ACUTE DYSPHAGIA

&
ODYNOPHAGIA
By rushika gaonkar(intern
10-11.)

The following conditions present acute

dysphagia as a symptom.

1.Adhijivha :
Prabandhane adho jivhaya shopho jivhaagra sannibha
Saankurah kaphapittaasrayhi laaloshaast ambhavan kharah
Adhijivha sarukkandurvaakyahaar vidyat krut.
Va.U.21/34,35

On the dorsal surface of the tongue, a swelling of the shape

of tongue develops due to kapha, pitta and rakta dushti. It
contains ankur, excessive salivation, burning sensation,
pain and kandu(itching) are also present. According to
Acharya Kashyapa, aruchi, glani (fatigue), stambha and
kapola shotha are also present. It is rough to touch. There is
difficulty in deglutition and speech.

Sadhyasadhyata: It is asadhya in pakwa

awstha.

Chikitsa:
Unnamya jivhamaakrushtam badishena adhijivhikam.Va.U.22/45
Chedayen mandalagrena tikshnoshnergharshanadi cha.
Tikshnashcha nasyadayah A.Sa.U.26/190
Patient is asked to elevate the tongue or the vaidya
elevates it with the help of badish yantra.Then with the help
of mandalagra shastra,chedan of adhijivha is done. After
chedan the vrana is rubbed with tikshna and ushna churna
and tikshna nasya is given.

Ranula:
It is a retention cyst in the floor of the mouth arising from
the minor salivary glands. It may penetrate the mylohyoid
muscle and present in the neck (Plunging ranula)
Clinical features:
It presents as a bluish, translucent cyst in the floor of the
mouth, resembling the frog belly.
Treatment:
Ranula confined to the mouth should be excised.
Plunging ranula should be marsupialised and the sublingual
gland excised.

2. Tundikeri:- (Acute Tonsillitis)

Shophah sthulastodadahaprapaki praaguktabhyam
tundikeri mata tu. Su.Ni.16/42
Hanusandhyashritah kanthe kaarpaasiphala sannibha.
Picchilo mandaruk shophah kathinastundikerika.
Va.U.21/47
The shotha occuring at talu region due to kapha and rakta
is called tundikeri. Toda, daha, paka are the symptoms. It
is as big as the seed of cotton. Acharya Vagbhata has
called it kantha roga and stated its site to be the inner
side of jaw. The shotha is hard, slimy to touch with slight
pain and fever.

3. Adhrusha
Shophah stabdho lohitastaludeshe raktaajneyah so
adhrusho rugjwaraadhyah. Su.Ni.16/42
Chikitsa : shastrakarma
The reddish shotha occuring at taalu pradesh due to rakta
is Adhrusha.It is stabdha, slow spreading and associated
with pain and fever
Acute Tonsillitis:
It is an infection of the tonsils occurring frequently up to
15yrs of age, but without any age bar. Both sexes are
equally affected.

Predisposing factors:
Endogenous :
Pre-existing upper respiratory tract infection
Pre-existing chronic tonsillitis.
Post nasal discharge due to sinusitis.
Residual tonsillar tissue after tonsillectomy.
General lowering of the resistance.
Exanthemata
Blood dyscrasias : Very low resistance due to diseases like
agranulocytosis, leukaemias, or hodgkins disease may
cause gangrenous tonsillitis.

Exogenous:
1. Ingestion of cold drinks or cold foods causes direct infection
or lowers the resistance by vasoconstriction.
2. Contagion: The infection may be contacted from other
individuals having infection .
3. Pollution and crowded ill-ventillated environment.
4. Imbedded foreign body.
Causative organisms: Respiratory gram positive cocci like
streptococcus, pneumococcus and diphtheroid organisms.
Haemolytic streptococcus has a special prediliction. It may
be a viral infection

Pathological types :
1. Acute Parenchymatous Tonsillitis : The tonsils are enlarged
& congested.
2. Acute Follicular Tonsillitis : The crypts are studded with pus
& stand out as multiple yellow spots on the red congested
tonsils.

Symptoms :
1. Raw sensation in the throat.
2. Pain in the throat, aggravated by swallowing, may be
referred to ears.
3. Refusal to eat children refuse to eat because of
odynophagia.
4. Voice is thick & muffeled due to thick secretions &
impeded movements of the palate.
5. Jugulodigastric nodes are enlarged & painful.
6. Malaise, fever, headache & tachycardia may be present.
7. Duration is usually 4 to 6 days.

