Behcet’s Syndrome

Bechts Syndrome

Oral ulceration seen in Behcet’s Syndrom

This is a condition of unknown causation characterised by painful ulcerative lesions involving the oral cavity and the genitalia. There may also be involvement of the central nervous system with encephalitis, inflammation of the eyes (uveitis) and arthritis of the joints. Treatment involves immunosuppressants together with systemic steroids.

Benign Vocal Cord Lesions

normal vocal cords

Normal smooth vocal cords

Note the two small bumps on the vocal cords

As previously stated, any abnormality of the vocal cord can present itself with hoarseness in the first instance. If the lesion however gets to a significant size, then this can also compromise the airway and give rise to associated stridor. The commonest benign lesion is the vocal cord or Singer’s nodule. A fleshy polyp can arise from the vocal cord after a severe infection and present with hoarseness. These conditions are easily diagnosed in the outpatient clinic by examining the larynx with a fibre-optic camera after application of local anaesthetic spray through the nasal passages and into the mouth if needed. In most instances the entire examination can be video-documented for future reference.

Fleshy polyp arising form the left vocal cord

Burning Mouth Syndrome

The cause of this is unknown and presents with symptoms of burning sensation in the oral cavity. It is important to rule out vitamin B deficiency, folate deficiency, diabetes, fungal infection and treat symptoms with a trial of steroid mouth wash. In postmenopausal women, hormone replacement therapy can be beneficial. Often no causation is identified and symptoms can be troublesome.

Candida Infection

oral thrushOral thrush can cause white lesions in the oral cavity which when scraped off can result in bleeding. Patients present with sore throat or burning sensation. Treatment is usually simple with antifungal oral preparations. It occurs commonly  in patients who are immunocompromised, such as diabetics or severely systemically ill patients. It can be a complication of antibiotic use and in patients who use steroid inhalation therapy for Asthma.

Diphtheria

This is now uncommon in developed countries following vaccination. The causative organism is Corynebacterium diphtheriae and it produces a toxin which can result in the development of thick membranous material lining the airway which eventually causes obstruction of the wind pipe. The toxin can also enter the bloodstream and can give rise to circulatory disturbance. Treatment with Penicillin is effective.

Epiglottitis

Epiglottits

The picture on the left shows a normal larynx whereas on the right, there is severe swelling due to epiglottitis. A tube is in place to ventilate the patient.

This is fortunately a rare condition now and is associated with a bacterial infection of the epiglottis. As a result of infection the epiglottis swells up considerably thereby risking narrowing of the airway. This occurs most commonly in children and can give rise to a severe sore throat associated with a hoarse voice and ultimately a compromise of the airway (stridor). This represents a medical emergency and patients need to be rushed to the nearest hospital where appropriate treatment can be given. Failure to do so can result in airway obstruction. Fortunately, this condition once diagnosed can be treated with aggressive antibiotic treatment. The patient invariably needs to have a tube inserted into the windpipe to allow oxygenation.

Erythema Multiforme

This can be a complication of drug therapy. In the major form it is also called Stevens-Johnson syndrome and the manifestations are vesicles in the oral cavity but can also affect the anogenital region, the eyes and the skin. It tends to occur in younger patients between the age of 10 and 30. The lesions are usually self limiting and resolving over two to six weeks.

erythema multiforme

Erythroplakia

erythroplakia with SCC

Side view of the tongue showing an early tongue cancer in the background of erythroplakia

 Erythroplakia means any red patch of unknown cause.  Any such persistent red patch for more than three weeks should be considered a possible pre-malignant condition and should be biopsied.

Functional dysphonia

Probably the commonest cause of hoarseness is what is called functional dysphonia. Here, the patient has a history of hoarseness but when examined with fibre-optic endoscopy, no abnormalities are seen affecting the vocal cords. However, there may be problems associated with the correct functionality of the larynx such that the vocal cords do not come together in a nice smooth fashion. This condition particularly affects the professional voice user or those who need to raise their voice frequently such as teachers. Treatment for this condition however is speech therapy and rarely is surgical intervention required. Even when vocal cords nodules (Singer’s nodules) develop, this can be managed by adequate speech therapy.

