Transcript Clinical Picture

Dr. Basil M.N. Saeed
Assistant Professor
Department of Surgery
College of Medicine
Mosul University
Is a funnel-shaped fibromuscular tube,
10-12 cm in length in adults.
Extends from the base of the skull to the level
of C6.
The pharynx is divided
anatomically into 3 parts;
Nasopharynx
Oropharynx
Laryngopharynx
(( Hypopharynx))
Behind :
The Nose
The Mouth
The larynx
Seen from behind
Nasopharynx
Oropharynx
Laryngopharynx
(Hypopharynx)
This extends from the base of the skull to
the hard palate.
At the junction of the roof and posterior wall
lies a small mass of lymphoid tissue called
adenoids (nasopharyngeal tonsil).
On the lateral wall, there are the openings
of the Eustachian tubes.
Behind which are hollows called the fossa
of Rosenmuller, which is the site of
nasopharyngeal malignancy
-Communicates
inferiorly with the
oropharynx through the
velo-pharyngeal
sphincter
Extends from the level of hard palate to the level of
hyoid bone and opens anteriorly into the oral
cavity. Behind the oral cavity (in front of
2nd&3rd Cervical vertebra)
The palatine tonsils are situated in it's lateral wall
Between the ant. and post tonsillar pillars.
From the soft palate
superiorly to tip of
epiglottis inferiorly
Communicates:
Anteriorly with
the oral cavity
Superiorly with the
nasopharynx
Inferiorly with
the hypopharynx
Behind the Larynx (in front of 3rd to 6th Cervical
vertebra)
From the tip of epiglottis
superiorly to
the lower border
of cricoid cartilage
inferiorly
Communicates:
- Anteriorly with the Larynx
- Superiorly with the oropharynx
- Inferiorly with the esophagus
The hypopharynx does not only
lie behind the larynx BUT also
Projects laterally on each side of the
larynx and is formed of :
- Postcricoid region
( behind the larynx)
- Two pyriform fossae
(on each side of the larynx
The pharyngeal wall consists of 4 layers:
1. Mucous membrane.
2. Pharyngobasilar fascia.
3. Muscle layer.
4. Buccopharyngeal fascia.
1- Mucus Membrane
The lining epithelium is stratified squamous
except in the nasopharynx, where
columnar epithelium is found.
2- Pharyngobasilar fascia
This fascia is strengthened posteriorly by a
strong band called the median raphae.
3- Muscular Layer
I- Circular (outer): which consist of 3
constrictor muscles overlapping one another
from below upwards.
1. Superior constrictor.
2. Middle constrictor.
3. Inferior constrictor.
The inferior constrictor muscle is composed
of 2 parts:
a. Thyropharyngeus (oblique): arises from
the thyroid cartilage.
b. Cricopharyngeus (transverse): arises
from the cricoid cartilage and passes
transversely backwards forming the
upper oesophageal sphincter.
All the constrictor muscles are inserted
posteriorly into the median pharyngeal
raphae.
Functions
The constrictor muscles propel the bolus
of food down into the esophagus
The Cricopharygeus (lower fibers of the
inferior constrictor) act as a sphincter,
preventing the entry of air into the
esophagus between the acts of
swallowing
Killian dehiscence: this is a potential gap
between the fibers of the
thyropharyngeus and cricopharyngeus.
The mucous membrane may bulge
between these two muscles when there
is incoordination of the pharyngeal
peristaltic waves.
Pharyngael Pouch
II- Longitudinal (internal): these
muscles elevate the larynx and shorten
the pharynx during deglutition:
1. Stylopharyngeus.
2. Salpingopharyngeus.
3. Palatopharyngeus
This fascia is loosely attached posteriorly
to the prevertebral fascia and laterally
connected to the styloid process and to
the carotid sheath
Subepithelial lymphoid tissue of the
pharynx (Waldeyer's ring)
Is a collection of sub-epithelial lymphoid
tissue around the entrance of the
respiratory and alimentary tracts.
1. Nasopharyngeal tonsil (adenoid).
2. Tubal tonsils: lie behind the openings of the Eustachian
tubes.
3. Palatine tonsils.
4. Lingual tonsils: which is embedded in the posterior 1/3
of the tongue.
5. Lateral pharyngeal bands behind the posterior
tonsillar pillar.
