Back to Dr. Davidson's Home Page Back to Table of Contents View PDF version (right click to save) THROAT A.   Acute Sore Throat B.   Peritonsillar Abscess C.   GERD D.   Hoarseness E.   Cough F.   Thyroid Nodule G.   Sleep Disordered Breathing H.   Neck Mass

ACUTE SORE THROAT

A. Penicillins remain the drug of choice for group A hemolytic Streptococcus, the bacteria responsible for acute tonsillitis. A seven to 10 day prescription is recommended. Amoxicillin 500 mg tid is adequate. Amoxicillin 500 mg - Disp: 30 tablets - Sig: i p.o. tid x 7-10 days Second generation macrolides are the drug of choice for penicillin allergic individuals. Amoxicillin 500 mg with clavulanate is a second line antibiotic - Disp: 30 tablets - Sig: i p.o. tid B. Chronic/recurrent/persistent sore throat is a diagnostic challenge. C. Sore throat is a diagnostic challenge. Unlike other algorithms in this series, Acute Sore Throat 1 provides some diagnostic information. Acute Sore Throat 2 is a treatment algorithm.

Overview of Acute Sore Throat

An acute sore throat is a very common problem. Most upper respiratory tract viral infections begin with a sore throat. Unfortunately many Americans bring virtually every sore throat to their physician. The key is to correctly diagnose bacterial tonsillitis, treat this with antibiotics, correctly diagnose viral infections, not treat these with antibiotics, and then recognize (preferably early) sore throat illnesses such as bacterial tonsillitis, gonorrhea, peritonsillar abscess, mononucleosis, candidiasis, tumor etc. The history is helpful, but the key to diagnosis is a good oropharyngeal examination. Most physicians have inadequate lighting, and hence most pharyngeal exams are made with a floppy wooden tongue blade and the light of an otoscope. While it is not necessary to have a coaxial, expensive fiberoptic headlight, you must have reasonable illumination. One or two wooden tongue blades usually will suffice. Then, you the physician, must have sufficient persistence to continue the examination until you have visualized the oral cavity, the lateral pharyngeal walls (including the tonsils), and the posterior pharyngeal wall. If the physical examination is well done, the correct diagnosis will follow. It is the hurried physician with a weak light and an uncooperative patient who misdiagnoses and mistreats. Acute Sore Throat Pathway 2 is the controversial algorithm. Our thinking is as follows: Cultures and rapid Strep tests are not the end all for diagnosing tonsillitis. Given the large number of patients presenting with sore throat, cumulatively these tests are very expensive. It is therefore our recommendation that those pharyngitides which behave like a viral infection, be treated as such. Antibiotics play no role in their treatment and are a wasted healthcare dollar. They place the patient at unnecessary risk of allergic reaction to the antibiotics and expose an incredible number of normal oral organisms to antibiotics thereby promoting resistant organisms both in the patient and in the world. While it may be true that it is easier to prescribe an antibiotic than to explain why you should not prescribe an antibiotic, most knowledgeable physicians will agree that antibiotics are not indicated for viral pharyngitis. If a diagnosis of viral pharyngitis is made, and in fact, the patient has tonsillitis, the fever and the sore throat will continue and the patient will return on the second or third infectious day. The correct diagnosis will then be made. While the patient may have suffered an extra day or two of morbidity, no other harm has been done. Classic streptococcal tonsillitis is readily diagnosed by history and examination. These patients are typically sicker, have a higher temperature, and they are more likely to have enlarged reactive cervical adenopathy. On examination the tonsils are red and exudative and the posterior pharyngeal wall will appear normal. These patients have bacterial tonsillitis and penicillin remains the drug of choice. Some patients fall in the middle, but this is a small percentage. The simplest is to assume that all of these have tonsillitis and to treat all with antibiotics. An alternative is to observe for 24 hours or use one of the rapid Strep cultures or tests to assist in diagnosis. Antibiotics are not indicated for the bacterial super infection of an upper respiratory tract viral illness. Steroids are not indicated in the treatment of either disease. There are an increasing number of bacterial tonsillitides resistant to amoxicillin. When such a case appears, reexamination is necessary to exclude peritonsillar abscess or one of the other causes of acute sore throat. Assuming the diagnosis remains tonsillitis, augmentin has become the second line antibiotic. Clindamycin or penicillin and metronidazole (Flagyl®) remain an alternative. In an appropriate setting with a very sick patient, a liter of lactated Ringer’s goes a long way to make the patient feel better. A 600 mg dose of clindamycin (for a 70 kg male) can be simultaneously as a 20 minute I.V. drip. Clindamycin is then given 300 mg p.o. q 6 hours for 10 days. We have all been taught to treat tonsillitis for 7-10 days to obviate the sequelae of rheumatic heart disease and glomerulonephritis. The occurrence of post streptococcal glomerulonephritis has essentially disappeared. The incidence of post streptococcal rheumatic heart disease is reduced, compared with 50 years ago, but does still occur. Lastly, if your patient has valvular heart disease, an artificial valve, or any condition which provides a nidus for infection, the tonsil should be swabbed for culture and sensitivity prior to instituting antibiotic therapy. Throat swabs are highly accurate if properly performed. Properly performed means swabbing across one tonsil, across the pharynx and across the other tonsil and swabbing sufficiently firmly that bacteria on and in the mucosa are captured by the swab. Too many swabbers simply dab up a little pharyngeal mucus and obtain insufficient material. Perhaps this should be renamed “a scrape biopsy”.

