#a" #o #he !ons#ri!#ion. 7"o##in$ may o!! r and por#ions of a m ra" #hromb s may be!ome de#a!hed and $i%e rise #o an embo" s or embo"i )*i$. +,.>H.. Three !"ini!a" si# a#ions are en!o n#ered 'i#h !er%i!a" ribs( #he simp"es# bein$ #he pa#ien# presen#in$ 'i#h a " mp in #he "o'er par# of #he ne!& 'hi!h may be %isib"e( bony hard and fixed. I# may !a se #enderness in #he s pra!"a%i! "ar fossa. A !er%i!a" rib 'i#h %as! "ar symp#oms o!! rs on"y 'hen #he rib is !omp"e#e( and pain in #he forearm( b # in some ins#an!es radia#in$ #o #he pper arm( is #he pre%ai"in$ symp#om. The pain is bro $h# on by se of #he arm and #he pain is a!!e"era#ed if #he arm is in a raised posi#ion a# #he #ime of exer!ise. The pain is re"ie%ed by res# and is d e #o is!haemi! !han$es in #he m s!"es of #he arm. The hand on #he affe!#ed side may be !o"der #han #he opposi#e side( may be!ome nd "y pa"e 'hen i#is he"d a"of# and may be!ome b" e 'hen i# is dependen# for a #ime. The radia" p "se may be "ess #han on #he norma" side and some#imes absen#. This 'i"" depend on #he "e%e" of !o""a#era" !ir! "a#ion. The dis#a" par# of #he s b!"a%ian ar#ery sho "d be a s! "#a#ed and #he sys#o"i! br i# 'i"" be si$nifi!an#. N mbness of #he fin$ers may o!! r( fo""o'ed by "!era#ion and %ery o!!asiona""y $an$rene. Trea#men# is by promp# ex#raperios#a" ex!ision of #he !er%i!a" rib #o$e#her 'i#h any bony prominen!e from #he firs# rib. I# may be ad%isab"e #o perform sympa#he#i! dener%a#ion of #he pper "imb. Tr e !er%i!a" rib 'i#h ner%e press re symp#oms is probab"y a rare o!! rren!e as mos# !ases ha%e been fo nd #o be re"a#ed #o !er%i!a" spondy"osis 'i#h press re on #he !er%i!a" roo#s in #he re$ion of #he in#er%er#ebra" foramina or by !arpa" # nne" syndrome 'hi!h may !a se 'as#in$ of #he #henar eminen!e. O#her !ondi#ions s !h as mo#or ne ron disease and syrin$omye"ia may !a se simi"ar symp#oms. If a !er%i!a" rib needs ex!ision i#is essen#ia" #o remo%e i#

'i#h i#s perios#e m or i#'i"" re$enera#e. 7are m s# be exer!ised #o a%oid dama$e #o #he bra!hia" p"ex s and phreni! ner%es. rauma to the nec$ #ut throat In #he ma0ori#y of !ases admi##ed #o a!!iden# and emer$en!y !en#res #he 'o nd does no# in%o"%e impor#an# ne ro%as! "ar s#r !# res b # on"y s&in( p"a#ysma and s#erno!"eidomas#oid or s#rap m s!"es. I# is( ho'e%er( pr den# #o exp"ore a"" of #hese 'o nds forma""y. Wo nds abo%e #he hyoid bone The !a%i#y of #he mo #h or pharynx may ha%e been en#ered and #he epi$"o##is may be di%ided %ia #he pre2epi$"o##i! spa!e. These 'o nds re; ire repair 'i#h absorbab"e s # res on a forma" basis nder a $enera" anaes#he#i!. If #here is any de$ree of asso!ia#ed oedema or b"eedin$( par#i! "ar"y in re"a#ion #o #he #on$ e base or "aryn$ea" in"e#( i#is ad%isab"e #o perform a #ra!heos#omy #o a%oid any s bse; en# respira#ory dis#ress. Wo nds of #he #hyroid and !ri!oid !ar#i"a$e 3" n# !r shin$ in0 ries or se%ere "a!era#ion in0 ries #o #he "aryn$ea" s&e"e#on !an !a se mar&ed haema#oma forma#ion and rapid "oss of #he air'ay. There may be si$nifi!an# disr p#ion of #he "aryn$ea" s&e"e#on. These pa#ien#s sho "d no# ha%e an endo#ra!hea" in# ba#ion for any "en$#h of #ime( e%en if #his is #he ini#ia" emer$en!y 'ay of pro#e!