3 pdf - pharynx - Muhadharaty

Lecture (3) pharynx Dr. Sa'ad Y. Sulaiman

The Adenoid

The nasopharyngeal tonsil, commonly called "adenoids", is situated at the
junction of the roof and posterior wall of the nasopharynx. It is composed
of vertical ridges of lymphoid tissue separated by deep clefts and covered
by  ciliated  columnar  epithelium.  Unlike  palatine  tonsil,  adenoids  have  no
crypts  and  no  capsule.  Adenoid  tissue  present  at  birth,  shows
physiological  enlargement  up  to  the  age  of  six  years,  and  then  tends  to

atrophy at puberty and almost completely disappeared by the age of 20.

Acute adenoiditis

It  is  acute  inflammation  of  the  adenoid  tissue.  It  may  occur  alone  or  in
association  with  rhinitis  or  tonsillitis.  It  produces  pain  behind  the  nose,
postnasal  discharge,  nasal  block  and  feeding  difficulties  in  babies.
Treatment is usually  medical.

Adenoid enlargement (Adenoid hypertrophy)

AETIOLOGY:

1- Physiological hypertrophy: Occurs at the age of 3 - 8 years and

produced from relative disproportion in size between the adenoids
and the cavity of the nasopharynx.

2- Pathological hypertrophy: Due to recurrent upper respiratory

infections.

SYMPTOMS:

1- Bilateral nasal obstruction :



Mouth breathing.



Speech hypo-nasality (Rhinolalia clausa).



Difficult suckling in infants. Noisy respiration (snoring) and wet

bubbly nose may be present.



Snoring and obstructive sleep apnea.

2-Bilateral nasal discharge :



Mucoid or muco-purulent due to mechanical obstruction of the

choanae.



Excoriation of the nasal vestibule and upper lip.



Post-nasal discharge may result in nocturnal cough, laryngismus

stridulus and gastro-intestinal disturbances as loss of appetite and
morning vomiting.

SIGNS:

1- Posterior rhinoscopy => shows the adenoids, but is difficult to be

performed in children.

2- Flexible fiberoptic endoscope is of great help to visualize the adenoid

in the postnasal space.

INVESTIGATION:

Lateral plain x-ray of the nasopharynx: A soft tissue shadow narrowing
the airway => diagnostic.

COMPLICATIONS:

1- Obstructive sleep apnea:

defined as a cessation of ventilation despite

effort for 10 seconds in older children, or 6 seconds in younger infants.

This may affect the patient in the following way:

a) During sleep; restless sleep (due to fragmentation of sleep by frequent
arousal) night mares and nocturnal enuresis.

b) During day time => morning headache, impaired concentration, poor
school performance, excessive daytime sleepiness (due to fragmentation

of sleep)

2- Descending infections:

Ear: Recurrent acute otitis media and secretory otitis media.

Respiratory: Recurrent rhinitis, sinusitis, pharyngitis, laryngitis and

bronchitis

3- Adenoids facies: Due to
under-development of the middle

1/3 of the face

a) Nose: Pinched nostril's

b) Mouth: Open mouth, short
upper

lip,

protruding

upper

incisors, high arched palate and

receding mandible

c) Face: Idiot expressionless

look.

TREATMENT:

Adenoidectomy operation => when adenoids are symptomatic or

complicated.

Adenoidectomy is indicated in:

1.  Upper airway  obstruction causing sleep apnoea.
2.  Chronic nasopharyngitis  refractory to medical treatment.
3.  Chronic or recurrent middle  ear infection.
4.  Secretory otitis media.
5.  Chronic sinusitis.

ACUTE TONSILLITIS

DEFINITION:
Acute inflammation  of the palatine  tonsils.
INCIDENCE:
Age:  Any, but much more common in children.

AETIOLOGY:
Causative organisms:  The most common organisms are:

1- Viral:

It has been stated that it is a viral infection of the tonsils that

predisposes to a bacterial infection.

On the other hand a virus may be the

sole agent responsible (e.g.Epstein-Barr virus, Adenoviruses and Herpes
simplex ).

2- Streptococci (Group A Beta-hemolytic).
3- Staphylococci.
4- Haemophilus influenzae.
5- Pneumococci.
6- Anaerobes.