PERITONSILLAR ABSCESS

A. Spray the superior pole with topical anesthesia. Inject local anesthesia with epinephrine. Aspirate with 10 or 20 cc syringe and 18 or 20 gauge needle. B. Organisms 10-15% are penicillin resistant Aerobes a. Streptococcus b. M. Catarrhalis c. H. influenzae d. Staphylococcus Anaerobes a. Bacteroides b. Peptococcus c. Fusobacteria d. Peptostreptococcus Antibiotics a. Clindamycin 600 mg IV drip, followed by clindamycin 300 mg p.o. q 6 h x 10 days b. Cephalexin 500 mg p.o. qid with Flagyl® 500 mg p.o. q 8 h x 10 days c. Augmentin® 500 mg p.o. tid or d. If penicillin allergic: second generation macrolides

Overview of Peritonsillar Abscess

No one really knows why a peritonsillar abscess develops. The best theory we know is the following: there is a small gland in the soft palate mucosa near the superior pole of the tonsil called Weber’s gland. This occasionally becomes infected and when it does spreads into the peritonsillar space. When this occurs, a peritonsillar infection develops. Peritonsillar abscess presents as would any bad bacterial pharyngitis. Ultimately, the patient becomes increasingly ill. Difficulty swallowing and even pain while speaking is common as the abscess progresses. The pain is greater on the infected side. On physical examination it may look like tonsillitis, but on careful examination, one will see that the uvula is edematous, the soft palate and superior pole of the tonsil are swollen and the tonsil is protruding into the pharynx. The uvula in the late stages, deviates away from the abscess. Once the diagnosis is suspected, treatment should be instituted. Given the 10-15% incidence of penicillin resistant organisms, one is obliged to treat with more than a first generation penicillin. Our own opinion is to treat with Augmentin®, penicillin and Flagyl® or with clindamycin. Most otolaryngologists would feel that all peritonsillar abscesses should be needle aspirated or incised and drained as a minimum. A number of primary care physicians who see these in an earlier state might not agree. If the tonsil is not particularly swollen and protuberant, but the diagnosis is suspect, antibiotic treatment is appropriate. Once an abscess forms, antibiotics alone will not cure the illness and some form of drainage is required. The easiest is needle aspiration. This is performed by anesthetizing the superior pole of the tonsil or the bottom of the soft palate, just above the tonsil. Spray first with a topical anesthetic (e.g., Cetacaine®), then inject 1 cc of lidocaine with epinephrine into the mucosa. An 18 or 20 gauge needle, preferably on a 10 or 20 cc syringe is then inserted near the superior tonsillar pole and the abscess contents aspirated. When an abscess exists, it is not uncommon to aspirate 5-30 cc of pus. The aspirate should be sent for culture and sensitivity. Many of these patients are already hydrating poorly and it is our current practice to insert an intravenous line, administer 1-2 liters of lactated Ringer’s, and administer the first dose of antibiotics intravenously. Assuming that the abscess is not advanced, assuming the patient is having no difficulty with respiration, and assuming the patient is swallowing sufficiently well to take their medicine, they can be sent home. If pus accumulates again it can be aspirated once or twice more. ENT referral can be made for incision and drainage; however this combined with the already existing discomfort, creates sufficient dysphagia and discomfort that the patient often requires hospitalization. Given concerns about recurrent peritonsillar abscesses and given that performing a tonsillectomy in the acute phase is easy and safe, it is our current recommendation that if the patient is sick enough to be admitted they should be brought to the operating room and both tonsils removed. If a PTA is successfully managed as an outpatient, the literature reports a 5-15% recurrence rate. Most recommend a prophylactic tonsillectomy. Certainly, if the peritonsillar abscess recurs, a tonsillectomy is indicated.

