THROAT & LARYNX

Condition of Throat and

Larynx
Adenoids
Tonsilitis
Peritonsillar abcess/
Quinsy
Foreign Body
Laryngitis
Neoplasm/ Laryngeal
Carcinoma
2

Side view of Throat/ Larynx

Normal Tonsil
pic

Adenoids
Def: Enlarged adenoids refers to swollen lymphatic tissue at
the back of the adenoids. Adenoids become swollen due to
viral and bacterial infection, or due to allergic reaction
Large adenoids can cause significant respiratory obstruction,
lead to chronic mouth breathing
Mouth breathing can cause permanent changes in facial shape,
i.e., adenoidal facies with elongation of the face and openmouthed, slack-jaw appearance
Respiratory obstruction at night, with snoring and even sleep
apnea can cause significant load upon the right side of the
heart
Chronic adenoid hypertrophy can cause blockage of the
eustachian tube and chronic ear disease and hearing loss
5

 The tonsils are two areas of lymphoid tissue

located on either side of the throat. The adenoids,
also lymphoid tissue, are located higher and
further back, behind the palate, where the nasal
passages connect with the throat. The adenoids
are not visible through the mouth.
6

Etiology
Cause: Staphylococcus, Staphylococcus aurea,
Homophylus Influenza, Pneumococcus, Virus

Clinical manifestations:
Blocked nose, breathing through mouth
Difficulty in breathing, noisy breathing at night
Otalgia (Fallness)/ earache
Halitosis bad breath
Pain at the back of nose
Nose discharge

Factor: Poor oral hygiene - infection

7

Treatment
Antibiotic
Analgesic
Surgical Adenoidectomy, for severe cases,
but not encourage
Adenoidectomy: Removal of adenoids soft
palette by using curette. Gauze is apply to
stop bleeding. Remove gauze after 2-3 mins
when bleeding stop.
Reason for adenoidectomy: impaired breathing
through nose, chronic infection or earaches
8

Tonsilitis
Def: Infection and swelling of the
tonsils, which are oval-shaped masses
of lymph gland tissue located on both
side of the back of throat.
Etiology:
Microorganism Streptococcus,
Staphylococcus aureus, Hemophylus
influenza, Pneumococcus, virus,
Shibella
9

Clinical manifestation of
Tonsilitis
Pain and dryness of the throat due to inflammation
Fever pyrexia temperature 38C as result of
infection
Tonsil redness and swollen as result of
inflammation
Otalgia
Swelling of cervical lymph nodes
Halitosis
Difficulty in breathing in severe cases
General malaise due to fever
Loss of apetite
Fatigue
Weight loss
10

Investigation & treatment

Investigation:
Throat swab C/S
Blood C/S

Treatment:

Voice test
Liquid diet reduce spicy and hot food
Balance diet
Oral hygiene, N/Saline gargle
Medication: Antipyretic, Antibiotic
Tonsillectomy severe and recurrent tonsillitis
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Tonsillectomy
Recurrent tonsilitis where medical treatment
failed to reduce
Peritonsillar abcess
Tonsil malignancy
Enlargement of tonsil which causes obstruction
of airway
Hypertrophy (enlargement) causing dental
malocclusion or adversely affecting oral-facial
(mouth-face) growth as documented by
orthodontist
Persistent foul taste or breath due to chronic
tonsillitis that is not responding to medical
therapy
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Tonsillectomy care

Pre-op care:
1.
Explain reasons of the surgery and consent
2.
Lab investigation: FBC (Hb, Plat, Twdc), PT/PTT, GXM in reserve, blood C/S,
Throat swab C/S
3.
NBM 6-8hrs before op to prevent aspiration
4.
Baseline vital signs
5.
Provide emotional supports to pt and family/caregiver

Post-op care:
1.
Position: Semi prone to encourage flow of secretion (blood and saliva)
and prevent airway obstruction
2.
Observe bleeding and vital signs
3.
Continue IVF
4.
Report signs of difficulty and bleeding, e.g. Frequent swallowing, excessive
secretion from mouth, hematoma in throat
5.
Analgesic provide saline gargle to loosen phlegm
6.
Nutrition encourage soft cold diet, e.g. Blend diet initially , ice cream, ice
water, porridge; normal diet when pt can swallow
13