6. Lymphoid nodules scattered on the posterior
pharyngeal wall
Hypertrophy of the lymphoid tissue of
Waldeyer's ring occurs in the earlier
years of childhood.
Maximum bulk is obtained at the age of
3- 6 years, and in old age it atrophies
Waldeyer's ring is characterized by:
1. Sub-epithelial lymphoid tissue.
2. Lack a definite capsule.
3. They have efferent lymph vessels, but
no afferent vessels.
4. Function as one unit: when a member
of it is removed, the others parts
undergo compensatory hypertrophy.
Two masses of lymphoid tissue situated on each
side of the oropharynx.
The medial surface is exposed in the pharynx
and is pitted by a number of crypts.
The tonsil is related anteriorly and posteriorly to
the palatoglossus and palatopharyngeus
muscles.
Laterally the tonsil is enclosed by a dense fibrous
capsule separating the tonsil from the superior
constrictor muscle (tonsillar bed).
This capsule provide a convenient plane of
separation of the tonsil during tonsillectomy
The main supply is the tonsillar branch of
the facial artery, and decsending palatine
artery.
The venous drainage is to the
paratonsillar vein which drains to the
pharyngeal plexus, and the internal
jugular vein.
Lymphatic Drainage
Deep cervical chain of lymph nodes.
Sensory Nerve Supply
Nasopharynx: Maxillary nerve, trigeminal
Oropharynx: Glossopharyngeal nerve, trigeminal
Laryngopharynx: vagus nerve, and glossopharyngeal.
Motor supply
All the muscles of pharynx, except the stylopharyngeus,
are supplied by the pharyngeal plexus.
Pharyngeal branches of the IX and X nerves, and
sympathetic fibers from the superior cervical ganglion.
The stylopharyngeus is supplied by the glossopharyngeal
nerve
This space lies behind the pharynx and
extends from the base of the skull to the
superior mediastinum.
The anterior wall is formed by the
posterior pharyngeal wall and it's
covering buccopharyngeal fascia.
The posterior wall is formed by the
cervical vertebrae and their covering
muscles and fascia.
Contents:
Retropharyngeal lymph nodes of
Usually disappear
spontaneously during the
3rd or 4th year of life.
Rouviere.
This potential space lies lateral to the
pharynx and connects posteriorly with
the retropharyngeal space.
It extends from the base of the skull to the
hyoid bone.
It's bounded medially by the superior
constrictor muscle.
Laterally lies the medial pterygoid muscle,
the mandible and the parotid gland.
It's posterior wall is the prevertebral
muscles and fascia.
Contents
1. Deep cervical lymphnodes.
2. The last 4 cranial nerves and the cervical
sympathetic trunk.
3. Great vessels of the neck: carotid and
internal jugular vein.
Parapharyngeal space
1. Food and air inlet.
2. Play an important role in speech through
vocal resonance and articulation.
3.The protective function of Waldeyer's
ring.
4. Deglutition: it's divided into 3 stages:
a. Oral stage (voluntary).
b. Pharyngeal stage (involuntary).
c. Oesophageal stage (involuntary).
1- Sore throat (pain)
a. Inflammatory.
b. Neoplastic.
c. Neurological: IX neuralgia.
d. Blood dyscrasia: agranulocytosis and
leukaemia.
2- Dysphagia: is difficulty in swallowing whereas
odynophagia is painful swallowing.
Dysphagia: Intraluminal, Luminal , Extraluminal
3- Difficulty in breathing like stridor in Ludwig's
angina.
4- Difficulty in speech: Paralysis of the soft
palate(hypernasalily).
5- Neck mass Cervical lymphadenopathy
Nasopharynx: This can be done with postnasal mirror
and tongue depressor (posterior rhinoscopy), and it
can be thoroughly examined by rigid and flexible
endoscopes.
Oropharynx: It is simple with tongue depressor;
palpation may be needed for the tongue.
Hypopharynx: It can be done with the use of laryngeal
mirror to examine the larynx too. It can be done
thoroughly with the use of endoscope.
Neck examination: for cervical lymphadenopathy.
Other areas : ears are examined for secretory otitis
media in cases of nasopharyngeal tumours.
Radiography:
Plain films like lateral X-Ray of the skull, is needed in
nasopharyngeal mass like adenoids, and can demonstrate
bone erosion in cases of nasopharyngeal cancer.
Contrast films: barium swallow is needed in the diagnosis of
pharyngeal pouch, esophageal web and hypopharyngeal
mass.
