Download Diseases of the Oropharynx

Diseases of the
Oropharynx
By 3D group 2
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Melissa Ann Velasquez
Sarah Velasquez
Abelaine Venida
Jennifer Jeanne Vicera
Margaret Elaine Villamayor
Paolo Villanueva
Diogenes Villareal
Cherisse Vinoya
Emmerson Vista
Eunice Wong
•John Andrew Yam
•Marie Lourdes Ynson
•Mary Liezl Yu
•Dianne Joyce Yusi
•Aileen Zagala
•Camille Zayco
•Kaye Pamela Zozobrado
•Darwin Salonga
Anatomy of the Oropharynx
Examination of the Oral Cavity
Acute Pharyngitis
Etiology and Pathology
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Varies depending on the causative organism
Exudate = serous  thicker or mucoid  dry
and may adhere to the pharyngeal wall.
Hyperemia = pharyngeal wall blood vessels
become dilated.
Small white, yellow or gray plugs form in the
follicles or lymphoid tissue.
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Lateral pharyngitis = lateral wall
involvement
- lymphoid follicles or plaques on
the posterior pharyngeal wall, or localized
more laterally, are inflamed and swollen.
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Can be due to a viral causative agent
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In acute pharyngitis associated with
adenopathy in the absence of follicular
pharyngitis membrane formation
Vesicle formation on the mucous membrane,
ex. Herpes.
Signs and symptoms
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Onset
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Dryness and scratchiness of the throat
(+) malaise and headache
(+) slight fever
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Exudate in the pharynx invariably thickens
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Dysphagia
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Result of pain, referred pain to the ear, cervical
adenopathy, tenderness
Pharyngeal wall
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Difficult, with a rasping, hawking effort and cough
Hoarseness  Larynx
Reddened
Dry, glazed appearance
Coating of a mucoid secretion
Lymphoid tissue
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Red and swollen
Normal
Acute Pharyngitis
Treatment
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Antimicrobials
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Shortened course of the disease, decreased
incidence of complications
Warm throat irrigations
Supportive care
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Adequate fluid intake, light diet, aspirin when
indicated
Acute Tonsilitis
Etiology
Acute supppurative bacterial tonsillitis:
 ß- hemolytic Streptococcus Group A-most
common
 Streptococcus viridans
 Pneumococci
 Staphylococci
 H. influenzae
 Viral pathogens
Pathology
General inflammation
and swelling of the
tonsil tissue with an
accumulation of
leukocytes, dead
epithelial cells and
pathogenic bacteria.
Other pathologic phases that may
occur depending on the virulence of
organism:
1.
2.
3.
A simple inflammation of
the tonsil area
Formation of exudate.
Cellulitis of the tonsil and
its surrounding area
4.
Formation of
peritonsillar
abscess
5. Tissue necrosis
Symptoms
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Sore throat
Various degrees of dysphagia
General malaise
Fever- 104°F
Fetid breath
Otalgia
Complications: otitis media
Tender cervical adenopathy
Acute Tonsillitis Treatment
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Bed rest, adequate fluid intake, light diet
Oral analgesics – control discomfort
GARGLES
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Adds to a patient’s comfort & influence course of the
disease to some extent
3 glassfuls of gargling solution each time
Every 2 hours
Heat of gargling solution is probably more effective
than its medicinal content
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Isotonic saline solution, sodium perborate powder
which is especially useful in Vincent’s infections or
trench mouth
ANTIBIOTICS
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Treatment of choice
Penicillin – DOC unless organism is resistant or
patient is sensitive; erythromycin
Treatment should be continued for a full clinical
course, bet 5-10 days
Grp A B-hemolytic strep – maintain adeq antibiotic
therapy to reduce possibility of complications such as
RHD & nephritis
Lingual Tonsilitis
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1. Pharyngeal Tonsil
2. Palatine Tonsil
3. Lingual Tonsil
4. Epiglottis
LINGUAL TONSILS
The lingual tonsils are at
the back of the tongue
and cannot be seen by
looking in the mouth.