GERD

GERD (Gastroesophageal Reflux Disease) symptoms include: heartburn, sore throat and hoarseness. GERD is treated by antacids, bland diet, small evening meals, and elevation of the head of the bed, (not with pillows, but rather by placing six inch blocks under the head bed posts) OR the above plus gastric acid suppression. While the H2 suppressors and proton pump I inhibitors are expensive, failure to make a diagnosis is also expensive (additional visits and tests). Treating with GERD precautions plus a 30-day trial of gastric suppression at bedtime is often worthwhile. At this point you have either missed the diagnosis or have a difficult patient on your hands. ENT and psychiatric evaluations are the only way you will come to resolution.

Overview of GERD

Globus hystericus is a Freudian term and while it is true that a percentage of patients presenting with this feeling of a lump or soreness in their throat associated with swallowing will have stress as an underlying factor, many are organic in nature. Statistically, the most common cause is gastroesophageal reflux disease. If the patient is a smoker, tumor in the pharynx, hypopharynx, larynx, and cervical esophagus must be excluded. This is most easily performed through ENT consultation, whereby a good pharyngeal, hypopharyngeal, and laryngeal examination can be performed either by mirror or by fiberoptic exam. The physician will also palpate the oral cavity and the oropharynx. For all others with globus, empiric treatment for reflux disease is recommended. For those who fail reflux treatment, a fiberoptic laryngoscopy is mandatory. If negative, and with high suspicion that the complaint is stress related, stress reduction or psychotherapy is required. If the patient is not going to be happy with this, a barium swallow with a cervical cine can be ordered. This is rarely productive, for patients with cervical tumors, diverticula, or other obstructions rarely present with a lump-in-the-throat type of history. Nonetheless, we are sure an occasional abnormality is discovered and in any case it provides the primary care provider sufficient information to tell the patient there is no tumor.

Patient Instructions

Hiatal Hernia, Esophageal Reflux, Reflux Esophagitis and Gastroesophageal Reflux are common health problems which can be improved by following these guidelines: Eat small meals. Avoid large volumes of liquids with meals. Do not lie down or sit in a recliner after meals. Do not eat or drink 2-3 hours before going to bed. Elevate the head of your bed 6-8 inches by placing bricks or blocks under the legs at the head of the bed. Extra bed pillows are not adequate. A wedge-shaped pillow under the mattress at the head of the bed may work. Avoid alcohol, carbonated beverages, aspirin, caffeine, smoking and foods which you know cause heartburn or discomfort. Maintain proper weight. Antacids after every meal and at bedtime.

HOARSENESS

Laryngitis with a URI is almost always viral. Voice changes in someone at risk for laryngeal cancer requires laryngoscopy. If the PCP is not skilled at laryngoscopy, referral is required. Tumor must be excluded. A breathy voice is sometimes caused by vocal cord paralysis. Laryngeal cancer, thyroid cancer, mediastinal cancer, 10th nerve schwannoma or other neck tumor, CVA, or idiopathic are the usual causes. ENT referral is recommended. GERD (gastroesophageal reflux disease) is a common cause of voice change and cough. GERD Rx is discussed in the GERD algorithm. Post nasal drip: Post nasal drip is another common cause of voice change and cough. If specific diagnoses like sinusitis or allergic rhinitis cannot be made, treatment with antibiotics, nasal steroids, and nasal saline irrigation (see #3 under the allergic rhinitis algorithm) are prescribed. Post nasal drip with cough and voice changes is common, particularly in elderly males. Treatment is nasal irrigation, generally without antibiotics or nasal steroids. If the treatment is successful, the diagnosis is voice change of aging (presbylarynx) and post nasal drip. Treatment is hypertonic, pulsatile saline nasal irrigation bid and prn. One can expect resolution of symptoms with reasonable voice use and realistic voice expectations. Not all ENT referrals are equal. Some otolaryngologists are better skilled and some are subspecialized with additional training in videostroboscopy and acoustic analysis. This subspecialty is called laryngology and laryngology clinics are often called voice clinics or voice disorder clinics. If your regular ENT referral does not make a good diagnosis and treatment, send your patient to a voice disorders clinic. Voice rest is the only treatment required. Absolute voice rest is no talking. Regular voice rest is keeping normal soft conversation to a minimum without shouting or yelling. Patients whose employment requires speaking, (teachers or telephone operators) may require a 1-2 week work absence.