CT scan
MRI scan.
Laboratory investigations:
CBC, ESR, serum iron and iron binding capacity, monospot
test, serology for toxoplasma, brucella, CMV and HIV.
Biopsy for suspected lesions in the pharynx may be
needed.
Is an inflammation of the whole lining of
the oral cavity.
It could be:
-Viral infection: Herpes simplex
-Bacterial: Gingivitis.
-Fungal: candidiasis (thrush).
-Spirochaetes: Vincent's angina.
-Miscellaneous: Aphthus, Behcets
syndrome, pemphigus and pemphigoid.
Recurrent oral ulceration of unknown aetiology:
viral, psychogenic, endocrinal and autoimmune.
Clinical picture
This ulcer is typically quite sensitive and painful,
has a central necrotic base with a surrounding
red circumference.
Two types:
The minor form, more common, 3-6 mm in size
and multiple and heal within 7-10 days without
leaving a scar.
The major form, 1-2 cm in size, less common,
long lasting and heal with a scar.
Treatment
Is symptomatic:
-Oral antiseptic: like chlorhexidine gurgle.
-Topical application of local analgesic like
xylocaine.
-Topical steroids e.g. Kenalog in orabase.
It is a gingivitis producing ulceration and necrotic
membrane.
It is called "Trench Mouth"
Aetiology
Infection : Spirochaete, Borrelia vincenti & an
Anaerobic organism , Bacillus fusiformis.
Occurs in debilitated patients who have poor dental
hygiene.
Fever, sore throat , tender LN.
On examination
The lesions originate around the interdental
papillae and gums and may spread to
involve the tonsil and oropharyx. The ulcers
are painful, associated with foeter (fishy
odor), and covered by a slough.
Diagnosis
Swab for gram stain and culture.
Treatment
-Oral hygiene by mouth wash.
- Antibiotics like benzyl penicillin +
metronidazole.
Acute cellulitis of the floor of the mouth and
submandibular space secondary to soft tissue
infection.
Infection within a closed fascial space, tension
rises rapidly and laryngeal oedema may occur.
Aetiology
Root abscess of the lower premolar and molar
teeth (80%).The most usual organisms are
strepto. viridans and E. coli.
-Tonsillar infection.
-Submandibular sialadenitis
Clinical picture
The patient is ill, toxic > 38 oC with
odynophagia and salivation.
On examination
Indurated and usually non-fluctuant swelling
below the angle of the jaw.
The floor of the mouth becomes very
oedematous with the tongue pushed
upwards.
Potential complications
-Airway compromise due to laryngeal oedema.
-Spread into the parapharyngeal and
retropharyngeal spaces.
-Septicaemia.
-Aspiration pneumonia.
Treatment
-Early stages (early cellulitis): heavy antibiotics
covering aerobes and anaerobes.
-Drainage: If the state progress and the swelling
increases.
Curved incision 2 cm below the angle of the
jaw.
-Endotracheal intubation and
tracheostomy may be required
if laryngeal oedema
supervenes.
Acute pharyngitis
Acute inflammation of the mucous membrane of
the pharynx occurring primarily in winter
months.
Aetiology
Viral in origin( mostly adenovirus and
rhinovirus).
20 % are bacterial: mostly Pneumococci,
Haemophilus influenza and group A betahemolytic streptococci (S. Pyogens).
30 % No pathogen is isolated.
Pharyngitis may be part of the clinical
picture of measles, scarlet fever, infectious
mononucleosis and typhoid fever.
Symptoms
-Sore throat, Chills, Pyrexia, Headache and
Joint pain.
Sings
-Redness and injection the mucous membrane
of the pharynx.
-Hypertrophic and proliferation of lymphoid
tissue on the posterior pharyngeal wall with
particular aggregates in the lateral
pharyngeal bands.
- Oedema of uvula
-Tender and palpable cervical LN.
Treatment
-Symptomatic: bed rest, analgesics and fluid by
mouth.
-Antibiotics: if bacterial infection is suspected.
Generalized inflammation of the mass of the
tonsil, usually accompanied by a degree of
inflammation of the pharynx.
Any age group, most frequently found in
children.
Aetiology
Bacteria :group A B-haemolytic streptococcus,
pneumococcus, staphylococcus& Haemophilus
influenzae.
Viruses: rhinovirus, adenovirus &
enterovirus
Symptoms
Onset: often sudden :
-Sore throat & odynophagia.
