Diseases of the pharynx and oral cavity

DISEASES OF THE PHARYNX
AND ORAL CAVITY
((Handouts))
(A lecture for Final year Medical Students)
By
Khairy Alhag Abu Shara M.D.
Senior consultant ENT and Head &Neck surgeon
Ex-Chairman of ENT Medical council 99-06
MOH - Kuwait
2010-2011

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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
Adenoids
Chronic tonsils
Nasopharyngeal cyst
Angiofibroma
Pharyngeal moniliasis
Cancer palate
F.B. Perforating oesophagus
F.B oesophagus
(From Author's collection, copy write protected.)
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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
ANATOMY OF THE PHARYNX
1
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4
567
(Radio-Diagrammatic Topography)
The pharynx is a fibro-muscular funnel shaped tube which extends from skull base down to
upper end of esophagus
It is subdivided into:
– Nasopharynx = Epipharynx
– Oropharynx
– Hypopharynx = Laryngopharynx
Layers: mucous membrane, subepithelial lymphoid tissue, pharyngeal aponeurosis, a coat
from constrictor muscles, buchopharyngeal fascia.
The outer circular muscles are originated from narrow anterior origin and fan backwards to
be inserted into a posterior median fibrous raphe attached above to pharyngeal tubercle in
front of Foramen M:
Superior constrictor: From pterygo-mandibular ligament
Middle constrictor: From hyoid bone and stylo-hyoid ligament
Inferior constrictor: From Thyroid and Cricoid.
The gabs related to constrictors and the structures passing through it:
Above Sup. Constrictor:
Tensor palati, Levator palati , Pharyngo-Tympanic Tube
Between Sup. And Middle:
Stylopharyngeus muscle, Stylo-hyoid ligament, Glosso-pharyngeal Nerve
Between Middle and Inferior
Internal laryngeal nerve which pierces thyro-hyoid membrane
Nerve supply: Motor: 11 & Sensory: 9, 10
The nasopharynx act as an air passage, the hypopharynx is a food passage while the oropharynx is a
dual passage.
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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
After being chewed food will be swallowed via oropharyngeal and esophageal stages.
During swallowing the intra-pharyngeal pressure is elevated up to 100 cm water.
ANATOMY OF NASOPHARYNX
It is a cubical space 2.5x2.5x1 cm
In front of first cervical vertebra (Atlas)
The floor of which is the Soft palate
Anterior to it lie the Choanae 14X12 mm
Its roof and posterior wall form a curve which lie under the body of sphenoid and basilar
part of occipital bone
Laterally there are:
The pharyngo-tympanic tubes at the level of inferior turbinate
Torus tuberias
Pharyngeal recess
It is connected to the oropharynx through the palato-pharyngeal isthmus which has the fol owing boundaries:
– Posterior pharyngeal wal
– Posterior wal of soft palate
ANATOMY OF OROPHARYNX
It lies
Behind mouth and tongue
Below raised soft palate
Above the epiglottis
In Front of 2nd and 3rd cervical vertebra
Connected to oral cavity through the oro-pharyngeal isthmus which has the
following boundaries:
Soft palate (above)
Dorsum of tongue (below)
Palato glossal arches (On each side)
Waldeyer’s Ring and cervical Lymph Nodes
Inner ring: Palatine tonsils, tubal tonsils, Adenoids and lingual tonsils.
Outer ring: submental, submandibular, pre-auricular, post-auricular and occipital
Midline anterior group
Upper and lower deep cervical groups
Posterior triangle
ANATOMY OF HYPOPHARYNX
A RT
d
L T P
s
It is subdivided into:
Post cricoid space:
from arytenoids to lower border of cricoid (c6)
Pyriform fossae (Two):
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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
from pharyngo-epiglottic fold to upper end of esophagus, bounded laterally by thyroid
cartilage, medially by aryepiglottic folds, arytenoids, and cricoid cartilage
Post pharyngeal wall: from floor of vallecula to cricoarytenoid joint
ANATOMY OF THE ORAL CAVITY
•It is filled by tongue and bounded by teeth
•The tongue is a muscular organ covered by mucosa
•The oral cavity is subdivided into:
•Vestibule: between teeth &gums and lips &cheeks.