Contd
Health education:
1. Avoid gargle after surgery causes bleeding
2. Avoid sneezing, cough, blowing nose, active
exercise for 2 weeks until healed
3. Drink 2-3L of water daily to prevent bad breath
4. Avoid dry, hard and fried foods, e.g. Popcorn
until recovered
5. Report if bleeding is present
6. Throat discomfort for 4-8 days due to
membrane separation
7. Blackish stool due to ingestion of blood post-op
8. Conserve energy and rest vocal cord as much
as possible
14

Peritonsillar abcess
(Quinsy)
Def: collection of infected material in
area around the tonsils
The infection spreads from the tonsils
to surrounding tissue which forms
abcess.

15

Etiology & Incidence

Causative microbes:

Streptococcus
Staphylococcus aureas
Haemophilus Influenza
Pneumococcus
Virus

Incidence:
Unilateral or bilateral
Peritonsillar abcess in a complication of tonsilitis
Most common abcess cause: Group A hemolytic streptococcus
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Signs & Symptoms of Throat

Abcess

Peritonsillar abcess and retropharyngeal abcess have different signs and

symptoms

Peritonsillar abcess:
1. Severe throat pain
2. Ear pain on the same side of the abcess (occasional)
3. Tenderness of submandibular gland
4. Dysphagia (difficulty in swallowing) causes drooling
5. Fever
6. Chills
7. Malaise
8. Rancid breath
9. Nausea
10.Mumbled speech
11.Dehydration
12.Cervical adenopathy
13.Localised/systemic sepsis
17

Contd
Retropharyngeal abcess:
1. Pain
2. Dysphagia
3. Fever
4. Nasal obstruction abcess in upper pharynx
5. Dyspnea, progressive inspiratory stridor (from
laryngeal obstruction) lower position abcess
6. Children drooling and muffled crying
A very large abcess may press on the larynx,
causing edema, or may erode into major vessels,
causing sudden death from asphyxia or aspiration
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Clinical Manifestation
1. Throat and ear pain:

Difficulty in speech hoarseness of voice

Difficulty in opening mouth

2.
3.
4.
5.

Hyperpyrexia followed by rigor

Dehydration due to lack of fluid intake
Pus formation around tonsil soft tissue
Difficulty in breathing due to enlargement
and abscess formation
6. Oedema around tonsil (peritonsillitis)
7. Difficulty in swallowing even saliva due to
infected throat
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Diagnosis of Throat Abcess

Peritonsillar Abcess
Based on pt history of bacterial pharyngitis
Throat examinations; swelling of soft palate on the
abcessed side; displacement of uvula to the opposite
side; red, edematous mucous membrane; tonsil
displacement toward midline
Culture may reveal streptococcal infection

Retropharyngeal Abcess
Based on pt history of naso-pharyngitis or pharyngitis
Throat examination; soft, red bulging of posterior
pharyngeal wall
X-ray: larynx pushed forward and widened space
between the posterior pharyngeal wall and vertebrae
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Treatment for Throat Abcess

Antibiotic
Analgesic/ antipyretic
Throat irrigation aspirin mouth gargle
Tonsillectomy if recurred during 6-8 weeks

Early Stage:
1. Large doses of penicillin or another broadspectrum antibiotic are necessary
2. If pt is immune-compromised or has been
repeatedly hospitalized, antibiotic therapy
should include average for staphylococci and
gram-negative organism
21

Contd
Late Stage:
1. Peritonsillar abcess with cellulitis of the tonsillar space, primary
treatment is usually I & D (Incision & Drainage) under local
anaesthetic with antibiotic therapy for 7-10 days
2. Tonsillectomy, scheduled no sooner than 1 month after healing,
prevents recurrence but only recommended after several
episodes
After I & D:
1. Give antibiotics, analgesics and antipyretics. Stress the
importance of completing the full course of antibiotic therapy
2. Monitor vital signs, and watch for any significant changes or
bleeding. Assess pain and treat accordingly
3. If pt unable to swallow, ensure adequate hydration with IV
therapy. Monitor fluid intake and output, and watch out for
dehydration
4. Provide meticulous mouth care. Apply petroleum to the pts
lips. Promote healing with warm water with warm saline gargles
or throat irrigation for 24-36hrs after I&D.
5. Encourage adequate rest
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Foreign Body - Throat