Bilateral Nodules

Note the two small bumps on each side. These are typical vocal cord nodules (Singer’s Nodules)

Fungal Infections

oral thrushThe most common fungal infection in the oral cavity is due to candidiasis or thrush. It occurs commonly in immunocompromised patients or those on antibiotics for other conditions. Typically, patients have a sore throat and on inspection have white, slightly cheesy plaques in the oral cavity which when dislodged can bleed. The infection can progress downwards to involve the oesophagus and larynx. Treatment is with systemic antifungal medication.

Geographic Tongue (Benign Migratory Glossitis)

geographic tongueThis is a curious condition affecting 1% of the population where patches are seen involving the tongue which changes its position and size. These are generally asymptomatic but can cause anxiety in some patients. This requires no treatment.

Gonorrhoea

With increasing incidence of sexually transmitted disease, sore throats can be due to orogenital contact and infection with Neisseria gonorrhoeae bacterium. In addition to sore throat, there is often associate lymph gland enlargement and diagnosis is made by a throat swab. Treatment is with appropriate antibiotics although there is now increasing incidence of resistant bacteria.

Haemangioma

vocal cord haemagioma

Endoscopic view of larynx showing haemangioma of the left vocal cord obstructing the airway.

These are benign tumours of blood vessels and usually present in children with airway difficulty. In many instances, the lesion increase in size up to the age of 18 months and thereafter begins to regress. If airway is not compromised, then conservative approach can be adopted. Treatment with laser can also be used. In recent years the value of beta blockers has been investigated with some success.

Hairy Leukoplakia

hairy leukoplakia

Left side view of a tongue of a patient with HIV infection showing hairy leukoplakia.

This is seen in patients with HIV infection and presents with a lesion involving the tongue with a furry appearance. This is not pre-malignant and often no treatment is necessary.

Hand, Foot and Mouth Disease

This is a condition which usually affects children. It is characterised by an eruption of vesicles on the hands and feet and the oral cavity. It is thought to be secondary to a Coxsackie virus and can be associated with generalised symptoms of fever, malaise, runny nose and diarrhoea. Treatment is for symptoms which resolve spontaneously.

Herpes Simplex Infection

herpetic-gingivostomatitisThe typical virus that causes cold sores can also cause infection of the lining of the mouth and throat. This is known as gingivostomatitis. This can present with vesicles/this presents with vesicles within the oral cavity which then form a sloughy lining over the spots in the mouth and throat areas. The mouth is very sore and the symptoms can last for up to 2 weeks. Treatment with antiviral agent such as Acyclovir can reduce the severity of the infection. Topical local anaesthetic sprays help to reduce symptoms.

Herpes Simplex Virus

The primary infection with herpes simplex presents as inflammation of the gum and oral cavity. It can occur in children as young as one to three years of age and often following close contact with somebody with cold sores. Following the initial presentation with vesicles, these ruptured to create a yellowish white superficial ulcer with a surrounding red halo. The primary infection can be associated with a fever, headache and gut symptoms and there may be enlarged lymph glands. The initial attack last for up to two weeks. Treatment is for the symptoms and use of Acyclovir which is an antiviral agent may be helpful.

Hoarseness

Hoarseness is a symptom of a rough or gravely voice. It occurs as a result of pathology involving the larynx (voice box). The vocal cords come together during the act of speech and undulation of the lining of the vocal cords give rise to audible sound. Therefore, any abnormality of the coating of the vocal cords can give rise to change in the pitch and quality of the voice. Common causes include viral laryngitis, vocal cord nodules, polyps of the vocal cord and in rare instances, paralysis of the vocal cord itself. The vocal cord can also be affected by cancer and this is almost exclusive to smokers.  Any unexplained hoarseness for more than  3 weeks is an indication to seek medical help. During the assessment at the ENT Clinic, the larynx is examined with a  fibre optic camera and the nature of the cause for the problem can usually be identifed.