•Oral cavity proper:
•Roof=soft and hard palate
•Floor=Mucosa, Frenulum lingulae, deep lingual veins, Warton’s duct openings,
sublingual papillae and minor salivary glands
•Ant and lat=Teeth
•Post= It communicates to oropharynx through oropharyngeal isthmus: soft
palate above- dorsum of tongue below – palato-glossus arche on each side
Diseases of the pharynx
Congenital anomalies : clefts, pouches, cysts, etc…
Trauma
F.B.
Acute Pharyngitis
Reflux pharyngitis
Chronic Pharyngitis:
–Non specific
–T.B.
–Scleroma
D.D. of Pharyngeal Ulcers
Pharyngeal Pouch
Definition: It is a herniation of pharyngeal mucosa between oblique and circular fibers of
inferior constrictor muscle {Killian’s space}
History
Presentation
Diagnosis
Treatment
Foriegn Bodies
Varieties
Management
ACUTE PHARYNGITIS
Acute non specific
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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
Diphtheria
Vincent Angina
Moniliasis
Secondary to blood disease
Gastro-Esophageal Reflux
Gastric reflux is a major cause for many ENT problems e.g.
–Chronic laryngitis
–Peptic pharyngitis
–OME
–Night cough and choking
It could be silent ( without heart burn ) in 1/3 of patients.
Diagnosis by Ba. Study, endoscopy and pH measures
TTT: anti-acids – Diet
Ulcers of the pharynx and oral cavity
Traumatic
Viral: herpes, measles
Dyspeptic
Behcet’s disease
Syphilis
Diphtheria
Blood disease
Malignant
Drug induced
Skin disease[pymphigus]
Vitamin C deficiency
Tonsils
Anatomy: Between anterior and posterior pillars, it contains
Deep furrows called crypts. It is surrounded by a capsule, in relation to
superior constrictor, buccopharyngeal fascia and medial pterygoid muscle.
Blood Supply:
4
Tonsilar
From Facial Artery
3
Ascending palatine
From-Facial Artery
2 1
Ascending pharyngeal From Ext. Carotid
Descending palatine From Maxillary Artery
5
Dorsales Linguae
From Lingual Artery
Function
Acute tonsillitis
• AFT
• Diphtheritic
• Infectious mononucleosis
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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
Acute follicular tonsillitis
Fever, headache, malaise, fetor oris, sore throat
Crypts are full of pus
Plus or minus cervical lymphadenitis
Leucocutosis
Diphtheria
By: Corynebacterium diphtheriae
Incubation period: 2-5 days
Usually at school age
There is an adherent membrane
Bull dog neck due to bilateral cervical lymphadenitis
Complications
– Cardiovascular
– Renal
– Respiratory
– Paralytic: Eye, palate, pharynx, larynx, chest, limbs.
Treatment
• Rest to avoid heart failure
• Isolation
• Anti-Diphtheritic serum: 40-100,000 IU IM after sensitivity test
• Penicillin for 10 days
Prophylaxis
• Active: DPT vaccination
• Passive: ADS to contacts 3-10,000IU IM after sensitivity test
Infectious mononucleosis
Fever
Leucocytosis
Monocytes up to 70% and abnormal in 10%.
Positive monospot
Cervical Lymphadenitis
?? Epstien Bar Virus
Chronic tonsillitis
COMPLICATIONS OF TONSILLITIS
General:
• Rheumatic fever
• Arthritis
• Acute glomerulonephritis
Local:
• Quinsy, retropharyngeal abscess, AOM
Descending infection:
• Laryngitis
• Bronchitis
• Pneumonia
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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
INDICATIONS OF TONSILLECTOMY
Obstructive sleep apnea
Recurrent inflammation
Quinsy
Persistent cervical lymphadenitis
Local signs of chronisity
Septic focus
Diphtheria carrier
Tumors
Impacted F.B.
TONSILLECTOMY
Could be done by the following methods:
Guillotine
Dissection
LASER
• Tonsillectomy
• Tonsillotomy
COMPLICATIONS OF TONSILLECTOMY
Anesthetic: Spasm, Aspiration, Arrest.
Hemorrhage
Pulmonary
Injury of: palate, teeth, uvula
Incomplete removal
infection
• local
• general
ADENOID HYPERPLASIA
Symptoms
– Nasal:discharge, snoring, nasal tone, mouth breathing.