Overview of Hoarseness

There are two distinct abnormal voice qualities. The first is a breathy voice caused by paralysis or weakness of one or both vocal cords. This requires an ENT consultation. The second is a rough or coarse voice caused by a growth or swelling on the vocal cord. This results in a hoarse voice and is the subject of this algorithm. Viral infections affecting the larynx cause inflammation of the vocal cords. The resulting edema causes a hoarse voice. As with all upper respiratory tract viral infections antibiotics and other treatments are not beneficial. The patient should be encouraged to not force their voice and to use their voice gently, for if they force it, they may injure the vocal cord and develop nodules or other abnormalities. There are no acute bacterial infections that present like a viral laryngitis. Epiglottitis presents with pain and difficulty breathing. It does not present with hoarseness. If the patient is a smoker, cancer needs to be excluded. If the PCP can perform a good fiberoptic laryngoscopy, make a diagnosis, and exclude cancer—so be it. If that is not a skill in the PCP’s armamentarium, an ENT referral is recommended. Assuming the patient is not at high risk for cancer, voice quality is checked, the breathy voice is identified and referred, and the hoarse voice is then evaluated. If the history is one of voice abuse (e.g., as a high school cheerleader, a screaming parent, or a professional who is required to project their voice excessively) then voice rest is the preferred treatment. Absolute voice rest is difficult to achieve. This means writing every single thing you wish to communicate and most people do not tolerate this for more than a day or two. If the patient is willing, a 7-10 day course of absolute voice rest is optimal. Otherwise a 14-day trial of relative voice rest is advised. If the voice returns to normal, no further treatment is required. If it continues to be abnormal, the patient will not improve until they learn how to correctly use their voice. Speech therapists are the health professionals who best teach patients proper voice techniques. The two common medical causes for hoarseness are gastroesophageal reflux disease and post nasal drip. If these can be diagnosed in the history, treat them. If they cannot be elicited, and there is no other obvious cause, they can be empirically treated one at a time. If the hoarseness resolves, the patient can be safely observed, and if the hoarseness persists, an ENT referral is indicated. This is a greatly simplified algorithm and the differential for hoarseness, is in fact, extensive. Nonetheless, this raises the single important red flag (tobacco induced cancer) that needs to be diagnosed early and will successfully manage the vast majority of people with voice disorders.

COUGH

For cough with an etiology that is not obvious (e.g., pneumonia, sinusitis, etc.) many physicians begin with a chest x-ray. This algorithm is written for cases that have been already deemed NOT pulmonary, hence chest x-ray is either not required, or assumed to be negative. The (repeat) chest x-ray half way through the algorithm is usually weeks or even months after the “first” chest x-ray and is either a repeat, or if not previously obtained now necessary. See #3 in the GERD algorithm. See #5 in the hoarseness algorithm. Antibiotics treat Mycoplasma pneumoniae and bronchitis. The usual prescriptions are one of the following: a. Second generation macrolide b. Doxycycline 50-100 mg p.o. bid x 3 weeks Differential Diagnosis of Cough*

Table 1. Differential diagnosis for cough in an adult* PND Foreign body Allergic rhinitis Tracheobronchial tree Chronic sinusitis Laryngopharynx GERD/LPR Sinonasal Cough-variant asthma External auditory canal ACE Inhibitor medications Chronic bronchitis Pertussis (whooping cough) Bronchiectasis Neurogenic Lung carcinoma Traumatic vagal injury Subglottic stenosis Post-URI neuropathy Tracheomalacia Psychogenic Tracheoesophageal fistula Chronic aspiration Tuberculosis Zenker's diverticulum Sarcoidosis Congestive heart failure URI, upper-respiratory system *Otolaryngology-Head and Neck Surgery, Vol 134, No.4, April 2006