Mode of transmission: Droplet infection.

SYMPTOMS:

 General symptoms: Rapid onset of fever ( up to 40 degree), headache,

anorexia and malaise. There is often abdominal pain due to a
mesenteric adenitis.

 Pharyngeal symptoms:

a) Rapid onset of dysphagia with severe sore throat and referred
otalgia
b) Bad mouth odour (halitosis).

SIGNS:
1. General signs: High fever and flushed face. Febrile convulsions may

occur in children.

2. Pharyngeal signs:

a)  Acute  parenchymatous  tonsillitis:  Marked  hyperaemia  and  enlargement of
the tonsils
b)  Acute  follicular  tonsillitis:  The  crypts  are  full  of  purulent  exudates.  The
surface of the tonsil has yellowish  spots characteristic spotted appearance

c)  Acute  membranous  tonsillitis:  These  yellowish  spots  may  coalesce  =>
form a non-adherent yellowish  true membrane
3.  The tongue is furred and the breath is offensive.
4.  Cervical  signs:  Enlarged tender jugulo-digastric lymph nodes (just below

the angle of the mandible).

Differential diagnosis:
1- Simple  acute pharyngitis.
2-  Infectious  Mononucleosis  (glandular  fever),a  systemic  infection  caused
by  Epstein  Barr  virus,  diagnosed  with  blood  test  (monospot  test).  The
administration  of  ampicillin  may  result  in  the  eruption  of  skin  rash.
Spleenomegaly  may present in 50% of patients.
3- Scarlet fever. There is skin rash and strawberry tongue.
4- Diphtheria.
5- Ulcerative  gingivitis.
6- Agranulocytosis.

COMPLICATIONS:

1. Local complications:

a) Pharyngeal suppurations --> peri-tonsillar abscess, para-pharyngeal
abscess and retro-pharyngeal abscess.
b) Laryngitis
c) Otitis media

2. Systemic complications:

Rare and almost confined to childhood.
a) Rheumatic  fever => carditis and arthritis.
b) Acute glomerulo-nephritis.
How? They are due to an auto-immune reaction i.e. the antibodies produced
against  Streptococcus  beta-haemolyticus  cross-react  with  the  patient's  own
tissues
c) Septicaemia.

TREATMENT:
1.  Antibiotics therapy for 10 days to avoid recurrence.



Penicillin is still the antibiotic of choice either orally, intramuscularly

or intervenously.



Be aware of penicillin-resistance and give alternatives e.g. co-

amoxiclave, cephalosporin ±metronidasole.



Erythromycins were penicillin allergy

2. Supportive and symptomatic measures =>bed rest, generous fluid intake,

analgesics, antipyretics and gargles.

Chronic Tonsillitis

DEFINITION:

Chronic inflammation of the palatine tonsils.

AETIOLOGY:
It  follows  acute  and  subacute  tonsillitis  and  is  more  common  in  children
between the ages of 4-15 years. The predisposing factors are:
1.  Organism factor: Repeated attacks of acute tonsillitis.
2.  Treatment factor: inadequate dose or short course of antibiotics therapy.
3.  Patient factor: Low patient's resistance e.g. malnutrition.

SYMPTOMS:
1. History of repeated attacks of acute tonsillitis.
2. Sense of throat irritation => frequent hawking and hemming to clear the

throat.

3.  Bad mouth odour ( halitosis ) => due to accumulation of pus in the crypts
4.  Difficulty  in  swallowing;  if  hypertrophic.
5.  Snoring and obstructive sleep apnea --> if hypertrophic.

SIGNS:



Persistent enlargement of the jugulo-digastric lymph nodes



Marked tonsillar enlargement with congested anterior pillars.



Squeezing: The crypts ooze pus on pressure by a tongue depressor

TREATMENT:
Tonsillectomy operation; when chronic tonsillitis is symptomatic

Peritonsillar abscess (Quinsy)

Collection of pus in

Definition:
the  peri-tonsillar  space  which  is  a
connective  tissue  space  that  lies
between  the  tonsil  capsule  and  its

bed (superior constrictor muscle).

The swelling can extend to the softpalate and push the tonsil medially.
Quinsy is usually unilateral and most frequently affects adult males.