Infectious Mononucleosis (Glandular Fever)

glandular fever infectious mononucleosis

note the continuous membrane coating the tonsils unlike that in bacterial infection where there are white spots

This is a common condition in adolescents and young adults. It is caused by the Epstein-Barr virus and typically is associated with significant fever, general malaise, sore throat and enlargement of the lymph glands involving the neck. There may also be associated swelling of the liver and spleen. On occasions, this can be associated with a temporary jaundice. One distinguishing feature between glandular fever associated tonsillitis and that due to bacteria is the presence of a while film coating the tonsils (see picture) as opposed to the typical appearances of bacterial tonsillitis where there are spots (follicular tonsillitis). Treatment is again supportive and if the airway is in any way compromised, then a short course of high dose steroids may be beneficial. It is also not unreasonable to treat the patient with antibiotics as there is often a secondary bacterial infection. Glandular fever can take quite some time to resolve and patients can feel unwell for many weeks after the acute episode.

If symptoms of tonsillitis are recurrent, tonsillectomy may be indicated once the acute infection has settled.

Intracordal Cyst

Intracordal cyst

Left vocal intracordal cyst within the substance of the cord itself.

It is possible to get a variety of cystic lesions involving the vocal cords and these are best appreciated doing an examination technique called videostroboscopy. In this condition, flickering light can enable the movement of the vocal cord to be seen in slow motion. In this way, cystic lesions or indeed any lesion can be visualised more accurately. Such cysts need to be excised with microlaryngoscopy techniques.

Laryngitis

This term implies inflammation of the larynx and in particular the vocal cords. The most common would be viral episodes of upper respiratory infection giving rise to hoarseness due to swelling of the vocal cords. Occasionally, the symptoms can be quite severe and patient may lose their voice altogether. At this time, it is important to rest the voice and to allow the condition to resolve itself, which it does in the vast majority of instances. If however the patient was to shout or scream during the inflamed episode, then this runs the risk of causing bleeding under the surface of the vocal cord lining, which can ultimately result in polyp formation.

In children, there can be a viral infection which affects the larynx extending to the trachea and bronchi. This is called croup. Because the child’s airway is much smaller than an adult, even minimal swelling as a result of a viral infection can give rise to difficulties of breathing.

Laryngopharyngeal Reflux

Another common cause for sore throat is the presence of acid reflux in the throat region. This is known as laryngopharyngeal reflux and can present with a myriad of different symptoms. In addition to sore throat, symptoms include a constant need to clear the throat of mucus, persistent cough particularly at night, choking episodes at night, a feeling of a lump in the throat, a feeling of being strangled, a specific area of pain which may be felt during the act of swallowing but does not stop the actual act of swallowing food. It can also be a cause for hoarseness. What is most peculiar about this condition is that the above symptoms can occur in the absence of any heartburn symptoms, making patients believe that the problem is primarily in the throat region and unrelated to the stomach. The reason for this is that the lower part of the gullet and stomach has very good defence against the effect of acid and therefore to get symptoms of heartburn, there needs to be significant acid reflux to occur. However, the lining of the throat and voice box has no protection against acid and so even the smallest droplet of acid can give rise to a chemical burn and therefore symptoms.

Diagnosis is usually based on the patient’s symptoms.  Clinical examination with fibre-optic endoscopy in the outpatient setting can show either no abnormalities or in more advanced cases a number of changes consistent with laryngopharyngeal reflux. These include the presence of swelling of the lining (mucosa) of the back of the voice box. There may also be redness of the lining of the voice box. On more rare occasions, there can be the development of a vocal cord granuloma, which is a benign condition and can give rise to a more specific throat pain which can radiate to the ear.

The definitive investigation is a 24-hour pH manometry test which involves using a probe through the nostril into the gullet and measurements are made of the amount of acid reflux which occurs over a 24-hour period together with the pressures within the various parts of the gullet. As this can be quite an uncomfortable investigation, it is sometimes reasonable to put the patient on a diagnostic and therapeutic trial of anti-acid medication and if the symptoms are resolved, then no further investigations are usually required provided the fibre-optic examination of the pharynx and larynx was otherwise clear. In persistent cases, an opinion from a gastroenterologist is required and if throat symptoms persist despite adequate anti-acid therapy, then examination of the throat region under general anaesthetic is necessary (panendoscopy).

granuloma

See the whitish nodule at the back of the vocal cord seen on the right of the picture.