-Constitutional symptoms especially in
children.
-Referred otalgia and abdominal pain due to
mesenteric adenitis.
Examination
- Furred tongue & halitosis.
- Tonsils: enlarged red and swollen.
-The crypts become filled with pus (follicular
tonsillitis).
- A patchy membrane on the surface of the
tonsil (membranous tonsillitis).
-Cervical tender lymphadenopathy
jugulodigastric node.
Acute follicular tonsillitis
Differential Diagnosis
-Scarlet fever: Streptococcal infection
erythrogenic toxin.
Tongue has a strawberry appearance
Cutaneous punctate erythema.
-Glandular fever:
-Agranulocytosis and leukaemia.
-Acute diphtheria.
-Vincent's angina.
Complications
local
a. peritonsillar abscess(quinsy).
b. Retropharyngeal abscess.
c. Parapharyngeal abscess.
d. Acute otitis media.through the Eustachian tube.
General
a. Rheumatic fever and glomerulonephritis which
follow B- haemolytic streptococcal tonsillitis of
Lancet group A.
b. Subacute bacterial endocarditis.
c. Septicaemia.
Treatment
1. Bed rest, good oral fluid intake.
2. Antipyretics and analgesics.
3. Antibiotics: Penicillin, Erythromycin in allergy
to penicillin.
Lack of response may suggest the presence of Blactamase producing organism or even an
anaerobic one, in which augmentin and/or
metronidazole will be the antibiotic of choice.
Is a collection of pus between the fibrous
capsule of the tonsil and the superior
constrictor.
Usually unilateral, Adult males.
Complication of acute tonsillitis.
Clinical Picture
1. The patient looks ill, feverish with rigor .
2. Acute sore throat & referred otalgia,
Odynophagia). This makes the saliva dribbles
from the month.
3. Trismus: irritation of the pterygoid muscles .
4. Thick and muffled voice often called “hot potato
voice”.
Examination
1. The tonsil is congested and pushed medially
with the soft palate bulging downward and
forward.
The uvula may be pressed against the opposite
tonsil.
2. Red and enlarged anterior tonsillar pillar.
3. Tender and enlarged cervical lymph nodes
.
I. Medical : Effective in early peritonsillar
cellulitis.
II. Surgical : when considerable swelling is
present or in case of failure to medical
treatment.
1. Incision of the abscess: this is undertaken at the
point of maximum swelling of the soft palate.
The classical site is at a point where an
imaginary line through the base of the uvula is
intersected by a perpendicular line from the
junction of the anterior tonsillar pillar with the
tongue.
The tonsils might be removed 6-8 weeks
following quinsy.
2. Abscess tonsillectomy
-Viral infection: infectious mononucleosis.
-Bacterial: diphtheria and scarlet fever.
-Fungal: candidiasis.
-Spirochaetes: Vincent's angina.
-Blood dyscrasia: agranulocytosis and
leukaemia.
Is a systemic infection by Epestein Barr virus
which spread by droplets transmission. It is a
disease of young adults and characterized by
an increase in atypical lymphocytes.
Clinical picture
-Anorexia and low grade fever.
-Sore throat associated with odynophagia.
-Pharyngeal congestion with superficial
ulceration of the tonsils. Red spots may appear
on the palate.
-Generalized lymphadenopathy.
-Spleenomegaly.
Investigation
1. CBP increase in atypical lymphocytes
(mononuclear cells).
2. Positive Paul-Bunnell and monospot
tests.
Treatment
Is non specific
1. Antipyretics & analgesics.
2. Antibiotics play no role in treatment and
ampicillin is not given as it may cause
skin rash.
Is a specific infection by Corynebacterium
diphtheriae which is disseminated by
droplets.
Children are mostly affected with a mortality
of 10%.
Clinical picture
The patient is severely ill, although the
temperature seldom rises above 38 oC.
The disease is characterized by the
appearance of a membrane on the tonsils,
soft palate and posterior pharyngeal wall.
The disease may spread to affect the nasal
cavities and nasopharynx.
The membrane is usually grey in colour,
firmly attached to the mucosa and leaves
a bleeding surface when it's removed.
-Tender and enlarged cervical lymph
nodes.
Investigation
Swab for bacteriological examination
including part of the membrane.
Complications
-Laryngeal obstruction and stridor 
tracheostomy.
-Myocarditis and neuritis.