Aetiology: In patient with acute tonsillitis, the infection may passe through

crypta magna (the largest tonsillar crypt) towards the peri-tonsillar space.

Symptoms:
Quinsy  usually  follows  acute  tonsillitis.  The  patient  looks  ill  with  fever  and
may  be  rigor.  There  is  acute  pain  in  the  throat  radiating  to  the  ear,  and this
makes swallowing  so difficult that saliva  dribbles from the mouth.

Signs:



The

examination

may

difficult because of marked
trismus due to reflex muscle
spasm.



In the affected side, the palate

is  edematous  and  bulging;  the
uvula  is  edematous,  pushed  to
the  other  side  and

the tonsil is

pushed

downwards

and

medially may have pus on its
surface.



The cervical nodes are enlarged

and tender.

Uvula

Differential Diagnosis:
1. Dental abscess of the upper molar tooth.
2. Parapharyngeal swelling.

Complications



Parapharyngeal abscess



Laryngeal edema



Rupture with aspiration of pus



broncho-pneumonia.

Tonsils should be removed 6-8
weeks following quinsy.

Treatment:

Medical:  with  massive  paranteral
antibiotic  therapy  e.g.  pinicllin  or
licomycin.
Surgical:  if  there  is  failure  of
medical  treatment  after 24-48 hr.:
-  Drainage  of  the  abscess:  The
throat  is  sprayed  with  local
anesthetic  to  reduce  the  trismus,
then  aspiration  is  done  with  a
wide-bore  needle  from  the  most
prominent  part  of  the  swelling.  If
pus  came  out,  it  is sent for culture
and a long sinus forceps is plunged
into  the  same  area  and  pus  is
drained.

Rapid

improvement

follows but antibiotic should be
continued

until

resolution

complete.
Tonsillectomy is indicated after 4-6
weeks to avoid recurrence.

Tonsillectomy

Indications for tonsillectomy:

The indications for tonsillectomy are subject of controversy: No universal
agreement on the indication for tonsillectomy:

1. Recurrent attacks of acute tonsillitis which is frequent and severe enough

to interfere with the patient's general health (5-6 attacks per year for at
least 2 years).

2. Peritonsillar abscess (quinsy).
3. Sleep apnea syndrome: such children have tonsils, which meat in the

mid-line and cause gross difficulty in breathing.

4. Tonsillectomy for biopsy purposes when the tonsils are thought to be the

site of neoplasm.

5.  Diphtheria  carriers.
6.  Recurrent attacks of otitis media.
7.  Acute rheumatic  fever and acute nephritis  if streptococcus tonsillitis  has

been responsible for recurrence.

Contraindication for tonsillectomy:

1. Bleeding disorders on cloning problems.
2. Acutely inflamed tonsils and recent upper respiratory tract infection.

Here it's safer to wait 3 weeks because of greatly increased risk of
postoperative haemorrhage and pulmonary complications respectively.

3. Epidemic of poliomyelitis: There is evidence that the virus may gain

access to the exposed nerve sheaths and so give rise to the more fatal
bulbar form of the disease.

4. Cleft palate because tonsillectomy leads to scarring of soft palate which

affects repair and speech.

Postoperative care:

1. Careful monitoring of vital signs. So that any haemorrhage can be

detected.

2. Analgesics: paracetamol. Aspirin should be avoided due to its effect on

coagulation process.

3. Encourage the patient to move the muscles of the throat by swallowing,

talking and drinking. The movement will help in shedding of the slough
from the tonsillar fossae allowing healing to take place.

4. The patient should be warned that referred otalgia may be a predominate

complaint following tonsillectomy.

Complications of tonsillectomy:

1. Haemorrhage:

A. Primary haemorrhage: occurs at the time of operation. It's due to

recent  infection,  previous  quinsy  or  scarring.  It's  controlled  by
ligation  or  diathermy.  Excessive  bleeding  from  both  fossae  raise  the
question  of  coagulation  defect.  Here  blood  transfusion  may  be
necessary.

B. Reactionary haemorrhage: occur within few hours after the operation.

It's  due  to  inadequate  haemostasis  at  the  time  of  operation,  rise  of
blood  pressure,  reopening  of  vessels  or  due  to  slipping  of  ligatures.
It's  treated  by  preparing a blood and early return to the theatre where
the vessel is ligated.