Leukoplakia

This is a Greek word which means any white patch. It can result in any chronic inflammation, for example next to sharp teeth in the oral cavity. Because there is a chance of progression to malignancy, these can be considered to be pre-malignant in certain cases and they are always biopsied for histological confirmation. Those involving the tongue, lower lip and corners of the mouth are more suspicious and should be biopsied.

leukoplakia

Lichen Planus

This is a condition characterised by white patches in the oral cavity which can be either interlacing fine lines or patches. The most severe version is an erosive ulcerative lesion which can be very painful. In very rare instances erosive lichen planus can progress to malignant changes. Diagnosis is usually made based on the history, clinical findings and a biopsy.

Lichen Planus in mouth

Lichen Planus affecting the inside of the mouth. Note the tobacco staining of the teeth

Lumps in the Head and Neck Region

Any persistent lump in the head and neck region for more than three weeks needs to be investigated as to the possible cause. In the vast majority of cases, these are benign causes but cancer needs to be excluded. There are many different causes for lumps in the head and neck region and the descriptions below will be divided based on which types of glands or structures from which they arise.

lump in the neck

Note the lump just below the ear due to TB infection in this patient

Lymph Gland Enlargement

There are approximately 150 lymph glands in the neck and they usually increase in size in response to other disease processes such as infections. In the vast majority of instances, the lymph glands enlarge temporarily and resume their normal size which makes them barely palpable. Any lymph gland which is enlarged persistently for more than three weeks should be investigated as to its nature and again ultrasound with needle biopsy is the mainstay diagnostic test. Lymph nodes also increase in size in relation to primary malignant tumours. For this reason, all patients with head and neck lump should have a thorough ENT with fibre-optic endoscopy of the inside of the throat and voice box region.

Measles

This is a common condition in children and presents with generalised malaise, cold-like symptoms, rash and typical spotty lesions involving the buccal mucosa (Koplik’s spots). There is often associated tonsillar enlargement and again the vast majority of cases just resolve spontaneously. The instance of this infection is much less with immunisation.

Median Rhomboid Glossitis

Similar to the above condition, this is a condition where the central part of the tongue has a very red appearance and the normal papillae are absent. This can be associated with fungal infection and a trial of antifungal therapy is worthwhile. Usually, however, there are no symptoms.

Median Rhomboid Glossitis

Pemphigus Vulgaris

This is an autoimmune condition affecting the skin and the lining of the mouth. It usually affects middle-aged patients and presents with vesicles in the oral cavity which then rupture leaving painful ulcers. Diagnosis is made by antibodies against the surface epithelium and treatment is with systemic immunosuppressant such as steroids. A variation of this is benign mucous membrane pemphigoid although one major difference is that the ulcers can be non-painful.

Recurrent Aphthous Ulcers

Apathous Ulcers

Note the shallow whitish ulcer with a red surrounding, typical of aphthous ulcers.

These are of unknown causation and characterised by either single or multiple ulcers in the oral cavity which can be quite painful. They can last from five to 30 days and are thought to be associated with a variety of factors such as trauma, stress and hormonal changes. They can be part of a systemic condition such as Crohn’s disease. Treatment is with a topical steroid such as gargling with Fluticasone solution.

Recurrent Respiratory Papillomatosis

This is a human papilloma infection of the larynx and can give rise to the development of warty lesions. It can be transmitted from mother to child. Typically, this presents with hoarseness and occasionally stridor in childhood and diagnosis is made by examination of the larynx. In a small percentage of cases, the warty lesions or papillomas also involve the trachea. Treatment is use of laser to evaporate the lesions once diagnosis has been confirmed by previous histology examination. Unfortunately, these lesions have a tendency to recur. It is hoped that with the advent of vaccines against human papilloma virus that the incidence of this condition will gradually reduce.

laryngeal papilloma

Multiple papilloma involving both vocal cords especially the right.

