Pharynx

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Pharynx

• By
• Dr. Nourizadeh
• Assistant professor of E.N.T

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Anatomy

• 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.

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Anatomy

• 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.

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Mucous membrane of nasopharynx
Mucous membrane of oral pharynx
Superior constrictor
Middle constrictor
Mucous membrane of laryngeal pharynx
Inferior constrictor
Esophagus
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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.

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• 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.

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• 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.

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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.

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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.

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• In performing the head and neck examination, it
  is crucial to palpate the oral cavity and
  oropharynx, as tumors , can be palpable with only
  subtle surface abnormalities.

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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)

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• 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

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Infectious Disorders

• 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.

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Bacterial Adenotonsillitis

• 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
• Staphylococcus aureus
• Group A hemolytic streptococcus
• Haemophilus influenzae

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• The treatment of acute adenotonsillitis includes
• Increased oral intake
• Bed rest
• Analgesics
• Antipyretic medications
• The standard treatment for streptococcal
  tonsillitis is a 1014 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.

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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.
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• 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.

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• 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

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Scarlet Fever

• Group A ß-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

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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

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Diphtheria

• Corynebacterium diphtheriae (The incubation
  period is 15 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.

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• 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.

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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.

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• 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.

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• The treatment for diphtheria is generally
  considered an emergency, and antitoxins should be
  given within the first 48 hours of onset to be
  effective.

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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 cows 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.

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• 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

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Infectious Mononucleosis

• Synonyms Pfeiffers glandular fever, kissing
  disease
• It predominantly affects adolescents and young
  adults. The incubation period is 79 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
  8090 atypical lymphocytes (lymphomonocytoid
  cells, Pfeiffer cells).

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• 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.

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• 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.

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• 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.

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Peritonsillar Abscess (Quinsy)

• 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.

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• 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.

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• Treatment
• Incision and drainage
• Tonsillectomy
• Intravenous antibiotics (Penicillin or
  Clindamycin)
• Hydration
• Analgesic

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Retropharyngeal Space Infection

• 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.

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• 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.

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• Cortisone should also be administered in patients
  with significant dyspnea.

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Parapharyngeal Space Abscess

• 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.

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• 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.

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Foreign body
The foreign material should be removed as soon as
possible due to the risk of superinfection.
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NEOPLASMS

• 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.

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Lymphoma

• 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.

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• 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
• Dysphagia
• Trismus
• Globus sensation
• Neck mass
• Ear pain

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• 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.

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Hypopharyngeal Carcinoma

• 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.

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• 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.

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Chronic Pharyngitis

• 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

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• 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.

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Chronic Tonsillitis

• 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.

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• 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 ß-hemolytic streptococci.
• Palpation the tonsillar lymph nodes at the
  mandibular angle may be enlarged.
• Laboratory tests 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

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• Treatment
• Tonsillectomy

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Obstructive Sleep Apnea Syndrome (OSAS)

• 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.

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• 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.

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Physical Examination

• 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

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• Objective measuring techniques
• O 2 saturation
• Respiratory sounds
• Heart rate on an outpatient basis
• Gold standard for confirming OSAS

Polysomnography
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Treatment

• 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
  sleepwake 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.)

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• 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.

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