The exotoxin produced by the
microorganism is toxic to the heart and
nerves.
Neuritis is in form of paralysis of soft palate
and ocular muscles.
Usually follows acute or subacute attacks of tonsillitis.
More common in children between the age of 4-15
years.
There is a chronic inflammatory hypertrophy, usually
associated with adenoid enlargement.
Clinical picture:
Persistent or recurrent sore throat.
Persistent cervical adenitis.
Marked tonsillar enlargement with congested
anterior pillars.
Treatment is usually surgical( tonsillectomy ) if
symptoms persist.
Indications for tonsillectomy
1. Recurrent attacks of acute tonsillitis.
2. Peritonsillar abscess (quinsy).
3. Sleep apnea syndrome.
4. Tonsillectomy for biopsy purposes.
Others:
Diphtheria carriers.
Recurrent attacks of otitis media ??
Acute rheumatic fever and acute
glomeluronephritis if streptococcus tonsillitis
has been responsible for recurrence
Contraindications
1. Bleeding disorders or clotting problems.
2. Acutely inflamed tonsil and recent upper
respiratory tract infection.
3. Epidemic of poliomyelitis: fatal bulbar
paralysis
4. Cleft palate: tonsillectomy leads to
scarring of the soft palate which affects
repair and speech.
Postoperative care
1. Nursing of patient in tonsillectomy position.
2. Careful monitoring of vital signs.
3. Analgesia: paracetamol. NSAID should be
avoided.
4. Encourage the patient to move the muscles
of the throat by swallowing, talking and
dinking: shedding of the slough from the
tonsillar fossa allowing healing to take
place.
Complications
1. Haemorrhage
a. Primary: Recent infection, previous quinsy
or severe scarring. Excessive bleeding from
both fossae :coagulation defect.
Blood transfusion may be necessary.
b. Reactionary haemorrhage, within 24 hours.
Preparing blood and early return to the
theatre.
c. Secondary: Occurs some 5-8 days after the
operation. It's due to infection.
Readmission to the hospital and a course of
antibiotics is ordered.
2. Trauma: Teeth are at risk during
tonsillectomy. Insertion of the mouth gag
can lead to dislocation of the TMJ.
3. Infection: Prolongation of the pyrexia is a
sign of infection which if untreated may lead
to secondary haemorrhage.
4. Otitis media: should be distinguished from
referred otalgia.
5. Chest complications: URTI at the time of
operation or due to inhalation of blood or
broken tooth.
Chronic irreversible inflammation of the mucous
membrane of the pharynx with hyperplasia of
it's various elements.
The normal lymphoid tissue on the posterior
pharyngeal wall undergo hypertrophy so
called granular pharyngitis.
The strip of lymphoid tissue in the posterior
tonsillar pillar may undergo an overgrowth
forming the lateral pharyngeal band.
Aetiology
Usually obscure:
-Recurrent attacks of acute
pharyngitis.
-Persistant neighbourhood
infection as chronic sepsis in
the sinuses, teeth, and gums.
Bronchiactasis is said to be associated with
chronic pharyngitis.
-Exogenous irritants such as tobacco,
alcohol and industrial fumes.
-Endogenous irritants as gastroesophageal
reflux.
-Allergic factors.
Clinical picture
1. Sorethroat , no constitutional symptoms and
the condition persists for weeks or months.
2. Foreign body sensation in the throat and
tendency to clear the throat, which results
from postnasal drip bathing the posterior
pharyngeal wall.
3. Tiring of voice (not hoarseness).
Examination
Simple (catarrhal) type: redness and congestion
of the pharyngeal mucosa. The uvula may
appear enlarged or elongated.
Hypertrophic (granular) type: small nodules are
scattered on the posterior pharyngeal wall
giving a granular appearance. The lateral
pharyngeal bands may be prominent.
Treatment
1.Treat the cause:
Sinusitis, allergy, and GERD.
2. Avoidance of irritants: smoking, alcohol, and
food.
3. Reassurance by the exclusion of malignancy.
4. Soothing gargles.
5. Antibiotics in acute exacerbation and fever.
The adenoids lie between the roof and posterior wall of the
nasopharynx.
Adenoids differ from tonsillar tissue in that it's bounded
by no capsule, contains no crypts and covered by ciliated
epithelium.
Hypertrophy of the nasopharyngeal tonsil,
sufficient to produce symptoms, most commonly
between 3-7 years of age.