Reinke’s Oedema

This is a condition seen in middle-aged smokers. It can rarely be associated with lack of thyroxine. Here, there is water logging of the vocal cords in the undersurface. Treatment is usually to stop smoking, treat any underactive thyroid function and speech therapy. In very rare instances, surgery may be required.

Reinkes oedema

Note the swelling of both vocal cords.

Reiter’s Syndrome

This is a condition associated with HLA B27. This may be associated with a sexually transmitted disease secondary to Chlamydia, but also other bacterial infections which normally affect the gut. The symptoms include vesicles and ulcers involving the mucocutaneous junction in the oral cavity and associated with arthritis, urethritis and the condition can last up to three to four months. Treatment with Doxycycline can be helpful in the sexually transmitted disease version.

Salivary Gland Tumours

We have three pairs of main salivary glands which are the parotid glands, situated below the ear and behind the jawbone, the submandibular gland under the horizontal part of the jawbone and tongue, and lastly the sublingual gland which is in the floor of the mouth just below the mobile part of the tongue. The salivary glands can be affected by growths which are in the main benign but can also be malignant in nature. Tell-tale signs of malignancy include paralysis of the facial nerve which travels through the parotid gland and supplies the muscles of the face. Again, ultrasound and needle biopsy are mainstays of diagnostic tests to assess nature of the problem. Occasionally, the parotid and submandibular glands can increase in size itself due to the presence of a stone in the duct giving rise to a backlog of saliva and swelling with meals.

Sarcoidosis

This is another granulomatous condition of unknown causation. It can affect the larynx in up to 5% of patients with sarcoidosis diagnosis. There is usually associated lymph gland enlargement in the chest and diagnosis is usually made by examination of a biopsy sample. Treatment is with high dose steroids.

Sore Throat

Sore throats or pharyngitis are most commonly caused by infections affecting the lining of the throat. They can be either viral, bacterial or occasionally fungal in causation.

Stridor

Stridor is a Latin word, meaning a harsh creaking sound and it is an audible sound during breathing caused by obstruction of airflow. Stridor can be described as that occurring during inspiration and this usually implies a problem involving the voice box region or it can be during expiration when the problem is lower down involving the trachea or bronchi. It can also occur during both inspiration and expiration (biphasic)  implying a problem of the upper trachea region.

Any patient that has stridor should be seen as a matter of urgency in the A&E Department and then referred on to ENT, for a thorough head and neck examination with fibre-optic endoscopy. If however the stridor is very severe and the patient is unable to maintain the oxygen levels, it may be necessary to either perform a tracheostomy urgently or to intubate beyond the obstruction. Causes for inspiratory stridor include all those conditions which can cause obstruction above the level of the vocal cords. In children, this can be due to floppiness of the epiglottis in a condition called laryngomalacia. Infections can cause swelling of the upper airway and epiglottitis has been described previously as an important cause for stridor in children particularly.

Biphasic stridor is seen in patients with infections that affect the larynx, trachea and bronchi such as in croup. One must also consider foreign bodies particularly in children as a classic presentation is that of biphasic stridor due to obstruction of the right main bronchus. Tumours of the upper respiratory tract can also present with stridor and this can be either due to congenital abnormalities in children such as benign haemangiomas, which are tumours of blood vessels or malignant tumours in adults. Some babies, who require intubation in the first few days or weeks following birth for other medical problems, may end up with irritation of the upper trachea and following this difficulty in breathing due to subglottic stenosis which is a narrowing of the windpipe, just below the vocal cords. Occasionally, this requires a reconstructive operation to improve and increase the diameter of the trachea.

Expiratory stridor is most commonly seen in problems of the lungs such as asthma but occasionally this can occur in patients with foreign body or weakness of the wall of the trachea as seen in tracheomalacia.

Syphilis

Another sexually transmitted disease which is increasing in incidence is syphilis. This is caused by a bacterium called Treponema pallidum and goes to three stages of infection. The primary stage is characterised by a painless ulcerated chancre, which can be anywhere at the site of entry, including the soft palate, tonsils or tongue. The chancre is usually associated with localised lymph gland enlargement which is painless. Treatment at this stage with Penicillin is effective.