Function: guard for
infective agents.
Composition:
 Crypts lining by stratified
squamousnonkeratinizing
epithelium infiltrated with
small lymphocytes.
 Lymphatic nodules
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LINGUAL TONSILITIS
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Less common than infections of the faucial
tonsils due to the absence of the complex
crypt arrangement and not as large as the
latter.
Rarely, acutely inflamed along with the
faucial tonsils.
More common among tonsillectomized
patients and adults.
Diagnosis
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Examination with a laryngeal mirror or a
fiberoptic rhinolaryngoscope will reveal the
presence of
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acutely inflamed and tender tissue mass
with white exudate at the base of the
tongue is diagnostic of lingual tonsillitis.
Lingual Tonsillitis Symptoms
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Lingual tonsillitis presents with fever, sore
throat, dysphagia, muffled voice, and pain
at the level of the hyoid bone during
swallowing.
The pharynx may appear normal or mildly
hyperemic on physical examination.
Lingual Tonsillitis
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The anterior neck may be tender at the level of
the hyoid bone, and cervical and submandibular
adenopathy may be observed.
A patient's voice also may have the classic
muffled quality characteristic of severe tonsillar
enlargement, but in lingual tonsillitis the uvula
and peritonsillar area show no deviation or
edema.
TREATMENT
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Culture followed by appropriate
antibiotic therapy is required.
Lingual tonsillectomy by CO2 laser is
performed when medical mgt is not
effective.
Membranous Pharyngitis
VINCENT’S OR PLAUT’S ANGINA
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An acute necrotizing infection of the
pharynx and mouth caused by a
combination of fusiform bacilli (Fusiformis
fusiformis) and spirochetes (Borrelia
vincentii) which are normally present in
the oral cavity
Encountered in a limited form without
systemic reaction and may be associated
with other throat inflammations
CLINICAL MANIFESTATIONS
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Commonly seen in young adults
Presents with a unilateral sore throat that
increases in intensity over several days
with an associated referred earache on the
same side. In addition, the patient
complains of tender cervical adenopathy
and foul breath
Vincent’s Angina
A deep well circumscribed unilateral ulcer of one tonsil. The base of the ulcer
is gray and bleeds easily when scraped with a swab.
DIAGNOSIS
Diagnosis is confirmed by using a gentian
violet-stained smear of the pharyngeal
exudate, which demonstrates the
presence of fusiform bacteria and
spirochetes
TREATMENT
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Supportive measures
Hydrogen peroxide mouthwash
Penicillin or Clindamycin
Surgical debridement
Diphtheria
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Corynebacterium
diphtheriae or C.
ulcerans
Pharynx is most
common site of
infection
Occurs more in nonimmunized individuals
Diphtheria
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Caused by the toxin produced by the
organism
Sore throat – most common initial
complaint
Nausea, vomiting, dysphagia
Diagnosis
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Examination: membrane
present over tonsillar
area with spread to
adjacent structures
Membranes dirty or dark
green
May obstruct view of
tonsils
Bleeding occurs with
elevation of the
membrane
Diagnosis
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Causative organisms: toxigenic strains of
Corynebacterium diphtheriae or C.
