THE PHARYNX. Mohammed ALESSA MBBS, FRCSC Assistant professor Consultant Otolaryngology, Head & Neck Surgery

Transcription

1 THE PHARYNX Mohammed ALESSA MBBS, FRCSC Assistant professor Consultant Otolaryngology, Head & Neck Surgery

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3 Cavity of the pharynx

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5 The Nasopharynx

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7 The Oropharynx

8 The oropharynx

9 Tonsils Size

10 Grading the Size of Tonsils Grading system: A. 0 tonsils in fossa B. +1 tonsils less than 25% C. +2 tonsils less than 50% D. +3 tonsils less than 75% E. +4 tonsils greater than 75%

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12 The Laryngopharynx (Hypopharynx)

13 Pharyngeal Wall Mucous membrane Submucosa Muscular layer Fibrous layer (Buccopharyngeal fascia)

14 Mucous membrane Nasopharynx Ciliated columnar epithelium Oro and hypopharynx Stratified squamous epithelium

15 Submucosa Nerves, blood vessels, and lymphatics Mucous and salivary glands Subepithelial lymphoid tissue

16 Subepithelial lymphoid tissue

17 Characteristics of Waldeyer s Ring No afferents Efferent to deep cervical nodes No capsule except the palatine tonsils

18 Pharyngeal Wall Mucous membrane Submucosa Muscular layer Fibrous layer Buccopharyngeal fascia

19 Muscular layer External: The three constrictors -1 superior 2 middle 3 - inferior Internal: Stylopharyngeus Salpingopharyngeus Palatopharyngeus

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21 Pharyngeal Wall Mucous membrane Submucosa Muscular layer Fibrous layer (Buccopharyngeal fascia)

22 Nerve Supply Trigeminal Glossopharyngeal Vagus Sympathetic: cervical ganglia

23 Arterial from the external carotid artery Ascending pharyngeal The lingual artery The facial artery The maxillary artery Venous drainage to the internal jugular Blood supply

24 Lymphatics Retropharyngeal nodes Deep cervical (jugular) nodes

25 Jugulo-Diagastic nodes

26 Physiology of the Pharynx

27 Functions of the pharynx Respiratory Channel Deglutition

28 Deglutition Oral Stage Pharyngeal Stage Esophageal stage

29 Functions of the pharynx Respiratory Channel Deglutition Speech Taste Immunity

30 Immunity function of the pharynx Production of immunoglobulins, plasma cells and lymphocytes by the subepithelial lymphoid tissue

31 DISEASES OF THE NASOPHARYNX

32 ACUTE INFECTION OF NASOPHARYNX Pathologically: is a part of acute rhinitis (common cold) Clinically: has no specific clinical features

33 ADENOIDS

34 DEFINITION Hypertophy of the nasopharyngeal tonsils sufficient to produce symptoms

35 CLINICAL FEATURES Usually in children Nasal obstruction Mouth breathing Snoring, sleep disturbance, apnea etc Ear symptoms due to Eustachian tube obstruction Adenoid face

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37 EXAMINATION

38 EXAMINATION

39 EXAMINATION

40 Normal nasopharynx Adenoid

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42 PLAIN X- RAY Normal Adenoid

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45 TREATMENT Adenoidectomy

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47 Local Contraindication of Adenoidectomy Palatopharyngeal incompetence

48 DISEASES OF THE OROPHARYNX

49 ACUTE INFECTIONS OF THE OROPHARYNX Acute tonsillitis Acute non-specific pharyngitis Acute diphtheria Infectious mononeuclosis Vincent s angina Scarlet fever Moniliasis

50 ACUTE TONSILLITIS

51 ETIOLOGY A disease of childhood, with a peak incidence at about 5 to 6 years of age

52 CAUSATIVE ORGANISMS Viral: Influenza, Parainfluenza, Rhinovirus, Adenoviruses, Respiratory syncytial virus, Coronaviruses Bacterial: Beta Hemolytic Streptococcus (Group A) Others: Strept pneumonia, H. infleunzae, Staph. aurius etc

53 Clinical features Malaise, fever, headache, limb and back pain Sore throat, odynophagia, dysphagia Otalgia

54 THROAT EXAMINATION A. Parenchymatous tonsillitis B Follicular tonsillitis

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56 C. Membranous tonsillitis

57 NECK EXAMINATION Enlargement and tenderness of the jugulodigastric lymph nodes

58 INVESTIGATIONS Throat swab CBC

59 TREATMENT Symptomatic & supportive treatment Antibiotics Penicillin V for 5-7days drug of choice Erythromycin second line Amoxicillin and Ampicillin better absorption

60 General: COMPLICATIONS OF ACUTE TONSILLITIS Acute rheumatism Acute glomerulonephritis Septicaemia Local: Peritonsillitis & peritnosillar abscess ( Quinsy)