Usually sharp objects, e.g. fishbone,
chicken bone, dentures which can get stuck
and cause obstruction at pharyngeal or
laryngeal sphincter
Young children are naturally curious and
may intentionally put shiny objects, e.g.
coins, button, batteries in their mouths
Physical assessment:
History of neck tenderness during palpations
(swollen neck)
Pt complains of pain, unable to swallow saliva
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Diagnosis & Treatment

Diagnostic examination:
Direct laryngoscopy
Radiography lateral neck

Treatment:
Doctor remove the foreign body after
confirmation of foreign bodys location
Long forceps is used to pull out the object but
care is taken not to damage the layers of mucous
in the larynx under GA
Observe patient for signs and symptoms of shock
after procedure, e.g. pallor, tachycardia and
decreased blood pressure
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Laryngitis
Def: Inflammation of the larynx,
resulting in hoarseness of voice
The tissues below the level of epiglottis
are swollen and inflammed
Causes swelling around the area of vocal
cords, which leads to inability of vocal
cords to vibrate normally
Hoarseness of voice sig. sign of
laryngitis
Often occurs during the course of an
upper respiratory tract infection - cold
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Etiology of Laryngitis
Caused by virus, e.g. upper respiratory infection
(colds etc)
Parainfluenzae virus, influenza virus, respiratory
syncytial virus, rhinovirus, coronavirus, and
echovirus. RARE: bacteria e.g. Group A
Streptococcus, M. Catacchalis, or that causes TB
may cause laryngitis
Immunocompromised pt, e.g. Acquired
Immunodeficiency syndrome (AIDS), infections with
fungi may be responsible for laryngitis
Irritation dust and smoke
Excessive use of voice
Tobacco
Alcohol
Disturbance of upper respiratory tract
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Signs & Symptoms

Sore, scratchy throat, runny nose, itchiness and
fatigue may occur
Difficulty in swallowing with streptococcal
infections
Pt may cough and wheeze, the voice will sound
strained, hoarse, and raspy
In extremely rare cases, the swelling of the
larynx may cause airway obstruction
More common in infants, due to the small
diameter of their airways. They may have a
greatly increased respiratory rate, and exhibit
loud high-pitched sounds with breathing (stridor)
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Clinical manifestation &

Investigation
Clinical manifestion:
1. Voice changes hoarseness, loss of voice (aphonia)
2. Dysphagia during swallowing and talking
3. Sore throat especially larynx and throat
4. Cough (no phlegm)
5. Systemic disturbances, e.g. fever, fatigue
Investigation:
1. History of smoking or alcoholism
2. Surgery
3. Upper respiratory tract infection
4. Family history of nasopharyngeal carcinoma
5. High risk occupations dusty places, e.g. Sawmill
6. Lab test: throat swab C/S
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Treatment

Talk less to rest vocal cord

Analgesic reduce pain
Gargle Thymol gargle
Cough mixture reduce irritation
Alternative treatments, e.g.
Aromatherapy, inhalation (benzoin),
lavender, frankincense, thyme,
sandalwood
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Cancer of the Larynx

Def: mostly begin in the glottis. The inner
walls of the larynx are lined with cells
called squamous cells.
Almost all laryngeal cancers begin in these
cells. These cancers are called Squamous
Cell Carcinoma (SCC)
If cancer of the larynx spreads
(metastasizes), the cancer cells often
spread to the back of the tongue, other
parts of the throat and neck, lung, and
other parts of the body.
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Etiology & Types of Laryngeal

Cancer

Male >55 years

Smoker
Vocal abuse excessive use of voice
People who suffer chronic laryngitis
Genetic
Exposure to radiation, chemicals

Types of Laryngeal Cancer:

1. Supra glottis infection: Epiglottis, False Vocal
cord
2. Glottis true vocal cord
3. Sub glottic below vocal cord
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Clinical Manifestation
Sore throat for many weeks
A lump in the neck/ swelling
Burning sensation when taking fruit juice or drinking hot
water
Weight loss
Loss of appetite
Hoarseness or continuous voice changes 3-4 weeks
A sore throat or feeling that something stuck in throat
Persistent cough
Problem in breathing
Bad breath
Earache
Dysphagia
Itchiness in throat
Dyspnoea (shortness of breath)
Aphonia (inability to make a sound)
Haemopstasis (cough blood)

