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By
Assistant professor of E.N.T
• The pharynx is a musculomembranous tube that extends from
the base of the skull to the level of the sixth cervical vertebra.
• The pharynx forms from the elongation and growth of the
primitive foregut.
• The mucosal lining of the oropharynx and hypopharynx is a
nonkeratinizing stratified squamous epithelium that is tightly
adherent to an underlying layer of fascia called the
pharyngobasilar fascia.
• The pharynx is surrounded by three constrictor muscles-the
superior, middle, and inferior constrictors .
• The pharyngeal muscles are enclosed by the buccopharyngeal
or visceral fascia. Areas of loose connective tissue surround
the visceral fascia of the pharynx and are potential spaces for
infection.
Mucous membrane of nasopharynx
Mucous membrane of
oral pharynx
Superior constrictor
Middle constrictor
Mucous membrane of
laryngeal pharynx
Inferior constrictor
Esophagus
THE TONSILS
• Waldeyer's ring is a continuous band of lymphoid tissue that surrounds
the upper pharynx.
•
The superior portion of the ring is located in the nasopharynx and is
composed of the adenoids. Laterally the palatine tonsils and anteriorly the
lingual tonsils complete the ring.
• Tonsillar crypts extend deeply into the body of the tonsil and are
surrounded by lymphoid nodules. Debris and foreign particles collect
within the crypts.
• The epithelium of the tonsils also varies by location. While the
pharyngeal tonsil is covered mainly by multiple rows of ciliated epithelium,
the palatine and lingual tonsils are covered by stratified, non-keratinized
squamous epithelium.
• The primary follicles are formed during embryonic
development and differentiate into secondary follicles after
birth.
• The secondary follicles mainly contain B lymphocytes at
various stages of differentiation, along with scattered T
lymphocytes.
• Tonsillar tumors or infections may result in ear pain due to
referred pain conducted by cranial nerve IX.
• The lymphatic tissue in the tonsillar ring is also termed the
mucosa-associated lymphatic tissue (MALT) of the upper
respiratory tract.
• Active phase lasts until 8-10 years of age.
• This function should not alter the decision to remove the
tonsils if a valid indication for tonsillectomy exists.
TONGUE BASE
• The sulcus terminalis, just posterior to the circumvallate
papillae, divides the anterior twothirds of the tongue from the
posterior oropharyngeal portion.
• The hypoglossal nerve provides motor innervation.
• Taste from the posterior tongue is mediated by the
glossopharyngeal nerve. The lingual artery provides an
abundant arterial supply.
Hypopharynx
• It is subdivided into:
 Pyriform sinus
 Posterior pharyngeal wall
 Postcricoid region
• The glossopharyngeal and vagus nerves form a plexus that
provides the motor and sensory innervation to the
hypopharynx.
• Additionally, the vagal innervation to the pyriform sinus
frequently results in referred pain to the ear mediated via
Arnold's nerve.
In performing the head and neck examination, it is crucial to
, as tumors , can
be palpable with only subtle surface abnormalities.
Radiology
• For a suspected retropharyngeal abscess, a lateral neck film
can reveal thickening anterior to the vertebrae.
• In general CT is preferable to magnetic resonance imaging
(MRI) for its ability to better distinguish the tumor's
relationship to osseous structures. MRI is particularly useful in
evaluating tongue base lesions.
• Barium swallow (Modified)
• Throat Cultures:
– At the initial presentation of tonsillitis, empiric antibiotic therapy is
sufficient and cultures are not cost effective.
– If the patient fails to respond to the antibiotic or the infection recurs
soon after, a culture may be useful in directing future therapy.
• Polysomnography:
Airflow
Oxygen saturation
Electroencephalogram
Rib cage and abdominal effort
Esophageal pressure
EKG
• The most common diseases of the oropharynx are
inflammatory processes.
• Pharyngitis is more common in children & adolescents than in
adults.
•
In children, pharyngitis is most common after the age of 6
months.
• Presents initially with high fever and severe pain on
swallowing, which often radiates to the ear. Other symptoms
are swollen tonsillar lymph nodes and muffling of speech due
to oropharyngeal swelling.