ulcerans
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Smears from nasopharynx and tonsil
cultured on MacConkey agar or Loeffler
medium
Suspicious strains tested for toxigenicity
Treatment
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Two phases
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Use of specific antitoxin
Elimination of organism
from oropharynx
Antitoxin: test patient
first for sensitivity to the
serum
40,000-80,000 units
antitoxin diluted in saline,
administerd IV
Treatment
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Antibiotic treatment:
Penicillin or erythromycin
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Eliminates carrier state
Repeat culture performed
to make sure clearance of
organism in the pharynx
Persistent organisms:
Long term treatment with
erythromycin
Complications
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Airway obstruction – tracheostomy
Cardiac failure
Muscle paralysis
Inflammatory process may spread to ears
(otitis media), lungs (pneumonia)
Pharyngeal Manifestations of
Blood Disorders
Infectious Mononucleosis
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Acute Infectious Disease
Fever, Malaise, Somnolence, LN
enlargement, Lymphocytosis
Viral (EBV or CMV)
Signs and Symptoms:
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Sore Throat
Tonsillitis
Fever
Chills
Malaise
Complaints of feeling tired
LN becomes enlarged and often ulcerates
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May block postnasal space
Signs and Symptoms:
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Macular Rash 40%
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Diffuse and short duration
Increased in patients receiving ampicillin
Splenomegaly in 30%
Jaundice in 5%
Examthem on palate
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Short duration of usually less than 48 hours; commonly at the
junction of the hard and sof palate
Diagnostics:
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CBC
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Elevated WBC prodominated by neutrophils
Later followed by lymphocytic leukocytosis
Smear with examination for atypical lymphocytes
“Mono-spot” positive
Heterophil antibody titer exceeds 1:60
Throat culture to rule-out coexisting beta-hemolytic
streptococcal pharyngitis
Treatment:
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Symptomatic
Prednisone
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For severe obstructive disease
To reduce the ancillary inflammatory process
Patient’s activities should be substantially
reduced during the acute phase, with
gradual return to normal activities
Complications:
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Ruptured Spleen
Guillain-Barre ascending paralysis
CN paralyses
Acute Leukemia
Acute Leukemia
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First manifestations may be oral lesions
Signs and Symptoms:
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Enlarged tonsils with ulcerative lesions
Petechiae within the oral cavity
Bleeding in affected areas
Gingival ulceration
Low grade fever
Cervical adenopathy
Diagnosis may be by bone marrow aspiration and
peripheral blood exam
Peritonsillar Cellulitis
and Abscess
Etiology:
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Infections of the tonsil proceed to diffuse
cellulitis that could lead to peritonsillar abscess
May occur rapid or late
Unilateral and more common in older children
and young adults
Symptoms: marked dysphagia, pain referred to
the ear in the involved site, increased salivation,
fever
Symptoms:
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Swelling interferes with articulation and speech
is difficult
Inspection is difficult due inability to open mouth
Tonsil may appear normal as it is pushed
medially and swelling develops lateral to tonsil
Palpation – distinguishes an abscess from
cellulitis
Pathology:
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Suppurative infiltration occurs most often
in supratonsillar fossa
Causes edema of soft palate and
displacement of uvula across midline
Swelling extends to adjacent soft tissues,
causing painful swallowing
Bacteriology:
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Throat cultures are ineffective
Culture of the actual abscess is ideal
More common bacteria – Streptoccocus
pyogenes; less common – Staph. aureus
Peritonsillar Abcess:
Peritonsillar Abcess
Treatment:
1. Surgical incision and drainage or needle
aspiration technique
 When pus is collected – peritonsillar
abcess
 When no pus is collected – peritonsillar
cellulitis
2. Antibiotics and warm saline irrigation
Treatment:
Procedure for surgical incision:
Pharynx is sprayed with topical anesthesia
 2 mL of xylocaine with adrenaline are injected
 Incision through the mucosa near the superior pole of
the tonsillar fossa
 Tonsil suction to collect the pus
#in children and young adults drainage may be performed
after the application of cocaine to the site of incision and
to the sphenopalatine ganglion.
#younger children require general anesthetics
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Treatment:
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Immediate tonsillectomy is advisable for
complete drainage and alleviates the need
for a planned tonsillectomy six weeks
later, at which time there is frequent
scarring and fibrosis present in the
tonsillar capsule is less identified.