Symptoms
A-Nasal
- Nasal obstruction, mouth breathing, snoring , in
severe cases: OSA.
- Persistent nasal discharge & postnasal drip. The
child may be described as " always having a
cold".
- Nasal speech (rhinolalia clausa).
B- Aural
Recurrent attacks of otitis media and otitis
media with effusion.
C-General
Failure to thrive, mental dullness.
Pharyngitis and recurrent URTI
Examination
I. Adenoid facies.
1. Open mouth.
2. Prominent upper
incisor teeth.
3. Short upper lip.
4. Narrow nostrils.
5. Hypoplastic maxilla.
6. High arched palate.
7. Dull expression due to hypoxia and
deafness.
2. Mucoid and mucopus discharge from the
nose with postnasal catarrh.
3. Posterior rhinoscopy and fibroptic
endoscopy: lobulated mass, which
occasionally extends laterally.
Investigations
X-ray of the postnasal space
Complications
1. Persistent snoring and sleep apnea
syndrome.
2. Recurrent URTI.
3. Recurrent attacks of acute otitis media
and otitis media with effusion.
4. Orthodontic disturbances.
5. Speech problems (rhinolalia clausa).
6. Failure to thrive in infants.
Treatment
1. Conservative: in mild symptoms by
a. Treatment of allergy and sinusitis.
b. Local nasal steroids.
2. Surgical: if no response to medical
treatment by
Adenoidectomy
Contraindications
1. Cleft palate.
2. As tonsillectomy
Complications
1. Haemorrhage (Primary, reactionary or
secondary): Post nasal pack is inserted
under G.A. , may be blood transfusion.
2. Trauma to the uvula, soft palate and
Eustachian cushions.
3. Hypernasality(Rhinolalia aperta):
It occurs in case of submucosal cleft palate
or after excessive scaring of the soft
palate.
4. Incomplete removal and recurrence.
A chronic atrophic type of inflammation of the
mucous membrane of the pharynx. The major
changes occur in the postcricoid region initially
started by fissuring and hyperkeratosis followed
by fibrosis, web formation of stricture.
A small proportion of patients (3%) with this
condition progress to the stage of postcricoid
cancer.
Aetiology
It’s unknown but autoimmune and metabolic basis
may be presumed.
Clinical picture
-Common in females usually over 40 years.
-Dysphagia and feeling of a lump in the
throat.
-Pallor due to iron deficiency anaemia.
-Fissures at the angles of the mouth result from
angular stomatitis.
-Dryness of the tongue because of glossitis .
-Loss of weight
Investigations
-Haematological: CBP---- hypochromic
microcytic anaemia, low serum iron and
high iron binding capacity.
-Ba -swallow: web at the
postcricoid region.
-Endoscopy: changes of the
Postcroid
region.
Treatment
-Iron and vitamin B complex in high doses.
-Endoscopic dilation in resistant cases to
medical treatment to relieve dysphagia
and exclude malignancy ( by
histopathological examination).
-Keep the patient under observation,
because malignant changes can still
occur.
Sensation of a lump in the throat affecting
mainly females, which is brought on or
made worse by anxiety.
Aetiology
The condition is often regarded as
functional in which no other organic
cause can be found.
Recently the most accepted organic
theory is gastroesophageal reflux.
Clinical Picture
Sensation of a lump in the throat, which is,
noticed when the patient is swallowing
saliva and relieved by meals.
There is no true dysphagia and the patient
often has psychological stress or cancer
phobia.
Diagnosis
The condition should not be diagnosed
until an organic lesions has been
excluded in order not to miss an early
carcinoma.
-Ba -Swallow ---- cricopharyngeal spasm
-Endoscopy to exclude any abnormality
-Full haematological investigations
Treatment
Reassurance that there is no organic
disease or cancer
Antireflux therapy: Omeprazole +
Domperidone
Psychiatric consultation is required in
selected cases
An abscess in the potential space between
the buccopharyngeal and prevertebral
fascia. There are two distinct types.
Collection of pus in the retropharyngeal
space due to infection in the
retropharyngeal lymph nodes (lymph
nodes of Rouviere).
Parapharyngeal
space: orange
Retropharyngeal
space: blue
Aetiology
-Upper respiratory tract infection
(Tonsillitis, sinusitis)
-F.B penetrating the posterior pharyngeal
mucosa.
