Throat / Mouth

Tonsil problems

iStock_000023931445_MediumCauses:

Tonsil enlargement in adults may have intrinsic, unknown, infective or tumor origins. Some tonsils trap tonsilloliths (small concretions that are stone-like). May be aggravated by nose allergies, infections or laryngoesophageal gastric reflux.

Importance:

May result in blocked breathing passages, and snoring and obstructive sleep apnea. Recurrent tonsillitis could be associated with sore throats, fevers, poor feeding, antibiotic resistance and absence from work.

Investigations:

  • Oral cavity examination
  • Flexible nose endoscopy
  • Sleep study may be required – either home or hospital based for a night

Treatment offered:

  • Watchful waiting if episodes are isolated, mild and without significant airway obstruction
  • Fever, pain and antibiotic medications may be required.
  • Day surgery for tonsils removal may be required for chronic airway obstruction, severe or recurrent tonsillitis. Diathermy, radiofrequency and coblation methods are available.
Mouth Ulcers

Causes:

The exact cause is often unknown, and aggravated by stress, trauma, acidic fruits, braces or ill-fitting dentures. Poor health conditions need to be addressed – eg poor immune system, autoimmune disorders, vitamin B-12, zinc, folic acid, iron deficiency and gastrointestinal tract disease like Crohn’s disease. Some pain killers, beta-blockers and chest pain medications may predispose. Cancers need to be excluded in ulcers that persist and enlarge. Importance:

  • Painful, can be recurrent
  • Need to exclude cancers if lasting longer than 3 weeks, or if sores are unusually large and spreading

Investigations offered:

  • Blood tests to exclude systemic causes
  • Biopsy to exclude systemic disorder and cancer in some cases

Treatment offered:

  • Minor ulcers around 2-8mm diameter may take 2 weeks to heal.
  • Major ulcers which are larger and deeper take longer and can leave scars.
  • Antimicrobial mouth rinse, corticosteroid or antibiotic ointment, oral gel
  • Good dental hygiene important, may need referral to dentist
  • Referral to other medical specialists if needed
Gastroesophageal Reflux Disease (GERD)

Photo 34 gastric acid reflux laryngitisCauses:

The ring of muscle between the esophagus and stomach becomes weak or relaxes abnormally. In Gastroesophageal Reflux Disease (GERD), backflow of the acid/ non-acid eg pepsin contents from the stomach up into the voice box and laryngeal area causes irritation, phlegm and hoarseness in the throat. Obesity, pregnancy, coughing, vomiting, straining or sudden physical exertion can cause increased pressure in the abdomen. Some may have an undiagnosed small hiatal hernia, where a small portion of the stomach is trapped above the diaphragm.

Importance:

LERD may not be associated with gastric pain or heartburn sensation. More often, it is just chronic throat irritation worse after meals or sleep, or hoarseness of voice that prompts an evaluation. Long term however, there is a risk of cancer change in the esophageal and laryngeal and voice box mucosa if untreated.

Investigations:

  • Nasolaryngoendoscopy in the clinic
  • 24 hour double pH probe
  • Barium swallow/ meal
  • Evaluation by gastroenterology specialist
  • Esophageal manometry or Pepsin test (for non-acid gastric reflux)

Treatment:

  • Lifestyle modification: reduce weight, smoking, alcohol
  • Dietary modification: reduce spicy/ sour foods, chocolate, peppermint, fried/ fatty foods, caffeinated drinks
  • Avoid late meals near sleeping time
  • Medication for reflux
  • Work with gastroenterologist specialist for surgery (for strangulated hiatal hernia or recalcitrant and severe reflux)
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