– Aural: OME or recurrent AOM
Signs & investigations
– mucoid discharge
– X-ray
– Tympanometry
Complications: Adenoid faces, Rhinitis & sinusitis, O.M., Dry mouth, Dental caries,
Pharyngitis, Laryngitis, Bronchitis, Malaise and fatigue, Reflex: nocturnal enuresis,
laryngismus stridulus and cough.
Treatment: Adenoidectomy
POST-TONSILLECTOMY
AND POST ADENOIDECTOMY BLEEDING
PRIMARY
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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
REACTIONARY
SECONDARY
MANAGEMENT:
Resuscitation of a shocked patient
Stop bleeding by cautry, packing or ligation
Exclude any blood disease before surgery
Sleep Apnea Syndrome
Sleep related breathing disorders are common cause of excessive daytime sleeping and may
lead to
o
Pulmonary hypertension
o
Systemic hypertension
o
Cardiac arrhythmias
o
Mental dysfunction
o
Heart failure
o
Sudden death
Apnea
It means cessation of oro-nasal air flow for more than 10 seconds
Types
Central: No air flow or respiratory effort
Obstructive: No air flow despite respiratory effort. It occurs mostly in men 96%
Mixed
Nocturnal polysomnogram
EOG:
REM (At 3-6 am and associated with dreams and sleep apnea occurs during it)
Non REM
EEG: for sleep staging
ECG: Holter monitor
EMG: (chin) mylohyoid muscle tone for sleep staging
Oxygen saturation: to detect any desaturation
Chest-abdominal movements: to distinguish central from obstructive type
Oro-nasal air flow
Vibration transducer for body movements
Tape recording of snoring
Treatment of SAS
Medical
a.
Stop drugs
b.
Weight reduction
c.
Nasal medications
d.
Nasovent, dura-breath or easy breath
e.
Positional: Humped pajamas
f.
CPAP
g.
Tongue retaining device
Surgical
a.
Uppp = uvulo-palato-pharyngo-plasty
b.
Laser AUP, Cautary AUP, Radiofrequency AUP, Power AUP, etc.
c.
Maxillofacial
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Diseases of the pharynx and oral cavity
Khairy Alhag Abu Shara M.D.
d.
Midline laser glossectomy
e.
Tracheostomy
f.
Hyoid expansion
g.
Hyoid suspension
Laser assisted uvulo-palatoplasty (LAUP)
Is a limited LASER palatal resection which enlarges the naso- pharyngeal air space by
creating a new shorter and higher soft palate, Thus reducing or eliminating snoring and
improves the sleep pattern
BUT
Other contributing causes of Obstructive sleep apnea should be
Treated in the same time as a remedy for SAS
Deep neck suppurations in relation to the pharynx
QUINSY
Peritonsillar abscess
Fever, trismus, fetor oris, malaise
Unilateral tonsillar swelling
Leucocytosis
Treatment is incision & drainage, antibiotics and analgesics. The patient
is for tonsillectomy after 2 months.
ACUTE RETROPHARYNGEAL ABSCESS
Suppuration of retropharyngeal lymph nodes of Henle which atrophy after 5 years)
Source: from tonsils or adenoids
Symptoms: fever, toxaemia, dysphagia, stridor & torticollis
Radiography: broadening of the pre-vertebral soft tissue shadow
Treatment: I & D and antibiotics
Complications: inhalation and mediastinitis.
Para-pharyngeal Abscess
This space is pyramidal in shape its base is the skul base and tip to superior mediastinum
Medially : The pharynx with bucco-pharyngeal fascia over constrictors
Laterally: Parotid and Med pterigoid overlying the mandible
Lat&Down: SCM and infra-hyoid muscles
Posterior: The pre-vertebral fascia
Pus collects around carotid, jugular vein between the pharynx medially and the SCM laterally
It could be secondary to AFT, Quinsy or break down in suppurative lymphadenitis
There is neck swelling, medialization of the tonsillar bed and trismus
Complications: Mediastinitis, Meningitis and carotid blow out.
Treatment: I&D and antibiotics
Ludwig’s Angina
Cellulitis of mouth floor and tongue base
Secondary to dental or pharyngeal sepsis
Hard sub-mandibular induration
Tongue may protrude
Edema may spread to larynx
TTT:
Antibiotics
Wide Incision
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