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Investigation & Treatment

Investigation:
Indirect laryngoscopy examination of larynx using mirror
Biopsy HPE
Radiology CT Scan, Neck X-ray
Physical examination neck, thyroid, larynx and lymph
nodes for abnormal lumps or swelling
Treatment:
1. Radiation for carcinoma larynx without involving cervical
lymph nodes
2. Emergency tracheostomy If tumor is enlarged and involved
subglotis, it can cause airway obstruction, increase stridor
3. Laryngectomy follow by radiation on the tumor for carcinoma
larynx involving cervical lymph nodes
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Laryngectomy
Def: partial or complete surgical removal of the
larynx, usually as a treatment for cancer of the
larynx
Once the larynx is removed, air can no longer flow
into the lung. During surgery, the surgeon removes
the larynx through the incision in the neck
Tracheostomy is also performed by surgeon by
making an artificial opening called stoma in front
of the neck
Upper portion of trachea is brought to the stoma
and secured, making it a permanent alternative to
get air into the lungs
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35

36

Contd
The connection between throat and esophagus is not
normally affected, so after healing, the person whose
larynx has been removed can eat normally.
However, normal speech is no longer possible
Several alternate means of vocal communication can be
learned with the help of speech pathologist
PREPARATION:
1. Obtain consent after the procedure is thoroughly
explained
2. Lab investigation: blood and urine test. Chest X-ray and
EKG as per hospital protocol, e.g. patient > 40 years old
3. If total laryngectomy is planned, it may be helpful to
meet with speech pathologist for discussion of post-op
expectation and support
37

Aftercare
A person undergoing laryngectomy spends several days in ICU
and receives IVF and medication
Monitor vital signs regularly
Patient is encouraged to turn, cough, and deep breathe to help
mobilize secretions in the lungs
One or more drains are usually inserted in the neck to remove
any fluids that collected in the surgical site.
Drains are removed after 2 days, or when drainage become
minimal
Excess secretion suction
Breathing exercise physiotherapist
Daily and PRN dressing on tracheostomy tube
STO after 7-10 days post-op
It takes 2-3 weeks for the tissues of the throat to heal, during this
time pt must receive nutrition through Naso-gastric tube
When air is drawn in through the stoma, it does not have
opportunity to be warmed and humidified. To keep it from drying
out and crusted, pt is encouraged to breathe artificial humidified
air
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Contd
After surgery, an alternate method of the stoma is usually covered
with alight cloth to keep out unwanted particles from entering the
lungs
Care of stoma is extremely important, since it is the persons only
way to get air inside lungs
After laryngectomy, pt and his/her caregivers will be taught on
stoma care
Immediate communication such as writing notes, gestures or
pointing can be used
Pt with partial laryngectomy will gradually regain some speech
several weeks after the surgery, but the voice may be hoarse, weak
and strained
Speech pathologist will work with patient with total laryngectomy to
establish new ways of communicating
Many pt resume daily activities after surgery
Special precautions must be taken during showering or shaving
Special instruction and equipment is required for those who wish to
swim or water ski, as it is dangerous for water to enter the windpipe
and lungs via stoma.
39

Contd
Regular follow-up visits are
important, because there is a higherthan-average risk of developing a
new cancer in the mouth, throat, or
other regions of the head or neck.
Self-help and support groups are
available to help pts meet other who
face similar problems
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Complications
Complication:
Accumulation of secretions/ airway
obstructions
Injury to operation site
Stoma stenosis

Long term complication:

Infection to the lungs due to aspiration
Recurrent
Metastases, cancer spread to the neck
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Problems Faced by
Tracheostomy Patients

Secretion
Obstruction
Infection
Emphysema
Haemorrhage
Accidental decanulation
Axphysia
Loss of voice
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 pic

43

 pic

44

 pic

45

Throat - Procedure
1.
2.
3.
4.