Treatment:
Pathogens with a selection of antimicrobials
ETIOLOGY
Streptococcus
Bacteroides
Haemophilus
Fusobacterium
Staphylococcus
Peptococcus
ANTIBIOTIC
Penicillin
Cephalosporin
Clindamycin
Treatment:
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Warm saline throat irrigation provides
symptomatic relief from the pain of
pharyngitis of peritonsillar abcess
Atrophic Pharyngitis
Mild Cases
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–Mucosa appears thin & glistening or
glazed
–Absence of all but a few of the lymphoid
collections that are seen in an average
pharynx
–blanket of mucus thicker &
semitransparent
Advanced cases
“Pharyngitis sicca”
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Dry
Mucous coating gluelike in consistensy
Dry furrowed mucous membrane
Usually associated with atrophic dematitis
or rhinitis sicca
Etiology
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Not known definitely
Air not sufficiently warmed &
humidified by the nasal mucosa
Trophic mucosal changes
 hyposecretion of mucus
Symptoms
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Sense of dryness and thickness in the
upper pharynx.
Patient’s frequently clear their throats by
“hawking” in an attempt to dislodge the
adherent secretions.
Mild degree of hoarseness may be present
due to irritation of the larynx from the
frequent attempts to clear the throat.
Treatment
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Local application of Mandl’s paint to the pharynx
is beneficial to stimulate secretion.
10 drops of saturated solution of potassium
iodide may be given three times daily with meal.
Combination of both is desirable.
Breathing of warm moist air for 20-30 minutes
once or twice a day may be done to moisten the
inspissated secretion.
Pharyngitis Associated with
Tobacco
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Smoking
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Causes dry troublesome throat
Patients start with symptoms of mild
soreness then eventually with marked
pharyngitis sicca
Throat of a heavy smoker = dry, shiny and
hyperemic pharyngeal mucosa.
Chronic Tonsilitis
Chronic Tonsillitis
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Persistent infection of the tonsils
Repeated infections may cause the
formation of small pockets (crypts) in the
tonsils which harbor bacteria
Clinical Picture:
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2.
Enlarged tonsils, with evident hypertrophy and
scarring. Crypts seem partially stenosed, but an
exudate, often purulent, can be expressed from
them. In some cases, one or two crypts are
enlarged, and a considerable amount of “cheesy”
or “putty-like” material can be expressed from
them
Small tonsil, usually recessed and often referred to
as “buried”, in which the margins are hyperemic,
and a small amount of thin purulent secretion can
often be expressed from the crypts
Symptoms:
 Chronic sore throat
 Halitosis
 Tonsillitis
 Persistently tender cervical lymph nodes
 Breathing partially blocked by enlarged
tonsils
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Cultures usually show several organisms
of relatively low virulence and rarely
demonstrate beta-hemolytic streptococci
Treatment
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Prolonged courses of penicillin
Daily throat irrigations
Dental or oral irrigating device to cleanse
the tonsillar crypts
Tonsillectomy
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Surgical removal of tonsils
Relative Indication: recurrent episodes of
documented grp A beta-hemolytic
streptococcal infection
Tonsillectomy
Absolute Indications:
 Development of cor pulmonale by chronic airway
obstruction
 Tonsil or adenoid hypertrophy with sleep apnea
syndrome
 Hypertrophy to the extent of causing dysphagia
with associated weight loss
 Excisional biopsy for suspected malignancy
(lymphoma)
 Recurrent peritonsillar abscess or abscess
extending into adjacent tissue spaces
Tonsillectomy in children:
Indications:
 Documented recurrent bouts of tonsillitis (despite
adequate medical management)
 Tonsillitis assoc w/ persistent & pathogenic streptococcal
cultures (carrier state)
 Tonsil hyperplasia w/ functional obstruction
 Hyperplasia & obstruction remaining 6mos after
infectious mononucleosis
 Rheumatic fever history w/ heart damage assoc w/
chronic recurrent tonsillitis & poor antibiotic control
 Tonsil & adenoid hypertrophy assoc w/ orofacial or dental
abnormalities that narrow the upper airway
 Recurrent or chronic tonsillitis assoc w/ persistent cervical
adenopathy
Tonsillectomy
Contraindications:
 Repeated upper respiratory infections
 Systemic or chronic infection
 Fevers of unknown origin
 Enlarged tonsils w/o obstructive symptoms
 Allergic rhinitis
 Asthma
 Blood dyscrasia
 General inability or failure to thrive
 Poor muscular tone
 Sinusitis