Overview of Cough

A cough means different things to different specialists. To a psychiatrist this is pertussis nervosa. To a rhinologist it is a symptom of post nasal drip. To a gastroenterologist it is a symptom of gastroesophageal reflux disease. To a pulmonologist it is one of the symptoms of asthma or bronchitis. To the cardiothoracic surgeon a cough is a symptom of lung cancer. And to the pediatric otolaryngologist it may represent a symptom of foreign body aspiration. The head and neck surgeon suspects laryngeal cancer in the patient with cough. The infectious disease consultant’s top diagnosis might be tuberculosis. Therefore, the patient with cough may be understandably difficult for the primary care physician. The algorithm implies the primary care physician has collected a reasonable history and physical exam. If the patient is coughing up blood, this is tuberculosis or cancer. If the patient has a productive cough and all the other symptoms of pneumonia, the diagnosis is presumably infection. The algorithm is written for those elusive coughs for which no diagnosis is apparent. Begin with a TB (Mantoux) skin test or chest x-ray, simply because all of the treating physicians are going to need to examine the patient carefully. If, in fact, the cough is tuberculous, an unfortunate number of individuals will be needlessly exposed. Those with significant tobacco history require a chest x-ray and an ENT referral. Assuming no diagnosis is made at this point, the two most common irritative causes are gastroesophageal reflux disease and post nasal drip. If these are excluded by empirical treatment, a chest x-ray (if not already obtained) is now required. Antibiotics maybe recommended, for often this elusive cough represents low grade bronchitis. The antibiotics will treat the infection and generally confirm the diagnosis. When this fails a fiberoptic laryngoscopy is indicated. Assuming this has not been performed, an ENT consultation is required. If this fails to reveal a diagnosis, the last two consultations are pulmonary and psychiatry. These are expensive and therefore saved for last. Neuropathic pain meds may also be useful.

THYROID NODULE

We generally begin with an FNA. Cysts are found within and adjacent to thyroid neoplasms. Always beware and if concerned repeat the FNA. Observation is a life long responsibility. The TSH and thyroid must be watched, thyroid medications adjusted, and the nodule monitored. Should it enlarge, a repeat FNA is indicated.

Overview of Thyroid Nodule

The thyroid is not an easy organ to examine, but if a nodule is discovered, an evaluation is required. In all cases this begins with thyroid function tests and often an FNA. Both hyperthyroidism and hypothyroidism need to be diagnosed and both require treatment. More and more we rely on the TSH, but the best chemical examination is one which measures both TSH and T4. The real controversy exists in the evaluation of the nodule in a euthyroid or hypothyroid patient. Assuming no other signs or symptoms point towards malignancy (negative FNA), three months of suppression with thyroid hormone (levothyroxine, Synthroid®, Levoxyl®) is recommended. If this fails to suppress the nodule, further evaluation is required. Options include ultrasound, thyroid scans, and fine needle aspirations. Fine needle aspiration is highly accurate in diagnosing malignancy. It is easy, safe, and almost painless to perform. Most other pathways ultimately finish with fine needle aspiration and so many physicians who treat thyroid disease now recommend this as the first diagnostic test. If positive for tumor, the patient is referred for thyroidectomy. If the fine needle aspiration is benign, then continued suppression and observation are indicated. If while on suppression the nodule grows, a repeat fine needle aspiration is indicated. If the FNA is non-diagnostic, an ultrascan to rule out multi-nodular goiter is recommended. If, it is indeed a solitary nodule, the patient deserves an evaluation by a head and neck surgeon or an endocrinologist and probably should undergo a thyroidectomy.

SLEEP DISORDERED BREATHING

Positive Sleep Study is AHI > 15 or AHI > 5 with 2 co-morbidities Continuous positive airway pressure (CPAP). There are many excellent operations each tailored to the individual patient’s anatomy. Mandibular advancement device (MAD). These are dental appliances which protrude the mandible up to 12 mm. They are worn at night. They are sometimes helpful.