The secondary stage is associated with patches of ulceration in the mucus membranes with silvery painless erosions and raised red edges. At this stage, the patient may also complain of a sore throat.

The tertiary stage of syphilis can occur many years later and produces lesions called gumma. These are firm tumour-like masses which can occur in all parts of the body, including the oral cavity. Ultimately, the brain can be affected in the tertiary stage.

Thyroid Tumours

The thyroid gland is situated at the lower part of the neck and its purpose is to produce thyroxine and parathormone, which are essential hormones that regulate various activities of the body. They can be both benign and malignant tumours involving the thyroid gland. This can usually present as a firm lump in the neck which may or may not cause any particular symptoms. Occasionally, when the tumour is very large, it can cause a compression feeling but this is uncommon. The thyroid gland can become diffusely enlarged as part of a multicystic disorder. In some cases, thyroid disease is part of an autoimmune condition where the body attacks its own tissues. Any lumps in the thyroid gland can be easily determined by ultrasound examination and this allows the radiologist to perform a needle biopsy. This can give rise to an accurate diagnosis in most cases and can help the attending surgeon plan the best treatment.

During the development of the foetus, the thyroid gland starts at the base of the tongue and makes its way down the neck during the first few weeks of development. Sometimes, this developmental process can be affected and result in the presence of a cyst in the midline of the neck which can lie dormant until adulthood. It then presents with a swelling in the midline which can be completely asymptomatic. However, it can also develop into an infection. This is called a thyroglossal cyst. Treatment is usually by excision of the cyst and associated tract including the middle third of the hyoid bone (Sistrunk’s operation).

thyroid tumor

Patient with large swelling of the right side of her neck due to a benign tumour.

Tonsillitis

The tonsils are thought to have an immunological function in the first 18 months of life but thereafter have no useful function and are surplus to requirement. Seen under the low-power microscope, the tonsil has deep clefts which reach to the inside of the tonsil and harbour numerous bacteria. Every now and again, these bacteria can become virulent and give rise to an episode of tonsillitis. The bacteria invade the surrounding tissues and give rise to sore throat and associated symptoms can include fever, general malaise and inspection of the tonsils reveals white spots with sometimes pus-like material emanating from the crypts of the tonsils. As a result of the acute episode, the body builds up a defence with an increase in white blood cells and together with treatment with antibiotics, the acute infection usually settles after seven to ten days. However, the bacterium may then reside dormant in the depths of the tonsil until the next occasion. In some patients, the bacteria remain quite active and give rise to persistent sore throat symptoms with acute exacerbations (chronic tonsillitis). The common organisms causing this infection are Streptococcus and Staphylococcus. Treatment of these infections is with appropriate antibiotics. In an ideal world, a throat swab would be taken in the outpatient setting but a course of broad-spectrum antibiotics such as Penicillin V is started pending the throat swab result.

There are now guidelines as to the surgical management of recurrent tonsillitis and usually if a patient has a history of four or more episodes in a 12-month period for two consecutive years, then this fulfils the criteria for tonsillectomy. However, this guideline is not set in stone and patients with very mild symptoms but frequent episodes can sometimes be observed whereas patients with few episodes but are more severe and result in much time loss from work or school may benefit from tonsillectomy.

follicular tonsilltis

Typical apppearances of bacterial tonsillitis with white spots on the surface of enlarged tonsils. They can sometimes meet in the middle giving rise to difficulty in breathing and

glandular fever infectious mononucleosis
Tonsillitis due to glandular fever viral infection. Notice the continuous film of white debris as opposed to isolated spots which differentiate this from bacterial tonsillitis

swallowing.

Vesicular or Ulcerative Lesions

The conditions below are characterised by the development of blisters or ulcers in the oral cavity. These can give rise to a painful condition in the mouth and depending on the course can be part of a range of symptoms and signs of a variety of clinical conditions, some of which are detailed below.