#in$ #he air'ay. The "arynx is a de"i!a#e #hree2#iered sphin!#er and #he presen!e of a forei$n body in i#s " men af#er se%ere disr p#ion $i%es rise #o ma0or fibrosis and "oss of "aryn$ea" f n!#ion. These in0 ries are fre; en#"y an abso" #e indi!a#ion for a "o' #ra!heos#omy( fo""o'in$ 'hi!h #he "arynx !an be !aref ""y exp"ored and dama$ed !ar#i"a$es reposi#ioned and s # red( and #he para$"o##i! spa!e drained. An ind'e""in$ s#en# of sof# spon$e shaped #o fi# #he "aryn$ea" " men and he"d by a ny"on re#ainin$ s # re #hro $h #he ne!& may be "ef# in p"a!e for approxima#e"y > days. This s#en# !an be remo%ed endos!opi!a""y af#er ! ##in$ #he re#ainin$ s # re and as #he "aryn$ea" dama$e hea"s #he pa#ien# may #hen be de!ann "a#ed. Division of the trachea Wo nds of #he #ra!hea are for# na#e"y rare b # #hey sho "d a"" be forma""y exp"ored( and in order #o ob#ain ade; a#e expos re i#is s a""y ne!essary #o di%ide and "i$a#e #he #hyroid is#hm s. A sma"" #ra!heos#omy be"o' #he 'o nd and #hen repair of #he #ra!hea 'i#h a "imi#ed n mber of s bm !osa" s # res is appropria#e. In se"f2inf"i!#ed 'o nds #he re! rren# "aryn$ea" ner%es( 'hi!h "ie pro#e!#ed in #he #ra!heo2oesopha$ea" $roo%es( are rare"y in0 red. Ho'e%er( in s#ab 'o nds #o #he ne!& any ner%e may be in%o"%ed in!" din$ #he %a$ s( re! rren# "aryn$ea" ner%e or !er%i!a" sympa#he#i! !hain. Brimary repair is rare"y possib"e b # may be nder#a&en a# #he #ime of forma" exp"ora#ion of a ma0or ne!& 'o nd. Vas! "ar !omp"i!a#ions of ! # #hroa# In !on#ras# #o ner%e dama$e( %as! "ar dama$e !an be se%ere. /a0or haemorrha$i! sho!& may o!! r as a !onse; en!e of in0 ry #o #he !ommon !aro#id( ex#erna" or in#erna" !aro#id( or a %eno s air embo"ism as a res "# of dama$e #o one of #he ma0or

%eins( mos# !ommon"y #he in#erna" 0 $ "ar. Infe!#ion of "ar$e ne!& 'o nds is no# n!ommon( and !e"" "i#is may s per%ene and spread inferior"y #o #he medias#in m. 9 r$i!a" emphysema may res "# if dama$e #o #he #ra!hea is no# re!o$nised and air es!apes in#o #he ne!&. Oesopha$ea" and pharyn$ea" fis# "a may o!! r b # s a""y hea" spon#aneo s"y. Aphonia or dysphonia may fo""o' in0 ry #o #he %o!a" fo"ds or di%ision of #he re! rren# "aryn$ea" ner%es. 9#enosis of #he #ra!hea or "arynx may be !a sed by s!arrin$ from ma0or in0 ries d e #o road #raffi! a!!iden# or a##emp#ed han$in$. Wo nds of #he !er%i!a" por#ion of #he #hora!i! d !# Wo nds #o #he #hora!i! d !# are for# na#e"y rare and mos# of#en o!! r in asso!ia#ion 'i#h disse!#ion of "ymph nodes in #he "ef# s pra!"a%i! "ar fossa. When dama$e #o #he d !