The diagnosis of Sleep Disordered Breathing (SDB), typically Obstructive Sleep Apnea (OSA), is frequently missed. Many have SDB and are unaware that how they sleep and how they feel during the day is not normal. Classic symptoms are daytime sleepiness, falling asleep during the day while sitting, driving, or watching television. Other symptoms include snoring and morning headache. Poor job performance and failing personal relationships are common sequelae, but in and of themselves are not indicators of OSA. If in doubt, rule it out with a sleep test either a polysomnogram or a home sleep test. The multichannel home sleep study measures airflow, oxygen in the blood, body position, respiration and respiratory effort. This is ideal for diagnosing obstructive sleep apnea. Positive airway pressure (PAP) is the current therapy for patients with SDB. Continuous positive airway pressure (CPAP) is now being replaced by auto-titrating positive airway pressure (APAP). Collectively these are now referred to as PAP therapy. PAP therapy is administered by a nasal or full face mask delivered by a miniature respirator. Properly administered PAP therapy manages the majority of sleep apnea patients. In all patients with OSA it is the first line treatment. PAP therapy is not for everyone. Some cannot tolerate the mask, others cannot tolerate the air blowing in their nose, and others find it unaesthetic. Surgery Surgery works for some, but not for all. Operations include septoplasty, inferior turbinate reduction, endoscopic sinus surgery, nasal polypectomy, adenoidectomy, tonsillectomy, uvulectomy, uvulopalatopharyngoplasty (UPS) and an assortment of tongue base procedures. Maxillomandibular advancement is also recommended as is tracheostomy.

Overview of Sleep Disordered Breathing

Snoring is the premier symptom of sleep disordered breathing (SDB). Is a major social nuisance and is an independent risk factor for hypertension. A more complete list of co-morbidities is shown in Table 1 and additional information can be found on Dr. Davidson’s website at http://drdavidson.ucsd.edu. Is the patient sleepy during the day? Does the patient wake-up with frontal headaches? Does the patient fall asleep during the day? Does the patient fall asleep driving? Does the patient fall asleep watching TV when he/she would prefer not, sitting and reading, as a passenger in a car, sitting and talking to someone, or even sitting quietly after lunch? If so, these are signs of sleep deprivation and require explanation. If the answers to these questions point to sleep apnea, a work up is advised. A home study is today’s best sleep evaluation. SpO2 and respiration are monitored. This reliably diagnoses normals and patients with SDB. Inconclusive results point to other diagnoses and require a sleep medicine evaluation and sometimes a more complex sleep evaluation. For those with sleep apnea the correct treatment is a positive airway pressure (PAP) or auto adjusting airway pressure (APAP). For those who fail PAP therapy, surgery is considered. If the patient does not have symptoms of SDB or if the symptoms are equivocal and the studies are negative, then the patient has a snoring disorder. This is a major complaint especially for those who cannot travel with companions and cannot cohabitate a bedroom with their spouse. The standard recommended surgery is nasal surgery to reduce inspiratory resistance combined with some form of palatal suffering. Palatal Dacron implants are the preferred procedure today. Alcohol injection also works. If the patient has large tonsils and particularly if they are young and likely to accumulate weight with age, this is an individual who is going to develop sleep apnea and the correct operation for this individual is a tonsillectomy. If the patient has large tonsils and particularly if they are young and likely to accumulate weight with age, this is an individual who is going to develop sleep apnea and the correct operation for this individual is a tonsillectomy.

Table 1. Prevalence of SDB Co-Morbidities Category Condition Prevalence General Male 24% Female 9% Obesity Male 90% Female 50% Cardiac Hypertension All: 35%   Uncontrolled: 80% Congestive heart failure 50% Coronary artery disease 30% Arrhythmias 50% Respiratory Pulmonary hypertension 20% Asthma 15% Neurologic Stroke 67% Headache General: 49%   In the morning: 74% Metabolic Insulin resistance Metabolic syndrome Gastrointestinal Gastroesophageal reflux disease 15% Genitourinary Erectile dysfunction 100% (only significant for severe SDB) Nocturia, enuresis 48% Motor Vehicle Accident 7 times normal Excessive Daytime Sleepiness 10%