Clinical Picture
Mostly affects infants and it's of acute
onset
1. The patient is ill, toxic and feverish.
2. Sore throat with pain and discomfort on
swallowing and the patient may drool
saliva.
3. Nasal obstruction in upward situated
abscess and laryngeal obstruction
(stridor) in those situated downward
Examination
-Swelling on one side of the posterior
pharyngeal wall.
-Cervical lymphadenopathy.
Investigations
Lateral X-ray of the neck, which shows
increase in prevertebral soft tissue
shadow or an air-fluid level.
Treatment
Under the cover of intravenous
antibiotics, the abscess should be
drained vertically through the posterior
pharyngeal wall.
1. Drainage under G.A. with endotracheal
tube.
2. If no facility for G.A. an assistant should
be ready to turn the patient over quickly
after drainage to avoid inhalation of pus.
A sucker should be present to aspirate
the pus.
This is caused by TB of the cervical spine.
Clinical Picture
Occurs in older children, adolescents
and adults. It’s of slow onset and
presents as:
-Pharyngeal discomfort rather than pain.
-Mild dysphagia.
Examination
1. Painless swelling on the posterior pharyngeal
wall.
2. Enlarged and painless cervical
lymphadenopathy.
Investigations
Lateral X-ray of the neck shows evidence of bone
destruction and loss of the normal curvature of
the cervical spine.
Treatment
1. Drainage through the neck and never
through the mouth to avoid secondary
infection.
2. Full anti T.B. therapy must be ordered.
Chronic retropharyngeal abscess
A suppurative infection of the
parapharyageal space.
Aetiology
-Complication of tonsillitis or
tonsillectomy.
-Infection or extraction of the lower third
molar tooth.
-Extension of mastoid infection
Clinical Picture
Occurs mostly in adolescents and adults
-The patient is feverish , ill and toxic.
-Acute sore throat with trismus because of
spasm of the medial pterygoid muscle .
Examination
-Tender and firm swelling in the upper
part of the neck.
-The pharyngeal wall and tonsil are
pushed medially.
Complications
1- Acute oedema of the larynx
tracheostomy.
2. Thrombophlebitis of the IJV with septicaemia.
3. Carotid artery erosion.
4. Cranial nerves and sympathetic chain
involvement leading to Horner,s syndrome.
5. Spread of infection into the mediastinum.
Treatment
Antibiotics should be commenced before
culture and sensitivities are available:
I.V. penicillin + Metronidazole
If the general condition is stable and airway is
patent investigations can be done:
1. WBC ↑, ESR ↑
2. Needle aspiration will prove the diagnosis( if
doubtful) and pus is send for culture.
3. Orthopantomogram ( OPG) may shows root
abscess.
4. Ultrasound of the neck can differentiate
between cellulites and abscess collection.
If there is no improvement within 24 hours
abscess must be drained:
Under GA and ETT collar incision is done in
the neck at the level of hyoid bone at the
anterior border of sternomastoid muscle, pus is
evacuated and drain is inserted.
Nasopharynx
Benign:
Angiofibroma (Most
common)
Papilloma
Haemangioma
Craniopharyngioma
Malignant: Nasopharyngeal carcinoma
Adenocarcinoma
Fibrosarcoma
Rabdomyosarcoma
Oropharynx
Benign:
Papilloma
Malignant: Epithelial: squamous cell
cacrcinoma
Lymphoma: Hodgkin's and nonHodgkin's
Salivary gland: Adenocystic
carcinoma
Hypopharynx
Benign: Fibrolipoma and leiomyoma
Malignant: Squamous cell carcinoma
(pyriform fossa, postcricoid
posterior pharyngeal wall).
Is a vascular tumour of the
nasopharynx occurring almost entirely in
adolescent males (7-19 years with a mean
of 14 years. The tumour has a tendency to
regress after puberty. Although the tumour
is benign, but it is locally invasive and
behaves as malignant.
Aetiology
The exact aetiology is unknown
but various theories have been postulated.
1. Hormonal theory based on that it is a
tumour of males.
2. Remnants of embryonic tissue.
3. Hamartoma or paraganglioma.
Pathology
The tumour takes origin from the
periosteum on the lateral wall of the
nasopharynx close to the sphenopalatine
foramen . Extension occurs:
1. Anteriorly to the nasal cavity and ethmoid.
2. Superiorly to the base of the skull.
3. Laterally to the pterygoid fossa, maxillary
antrum and orbit.