# is no# re!o$nised a# #he #ime of opera#ion( !hy"e may s bse; en#"y "ea& from 'o nd in amo n#s p #o 5 "i#resCday and( as a res "#( #he pa#ien# may 'as#e rapid"y. Trea#men# 9ho "d #he dama$e be re!o$nised d rin$ an opera#ion( #he proxima" end of #he d !# m s# be "i$a#ed. Li$a#ion of #he d !# is no# harmf " be!a se #here is a n mber of anas#omo#i! !hanne"s be#'een #he "ympha#i! and %eno s sys#em in #he "o'er ne!&. If nde#e!#ed( !hy"e s a""y s#ar#s #o dis!har$e from #he ne!& 'o nd 'i#hin 5+ ho rs of #he opera#ion. On o!!asions firm press re by a pad and banda$e #o #he "o'er ne!& may s#op #he "ea&a$e b # fre; en#"y #his is ns !!essf " and i# is bes# #o re2exp"ore #he 'o nd and "o!a#e and "i$a#e #he dama$ed d !#. If #he pa#ien# is $i%en some !ream #o drin& 5 ho rs before #he opera#ion #he ! # end of #he d !# is more easi"y fo nd 0 s# "a#era" #o #he "o'er + !m of #he "ef# in#erna" 0 $ "ar %ein. If i# pro%es impossib"e #o find #he d !#( par#i! "ar"y in an area of oedema#o s and fra$i"e #iss e( #he 'o nd !an be pa!&ed firm"y 'i#h a Whi#ehead1s %arnish pa!& and a""o'ed #o hea" by $ran "a#ion. Inflammatory conditions of the neck Barapharyn$ea" and re#ropharyn$ea" abs!ess forma#ion has been !o%ered ear"ier in #his !hap#er. L d'i$ an$ina L d'i$ des!ribed a !"ini!a" en#i#y !hara!#erised by a bra'ny s'e""in$ of #he s bmandib "ar re$ion !ombined 'i#h inf"amma#ory oedema of #he mo #h. I# is #hese !ombined !er%i!a" and in#raora" si$ns #ha# !ons#i# #e #he !hara!#eris#i! fea# re of #he "esion( as 'e"" as #he p #rid ha"i#osis #ha# is a"'ays presen#. The infe!#ion is of#en !a sed by a %ir "en# s#rep#o!o!!a" infe!#ion asso!ia#ed 'i#h anaerobi! or$anisms and some#imes 'i#h o#her "esions of #he f"oor of #he mo #h s !h as !ar!inoma. The infe!2 #ion en!ompasses bo#h sides of #he my"ohyoid m s!"e !a sin$ oedema and inf"amma#ion s !h #ha# #he #on$ e may be disp"a!ed p'ards and ba!&'ards $i%in$ rise ini#ia""y #o dyspha$ia and s bse; en#"y #o po#en#ia" obs#r !#ion of #he air'ay. 7"ini!a" !a se Un"ess #he infe!#ion is !on#ro""ed !e"" "i#is may ex#end do'n #he ne!& benea#h #he deep fas!ia" "ayers #o in%o"%e #he "arynx !a sin$ $"o##i! oedema. Trea#men# An#ibio#i! #herapy sho "d be ins#i# #ed as soon as possib"e sin$ in#ra%eno s broad2 spe!#r m an#ibio#i!s s !h as amoxy!i""in or !ef roxime !ombined 'i#h me#ronidaDo"e #o !omba# #he anaerobes. In ad%an!ed !ases 'here #he s'e""in$ does no# s bside rapid"y 'i#h s !h #rea#men#( a ! r%ed s bmen#a" in!ision may be sed #o drain bo#h