Surgery for Snoring and Sleep Disordered Breathing

As the field of Sleep Medicine evolves, better understanding and newer treatments are being developed. For those with snoring alone or those with snoring and sleep apnea, nasal PAP therapyis the premier treatment. Those who do well with PAP therapy are cured of snoring, and are well treated for their obstructive sleep apnea. For those who do well with PAP therapy, the treatment is safe, effective and cost-effective. Not everyone does well with nasal PAP therapy. Some find it an intrusion into their lives. Others find it claustrophobic or otherwise not tolerable. For these individuals, consultation for surgery is recommended. The evaluation of an individual interested in surgical therapy includes a thorough examination of the nose, mouth and pharynx (throat). If obvious obstructive anatomy is evident, and if the nature of the sleep apnea is such that surgery stands to improve the condition, then surgery will be recommended. Our standard sleep evaluation form is presented on Dr. Davidson’s website. Surgical therapies vary from very simple operations with minimal risk to very complex operations with significant discomfort and concerning risks and potential complications. Surgeries that have been used in the treatment of snoring and sleep apnea include septoplasty, an operation to straighten the cartilage on the interior of your nose or turbinate reduction, an operation to reduce the natural filters of the nose, filters which often become swollen and congested, particularly in patients with allergic rhinitis. Endoscopic sinus surgery and nasal polypectomy may also be recommended. Adenoidectomy is certainly recommended for those with swollen adenoids. Tonsillectomy is recommended for those with big tonsils, particularly those in whom the tonsils are felt by the examining physician to potentially play a role in the nighttime airway obstruction. Lingual tonsillectomy may also be recommended. Snoring is produced for the most part by vibrations of the uvula. This is the tissue that hangs down at the far end of your soft palate. Snoring is therefore often treated either by removing the uvula or removing the uvula and a portion of the soft palate. This operation is called a uvulopalopharyngoplasty and is abbreviated UP3. Several variations on this theme exist and the operations are of necessity tailored to the individual. Dacron palatal implants produce a similar result with far less pain and inconvenience. The most difficult problems are with those in whom the obstructions and the snoring are caused, at least in part, by the tongue falling backward. Several operations attempting to reposition the tongue have been developed. All are successful some of the time. None are successful all of the time. The names of these surgeries include: genioglossus advancement, hyoid suspension and tongue reposition. If all else fails, almost all obstructive sleep apnea can be successfully treated by maxillo-mandibular advancement. This is a complex operation in which the bones holding the upper teeth and the bone holding the lower teeth, called the mandible, are surgically cut and moved so that the lower part of your face is moved forward approximately 12 millimeters. By doing this the airway in the back of the throat is expanded and the sleep apnea cured. This is called maxillomandibular advancement. While an excellent operation, this is the most extreme of undertakings and is only employed for disabling sleep apnea in patients in whom all other treatments have been unsuccessful. Tracheostomy is also successful and for severe SDB patients who cannot use PAP therapy, the operation of choice. Mandibular advancement devices are touted by the dental profession. There are myriad of fly-by-night medical and surgical treatments. Our general philosophy is that unless these are being evaluated in a University-approved research study, they are a waste of money and place patients at undue risk.