• On examination, the tonsils are red and swollen, often
contacting each other in the midline with yellowish or white
spots or vesicles formed on them.
• Malodorous breath can also accompany this disorder.
• The most common bacterial causes of acute
pharyngitis/tonsillitis:
• The treatment of acute adenotonsillitis includes:
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Increased oral intake
Bed rest
Analgesics
Antipyretic medications
• The standard treatment for streptococcal tonsillitis is a 10–14
day course of penicillin V.
• This regimen should be continued for at least 7 days to avoid
late complications (see below).
• Macrolides or oral Cephalosporins can be used in patients
allergic to penicillin. Analgesics are also administered for pain
relief.
Asymptomatic patients with a positive rapid test should not be
placed on antibiotics. Conversely, a culture should be taken in cases
where there is clinical suspicion of streptococcal tonsillitis but the
rapid test is negative.
• Antibiotics are indicated, however, in cases where the
offending organism is group A hemolytic streptococcus.
• The purpose of antibiotic treatment in these cases is
prevention of potential renal and cardiac sequelae.
• In addition, treatment of strep tonsillitis
– Shortens the length of the illness
– Irradicates the streptococcus from the pharynx so the infection cannot
be transmitted to others
– Prevents possible suppurative complications
• The drug of choice is penicillin (if the patient is not penicillin
allergic) for a 10-day course. Erythromycin can be used as a
second-line agent. Clindamycin can also be utilized in patients
who are allergic to penicillin.
• Another treatment option would be a first-generation
cephalosporin. it is generally accepted that if the community
failure rate with penicillin is less than 10%, penicillin should
be the first-line treatment.
• Complications:
– Peritonsillar edema and airway obstruction leading to a peritonsillar
abscess
– Deep neck infection
– Septicemia
– Rheumatic fever
– Glomerulonephritis
– Lingual tonsillitis
– Streptococcal gingivostomatitis
Scarlet Fever
• Group A β-hemolytic Streptococci that produce the scarlet
fever exotoxin.
• Sign & symptoms:
– A rash that begins on the trunk. (“perioral pallor”)
– A bright red tongue with a glistening surface and hyperplastic
papillae (“raspberry tongue”). (Pathognomonic feature)
– The tonsils are greatly swollen with a deep red color.
– An enanthema of the soft palate with hemorrhagic areas.
• The diagnosis is established by:
– The overall clinical picture + a positive rapid streptococcal test
Treatment
Medical therapy relies on penicillin, as in acute tonsillitis.
the oral cavity should be rinsed with mild antiseptic solutions
analgesics should be given for pain
Complications:
Necrotizing scarlet fever tonsillitis
Septic complications
– Extensive soft-tissue infections
– Toxic-shock-like syndrome
Rheumatic fever
Diffuse hemorrhagic glomerulonephritis
Rheumatoid arthritis
• Corynebacterium diphtheriae (The incubation period is 1–5 days)
• Transmition routes:
– Droplet inhalation
– Skin-to-skin contact
• Pathogenesis?
• Diphtheria is generally suspected if a dirty-gray membrane
covers the tonsils, tonsillar pillars, soft palate, and uvula.
• Two main forms are distinguished based on their clinical
presentation:
Local, benign pharyngeal diphtheria
Primary toxic, malignant diphtheria
• The disease begins with moderate fever and mild swallowing
difficulties. The clinical picture becomes fully developed in
approximately 24 hours, characterized by severe malaise,
headache, and nausea.
• The symptoms of this condition are generally mild but can
progress to upper airway obstruction or cardiac toxicity.
Treatment
First, the patient should be isolated.
Diphtheria antitoxin (200– 1000 IU/kg body weight)
should be administered by intravenous or
intramuscular injection.
– Allergy to the antitoxin should be excluded (with a
skin test) before it is administered.
Penicillin g should also be administered.
• Discharge from the hospital is contingent upon test results:
three smears taken at 1-week intervals must all be negative.
• Two percent of patients continue to carry the bacterium and
should undergo tonsillectomy.
The treatment for diphtheria is generally considered an
emergency, and antitoxins should be given within the first 48
hours of onset to be effective.