Signs :
1. Tonsils become congested & swollen.
2. Secretions increase & become tenacious.
3. Movements of palate become impeded due to pain.
4. Halitosis may be present.
5. Jugulodigastric nodes get enlarged & tender.

Treatment :
1. Bed rest & soft diet are advised.
2. Antibiotics : Acute tonsillitis responds promptly to most
antibiotics as well as sulphonamides. Mild infection may
resolve without antibiotics.
3. Analgesics are advised to reduce pain & pyrexia.
4. Warm saline gargles are soothing.
5. Lozenges with local anaesthetic action may be comforting

4.

Rohini
Vataja Rohini:-(Diphtheric Pharyngitis)
Hanushrotrarukkari. Va.U.21/42
Vatatmakopdravagaadhyukteti vatatmaka upadravah.
Kampavinaamstambhaadayasteyratishayamanugata
Madhukosha Ma.Ni.Pa 261
On all 5 sides of tongue, painful mamskur develop. They
cause obstruction of the throat & dysphagia. There is talu
shosha, there is pain in ear & jaw. Kampa, vinam, stambha
like upadrava of vata are present.

Kaphaja Rohini
Kaphen Picchila Panduh v.a.u.21/44
Kaphaja rohini is guru, sthira & does not form paka soon,
picchila & panduvarni. This causes srotorodha, thus leading
to shwas kanthaavrodha & change in voice.

Vataja Rohini Chikitsa:Vatakim tu hrute rakte lavanayhi pratisaaryet.

Sukhoshnan sneha gandushaan dhaaryechyaapya
bhikshnashah. Su.Chi.22/60/61
Atham antarbaahyatah swinnam vatarohinikam likhet.
Angulishastrena aashupatuyuktanakhena va.
Panchamulambu kavalah tailam gandushanavanam.
Va.U.22/58,59
Elapunarnavasinhikapittha kalka payovipakwam tailam
gandusho navanam cha. A.sa.U.6.Pa.191

Raktamokshan is done by siravedha.

Swedan is done to antarbahya rohini & then lekhan is done

with angulishastra or with nails filled with lavan.

Gandush is done with sukhoshna sneha.
For that ela, punarnava, adulsa, kapittaha their kalka & milk
siddha taila is used. It can be used for nasya.
Kadha of brihat panchamoola is used for kavala dharan.

Kaphaja Rohini Chikitsa:

Agaardhumkatukayhi shleishmiki pratisaaryet shweta
vidanga dantishu tailam siddham sasaindhavam.
Nasyakarmani yoktavyam tatha kavaladharne.
Su.Chi.22/62,63
Katukayhi katuvargoktayhi Arunadatta
Swedayitwa vilikhya pratisaaryet.-A.Sa.U.26.Pa 192
Swedan & lekhan is done. Pratisaran is done with
gruhadhuma & churna of katuvarga medicines. Vacha,
vidanga, danti siddha taila with saindhav is used for nasya
& kavala.

Diphtheric Pharyngitis :
Aetiology :
Children between the age of 2 to 5 yrs. are usually
affected.
Corynebacterium diphtheriae is the cause.

Clinical Features :
Symptoms :
1. Raw sensation in the throat.
2. Pain in the throat occur which is often aggravated by
swallowing. It may be referred to the ears.
3. Refuse to eat : Children refuse to eat because of
odynophagia.
4. Voice may be thick & muffled due to thick secretions &
impeded movements of the palate.
5. Jugulodigastric nodes may be enlarged & painful.
6. Constitutional symptoms like malaise, fever, headache &
tachycardia may be present.
7. Duration of acute tonsillitis is usually 4 to 6 days.

Signs :
1. The tonsils become congested & swollen.
2. Secretions increase & become tenacious.
3. Movements of the palate become impeded due to pain.
4. Halitosis may be present
5. Jugulo digastric nodes get enlarged & tender.

Treatments :
1. Bed rest & soft diet
2. Isolation of patient
3. Antitoxin is given immediately if diptheria is clinically
suspected 20,000 units per patch are given parentarally
4. Penicillin & erythromycin control the infection.
5. Immunisation of contacts should be performed.
6. Tracheostomy is necessary in those cases who also have
diphtheric laryngitis with respiratory obstruction.