s bmandib "ar #rian$"es. The my"ohyoid m s!"e may be in!ised #o de!ompress #he f"oor of #he mo #h. 9imp"e b # $enero s !orr $a#ed drains may be p"a!ed in #he 'o nd 'hi!h is #hen "i$h#"y s # red. This opera#ion may be !ond !#ed nder "o!a" anaes#hesia and on rare o!!asions an addi#iona" #ra!heos#omy may be ne!essary. 7er%i!a" "ymphadeni#is )Tab"e +,.-+. There are approxima#e"y FGG "ymph nodes in #he body6 no fe'er #han ,GG of #hem "ie in #he ne!&. Inf"amma#ion of #he "ymph nodes of #he ne!& is ex!eedin$"y !ommon. Infe!#ion o!! rs from #he ora" and nasa" !a%i#ies( #he pharynx( "arynx( ear( s!a"p and fa!e. The so r!e of #he infe!#ion m s# be so $h# sys#ema#i!a""y. A! #e "ymphadeni#is The affe!#ed "ymph nodes are en"ar$ed and #ender( and #here may be %aryin$ de$rees of $enera" !ons#i# #iona" dis# rban!e of #he pa#ien# 'i#h pyrexia( anorexia and $enera" ma"aise. The #rea#men# in #he firs# ins#an!e is dire!#ed #o #he primary fo! s of infe!#ion( for examp"e #onsi""i#is or a den#a" abs!ess. If( despi#e an#ibio#i! #herapy( #he pain !on#in es or abs!ess forma#ion o!! rs in #he "ymph nodes( parapharyn$ea" or re#ropharyn$ea" spa!e #hen s r$i!a" draina$e may be re; ired. 7hroni! "ymphadeni#is 7hroni! pain"ess "ymphadenopa#hy may be ei#her # ber! " s( in !hi"dren or yo n$ ad "#s( or d e #o se!ondary ma"i$nan# me#as#ases mos# !ommon"y from a s; amo s !ar!inoma in o"der peop"e. Lymphoma a"so !ommon"y presen#s in !er%i!a" nodes in yo n$ ad "#s.7aref " inspe!#ion of #he pper air'ays and food passa$es is essen#ia" #o ex!" de primary ma"i$nan!y of #he nasopharynx( #onsi"( #on$ e base( piriform fossa or "arynx. *ine need"e aspira#ion of en"ar$ed !er%i!a" "ymph nodes is preferab"e #o any form of open biopsy. T ber! "o s adeni#is T ber! "osis )T3. remains a prob"em #hro $ho # #he 'or"d and is s#i"" a !ommon !a se of !er%i!a" "ymphadenopa#hy. The !ondi#ion mos# !ommon"y affe!#s !hi"dren or yo n$ ad "#s( b # !an o!! r a# any a$e. The deep pper !er%i!a" nodes are mos# !ommon"y affe!#ed( b # #here may be a 'idespread !er%i!a" "ymphadeni#is and #he ma#!hin$ #o$e#her of a s bs#an#ia" n mber of "ymph nodes may be e%iden#. In mos# ins#an!es #he # ber! "ar ba!i""i $ain en#ran!e #hro $h #he #onsi" of #he !orrespondin$ side of #he "ymphadenopa#hy. 3o#h bo%ine and h man T3 may be responsib"e. In approxima#e"y FG per !en# of !ases #he # ber! "o s pro!ess is "imi#ed #o #he !"ini!a""y affe!#ed $ro p of "ymph nodes b # a primary fo! s in #he " n$s m s# a"'ays be s spe!#ed and in%es#i$a#ed. As rena" and p "monary T3o!!asiona""y !oexis#( #he rine sho "d be examined !aref ""y. Rare"y( #he pa#ien# may de%e"op a na# ra" resis#an!e #o #he infe!#ion and#he nodesmay be de#e!#ed a# a "a#er da#e as e%iden!ed by !a"!ifi!a#ion on an <2ray. This !an a"so be seen af#er appropria#e $enera" #rea#men# of # ber! "o s adeni#is. If #rea#men# is no# ins#i# #ed( #he !asea#ed node may "i; efy and brea& do'n 'i#h #he forma#ion of a !o"d abs!ess in #he ne!& )*i$. +,.@G.. The p s is firs# !onfined by #he deep !er%i!a" fas!ia b # af#er 'ee&s or mon#hs #his may be!ome eroded a# one poin# and #he p s f"o's #hro $h #he sma"" openin$ in#o #he spa!e benea#h #he s perfi!ia" fas!ia. The pro!ess has no' rea!hed #he 'e""2&no'n s#a$e of a ?!o""ar s# d1 abs!ess. The s perfi!ia" abs!ess en"ar$es s#eadi"y and( n"ess s i#ab"e #rea#men# is adop#ed( #he s&in 'i"" soon be!ome reddened o%er #he !en#re of #he f" !