Tuberculosis
• Very rare (0.2%)
• Clinical manifestations:
• Primary complex: A primary tuberculous complex in the
tonsillar and cervical lymph-node region is most common in
children who have become infected by drinking cow’s milk
contaminated with tubercle bacilli. The primary complex in
these cases consists of a typical ulcerative lesion of the oral
mucosa and tonsil, associated with regional cervical
lymphadenopathy. “cold abscesses” may form about the
cervical spine.
– Miliary tuberculosis: involvement of the oral mucosa can
result from hematogenous spread, appearing as multiple
pinhead-size papules, some hemorrhagic, that form on the
oral mucosa.
• Diagnosis:
– The detection of acid-fast rods in smears, sputum, bronchial
secretions, gastric juice, or biopsy material.
– Biplane chest radiographs
– Tuberculin skin test
– Calcifications detected by ultrasound in enlarged cervical lymph
nodes are pathognomonic for tuberculosis.
– Cervical lymph-node biopsy
• Synonyms: Pfeiffer’s glandular fever, kissing disease
• It predominantly affects adolescents and young adults. The
incubation period is 7–9 days.
• The patient may present with fever, pharyngitis, cervical
adenopathy, and splenomegaly. Other symptoms include malaise,
sore throat, dysphagia and odynophagia. (tonsillitis as the initial or
cardinal symptom)
• Examination will reveal enlarged tonsils, often with a dirty-gray
exudate. The soft palate may be edematous with petechiae.
• The blood count initially shows leukopenia, followed later by
leukocytosis (20,000/μL) with 80–90% atypical lymphocytes
(lymphomonocytoid cells, Pfeiffer cells).
• In mononucleosis, the white blood cell count is elevated to
10,000 to 15,000 with 50% or more lymphocytes, which are
atypical in structure.
• EBV serology (especially IgM and IgG) is another important
test. (ELISA)
• The serum hepatic enzymes should be determined to exclude
concomitant involvement of the liver or spleen.
• Upper abdominal ultrasound and an electrocardiogram are
also recommended.
• Treatment is supportive, including bed rest, until the fever has
resolved, with a gradual return to physical activity.
• The agents of choice for pain relief are acetaminophen or
ibuprofen. Aspirin products should not be used, as they could
cause bleeding problems if tonsillectomy is required.
• Ampicillin and Amoxicillin should be avoided because they
frequently induce a pseudoallergic rash.
• Care must be taken in patients with splenomegaly to avoid
physical activity.
• Rarely, hospital admission is required due to tonsillar
hypertrophy and airway obstruction. In these cases
monitoring for potential airway obstruction is appropriate,
and corticosteroids may be of use.
• If the severity of airway obstruction is significant and/or the
airway obstruction fails to resolve with supportive care and
corticosteroids, tonsillectomy and/or adenoidectomy may be
warranted.
• Peritonsillar abscesses usually occur in patients with recurrent
tonsillitis or those with chronic tonsillitis that has been
inadequately treated. the absence of any history of tonsillitis is not
uncommon.
• This disease process is more common in young adults. Usually the
process begins with a peritonsillar cellulitis that progresses into an
abscess that extends beyond the tonsillar capsule. The abscess
forms in the potential space between the buccopharyngeal fascia
and the capsule itself. Abscess within the body of the tonsil itself is
actually rare.
• The swelling usually causes edema of the soft palate and displaces
the tonsil medially forward and downward. This generally causes
deviation of the uvula to the normal side.
• Patients generally complain of extreme unilateral soreness of
the throat with odynophagia, drooling, and trismus. Otalgia
on the side of the infection is not uncommon.
• Because it can be difficult at times to differentiate a
peritonsillar cellulitis from a true abscess, some opt to initially
treat with 24 hours of intrayenous antibiotics and hydration. If
the patient improves during this time, the infection is most
likely a cellulitis that will probably continue to improve with
parental antibiotics.
•
Bearing in mind that most patients harbor a mixed spectrum
of aerobic and anaerobic organisms.