5.
Kantha shaaluka :(Adenoids)
Kolasthimatrah kaphasambhawo yo granthirgale
kantakabhutah kharah sthirah shastranipaata sadhyastam
kanthashaalukamiti bruvanti .-Su.Ni.16/51
Antargale ghurghurikanvitam cha
shaalukamucchwasanirodhakaari.. Ca.Chi.12/75
Granthi developes in gala region of the size of borum seed.
There is pricking pain in the throat. Its shape is like
kamalkanda & it grows slowly. Sparsha is khara. It is
shastrasadhya. According to acharya Vagbhata there is
kapha dosha adhikya & that leads to margavrodh. The
patient has difficulty in breathing, keeps the mouth open in
sleep & snores shwas, kasa are present.

Adenoids
When hypertrophied nasopharyngeal tonsil starts producing
symptoms.
Aetiology :
Adenoids occur usually between the age of 3 yrs. & 10 yrs.
May be present earlier.
The hypertophy of nasopharyngeal tonsil is often
physiological, but is considered to be unhealthy if it
produces symptoms.
In many cases, infection supervenes
Tuberculosis may be present.
Predisposing Factors
Similar to those for acute & chronic tonsilitis

Clinical Features :
A.Associated with obstruction
1)Nasal obstruction leads to mouth breathing snoring, drooling of
saliva from the mouth & difficulty in eating, particularly in infants.
a. Adenoid facies may develop gradually nose becomes
pinched & narrow because of the lack of respiratory air flow
there is a chronic nasal discharge.
b. Mouth remains open, particularly at night. The teeth start
protruding & become irregular & crowded, lower jaw
becomes under-shot. High arched palate develops. There is
drooling of saliva. The face becomes expressionless. All
these features combine to give Adenoid Facies.
c.
Chest becomes flattened
d. Voice becomes flat & toneless (Rhinolatia clausa)

2) Eustachian Tube Obstruction : It may occur which leads to

B)
1.
2.
3.
4.
5.

middle ear diseases like Eustachian catarrh, serous otitismedia

acute otitis media & chronic otitis media. This results in
deafness or otorrhoea.
Associated with infection :
Nose : Purulent discharge from nose due to rhinitis & sinusitis
may occur.
Throat : Recurrent upper respiratory tract infection is frequent.
The patient may have post nasal discharge, pharyngitis
tonsillitis & cough.
Ear : Recurrent Eustachian catarrh, acute otitis media, chronic
otitis media or serous otitis media may occur.
Lymphadenitis : upper deep cervical nodes & the nodes in the
upper part of the neck get infected.
Bronchial Asthma & bronchitis, if present may get aggravated.

C) General :
Nocturnal enuresis & night terrors may be present due to
suffocation.
2. Mental Backwardness is not real but the child may become
backward in studies because of deafness.
Diagnosis :
1. Clinical features clinch the diagnosis in most of the cases.
2. Posterior Rhinoscopy may reveal adenoids in a co-operative
child.
3. Digital palpation of the nasopharynx may detect adenoids, but
is an unpleasnt procedure hence avoided.
4. Radiological examination of the lateral view of the nasopharynx
for soft tissue shadow may reveal adenoids.
5. Examination under general anaesthesia at the time of
tonsillectomy can be easily carried out & adenoidectomy may
be performed, if necessary.
1.

Treatment :
A. Conservative
In mild cases, conservative treatment may take care of
adenoids. This is complemented by natural involution.
1. Antibiotics are useful for acute inflammation.
2. Decongestants may be useful in re-establishing breathing.
3. General improvement in health & hygiene may help.
4. Exercises : Breathing exercises should be advised.
B) Surgical :
1. Adenoidectomy is advised to patients having persistent or
recurrent problems.
2. Antral lavage may be required for concurrent sinusitis.
3. Grommet may have to be inserted in the ear drum of a patient
having secretory otitis media.

6.

