larynx

1. Diseases of Pharynx
TEKLEWEINI ABRHA (MD)

2. Pharynx
• Conical fibromuscular tube
• Lined with skeletal muscle
• Runs from skull base to C6
vertebrae
• Connects nasal cavity & mouth to
esophagus & larynx
• Common passage for food and air
• Divided into 3 regions
– Nasopharynx (epipharynx)
– Oropharynx (mesopharynx)
– Laryngopharynx (hypopharynx)

4. Nasopharynx
• Lined by Ciliated pseudostratified columnar epithelium
• Found Posterior to Nasal Cavity, inferior to Sphenoid bone &
superior to Soft Palate
• It has pharyngeal tonsils (adenoids) & tubal tonsils
• Function
– As a conduit of air
– Through Eustachian tube - ventilates middle ear cavity
– Prevents regurgitation
– A resonating chamber
– A draining cannel for mucus secretion

5. Oropharynx
• Lined with thick, protruding stratified squamous epithelium due to
great friction
• Location
– Posterior to Oral Cavity
– Runs from Soft Palate to Epiglottis
• Palatine tonsils & lingual tonsils are found in this part.
• Function –
– for passage of air & food
– Helps in pharyngeal phase of swallowing
– Vocal tract
– Helps in appreciation of taste

6. Laryngopharynx
• Stratified squamous epithelium
• Location - Posterior to Larynx
• Continuous with esophagus (digestive system) & larynx
(respiratory system)
• Subdivided in to 3 regions – piriform sinus ,posterior cricoid
region & posterior pharyngeal wall
• Function
– Common pathway for air & food
– For vocal resonance
– Help in deglutition

7. Tonsils
• Simple lymphoid organs
– MALT: mucosa-associated
lymphoid tissue
• Form ring around opening
of pharynx
• 4 groups
– Palatine (pair)
– Lingual
– Pharyngeal
– Tubal (pair)

8. Disease of the nasopharynx
• Congenital-transsphenoidal meningoencephalocele
– Glioma ,dermoid cyst
• Inflammatory –
– Adenoiditis –viral ,bacteria
• Tumours
• Benign-juvenile nasopharyngeal angiofibroma is the
most common
• Malignant -90% are SCC ..

9. Adenoiditis
• viral ,bacterial
• Acute ,chronic ,recurrent
• Etiology –recurrent rhinitis ,sinusitis
,tonsilitis ,allergy
• Clinical features
– Nasal obstruction ,nasal discharge
– Rhinitis/sinusitis
– Hyponasal voice
– Recurrent otitis media, chronic
suppurative otitis media(CSOM)
– Obstructive sleep apnea(OSA)
– Post nasal drip and cough
– Pulmonary HTN ,corpulmonale if long
standing

10. Adenoiditis…
• Diagnosis –rigid or flexible endoscopy
– Lateral neck X-ray
• Treatment- treat predisposing factors like rhinitis, sinusitis or
tonsillitis
- Decongestant nasal drops ,antihistamine
Indications for surgery (adenoidectomy)
– OSA, corpulmonale
– Chronic nasopharyngitis
– CSOM
– Recurrent AOM
– Suspect malignancy
– Chronic sinusitis

11. Disease of the oropharynx
• Congenital
• Inflammatory -tonsilitis
• Tumors
– Benign
– malignant

12. Acute Tonsillitis
Etiology
• Group A beta-hemolytic streptococcus and Group G streptococcus
• S. pneumoniae, S. aureus, H. influenzae, M. catarrhalis
• Epstein-Barr virus (EBV)
• 4 types
– Acute caterrhal tonsilitis
– Acute follicular tonsilitis
– Acute parenchymatous tonsilitis
– acute membraneous tonsilitis

13. Acute Tonsillitis…
Clinical Features
• symptoms
– sore throat
– dysphagia, odynophagia, trismus
– malaise, fever
– otalgia (referred pain to the ear)
• signs
– tender cervical lymphadenopathy especially
submandibular, jugulodigastric lymph nodes
– tonsils enlarged, inflammation ± exudates
– strawberry tongue
– palatal petechiae (infectious mononucleosis)

14. Acute Tonsillitis
Investigations
• CBC
• swab for C&S
Treatment
• Supportive (bed rest, soft diet, ample fluid intake )
• gargle with warm saline solution
• analgesics and antipyretics
• antibiotics for 7-10 days
– only after appropriate swab for C&S
– 1st line - penicillin or amoxicillin (erythromycin if penicillin
allergic).
– 2nd line – Augmentin if no response to the above Abxs
– will avoid serious sequela and to provide earlier symptomatic
relief

15. Acute Tonsillitis
Complications
• Chronic tonsilitis with recurent acute attack
• AOM
• Deep neck space infection
• Abscess: peritonsillar, intratonsillar ,retropharyngeal,
or parapharangeal
• Sepsis
• Rheumatic fever
• Glomerulonephritis
• Subacute bacterial endocarditis

