An adenoid is a collection of lymphatic tissue (part of the immune system), which sits at the back of the nose. Adenoids are larger in young children and tend to shrink towards teenage years. Because they sit at the back of the nose, they can lead to nasal obstruction or interfere with normal function of the Eustachian tubes (tubes opening at the back of the nose that ventilate the middle ear). It is unusual to have to remove adenoids in isolation and they are usually removed in combination with grommet surgery on the ears or as part of treatment for obstructive sleep apnoea in children. Adenoids are removed under general anaesthesia and they are accessed through the mouth. Adenoid surgery is relatively painless and complications are unusual.
The cough is a protective mechanism for the airway and helps to clear secretions or foreign material from the larynx and/or the windpipe. We all have a tendency to cough when we have infections of the throat or chest. Most people would tend to see their doctor if the cough persists beyond a week or two and the general practitioner will listen to the chest, examine the mouth and throat, and if appropriate, prescribe antibiotics or refer the patient for further investigations. A cough that produces discoloured sputum is usually due to infection, but a non-productive cough that persists more than eight weeks is described as chronic.
Most patients with a chronic cough will initially be referred to a respiratory physician who will examine and investigate the respiratory system. If there is no disease in the chest, then the most common causes of cough are due to laryngeal hypersensitivity secondary either to gastroesophageal reflux, postnasal drip (“catarrh”) or asthma. A cough can also be precipitated and exacerbated by certain drugs and allergies. Occasionally, chronic cough is habitual or psychological in origin. Frequently, respiratory physicians who have failed to get to the bottom of a chronic cough scenario will seek the opinion and advice of an Ear, Nose and Throat specialist, who has an interest in this condition. The ENT doctor will generally examine the nose, investigate the sinuses, look at the larynx and pharynx, and treat any positive findings.
Dysphagia is difficulty in eating or drinking due to a disruption of the swallowing process. Sudden onset dysphagia can be due to the impaction of something that has been swallowed, such as a bone or a bolus of meat that has become stuck somewhere in the throat or oesophagus (“gullet”). The patient is advised to attend their local emergency department for appropriate investigations and management. Painful swallowing (odynophagia) can occur with infections in the throat, for example with tonsillitis. In the absence of infective causes, patients should seek the advice of their general practitioner as tumours and growths can also present in this manner. Swallowing problems can also occur following head and neck surgery, strokes, and neuromuscular degenerative disorders (such as motor-neurone disease or multiple sclerosis). Certain drugs can also precipitate swallowing problems and the swallowing generally deteriorates with age. Swallowing problems become an issue when the patient fails to obtain adequate nutrition and starts to lose weight or the patient has frequent chest infections because of aspiration of secretions or food materials. These patients should have their swallowing formally assessed by a specialist, such as ENT surgeon, who will have access to the full complement of tests and treatments.
The most common serious head and neck cancer in the United Kingdom is cancer of the larynx (voice box). Cancers can also occur in the oral cavity (mouth), pharynx (throat), salivary glands, nose and sinuses. The majority of these patients have a history of smoking and alcohol consumption. Cancers of the head and neck may present with a lump in the neck and be otherwise asymptomatic, but more commonly, they are associated with pain, voice problems, swallowing problems and depending on where they originate, ulceration of the mouth or throat. Anyone with such a problem persisting for more than three weeks should see their general practitioner, who will perform an examination and, if appropriate, refer to a Head and Neck specialist.
However, it is important to note that many of these symptoms and findings can be associated with less serious conditions in the head and neck and do not always represent a malignancy (cancer), but it is always wise to be cautious.
Hoarse voice or dysphonia is used to describe a change in the voice from the person’s normal voice. A hoarse voice generally means that there is a problem within the larynx, such that the vocal cords do not come together to vibrate in the normal fashion. The most common cause of a hoarse voice is a respiratory tract infection, such as a “cold” or influenza. Other causes of hoarse voice include nodules, polyps and cysts. Material refluxing from the stomach contains acid and digestive enzymes and these can also irritate the larynx and produce a hoarse voice.