Valayah:-(Malignant Tumours)
Balaas evaayatamunnatam cha shopham karotyannagatim
nirvaaya.
Tam sarvathaivaaprativaar viryam vivarjaniyam valayam
vadanti. Su.Ni.16/53
Annagati nivaaryeti annasya gatiryena srotasaa so
annagatihi annavahasrotaha. Nya cha

Annavaha srotas gets obstructed due to kapha. It is due to

the Shotha at that region. The Shotha is unnat & ayat.
Initially there is feeling of obstruction while deglutition &
later solid food cannot be taken. Only liquid diet is taken. If
there is further srotorodha then no aahar can be taken. As
aahar is slowly reduced, dhatuposhan is affected & patient
becomes thin & weak.
Sadhyasadhyata: Asadhya

7. Vrunda:
Samunnatam vruntammandadaham tivrajwaram
vrundamudaaharanti.
Tam chaapi pittakshataja prakopadavidyaat satodam
pawanaasrajam tu. Su.Ni.16/56
Galaparsghavagah Va.U. 21/46
Vrunda chikitsa : Treatment is similar to kaphaja rohini
On the right & left side of gala an elevated & round swelling
occurs that is called vrunda. There is tivra daha & tivra
jwara. It is caused due to pitta & rakta dushti. When vayu &
rakta are responsible, shoola is present

Malignant Tumours of the oral cavity .Malignant

tumours can arise from :
a. Lips
b. Cheeks
c. Oral Tongue
d. Floor of the mouth
e. Hard palate
f. Retromolar trigone
g. Gingiva
h. Mandible
Squamous cell carcinoma is the commenest malignancy of the
oral cavity. Adenocarcinoma may arise from salivary glands on
the palate & fauces.

Prediposing Factors :
1. Alcohol abuse
2. Smoking
3. Tobacco & paan chewing
4. Poor oral hygiene
5. Sharp teeth & ill fitting dental appliances

Clinical Features :
1. Ulcerated mass with raised margins & surrounding
induration is the most common presentation.
2. Pain can be severe & referred to the ear.
3. Trismus may occur with lesions in trigones region.
4. Dysphagia may be present in posterior lesions.
5. Metastases lymph nodes draining the affected area may be
involved. Distant metastases can occur in late stage.

TNM Classification :
Tumour
T1
upto 2 cm diameter
T2
2 to 4 cm diameter
T3
More than 4 cm diameter
T4
Spread to surrounding structure
Nodes
No

No nodes

N1
N2
N2a
N2b
N3

Single ipsilateral lymph node upto 3 diameter

Single ipsilateral lymph node from 3 to 6 cm diameter
Multiple ipsilateral lymph nodes upto 6 cm size
Bilateral or contralateral nodes upto 6 cm diameter
Nodes larger than 6cm diameter

Metastases
Mo Nil
Ms
Present
Mx
Cannot be asessed
Staging is similar to that of carcinoma of a larynx

Treatment : The choice of treatment is determined by the

location & the stage of the primary tumour.
Surgery : For stage 1 & stage 2 oral cancer, surgical
treatment consists of excision of the tumour with adequate
margin & repair of the defect by primary closure or by flap.
Clinically positive nodes are treated by radical neck dissection.
Radiation : Can be by brachy therapy, external beam therapy
or both. Early cases yield similar results with either surgery or
radiation. Extensive oral cancer requires a combined approach
with surgery followed by radiotherapy. Chemotherapy may be
required in combination with surgical treatment & radio
therapy.

Acute Retropharyngeal Abscess :

It is a very painful condition resulting from infection of the
retropharyngeal lymph nodes. It usually occur only in children,
because the nodes gradually atrophy, as one grows up.
Aetiology :
1. It occurs in children usually under the age of 1 yr.
2. It is more common in boys.
3. Nasopharyngeal or oropharyngeal infection may cause infection of
the nodes
4. Debility or exanthemata may predispose to inflammation of
retropharyngeal nodes.
5. Trauma to pharyngeal wall by a sharp foreign body may cause it.
6. Mastoid abscess may rarely track along the Eustachian tube to the
retropharyngeal space.
7. Causative organisms are usually streptococcus & staphylococcus.

Clinical Features :
1. Dyspnoea may be caused by pressure on the larynx.
2. Dysphagia child finds it difficult to swallow.
3. Croupy cough is often present.
4. Voice: cry of the child becomes like quacking of a duck.
5. Blocking of the Nose : due to the spread of oedema to
nasopharynx may occur.
6. Child develops fever & becomes restless.
7. Oral cavity : There is unilateral swelling in the posterior
pharyngeal wall which shows signs of acute inflammation once
the abscess forms, it present as a soft, fluctuating swelling ,
which extends upwards towards the nasophynx & downwards into
the cricopharynx, but does not cross the midline to the median
raphe.