61 PERITONSILLAR ABSCESS (QUINSY) An abscess between the tonsil capsule and the adjacent lateral pharyngeal wall

62 CLINICAL FEATURES More common in adults Usually unilateral Usually follow an attack of tonsillitis Sever pain > one side Unilateral earache and cervical lymphadenitis More odynophagia & drooling Trismus Thickened speech (hot potato voice)

63 EXAMINATION

64 EXAMINATION

65 TREATMENT IV antibiotics Incision and drainage followed by elective tonsillectomy 6-8 weeks later? Hot (abscess) tonsillectomy

66 General: COMPLICATIONS OF ACUTE TONSILLITIS Acute rheumatism Acute glomerulonephritis Septicaemia Local: Peritonsillitis & peritnosillar abscess ( Quinsy) Neck Abscess

67 Neck abscess

68 General: COMPLICATIONS OF ACUTE TONSILLITIS Acute rheumatism Acute glomerulonephritis Septicaemia Local: Peritonsillitis & peritnosillar abscess ( Quinsy) Neck Abscess Parapharyngeal abscess

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72 Clinical features of parapharyngeal abscess Systemic manifestations Pain, trismus, swelling

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75 CLINICAL FEATURES Systemic manifestations Pain, trismus, swelling

76 Laboratory and bacteriology CT MRI INVESTIGATION

77 PRINCIPLES OF TREATMENT Secure the airway Antimicrobial therapy Surgical drainage

78 DRAINAGE OF PARAPHARYNGEAL ABSCESS External cervical incision In order to avoid injury to the great vessels

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80 General: COMPLICATIONS OF ACUTE TONSILLITIS Acute rheumatism Acute glomerulonephritis Septicaemia Local: Peritonsillitis & peritnosillar abscess ( Quinsy) Neck Abscess Parapharyngeal abscess Retropharyngeal abscess

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82 Anatomy of retropharyngeal space

83 ACUTE RETROPHARYNGEAL ABSCESS Due to suppuration of the retropharyngeal lymph nodes present in the retrophayngeal space

84 CLINICAL FEATURES Systemic manifestations Respiratory obstruction Odynophagia & Dysphagia Swelling of posterior pharyngeal wall (usually unilateral)

85 INVESTIGATION Laboratory and bacteriology Plain X-rays

86 PLAIN X-RAYS Normal Retropharyngeal abscess

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88 CT

89 MRI

90 TREATMENT OF ACUTE RETROPHAYNGEAL ABSCESS Secure airway Antimicrobial Surgical drainage Trans oral

91 CHRONIC RETROPHARYNGEAL ABSCESS Tuberculous (cold abscess) Usually due to TB spines but may be secondary to TB lymphadentis Symptoms are insidious Treatment is by anti tuberculous medication, repeated aspiration and external drainage

92 Ludwig s Angina Infection of the submandibular space

93 Causes of Ludwig s Angina Usually secondary to dental infection or trauma

94 Presentation of Ludwig s Angina

95 TREATMENT Secure airway Most cases respond to antibiotics Drainage may be needed

96 Complications of neck spaces infections Respiratory obstruction Spontaneous rupture (inhalation pneumonia Extension of infection Other spaces Carotid & internal jugular Mediastinitis

97 ACUTE INFECTIONS OF THE OROPHARYNX Acute tonsillitis Acute non-specific pharyngitis Acute diphtheria Infectious mononueuclosis Vincent s Angina Scarlet fever Moniliasis

98 ACUTE NONSPECIFIC PHARYNGITIS

99 ACUTE INFECTIONS OF THE OROPHARYNX Acute tonsillitis Acute non-specific pharyngitis Acute diphtheria Infectious mononueclosis Vincent s Angina Scarlet fever Moniliasis

100 ACUTE DIPHTHERITIC PHARYNGITIS A severe infection caused by Corynebacterium diphtheriae Affect children at age 2-5 years Spread by droplets or contaminated articles The incidence has fallen markedly because of immunization

101 PATHOLOGY Local grayish membrane (composed of fibrin, leukocytes, and cellular debris) Exotoxins travels to heart and nervous system

102 CLINICAL MANIFESTATIONS Systemic symptoms due to the exotoxins Toxemia Mild fever Tachycardia Paralysis Local manifestations Sore throat Membrane Marked lymphadentitis ( bull neck )

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104 DIAGNOSIS Isolation of the organism

105 TREATMENT Starts before culture confirmation Airway maintenance Antitoxin Antibiotics (erythromycin, penicillin G, rifampin, or clindamycin)

106 Vaccine PREVENTION

107 COMPLICATIONS Respiratory obstruction Heart failure Muscular paralysis

108 ACUTE INFECTIONS OF THE OROPHARYNX Acute tonsillitis Acute non-specific pharyngitis Acute diphtheria Infectious mononueclosis Vincent s Angina Scarlet fever Moniliasis