16. Chronic tonsillitis
• Aetiology
– As a complication of acute tonsilitis
– Chronic infection in sinuses or teeth
• Types
– Chronic follicular tonsillitis
– Chronic parenchymatous tonsillitis
– Chronic fibroid tonsillitis
• Clinical feature –recurrent attack of sore throat ,
– chronic irritation in throat with cough ,
– bad test in mouth ,foul breath
– thick speech ,difficulty of swallowing

17. Chronic tonsillitis…
• On examination
– Tonsilar enlargment ,yellowish beds of pus
– Enlargement of jugulodigastric LNs
• Mx –conservative
– Mx of co-existing disease eg.Chronic infection in
sinuses or teeth
– Antibiotic – similar to acute tonsilitis but longer
duration( 10-14 days)
– Tonsillectomy
what are the indications??????

18. Tonsil Hypertrophy

19. Indications for Tonsillectomy
• Absolute
• OSA, cor pulmonale
• Suspect malignancy
• Hemorrhagic tonsillitis
• Severe dysphagia
• Relative
• Tonsillar hypertrophy
• Recurrent tonsillitis
• Complications of tonsillitis

20. Obstructive sleep apnea syndrome (OSAS)
• Definitions
– Apnoea
• Cessation of airflow at nostrils for 10 seconds or longer
Causes of OSAS:
• Nose
– Polyps
– Deviated nasal septum
– Choanal stenosis

21. • Pharynx
– Adenoidal hypertrophy
– Nasopharyngeal tumor
– Large palatine/lingual tonsils
– Retropharyngeal mass
– Large tongue
– Obesity
• Supraglottic- - laryngomalacia
• Cerebral palsy

22. Clinical features of OSAS
• Frequent wakening and disturbed sleep pattern
• Snoring
– Sign of partial airway obstruction
• Apnoeic episodes
• Daytime somnolence
• Signs
• Poor nasal airway
• Mouth breathing
• Noisy respiration
• Grossly hypertrophic tonsils
• Short, thick neck
• Obesity
• Complications of OSAS:
– Pulmonary hypertension , Corpulmonale , failure to thrive

23. Special investigations
• Lateral neck X-ray, CXR, ECG
• Nasal endoscopy
Treatment –Mx the cause
For eg.
– Adenotonsillectomy adenotonsillar hypertrophy
– Chemo-radiotherapy for nasopharyngeal Ca.
– Advice on weight reduction sleeping on lateral position for
obesity

24. Deep neck space infections
• Neck spaces by far the most complex anatomy
• Compartmentalization →prevent spread of infection
• Prevention, spread & treatment based on anatomy
• Commonly arise from a septic focus of the mandibular
teeth, tonsils, parotid gland, deep cervical LNs, middle
ear, or PNS
• Often rapid in onset and may progress to fatal
complications.

25. • Neck spaces
- Entire length of the neck
- Prevertebral space
- Retropharyngeal space
- Danger space
- Visceral vascular space
- Infrahyoid
- Pretracheal space
- Suprahyoid
- Parapharyngeal space
- Submandibular space
- Parotid space
- Masticator/buccal space
- Peritonsillar space
- Temporal space

28. Causes
• Adults
- Odontogenic infections most common
- Salivary gland infections, FBs, trauma, instrumentation, URTI
• Pediatrics
-Tonsillitis most common cause followed by odontogenic infectios.
Bacteriology
– Mixed infection
– Usually reflect oropharyngeal flora
– Streptococci are the most commonly cultured organism

29. Diagnosis
Symptoms Signs
• Pain
• Fever
• Swelling
• Dys/odynophagia
• Trismus
• Resp. difficulty
• Toothache
• Swelling
• Dental abnormality.
• Flactuant mass
• Oropharyngeal diseases.
• Trismus

30. Radiology
• Plain films
PA & lateral neck X ray
- FB, tracheal deviation, subcut air, soft tissue edema
- Important in the diagnosis of pretracheal & retropharyngeal abscess
CXR
- Pulmonary edema, pnumothorax/pnumomediastinum, hilar LAP
- Mediastinal widening in mediastinitis
Panorex oral view
– Apices of 2nd & 3rd mandibular molars extend below myelohyoid line
• CT/MRI
• U/S
- Guides aspiration & supplement diagnosis, but it is Operator
dependent

31. Management
• Securing the airway is the 1st priority
- Humidified air & observation enough for most
- Intubation/cricothyrotomy/tracheostomy
• Fluid resuscitation often indicated
• Antibiotics
- Emperic till culture result arrives
- Immunocompetent
- ceftriaxone/cefoxitine

32. - Compromised
- Clindamycin + ciprofloxacin
- S. aureus suspected add vancomycin
- Necrotizing cervical fascitis
- Ceftriaxone + clindamycin/metronidazole
• Surgical management
– Tooth extraction if inciting tooth disease identified
– Incision & drainage
- Abscess
- Impending complications
- No improvement after 48 hrs of parentral antibiotics