# a#in$ s'e""in$ and before "on$ a dis!har$in$ sin s o!! rs in #he ne!&. Trea#men#. The pa#ien# sho "d be #rea#ed by appropria#e !hemo#herapy( as !onfirmed by assessmen# of abs!ess !on#en#s for sensi#i%i#ies #o #he an#i# ber! "o s dr $s. If an abs!ess fai"s #o reso"%e despi#e appropria#e !hemo#herapy and $enera" meas res( o!!asiona""y ex!ision of #he abs!ess and i#s s rro ndin$ fibro s !aps "e is ne!essary

#o$e#her 'i#h #he re"e%an# "ymph nodes. If #here is a!#i%e T3 of ano#her sys#em( for examp"e p "monary( #hen remo%a" of # ber! "osis "ymph nodes in #he ne!& is inappropria#e. The nodes are !ommon"y re"a#ed #o #he in#erna" 0 $ "ar %ein( !ommon !aro#id and %a$ s ner%e( and #hey may be asso!ia#ed 'i#h a $rea# dea" of s rro ndin$ fibrosis. 9 r$ery !an be diffi! "# and a por#ion of #he in#erna" 0 $ "ar %ein may re; ire ex!ision 'i#h !onsiderab"e !are #o a%oid dama$e #o #he %a$ s or #he !er%i!a" sympa#he#i! #r n&. A $ood %ie' and a!!ess sho "d be ob#ained a# a"" #imes d rin$ #his s r$ery and #he s#erno!"eidomas#oid m s!"e di%ided #o fa!i"i#a#e a!!ess( par#i! "ar"y if #he disease is ad0a!en# #o #he spina" a!!essory ner%e or #he hypo$"ossa" ner%e. The rese!#ed nodes sho "d be sen# for bo#h pa#ho"o$i!a" and mi!robio"o$i!a" ana"ysis. &rimary # mo rs of #he ne!& Ne ro$eno s # mo rs #hemodectoma (carotid body tumour). This is a rare # mo r b # #here is a hi$her in!iden!e in areas 'here peop"e "i%e a# hi$h a"#i# des( for examp"e in Ber and /exi!o 'here in!reased n mbers ha%e been repor#ed as a !onse; en!e of !hroni! hypoxia "eadin$ #o !aro#id body hyperp"asia. The # mo rs mos# !ommon"y presen# in #he fif#h de!ade and approxima#e"y -G per !en# of pa#ien#s ha%e a fami"y his#ory. There is an asso!ia#ion 'i#h phaeo!hromo!y#oma. The # mo rs arise from #he !hemore!ep#or !e""s on #he media" side of #he !aro#id b "b and a# #his poin# #he # mo r is adheren# #o #he !aro#id 'a"" )*i$. +,.@-.. The !e""s of #he !hemode!#oma are no# hormona""y a!#i%e and #he # mo rs are s a""y beni$n 'i#h on"y a fe' pro%en me#as#ases in a sma"" n mber of !ases. 7"ini!a" fea# res. The pa#ien#s of#en presen# 'i#h a "on$ his#ory of se%era" years of a s"o'"y en"ar$in$ pain"ess " mp a# #he !aro#id bif r!a#ion. Abo # one2#hird of pa#ien#s presen# 'i#h a pharyn$ea" mass p shin$ #he #onsi" media""y and an#erior"y. The mass is firm( r bbery( p "sa#i"e and is mobi"e from side #o side b # no# p and do'n( and !an some#imes be emp#ied by firm press re( af#er 'hi!h i# 'i"" s"o'"y refi"" in a p "sa#i"e manner. A br i# may a"so be presen#.9'e""in$s in #he parapharyn$ea" spa!e 'hi!h of#en disp"a!e #he #onsi" media""y sho "d no# be biopsied from 'i#hin #he mo #h. In%es#i$a#ions.When a !hemode!#oma is s spe!