109 INFECTIOUS MONONUECLOSIS Systemic infection caused by Epstein-Barr Virus (EBV) Selectively infects B-lymphocytes Clinical disease is usually seen in young adults

110 CLINICAL MANIFESTATIONS Clinical triad Fever Lymphadenopathy Pharyngitis and/or tonsillitis

111 INFECTIOUS MONONUCLEOSIS

112 CLINICAL MANIFESTATIONS Clinical triad Fever Lymphadenopathy Pharyngitis and/or tonsillitis Other clinical findings Splenomegaly 50% Hepatomegaly 10% Rash 5%

113 DIAGNOSIS CBC with differential (atypical lymphocytes) Detection of heterophil antibodies (Paul- Bunnel or Monospot test)

114 TREATMENT Symptomatic & supportive treatment Steroids (severe cases) Avoid ampicillin

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116 COMPLICATIONS Autoimmune hemolytic anemia Cranial nerve palsies Encephalitis Hepatitis Pericarditis Airway obstruction

117 VINCENT S ANGINA Subacute infection due to Spirochaeta denticolata and Vincent s fusiform bacillus Most commonly in overcrowded conditions trench fever Mild local and systemic symptoms

118 VINCENT S ANGINA

119 VINCENT S ANGINA Subacute infection due to Spirochaeta denticolata and Vincent s fusiform bacillus Most commonly in overcrowded conditions trench fever Mild local and systemic symptoms Management is with penicillin and local oral hygiene

120 SCARLET FEVER

121 SCARLET FEVER

122 SCARLET FEVER

123 FUNGAL PHARYNGITIS

124 CAUSES Long term antibiotics Immunosuppresion (Leukopenia, Corticosteroid therapy etc)

125 CANDIDIASIS (MONILIASIS, THRUSH)

126 CANDIDIASIS (MONILIASIS, THRUSH)

127 Treatment Nystatin Fluconazole

128 CHRONIC TONSILLAR HYPERTOPHY

129 CAUSES Chronic or frequent acute infections Idiopathic (?exaggerated immune response)

130 PRESENTATION Upper airway obstruction Mouth breathing, snoring Disturbed sleep and apnea Pulmonary hypertension, cor pulmonale and heart failure

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133 TREATMENT Tonsillectomy & adenoidectomy

134 CHRONIC INFECTIONS OF THE PHARYNX

135 CHRONIC NON-SPECIFIC PHAYNGITIS Primary Secondary Sinonasal disease Dental infections Chest infections Smoking Gastro esophageal reflux

136 CLINICAL FEATURES Sore throat Irritation Cough O/E

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138 TREATMENT Treatment of the cause Humidification

139 CHRONIC SPECIFIC PHARYNGITIS Tuberculosis Syphilis Lupus vulgaris Leprosy Sarcoidosis

140 CHRONIC TONSILLITIS Persistent or recurrent sore throat Persistent cervical adenitis Halitosis Congested tonsils

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142 TREATMENT Tonsillectomy

143 TONSILLECTOMY

144 INDICATIONS Obstructing tonsillar enlargement Suspected malignancy

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146 INDICATIONS Obstructed tonsillar enlargement Suspected malignancy Repeated attacks of tonsillitis Chronic tonsillitis One attack of quinsy Others

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148 CONTRAINDICATIONS Bleeding tendency Recent URTI

149 COMPLICATIONS Hemorrhage Primary Reactionary Secondary Respiratory obstruction Injury to near-by structures Pulmonary and distant infections

150 Primary Hemorrhage Bleeding occurring during the surgery Causes Bleeding tendency Acute infections Aberrant vessel Bad technique Management General supportive measures Diathermy, ligature or stitches Packing

151 Reactionary Hemorrhage Bleeding occurring within the first 24 hours postoperative period Causes Bleeding tendency Slipped ligature Diagnosis Rising pulse & dropping blood pressure Rattle breathing Blood trickling from the mouth Frequent swallowing Examination

152 Reactionary Hemorrhage Treatment General supportive measures Take the patient back to OR Control like reactionary hemorrhage

153 Secondary hemorrhage Occur 5-10 days posoperatively Due to infection Treated by antibiotics May need diathermy or packing

154 Pharyngeal (Zenker s) Pouch A mucosal sac protruding through Killian s dehiesence

155 Pathogenesis Most probably related to neuromuscular incoordination? Failure of relaxation of cricopharyngeus?early closure of cricopharyngeus? Spasm of cricopharyngeus

156 Clinical Features Dysphagia Regurgitation Aspiration

157 Clinical examination Barium swallow Diagnosis

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159 Diagnosis Clinical examination Barium swallow Endoscopy

160 Excision Treatment

161 THANK YOU