• Treatment:
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Incision and drainage
Tonsillectomy
Intravenous antibiotics (Penicillin or Clindamycin)
Hydration
Analgesic
• The retropharyngeal space lies behind the pharynx and
esophagus, just anterior to the prevertebral fascia. It extends
superiorly to the base of the skull and inferiorly to the
bifurcation of the trachea.
• Patients generally present with trismus, drooling, dyspnea,
dysphagia, and a mass, often fluctuant, on one side of the
posterior pharyngeal wall.
• Lateral radiographs of the neck are also helpful in diagnosis. It
is important, however, to have proper positioning of the
patient at the time of X-ray; otherwise the results may be
misleading. The patient should have the neck extended in a
true lateral position for the X-ray.
• A more sensitive evaluation is through a computed
tomography scan of the retropharynx. A ring-enhanced lesion
in this area is suggestive of an abscess. The presence of air
within the lesion confirms that an abscess is present.
• Once an abscess is diagnosed or suspected, either by air
within the area of swelling, by CT scan evaluation, or by
failure to improve on antibiotics a drainage procedure in the
operating room is required. This is performed under general
anesthesia.
• Cortisone should also be administered in patients
with significant dyspnea.
• The parapharyngeal space is cone shaped. Superiorly it starts at the
base of the skull and inferiorly its margin ends at the hyoid bone.
The superior constrictor muscle is the medial boundary, and the
parotid gland, the mandible, and the pterygoid muscle are its lateral
margins , the prevertebral fascia is present posteriorly.
• A parapharyngeal space abscess can develop when infection or pus
from the tonsillar region goes through the superior constrictor
muscle. The abscess then forms between the superior constrictor
muscle and deep cervical fascia.
• Patients can present with toxemia and pain in the throat and neck,
with tender swelling of the neck in the region of the angle of the
mandible. Examination may reveal tonsillitis and/or medial
displacement of the tonsil.
• Trismus may also be present due to inflammation and edema
around the pterygoid musculature. If only the posterior
compartment is involved, there may be no trismus, but rather
swelling of the lateral pharyngeal wall and perhaps of the
posterior tonsillar pillar. This condition is best diagnosed by CT
scan.
• Once a parapharyngeal abscess is identified it needs to be
surgically drained.
Foreign body
The foreign
material should
be removed as
soon as possible
due to the risk
of
superinfection.
• The overwhelming majority of malignant tumors of the
oropharynx are squamous cell carcinomas.
• Approximately 80% are located in the palatine tonsils or
tongue base.
• Less common sites are the soft palate and posterior wall of
the pharynx.
• In most patients, chronic nicotine and alcohol abuse have a
major etiologic role in the development of oropharyngeal
cancers.
• The lymphomas occur most commonly in the tonsil where
they represent 16% of all neoplasms.
• Lymphomas can occur anywhere in Waldeyer's ring, and are
almost always non-Hodgkin's lymphomas.
•
Treatment is primarily nonsurgical.
• Pharyngeal squamous cell carcinomas are strongly associated mouth
tobacco and alcohol use.
• There are weak associations with poor oral hygiene, syphilis, human
papilloma virus, and epstein-barr virus.
• Patients with plummervinson syndrome have an increased risk of
postcricoid carcinoma.
• Symptoms:
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Dysphagia
Trismus
Globus sensation
Neck mass
Ear pain
• The treatment of choice for most cases is surgical tumor
removal.
• A neck dissection may be necessary on one or both sides,
depending on the location and stage of the primary tumor.
• Postoperatively, radiation should usually be delivered to the
tumor site and lymphatic pathways.
• Alternatives for the treatment of advanced tumors (T3, T4)
are primary radiotherapy or combined radiation and
chemotherapy.
• Greater than 95% of cancers in the hypopharynx are
squamous cell carcinomas. Verrucous carcinoma can occur in
the hypopharynx and, similar to its laryngeal counterpart, can
be treated by wide local excision.
• Due to the high incidence of nodal disease and aggressive
behavior at the primary site, the cure rates for
hypopharyngeal tumors are poor.
• The majority of hypopharyngeal carcinomas occur in the
pyriform sinus.