8. Neck is held stiff. There may be torticollis.

9. Acute lymphadenitis. The jugulodigastric lymph nodes or
the lymph nodes in the upper part of the posterior triangle
may be inflammed.
Radiology :
Lateral view of the neck may show the soft tissue swelling
in the retropharyngeal space. There may be fluid level in
the swelling.

Treatment :
1. Antibiotics are administered to control the infection.
2. Analgesics & anti-inflammatory drugs are give.
3. Steroids may be advised if laryngeal oedema is
impending.
4. Nutrition : Proper fluid intake should be maintained.
5. Incision & drainage of the abscess should be performed
transorally.
6. Tracheostomy may be required if laryngeal oedema
develops.

Kantha shaaluka Chikitsa:

Visraavya kantha shaalukam saadhayettundikerivat.
Ekkalam yavannam cha bhunjit snigdham alpashaha.
Su.Chi.22/64,66
Raktamokshan is done. Shastrakarma is done. One time yavanna
is eaten.

Vrunda Chikitsa:
Treatment is similar to kaphaja rohini

Foreign Bodies :
Sharp small foreign bodies like fish bones may pierce the tonsils.
Larger shaap irregular foreign bodies may get stuck in the
valleculae or pyriform fossae. They cause pain & pricking
sensation smooth foreign bodies may be held up above the
cricopharynx & produce dysphagia.

Treatment :
1. Tonsillar foreign body is removed by a nasal dressing
forceps. For a foreign body embedded in the tonsil,
tonsillectomy may be required.
2. Laryngopharyngeal foreign bodies are removed by direct
laryngoscopy or by mackenzie forceps. Laryngoscopic
control often the foreign body passes down to the stomach.
If the sensation persists for more than 48 hrs. endoscopy is
indicated.
Carcinoma of the vocal cords (Glottic)

Aetiology :
1. It is usually seen after the age of 45 yrs. Sarcoma may occur
at an early age.
2. It is very common in males
3. Premalignant conditions
a. Single papilloma may become malignant.
b. Leucoplakia is a premalignant condition.
4. Precipatating factors
a. Smokers have a higher incidence of laryngeal
malignancy
b. Chronic irritation
c. Atmospheric pollution

Symptoms :
1. Hoarseness
2. Cough of dry nature
3. Raw sensation in the throat
4. Blood stained sputum may be coughed up
5. Stridor is present in advanced cases
6. Lymph node metastasis is a late symptom
7. Widening of the larynx may occur
8. Dysphagia is a late symptom.

Signs :
1.Site : Usually the growth arises from the anterior half of
the vocal cord from its edge or upper surface.
2.Morphology : It is usually a cauliflower like growth, but it
may be ulcerative leucoplakia may undergo malignant
change.
3.Movements : As the growth progresses, movements of the
vocal cords may be affected due to fixation of the cords.

Spread :
1. Continuity
a. Forwards to the anterior commissure & to the anterior
portion of the opposite vocal cord.
b. Backwards to the arytenoid cartilage & inter arytenoid
region.
c. Upwards towards the ventricle
d. Downwards to the subglottic region
e. Laterally to the cartilage, making the vocal cord fixed.
2. Lymphatic : The vocal cords have a poor lymphatic drainage &
hence the spread to lymph node is a late phenomenon.
3. Blood stream : Spread by blood stream may occur rarely as a
late feature.

Investigation :
1. Biopsy performed by direct laryngoscopy micro
laryngoscopy. Endoscopy helps to estimate extent of
growth.
2. Routine Investigations like blood, urine, blood sugar &
electrocardiogram required for determining general fitness
for surgery
3. VDRL test
4. Radiograph of the Chest
5. Soft tissue radiographs
6. CT scan

Treatment :
The treatment depends upon :
1. Stage of the growth
2. Histopathology
3. General fitness of patient
4. Facilities available
5. Occupation
Stage of growth :
Stage & I Stage II : Irradiation or surgery by laryngo
fissure technique. Radiotherapy is preferred as the function
of larynx is unaffected. Partial laryngectomy to preserve
laryngeal function.