Growth of tumours in the larynx, on the vocal cords, can be benign (non-cancerous) or malignant (a cancer). It is therefore important to seek medical advice from the general practitioner if a hoarse voice persists for more than three weeks, and especially if it is associated with difficulty in swallowing and discomfort in the throat. Cancer of the larynx can occur at any age, but more commonly it occurs in smokers in the fifth or sixth decade of life.
Laryngotracheal stenosis is due to a disease or injury affecting the larynx or trachea that leads to a compromise of the airway. The symptoms are most commonly of shortness of breath, but there can also be voice problems or a chronic cough. Sometimes this condition is mistaken for asthma.
The most common causes are post-intubation (following a period of ventilation on the Intensive Care Unit). Idiopathic subglottic stenosis, Wegener’s granulomatosis, sarcoidosis and other inflammatory conditions are less common. The majority of these conditions can be treated with minimally invasive endoscopic microsurgery, sometimes using the laser. More significant injuries may require open reconstruction of the larynx or trachea. Following successful surgery, the majority of patients find improvements in their exercise thresholds and, if they have a tracheostomy tube present, frequently this can be removed.
There are three pairs of large salivary glands and many hundreds of microscopic salivary glands draining into the mouth and the throat. The largest salivary glands are the parotid glands, which sit in front of the ears in the tissues of the cheek. The submandibular glands are a smaller pair of glands that sit under the jaw bone and the sublingual glands are the smallest paired glands that sit in the floor of the mouth behind the front teeth. As well as keeping the mouth moist and lubricating food, the saliva that is produced, also contains antibodies and digestive juices.
Tumours in the salivary glands are relatively uncommon and the vast majority of these are benign (non-cancerous). The salivary glands are also prone to stones or narrowing of their ducts, which can lead to a painful swelling in the region of the affected gland. Any new swelling in the head/neck area that persists for more than two or three weeks should be reviewed by the general practitioner and if he or she feels that it is appropriate, a referral may be made to an ENT specialist.
Snoring is the noise generated by some people during sleep, due to the vibration of soft tissues around the palate, throat or the back of the tongue. Sleep related breathing disorders range from simple snoring to snoring with obstructive breathing episodes. If these episodes occur frequently, then the patient may have obstructive sleep apnoea.
Many people will snore when they are excessively tired, have been drinking alcohol or suffering with a blocked nose, perhaps as a result of a “cold”. Snoring tends to get worse as we get older because the tissues become more lax and they are more likely to vibrate. Being overweight can also exacerbate the problem, as the extra bulk of tissue can cause narrowing of the upper airways.
Children tend to snore and suffer with obstructive sleep apnoea because of enlarged tonsils and adenoids. Obstructive sleep apnoea in children leads to poor cognitive function and can cause behavioural problems. Since most of a child’s growth takes place during the deepest stages of sleep, poor sleep can cause a child to have impaired growth. In adults, obstructive sleep apnoea can cause excessive daytime tiredness and affect mental skills. Over time, untreated obstructive sleep apnoea can also put a strain on the heart and the lungs. An adult with simple snoring will often be advised to lose weight first before being referred to an Ear, Nose and Throat (ENT) specialist. When you do see an ENT specialist, he will perform a thorough examination of the nose, mouth, throat and larynx to determine the potential sites of airway vibration and obstruction. Treatment will be tailored to the individual. This may include medical treatment or surgery on the nose, on the palate or trial of a mandibular advancement prosthesis. This is like a tooth guard, worn at night, which pulls the lower jaw forward to hold the airway open. Where obstructive sleep apnoea is suspected, the patient will be referred for a sleep study which can be performed at home or in a hospital setting. If a diagnosis of obstructive sleep apnoea is made, then the patient will need a referral to a respiratory physician who specialises in sleep related breathing disorders. Depending on the severity of the sleep apnoea, the patient will certainly be advised to lose weight, if appropriate, and they will probably be issued with a CPAP (continuous positive airway pressure) device. This is a mask worn over the nose at night, which continually blows air through the nose to hold the upper airways open and prevent obstruction. This can significantly improve the patient’s quality of sleep and daytime functioning.