• In the rare early tumor, therapy can be planned that preserves
the larynx.
• Tumors limited to the lateral wall of the pyriform sinus
without extension to the pyriform apex can be treated
surgically via a lateral pharyngotomy with a neck dissection.
• Unfortunately, small tumors are rare and surgical treatment of
hypopharyngeal carcinoma usually necessitates total
laryngectomy. Neck dissections and postoperative radiation
therapy.
• The exact margin necessary is unclear, but given the
infiltrative nature of these cancers at least 2 -cm margins
should be obtained.
• Chronic pharyngitis :
Long term exposure to various noxious agents (nicotine,
alcohol, chemicals, gaseous irritants)
Chronic mouth breathing
Chronic sinusitis
• Sign & symptoms:
Dry throat sensation
Frequent throat clearing
The drainage of a viscous mucus
Dry cough
Foreign-body sensation in the pharynx
• The pharyngeal mucosa appears red and “grainy” due to the
hyperplasia of lymphatic tissue on the posterior pharyngeal
wall.
• The pharyngeal mucosa may also have a smooth, shiny
appearance in some cases (atrophic form).
• Treatment:
Any agents causing the pharyngitis should be avoided.
Herbal product such as sage or chamomile can be used in
a steam inhalation to moisten the airways.
In patients with nasal airway obstruction due to septal
deviation or turbinate hyperplasia, a surgical procedure
should be done.
• Bacteria that grow on cellular debris in poorly drained crypts
can perpetuate a smoldering inflammation, chronic tonsillitis.
• In this condition the palatine tonsils provide a “focus” that can
sustain a variety of diseases in other parts of the body
(rheumatic fever, glomerulonephritis, iritis, psoriasis,
inflammatory heart disease, pustulosis palmaris and plantaris,
erythema nodosum).
•
Symptoms:
Recurrent episodes of pain or
Asymptomatic course.
The most frequent complaints are lethargy, poor appetite, a bad taste
in the mouth, and a fetid breath odor.
• Small, firm, immobile tonsils with associated peritonsillar
redness. Occasionally a purulent liquid can be expressed
from the crypts. Tonsillar smears are found to contain group A
β-hemolytic streptococci.
the tonsillar lymph nodes at the mandibular angle
may be enlarged.
an elevated ESR and CRP and a left shift in
the differential blood count are present as signs of the
inflammatory process.
• An antistreptolysin titer of approximately 400 IU/ml or higher
is considered pathologic
Treatment:
• Apnea?
• Peripheral vs. Central.
• There is a tendency for the velum, oropharynx, and/or
hypopharynx to collapse during sleep, narrowing the pathway
for airflow and causing periods of apnea or hypopnea that can
last up to 2 minutes. This leads to frequent arousals from
sleep and gasping for air, preventing a normal sleep pattern.
• Symptoms:
Morning lethargy
Daytime fatigue
Tendency to fall asleep during the day.
Witnesses additionally report irregular snoring with
periods of apnea followed by “gasping” and loud snoring.
Obesity is usually present as an accompanying condition.
An elongated uvula
A narrow velopharyngeal passage
A bulky soft palate with a small oropharyngeal lumen
Hyperplastic tongue base
Hyperplasia of the palatine tonsils
The nasal airway should also be examined for possible septal
deviation, turbinate hyperplasia, or other abnormalities.
Müller maneuver
• Objective measuring techniques:
– O 2 saturation
– Respiratory sounds
– Heart rate on an outpatient basis
• Gold standard for confirming OSAS:
Polysomnography
General treatment measures consist of:
Weight reduction
Abstinence from alcohol and nicotine
Avoiding big meals, especially at night.
It is also important to establish a regular sleep–wake cycle
and avoid the use of sedatives.
• Esmarch splint
• Continuous positive airway pressure (CPAP) mask
• Surgical treatment (Surgical treatment requires very careful patient
selection, because many patients will derive little or no benefit from the
operation.)
• The result of the Müller maneuver can be helpful in selecting
patients for a surgical procedure on the soft palate.
• An established procedure is the uvulopalatopharyngoplasty
(UPPP) with tonsillectomy.