State III & Stage IV : (with fixation of cords or cartilage

involvement) treated by total laryngectomy. If lymph nodes
are involved, block dissection of neck.
Laser Surgery :
Advanced Cases : Palliative treatment is advised.
a. Analgesics
b. Antiobiotics
c. Tracheostomy for stridor
d. Ryle tube feeding or gastrostomy for dysphagia
e. Chemotherapy
f. Irradiation

Chemotherapy : In malignancy it may help as a palliative

measure to a certain extent. It is also given to reduce the
extent of growth.
Radiotheraphy :
It is useful under the following circumstances :
1. For early growths with the advantage of presenting voice.
2. In combination with surgery
3. Palliative measure for advanced cases
4. Anaplastic growths

8.

Gilayu :
Granthirgale twamalakaasthimaatrah shiroalparuk syaata
kapharakta murtihi sanlakshyate saktamivaashanam cha sa
shastrasaadhyastu gilayu saujnayah.- su.Ni.16/58
At jivha mula, in the gala region granthi of the size of amla
seed develops. It is the vriddhi & dushti of the mamsa
granthi on either side of tongue. They grow slowly & there
is mild pain. When there is increase in their size, there is
difficulty while breathing & eating. There is a feeling of food
getting obstructed in throat.

Gilayu Chikitsa :
Gilayushchaaapi yo vyaadhistam cha shastren saadhayet
.-Su.Chi.22/66
Shastrakarma is the treatment. Gilayu chedan is done &
stoppage of raktasrava is confirmed. When raktasrava
stops, pratisaran is done with honey. Gandush is done with
kwath of kashaya rasa dravya. Complete removal of gilayu
is confirmed. Shastrakarma is done only when condition is
worsened & medicines are ineffective Arogyavardhini &
chyavanprash can be given for 1 month. In case of shotha,
treatment is similar to galagraha in fever, suvarna malini
vasant & amrutarishta are effective.

Supragloltic & Laryngopharyngeal Malignancy

Symptoms :
Symptoms appear late as compared to the carcinoma of
the vocal cords.
1. Dysphagia
2. Pain in the throat. May radiate to ear
3. Foreign body sensation in the throat or a lump in the
throat may be felt.
4. Change of voice: As the vocal cords get involved,
horseness develops.
5. Blood stained sputum & cough.
6. Hard cervical lymph node swelling
7. Stridor & inspiratory dyspnoea in advanced cases.

Signs :
1. Cauliflower like growth or an ulcer seen on indirect
laryngoscopy
2. Pooling of saliva is present due to irritation & dysphagia.
3. Hard metastatic lymph nodes.
Diagnosis :
Diagnosis is made by clinical examination Histopathological
examination is essential.
Investigations :
Similar to those for glottic carcinoma

Treatment :
1. Stage I & II : Radiotherapy or surgery. Conservative
laryngectomy may be done for selected cases.
2. Stage III & IV : laryngopharygectomy with neck dissection.
Combination of irradiation, chemotherapy & surgery
improve the prognosis to some extent.
3. Palliative treatment : Similar to that for glottic carcinoma.

9. Galougha:-(Acute Retropharyngeal Abscess)

Shopho mahannajalawrodhe tivra jwaro vata gale
nirhanta.
Kaphena jate rudhiraan vitena gale galougha parikirtyate
a sou. Su.Ni.12
It is a shotha occurring in gala region due to kapha &
rakta prakop. There is tivra jwara. There is obstruction in
food, liquid intake & air intake.
Sadhyasadhyata: It is asadhya

Neurological Disorders :
Clinical Features :
The disorders may be sensory or motor
Sensory :
1.Anaesthesia may be unilateral or bilateral.
2.Hyperaesthesia may be normal or abnormal.
3.Paraesthesia is often functional
4.Neuralgia : Glossopharyngeal neuralgia may be due to
an elongated styloid process.

Motor :
1. Palatal : There may be unilateral or bilateral paralysis

with nasal twang & nasal regurgitation

2. Pharyngeal : The gag reflex is absent there is dysphagia.

On swallowing the food may enter into the

tracheobranchial treee producing coughing, spasms,
cyanosis & inhalation pneumonia.
3. Associated neurological lesions may be present.

Treatment :

1. Cause should be treated.

2. General
a. Ryle tube feeding is required for pharyngeal

palsy.
b. Tracheostomy may be required for
trancheobronchial toilet, if there is recurrent
inhalation of liquids & food into the
trancheobronchial tree.
c. Gastrostomy is rarely required.

ACUTE
PHARYNGITIS

ACUTE
TONSILLITIS 1

ACUTE
TONSILLITIS 2