Pathology
Microscopically, the tumour consist of
vascular spaces abounding in a stroma of
fibrous tissue. The vascular spaces
consist of thin-walled sinusoidal vessels
unsupported by a muscular coat. This
account for the severe bleeding as the
vessels loose the ability to contract.
Clinical Picture
The patient is nearly always a young
boy with a mean age of 14 years.
1. Repeated attacks of epistaxis which can
be extremely profuse due to absence of
muscular coat from the sinusoids.
2. Progressive nasal obstruction.
3. Conductive deafness occurs from
pressure on the Eustachian tubes.
Examination
1. Endoscopy and posterior rhinoscopy:
smooth, rubbery lobulated mass in the
nasopharynx.
2. Middle ear effusion.
3. Mass in the nasal cavity or on the cheek if
the tumour has extended anteriorly or
laterally.
4. Proptosis results from extension of the
tumour to the
orbit through the
infraorbital
fissure.
Investigation
1. Imaging:
a. X-ray of the base of the skull and a lateral
view of the skull.
b. CAT scan, MRI and MRA.
c. External carotid arteriography.
2. Biopsy is contraindicated because of fatal
bleeding.
Differential Dx
Antrochoanal
polyp.
2. Nasopharyngeal
carcinoma
Treatment
1. Surgical excision Haemorrhage is the
main danger of operation, so adequate
blood should be prepared before the
operation.
2. Embolization is indicated preoperatively
to control the vascularity of the tumour.
3. Radiotherapy should be reserved for
patients with inoperable intracranial
extension and recurrent tumours.
This tumour is common in south east
Asia especially in China.
Aetiology
Is exactly unknown
1-Viral: Epestain-Barr virus has been
suggested as a cause, but the exact role is
unknown.
2. Genetics: Chinese have a high genetic
susceptibility. Chinese population who
move to western countries retain a high
incidence suggesting a genetic
predisposition.
3. Environmental factors: common in southern
China.
a. Ingestion of salted fish.
b. Indoor cooking in homes without
Chimneys
Pathology
Most tumours arise from the fossa of
Rosenmuller. In endemic areas undifferentiated
carcinoma is the most
common histological type.
Spread of Nasopharyngeal Carcinoma
Direct, lymphatic (cervical L.N.) and blood borne
(rare)
-Anteriorly into the nasal cavity and paranasal
sinuses leading to nasal symptoms.
-Posteriorly to the retropharyngeal space and
lymphnodes of Rouviere.
-Laterally into the parapharyngeal space
involving the last 4 cranial nerves.
-Superiorly through the base of skull involving the
optic nerve and the cavernous sinus.
-Inferiorly to the oral cavity and retrotonsillar
region
Clinical Picture
Bi-modal age distribution with the
first age peak at 2nd decade and the other
peak at 5th – 7th decade of life. It affects
males more than females
-Cervical lymphadenopathy : is often the
presenting feature which may be
unilateral or bilateral.
-Nasorespiratory symptoms : nasal
obstruction, nasal speech and
epistaxis.
-Tinnitus and aural symptoms due to
Eustachian tube obstruction. This may
proceed to secretory otitis media.
-Neurological symptoms : the most frequently
involved nerves are V, VI, IX and X. The
latter 2 nerves paralysis lead to immobility
of the soft palate.
Involvement of the
sympathetic chain results
in Horner,s syndrome.
-Pain and headache due
to intracranial extension or sphenoidal
sinusitis
Examination
1. Endoscopy and posterior rhinoscopy.
one may see a large exophytic tumour but
a small tumour may be missed.
2. The palate is pushed downward and
paralyzed.
3. The neck should be palpated for
metastatic lymphnodes.
4. Middle ear effusion.
5. Parapharyngeal spread can cause
trismus.
Investigation
1. Imaging:
a. X-ray of the base of the skull---- bony
destruction involving the petrous bone,
foramen lacerum and carotid canal.
b. CT scan and MRI: MRI is superior to CT
scan in finding soft tissue involvement.
2. Biopsy under G.A.
Treatment
1. Radiotherapy is the treatment of choice
because surgical removal of the primary
growth is rarely possible.
2. Chemotherapy as an adjuvant to
radiotherapy is of contraverse issue.
3. Surgery in form of radical neck
dissection is reserved for patients with
persistent or recurrent neck disease
following radiotherapy.