#ed a d p"ex s# dy and( if indi!a#ed( a !aro#id an$io$ram sho "d be !arried o # #o demons#ra#e #he !aro#id bif r!a#ion 'hi!h is s a""y sp"ayed and a b" sh 'hi!h o #"ines #he norma" # mo r %esse"s. This # mo r m s# no# be biopsied and fine need"e aspira#ion is a"so !on#raindi!a#ed. Trea#men#.3e!a se #hese # mo rs rare"y me#as#asise and #heir o%era"" ra#e of $ro'#h is s"o'( #he need for s r$i!a" remo%a" m s# be !onsidered !aref ""y as !omp"i!a#ions of s r$ery are po#en#ia""y serio s. The opera#ion is bes# a%oided in e"der"y pa#ien#s. Radio#herapy has no effe!#. In some !ases i# may be possib"e #o disse!# #he # mo r a'ay from #he !aro#id bif r!a#ion( b # a# #imes 'hen #he # mo r is bar$e i#may no# be separab"e from #he %esse"s and rese!#ion 'i"" be ne!essary s !h #ha# a"" appropria#e fa!i"i#ies sho "d be a%ai"ab"e #o es#ab"ish a bypass 'hi"s# a %ein a #o$raf# is inser#ed #o res#ore ar#eria" !on#in i#y in #he !aro#id sys#em. !agal body tumours. Va$a" para$an$"iomas arise from nes#s of para$an$"ioni! #iss e of #he %a$ s ner%e 0 s# be"o' #he base of #he s& "" near #he 0 $ "ar foramen. They may a"so be fo nd a# %ario s si#es a"on$ #he ner%e do'n #o #he "e%e" of #he !aro#id ar#ery bif r!a#ion. 7"ini!a" fea# res. They a"so presen# as s"o'"y $ro'in$ and pain"ess masses in #he an#ero"a#era" aspe!# of #he ne!&( and may a"so ha%e a "on$ his#ory !ommon"y of 5=, years before dia$nosis.

Dia$nosis is !onfirmed by 7T and /RI s!annin$ and addi#iona" ar#erio$raphy if ne!essary. They may spread in#o #he !rania" !a%i#y and s r$ery may be re; ired. Peripheral nerve tumours. 9!h'annomas are so"i#ary and en!aps "a#ed # mo rs a##a!hed #o or s rro nded by a ner%e. Bara"ysis of #he asso!ia#ed ner%e is n s a". The %a$ s ner%e is #he !ommones# si#e for #hese # mo rs 'i#hin #he ne!&. Ne rofibromas a"so arise from #he 9!h'ann !e"" and may be par# of %on Re!&"in$ha sen syndrome of m "#ip"e ne rofibroma#osis. / "#ip"e ne rofibroma#osis is an a #osoma" dominan# heredi#ary disease and #he ne rofibroma#a may be presen# a# bir#h and of#en m "#ip"e. These "esions may o!! r in #he ne!& and in abo # -G per !en# of #hese # mo rs ma"i$nan# !han$e o!! rs( a"#ho $h #hey s a""y en"ar$e s"o'"y o%er a period of many years and #he pain"ess ne!& mass is #he on"y si$n. As 'i#h #he "esions abo%e( dia$nosis re; ires an$io$raphy and s!annin$ #o differen#ia#e #hem from o#her parapharyn$ea" # mo rs( b # on o!!asions #he dia$nosis m s# 'ai# n#i" ex!ision. 'econdary carcinoma of the nec$ 9e!ondary !ar!inoma#o s infi"#ra#ion of #he !er%i!a" "ymph nodes is a !ommon o!! rren!e from impor#an# primary si#es in#he head and ne!&. These are nasopharynx( #onsi"( #on$ e( piriform fossa and s pra$"o##i! "arynx. A"" of #hese areas m s# be !aref ""y assessed #o sear!h for #he primary $ro'#h before !onsiderin$ biopsy or any s r$ery on #he ne!&. In%es#i$a#ion is f r#her assis#ed by fine need"e aspira#e of #he ne!