Viral Pharyngitis

There are many respiratory viruses that can give rise to sore throat symptoms as part of an upper respiratory tract infection. These include Adenovirus, Influenza virus, and Coxsackie virus. Patients will complain of a sore throat associated with pain on swallowing, general malaise, fever and possible cough symptoms. It can be quite difficult to distinguish by examination whether the sore throat is due to a virus or a bacterium but the absence of white debris seen on the tonsils is usually associated with a viral cause. In the vast majority of cases, supportive treatment is all that is necessary with adequate fluid intake and Paracetamol to keep the temperature down. Gargling with soluble Aspirin can be of benefit to adults. A number of preparations are available over the counter which have a local anaesthetic effect and can also reduce symptoms, albeit temporary.

Vitamin-Related Glossitis

Lack of vitamin B can result in a form of glossitis which can be associated with a burning sensation. Iron deficiency can be related to cracking of the edges of the mouth (angular cheilitis). Fortunately these are not seen nowadays.

Vocal Cord Paralysis

The vocal cords have a curious nerve supply. The nerve that controls the vocal cord starts in the brain and travels through the neck. On the left side, it descends down into the chest and winds itself around the bronchus before travelling upwards into the neck and supplying the muscles on the left side of the larynx. On the right side however, the nerve merely travels from the brain to the neck itself. For this reason, paralysis of the left vocal cord is more common particularly after conditions that affect the chest such as lung cancer. However, 80% of patients presenting with hoarseness due to a paralysed vocal cord are described as idiopathic, meaning that no obvious cause has been found. The list of causes of a vocal cord paralysis includes infections, tumours, metabolic conditions, inflammatory diseases, following surgery in the head and neck and chest, trauma to the neck, head injury, and vascular causes such as having a stroke. Typically, the patient presents with a hoarse voice and associated cough. Occasionally, patients have coughing bouts during meals as food and drink goes down the windpipe. There is often a typical breathy voice, which is characteristic of vocal cord palsy. Diagnosis is made by clinical examination with fibre-optic endoscopy where one vocal cord is seen to be immobile. Management includes complete head and neck examination together with imaging from the base of the skull right down to the middle of the chest. This is done by CT and/or MRI. Any suspicious areas will need to be biopsied. If the cause is idiopathic, then speech therapy may be helpful in regaining some functionality and indeed in many instances this is spontaneous. However, in those patients in whom the recovery is not complete and the patients are symptomatic, then augmentation of the vocal cord by injecting it with an inert material is often helpful. There are a variety of operative procedures that have been described which can allow the vocal cord to travel to the midline and improve the voice.

In very rare instances, the vocal cord palsy can be bilateral. This is often a medical emergency as the airway is compromised. The commonest cause is usually due to thyroid surgery when the recurrent laryngeal nerves have been cut inadvertently or perhaps necessarily in the presence of thyroid cancer. Once established, the patient will need to have excision of part of the larynx in order that the airway can be improved but this is usually at the expense of voice quality.

Vocal Cord Polyps

vocal cord polyp

fleshy polyp arising form the right vocal cord

These are usually one-sided but can occasionally be on both sides. Risk factors include vocal abuse and smoking. This lesion can be easily dealt with by a use of a laser to excise the polyps. Postoperatively, speech therapy is required.

Wegener’s Granulomatosis

wegenersThis is a rare but important condition associated with formation of granulomas and associated damage to blood vessels. It can give rise to destruction of cartilage and inflammation of the larynx, giving rise to hoarseness and throat pain. It also involves the nasal cavity and can present with symptoms of chronic sinusitis, nasal crusting, septal perforation and a saddle deformity of the nose ( see above). More serious complications include lung and kidney involvement which can lead to kidney failure in some instances. Treatment is with steroids and anti-inflammatory medication.

White Spongy Naevus

white sponge tongueThis is more frequent in childhood and involves the buccal mucosa. It seems to pass along family lines and presents with a large raised corrugated patch. Diagnosis is made by biopsy of the lesion.

Whooping Cough

This is caused by bacterium called Bordetella pertussis. This is also rare in developed countries and is associated with paroxysmal coughing bouts. Treatment is supportive.