Table 2. Medical conditions associated with SDB Category Condition Reference Cardiac Hypertension 30% 1 Drug-Resistant Hypertension 83% 2 Congestive heart failure 76% 3 Ischemic heart disease 38% 4 Dysrhythmias 58% 5 Atrial Fibrillation 49% 6 Respiratory Pulmonary Hypertension 77% 7 Asthma 18% 8 Neurologic Stroke 90% 9 Metabolic Type II Diabetes 15% 10 Metabolic Syndrome 50% 11 Gastrointestinal Gastroesophageal reflux disease 60% 13 Genitourinary Nocturia 48% 14 References Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, D'Agostino RB, Newman AB, Lebowitz MD, Pickering TG. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000 Apr 12;283(14):1829-36. (Prevalence of HTN rates with increasing AHI in this article are: 43% (<1.5 per hour), 53% (1.5-4.9 per hour), 59% (5-14.9 per hour), 62% (15-29.9 per hour), and 67% (?30 per hour). Logan AG, Perlikowski SM, Mente A, Tisler A, Tkacova R, Niroumand M, Leung RS, Bradley TD. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. Hypertens. 2001 Dec;19(12):2271-7. Enburg O, Lamp B, Faber L, Teschler H, Horstkotte D, Topfer V. Sleep-disordered breathing in patients with symptomatic heart failure A contemporary study of prevalence in and characteristics of 700 patients. Eur J Heart Fail. 2007 Mar;9(3):251-7. Epub 2006 Oct 5. Mooe T, Franklin KA, Holmstrom K, Rabben T, Wiklund U. Sleep-disordered breathing and coronary artery disease: long-term prognosis. Am J Respir Crit Care Med. 2001 Nov 15;164(10 Pt 1):1910-5. Hoffstein and S. Mateika, Cardiac arrhythmias, snoring and sleep apnea, Chest 106 (1994), pp. 466–471. Gami AS, Friedman PA, Chung MK, Caples SM, Somers VK. Therapy Insight: interactions between atrial fibrillation and obstructive sleep apnea. Nat Clin Pract Cardiovasc Med. 2005 Mar;2(3):145-9. Wood CW Jr, McCrory D, Garcia JG, Abman SH, Ahearn GS; American College of Chest Physicians. Pulmonary artery hypertension and sleep-disordered breathing: ACCP evidence-based clinical practice guidelines. Chest. 2004 Jul;126(1 Suppl):72S-77S. Larsson LG, Lindberg A, Franklin KA, Lundback B. Symptoms related to obstructive sleep apnoea are common in subjects with asthma, chronic bronchitis and rhinitis in a general population. Respir Med. 2001 May;95(5):423-9. Noradina AT, Hamidon BB, Roslan H, Raymond AA. Risk factors for developing sleep-disordered breathing in patients with recent ischemic stroke. Singapore Med J. 2006 May;47(5):392-9. Reichmuth KJ, Austin D, Skatrud JB, Young T. Association of sleep apnea and type II diabetes: a population-based study. Am J Respir Crit Care Med. 2005 Dec 15;172(12):1590-5. Epub 2005 Sep 28. Ambrosetti M, Lucioni AM, Conti S, Pedretti RF, Neri M. Metabolic syndrome in obstructive sleep apnea and related cardiovascular risk. J Cardiovasc Med (Hagerstown). 2006 Nov;7(11):826-9. Fritscher LG, Mottin CC, Canani S, Chatkin JM. Obesity and obstructive sleep apnea-hypopnea syndrome: the impact of bariatric surgery. Obes Surg. 2007 Jan;17(1):95-9. Valipour A, Makker HK, Hardy R, Emegbo S, Toma T, Spiro SG. Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder. Chest. 2002 Jun;121(6):1748-53. A. Hajduk, P.J. Strollo Jr and R.R. Jasani et al., Prevalence and predictors of nocturia in obstructive sleep apnea-hypopnea syndrome—a retrospective study, Sleep 26 (2003), pp. 61–64

NECK MASS

I.V. antibiotics and hospitalization are tempered by clinical judgment. Some cases are safely treated with an office dose of systemic antibiotics followed by oral antibiotics. Some cases are safely managed with home health I.V. antibiotic treatments. Sick patients or “dangerous” infections require hospitalization. No diagnosis may mean a benign or malignant process. The larger the mass, the harder the mass, or the more likely it could be malignant or progressing, the earlier should the ENT referral be made.

Overview of Neck Masses

The only easy way to diagnose a neck mass is to know exactly what the patient has before you begin. Then, your only challenge is to prove it. The next most challenging is to have some idea of what the patient has, perform a few tests, narrow the differential, and then prove the final diagnosis. The most challenging is to have absolutely no idea whether this is a benign lymph node, malignant tumor, or a bizarre infectious disease. Probably the only thing worse is to think one knows what the disease is, only to discover one is 180 degrees off course. A thorough history and physical examination go a long way to postulating a correct first impression. There are a number of imaging techniques which are useful, but are intended for defining the illness, not for diagnosing it. CT scan, CT scan with contrast, MR, MR with contrast, ultrasound, and nuclear scanning all play some role, but when over used, are unnecessarily expensive. Fine needle aspiration (FNA) is finding an increasing role in the diagnosis of cervical masses. The FNA is typically performed with a 25 or 22 gauge needle. Bleeding is rarely a problem, tumor seeding has not been shown to occur, and diagnostic yields can reach as high as 90% for both infection and neoplasm. One should have a low threshold for referring the patient with a neck mass to a head and neck surgeon, especially one that persists or is symptomatic. A high suspicion of cancer is warranted in the smoker with a neck mass and required timely referral.