C. Secondary haemorrhage: occur 5-8 days after operation. It's due to

infection, often associated with a refusal of the patient to eat or an
upper respiratory tract infection at time of surgery. The patient should
be readmitted to the hospital and a course of antibiotics is ordered.

2. Trauma: capped or carious teeth are at risk during tonsillectomy.

Insertion of the mouth gag can lead to dislocation of the TMJ.

3. Infection: Pyrexia is not uncommon at the morning after tonsillectomy.

Prolongation of the pyrexia is a sign of infection which if not treated lead
to secondary haemorrhage.

4. Otitis media: It should be distinguished from referred otalgia.

5. Chest complications: It's more likely to occur if the patient has an URTI

at the time of operation or due to inhalation of blood or broken tooth.

6. Pain: it's common in adult especially in the first week till the slough

separates.

Other Diseases Affecting The Oropharynx

Plummer Vinson (Paterson Kelly) Syndrome

A chronic atrophic type of inflammation of the mucous membrane of the

mouth, pharynx and upper end of esophagus.
The  major  changes  occur  in  the  postcricoid  region  initially  started  by
fissuring  and  hyperkeratosis  followed  by  fibrosis,  web  formation  and
stricture.
The condition may be associated with achlorhydria and/or splenomegally.
A  small  proportion  of  patients  with  this  condition  progress  to  the  stage  of
postcricoid cancer.
Aetiology
It is unknown but autoimmune  and metabolic basis are presumed.
Clinical Picture
The disease is more common in females usually  over 40 years:

 Dysphagia and feeling of a lump in the throat.
 Pallor due to iron deficiency anemia.

 Angular stomatitis.
 Dryness of the tongue because of glossitis.

 Koilonychia.
 Loss of weight
Investigations:



Hematological:

- CBP: hypochromic microcytic anemia
- Low serum iron
- High iron binding capacity.



Ba-Swallow: web at the postcricoid region or upper esophagus.



Esophagoscopy: Fissuring, hyperkeratosis followed by fibrosis and web

formation.

Treatment

 Correction of anemia by iron and vitamin B complex in high doses.
 Endoscopic resection of the web to relieve dysphagia and exclude

malignancy (by histopathological examination).

 Keep the patient under observation because malignant changes can still

occur.

Globus Pharyngeus (Globus Hystericus)

Sensation of lump in the throat affecting  mainly  middle  aged females, which
is brought on or made worse by anxiety.
Aetiology
The condition is often regarded as functional  in which no organic cause can
be found.
Recently the most accepted organic theory is gastroesophageal reflux
diseases (GERD).
Clinical picture
Intermittent  sensation of lump in the throat usually  felt at or above the
sternal notch, noticed when the patient is swallowing  saliva  and relieved  by
meals!
There is no true dysphagia and no weight  loss and the patient  often has
psychological stress or cancer phobia.
Diagnosis
The condition should not be diagnosed until  an organic lesion  has been
excluded in order not to miss an early  carcinoma.
Clinical  examination  is normal.
1.  Flexible  fiberoptic  endoscopy(  under  local  anesthesia)  of  upper

aerodigestive tract

2.  Ba- swallow:  may show cricopharyngael  spasm
3.  Hematological  investigations  to exclude iron deficiency anemia
Treatment:
1.  Reassurance that there is no organic disease or cancer.
2.  Antireflux  therapy:  Omeprazole + Domperidone.
3.  Psychiatric consultation is required in selected cases.
4.  Remember that: dysphagia + weight  loss + pain radiating  to the ear +

enlarged neck lymph node= Malignancy is the cause until proven
otherwise!!!

-------------------------------------------------------

--------------------

Peritonsillar abscess (Quinsy)

Collection of pus in

Definition:
the  peri-tonsillar  space  which  is  a
connective  tissue  space  that  lies
between  the  tonsil  capsule  and  its
bed  (superior  constrictor  muscle).
The swelling can extend to the soft
palate

and

push

the

tonsil

medially.

Quinsy

usually

unilateral and most frequently

affects adult males.