Tonsils are small glands in the back of the throat that sit on either side of the soft “dangly” bit in the midline (uvula). They are part of the immune system and, as a result, help fight infection and germs. Fortunately, there is a surplus of such tissue at the back of the throat and in the neck, and removal of tonsils does not lead to a reduction in protection against future infections.
Tonsils may be removed if a person has recurrent severe sore throats (tonsillitis), more than five times a year. They may also be removed if the individual is suffering with obstructive episodes at night. Tonsils are also removed if a tumour or growth is suspected in one of them. Patients who have had a Quinsy, an infection leading to a collection of pus adjacent to a tonsil, are very prone to further such infections and a tonsillectomy may be performed in these cases. Many doctors are less inclined to remove tonsils, as infections can often be managed with antibiotics. However, if frequent infections are impacting severely on the patient’s quality of life and ability to study or work, then the procedure can be justified.
A tonsillectomy is nearly always performed under general anaesthesia and post-operatively patients are encouraged to eat and drink as normally as possible. Aside from the post-operative discomfort, there is a small risk of a bleed from the site of the surgery any time during the two-week post-operative recovery period. Anything more than minor spotting of blood in the sputum requires review by a doctor, and in most cases it is recommended that the patient attends the local emergency department. A tonsillectomy can also lead to altered taste or temporary numbness of the tongue, but this is highly unusual.
Vocal cord paralysis or vocal cord palsy usually occurs when there has been a disruption to the function of the nerve (recurrent laryngeal nerve) that supplies the larynx. There are two recurrent laryngeal nerves and they each supply one half of the larynx. The vocal cords normally separate during breathing, but come together and vibrate for vocalisation. Sometimes, the vocal cords will stop working because there has been trauma to the neck or injury to the larynx due to disease, or following a general anaesthetic. When one vocal cord is not working, the patient experiences a weaker and breathier voice, which fatigues easily and may have a higher pitch. Normal coughing may also be impaired. This is because the vocal cord that is not working tends to lie away from the midline, such that the paralysed vocal cord no longer makes contact with the opposite functional cord. The majority of vocal cord palsies are temporary sometimes as a result of neck surgery, such as thyroid surgery. Sometimes, the recurrent laryngeal nerve stops working because there has been an infection or they can be damaged by diseases in the head and neck, such as cancers.
Once a patient has been fully assessed by an ENT surgeon specialising in voice, appropriate investigations will reveal the cause of the cord palsy and the prognosis for the patient. Most patients will go on to see a speech and language therapist for appropriate exercises and never require surgical intervention. In those patients where adequate recovery is unlikely or speech therapy has been unsuccessful, surgery to the larynx can be considered. Surgery may include injections into the larynx to bring the non-functional vocal cord to the midline, or a thyroplasty procedure where a small incision is placed in the neck and the vocal cord is pushed to the midline with a very small implant. The surgeon will decide which technique is most appropriate for each patient.
We are all aware at that at puberty a boy’s voice “breaks” and becomes lower pitched, and this is in response to a surge of the male hormone testosterone. Interestingly, the girl’s voice at puberty also drops, but to a much lesser degree and this is in response to a surge in the female circulating hormones. With ageing, the female voice continues to gradually drop in pitch until old age, when the pitch may start to rise again. A man’s voice can become increasingly high pitched in old age. There is also a tendency to develop other medical conditions with age, and these may also have an impact on the quality of the voice. Other changes to the ageing voice may include tremor or voice fatigue. Part of the problem is that the vocal cords become thinner as we get older and more laxed. This leads to a weaker ‘breathier’ quality to the voice. With increasing numbers of elderly people wishing to remain in the work place, there are now procedures available to improve the older person’s voice, and these are often called “voice lifts”.
Patients wishing to have assessment and management of their ageing voice should seek the opinion of a laryngologist or a phonosurgeon. One of the procedures used is to remove fat from the patient’s abdomen and to inject it into the vocal cords to bulk them up, boosting vocal strength and projection with less vocal fatigue. Other patients will be helped by optimising co-existing medical problems and referral to a voice therapist.