& node. /ana$emen# The mana$emen# of #he in%o"%ed !er%i!a" "ymph nodes depends on #he o%era"" #rea#men# re$ime #o be $i%en #o #he pa#ien#. A If s r$ery is bein$ sed #o #rea# #he primary disease and #he !er%i!a" nodes are pa"pab"e( and in ex!ess of , !m( #hey maybe ex!ised en b"o! 'i#h #he primary "esion. A If radio#herapy is sed ini#ia""y( as is a"'ays #he !ase in !ar!inoma of #he nasopharynx( #hen radio#herapy may a"so be $i%en #o #he ne!& nodes 'ha#e%er #heir s#a$e. In #he !ase of #on$ e( pharynx or "arynx( ho'e%er( if #he node ex!eeds , !m in diame#er #hen s r$ery may be ne!essary for #he ne!& nodes e%en if #he primary is #rea#ed by radio#herapy. AIf radio#herapy is sed ini#ia""y( as is a"'ays #he !ase in !ar!inoma of #he nasopharynx( #hen radio$raphy may a"so be $i%en #o #he ne!& nodes( 'ha#e%er #heir s#a$e. In #he !ase of #he #on$ es( pharynx or "arynx ho'e%er( if #he node ex!eeds , !m in diame#er #hen s r$ery may be ne!essary for #he ne!& nodes( e%en if #he primary is #rea#ed by radio#herapy. If radio#herapy is sed ini#ia""y 'i#h reso" #ion of #he primary b # #here is s bse; en# resid a" or re! rren# noda" disease #hen #his si# a#ion 'i"" re; ire !er%i!a" "ymph node disse!#ion. ypes of nec$ dissection A 7"assi!a" radi!a" ne!& disse!#ion )7ri"e. =#he !"assi! opera#ion in%o"%es rese!#ion of #he !er%i!a" "ympha#i!s( #he "ymph nodes and #hose s#r !# res !"ose"y asso!ia#ed s !h as #he in#erna" 0 $ "ar %ein( #he a!!essory ner%e( #he s bmandib "ar $"and and #he s#ernomas#oid m s!"e. These s#r !# res are a"" remo%ed en b"o! and in !on#in i#y 'i#h #he primary disease if possib"e. The main disabi"i#y #ha# fo""o's #he opera#ion is #he droopin$ of #he sho "der d e #o para"ysis of #he #rapeDi s m s!"e as a !onse; en!e of ex!ision of #he a!!essory ner%e. A /odified radi!a" ne!& disse!#ion =in se"e!#ed !ases one or more of #he #hree fo""o'in$ s#r !# res are preser%ed( #he a!!essory ner%e( #he s#erno!"eidomas#oid m s!"e or #he in#erna" 0 $ "ar %ein( b # o#her'ise a"" ma0or "ymph node $ro ps and

"ympha#i!s are ex!ised. Whi!he%er s#r !# res are preser%ed a# #his disse!#ion sho "d be !"ear"y no#ed. A 9e"e!#i%e ne!& disse!#ion =in #his #ype of disse!#ion one or more of #he ma0or "ymph node $ro ps is preser%ed a"on$ 'i#h s#ernomas#oid m s!"e( a!!essory ner%e and in#erna" 0 $ "ar %ein. Under #hese !ir! ms#an!es #he exa!# $ro ps of nodes ex!ised m s# be do! men#ed. * r#her readin$ Hibber#(J. )ed..)-HHE. 9!o## 3ro'n1s O#o"aryn$o"o$y( Laryn$o"o$y and Head and Ne!& 9 r$ery( @#h edn( 3 ##er'or#h2Heinemann( Oxford. /aran( A.4.D.( 4aDe( /. and Wi"son( J.A. )-HH,. 9#eL# and /aran1s Head and Ne!& 9 r$ery( 3 ##er'or#h2Heinemann( Oxford. /!4re$or( ".A. and Ho'ard( D.J. )eds. )-HH5. Rob and 9mi#h1s Opera#i%e 9 r$ery. Head and Ne!& Bar# -( 3 ##er'or#h2Heinemann( Oxford. %anHasse"#( 7.A. and 4ibb( A.4. )eds. )-HH-. Nasopharyn$ea" 7ar!inoma( 7hinese Uni%ersi#y Bress( Hon$ :on$.