Examination of the throat

Taking throat swab C/S
Throat painting
Examination under laryngoscope

46

Examination of the
Throat
Aim:
To observe for any abnormalities, e.g. foreign body,
tonsilitis, abcess, adenoid gland enlargement

Equipment:
Tray:

Tongue depressor/ spatula, laryngeal mirror

2 Gallipots: i) swab and gauze ii) N/Saline
Sterile swab stick for specimen
1 dissecting forceps
1 bowl of warm water/ lamp for warming the laryngeal
mirror
Cap mackintosh
receiver
47

 pic

48

 pic

49

Procedure
Responsibilities BEFORE:
1. Inform pt
2. Prepare equipment and bring to pt
3. Provide privacy
4. Position pt head tilted and instruct pt to open mouth
Responsibilties DURING:
1. Assist doctor in the procedure, e.g. direct the light, stabilize
the position, instruct pt to keep mouth open throughout the
procedure, assist in taking specimen
Responsibilities AFTER:
1. Ensure pt comfort
2. Clear and clean equipment
3. Label specimen, lab form and send to lab ASAP
50

Taking throat swab (collect

specimen)
Aim:
To collect throat specimen for culture and
sensitivity (identify type of microbes and
suitable antibiotics)
For pt with URTI, sinus infection, throat infection

Equipment:

Tongue depressor, spotlight/ torchlight/ headlight

Sterile cotton tipped swab stick
Sterile specimen container with culture medium
Sterile glove
Biohazard bag
51

 pic

52

Procedure
1.
2.
3.
4.
5.
6.
7.

Inform pt to get cooperation

Wear gloves
Instruct pt to sit up right, open mouth and say AH~~
Direct torchlight in pts mouth
Observe for redness or whitish spots in the throat
Hold tongue depressor and press on tongue firmly
With right hand/ dominant hand, quickly swab the
tonsil to avoid gag reflex
8. Avoid touching the oral cavity, if accidentally touched,
the specimen is contaminated
9. Place swab inside the sterile specimen bottle
10. Label specimen, place in the biohazard bag and send
to lab
11. Discard gloves and wash hands
12. Record the procedure
53

Throat Painting
Aim:
To apply local medication, e.g. chronic
pharyngitis

Equipment:
Tray:

Medication in gallipot
1 artery forceps spencer wells artery forcep
1 dissecting forcep
Tongue depressor
torchlight
Cap mackintosh
receiver
54

Procedure
1.
2.
3.
4.
5.
6.
7.

Inform pt
Prepare equipment and bring to side of pt
Provide privacy
Patient position recumbent or sitting, head tilted
Place gauze in between forceps
Dip in medication
Instruct pt to open mouth and press tongue firmly
with tongue depressor
8. Wipe throat with gauze dip in medication
9. Give good lighting so that it is done properly
10.Comfort the patient
11.Clear and clean equipment
12.documentation
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Medications used for throat

painting
Chronic Pharyngitis:
Mandls paint
Potassium iodine 5%
Iodine 5%
Peppermint oil 1%
Glycerin

Fungal infection:
Gentian violet 0.5%
56

Endoscopic examination/
Laryngoscopy
Examination of larynx with use of scope, to
see the condition of back of the throat,
larynx (voice box), vocal cords.
Procedure done under local analgesia, e.g.
10% Xylocaine throat spray or GA if done in
OT, sedative is given 1 hour before
examination, e.g. secorbarbitor,
mereridine, narcotic
Atropine sulphate suitable for local and
GA in reduction of secretion
57

Nursing Responsibilities
Before (Pre-Laryngoscopy):
1. Pt is given explanation by doctor and consent is taken
2. Instruct pt to brush teeth and gargle with antiseptic solution night
and morning before procedure
3. NBM 8hrs before procedure
4. Remove dentures and acknowledge doctor if pt has any loose teeth
5. Reassure pt to reduce anxiety
6. Explain to pt short acting sedative is given in OT before procedure
and local analgesia (e.g. Lidocaine) is sprayed on the throat
After (Post-Laryngoscopy):
1. NBM until gag reflex return, e.g 2hrs
2. Assess gag reflex slowly, irritate the back of the throat with spatula
3. If gag reflex assist, start with sips of water follow by liquid / food to
avoid aspiration
4. If vocals cords were affected during procedure, advice pt to rest
voice for 3 days

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