Salute

Vivamus 2023 | Central Philippine University | College of Medicine

Otolaryngology: S01L08

Diseases of the Pharynx
Dr. Melita Jesusa Uy| 11-12-2021 | F | 10:00-12:00 PM

OUTLINE Fig.3 Otoscopy- you can sometimes see

otitis media and with effusion. That is why
I. Diseases of the A.Injuries and Foreign sometimes we perform Pure tone
Nasopharynx Bodies audiometry to rule out conductive hearing
loss
A. Adenoids B. Acute Inflammation
B. Benigh tumor C. Tonsillogenic
C. Malignant tumor complications

D. Congenital D. Benign Tumor
Choanal atresia III. References
E. Nasopharyngeal IV. Appendix
bursitis • Treatment
II. Diseases of the ® Adenoidectomy under general endotracheal anesthesia
Oropharynx and ® Myringotomy with ventilation tube insertion
Hypopharynx o Just like making a controlled hole on your eardrum and
putting a tube to maintain that hole for a certain period of
I. DISEASES OF THE NASOPHARYNX time for the fluid to drain out
o The tube will just extrude out naturally or you can
A. ADENOIDS removeit after 6 months
® Medical Management
o If it’s infected, you can treat with antibiotics and if it’s
• Hyperplasia of the pharyngeal tonsils
causing allergies you give anti-allergy or anti-
• Hypertrophy of your Adenoids (Doc)
inflammatory.
• Common in 3-6 years old FROM VIVA
• Clinical Manifestations: • Indications for Adenoidectomy
® Chronic airway obstruction ( mouth ® Chronic upper airway obstruction with resultant sleep
breathing) disturbances, cor pulmonale, or sleep apnea syndrome
® Nasal discharge ® Chronic purulent masopharyngitis despite adequate
® Snoring medical management
® Anorexia ® Chronic adenoiditis associated with production and
® Hyponasal voice persistence of middle ear effusions (serous otitis media or
® Frequently recurring infections of the mucoid otits media)
nose and PNS Fig.1 Adenoid Hypertrophy
® Recurrent acute suppurative OM that has not responded to
® Otits media medical management and prophylactic antibiotics
® Eustachian tube dysfunction ® Certain cases of chronic suppurative OM in children with
® Prolonged conductive hearing loss ~ delays in speech associated adenoid hypertrophy
development ® Suspicion of a nasopharyngeal malignancy (biopsy only)
® Maxillary deformity and dental malalignment
® Level 2 Lymph nodes B. BENIGN TUMORS

NICE TO KNOW! • A case of a 14 year old male patient, 9 month-history of right

“ The prolonged conductive hearing loss usually happens because hemifacial increase with ipsilateral nasal obstruction with no
the eustachian tube is blocked and there is fluid inside the middle nasal bleeding. The physical exam presented facial distortion
ear causing the conductive hearing loss.”
to the right,with no sight or eye alterations
- Doc Uy • Rhinoscopy showed tumor in all right nasal fossa and nasal
septum displaced to the left side.
• Diagnosis: • Oropharyngoscopy showed soft palate in bulging condition
® Posterior Rhinoscopy/Endoscopy • Tomography showed heterogeneous mass in all right nasal
® Otoscopy fossa,nasopharynx, pterygopalatine fossa, infratemporal area
® Pure tone audiometry and sphenoid sinus
o Assess for hearing loss because it may affect speech • MRI neither showed tumor extension in the orbit, in cavernous
development sinus nor intracranial

Fig.2 Posterior Rhinoscopy - you can

see enlarged, hyperemic adenoids and
sometimes with yellowish discharges

Fig. 4. Patient having a Benign tumor and a CT scan which almost occupies the right
side of the patient

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JUVENILE NASOANGIOFIBROMA
• Most common of benign tumors of the nasopharynx
• Less than 0.05% of all ear, nose and throat
• Occurs in boys of 10-18 years of age
• Although it is a benign tumor however it is aggressive (Doc)
• Symptoms:
® Obstructed nasal breathing
Fig. 7. Juvenile Nasoangiofibroma- (Upper left pic) Angiography showing the feeding vessels.
® Recurrent unprovoked epistaxis (Upper Right) Intraoral route. (Bottom pic) Extraoral route
o The first 2 symptoms in adolescent boy suggests this
benign tumor C. MALIGNANT TUMOR
® Headache
® Impaired eustachian tube ventilation with middle ear EPIDEMIOLOGY
effusion • Squamous cell carcinoma account for great majority of
® Conductive hearing loss malignant tumors of the nasopharynx
• Diagnosis • Lymphoepithelial carcinomas
® Endoscopy: well-circumscribed, vascularized mass with • Adenocarcinomas
superficial vascular markings in the nasopharynx or • Adenoid cystic carcinomas
posterior part of the nasal cavity • Malignant Melanoma
® Important: if angiofibroma is suspected, do not do biopsy • Sarcoma
• Lymphoma

ETIOLOGY
• Epstein-Barr virus (EBV)~ undifferentiated lymphoepithelial
carcinoma

SIGNS AND SYMPTOMS

Fig. 5. If angiofibroma is
suspected, don’t do your biopsy.
Especially in the clinics wherein
you can just perform it right away.
• Neck mass
• Unilateral conductive hearing loss with middle ear effusion
• Cervical lymph node metastasis
• Recurrent epistaxis
Fig. 6. Juvenile Nasoangiofibroma- it is usually • Nasal airway obstruction
reddish, hyperemic, violaceous
• Headache
• Cranial nerve palsies

• Uncommon, benign and very vascular tumor

• Up to 0.5% of head and neck tumors
Fig. 8. When you see patients like this you
• Occurring almost exclusively in males refer it to ENT specialists so you can have the
• Average age of onset - 15 years old nasopharynx checked first. Some physicians
will do biopsy and eventually it will just result
• Diagnosis: Imaging Studies to metastatic carcinoma. So have the
® MRI or CT Scan nasopharynx examined first because that
® Angiography might be the primary site of the tumor

o Used to pinpoint the source of the tumor

• Treatment:
® Surgical Removal
o This is a tumor of vascular origin- bleeding can occur
during surgery. Careful planning,pre-operative evaluation • Diagnosis
of patient should be done. ® Endoscopy: smooth, well-circumscribed tumor surface to
o 10 units of blood usually transfused or “pushed” or mucosal ulceration
“pumped” ® Some of these tumors are initially submucosal and are
o Usually transpalatal for small tumors easily missed at endoscopy
® Preoperative embolization of the feeding vessels
o Very expensive procedure
o 24-48 hours before surgery (Doc)
o 72 hours before surgery ( Viva)
§ So that you will avoid neoangiogenesis prior to
surgery
o If you block a feeding vessel, there may still be collaterals
o Usual feeding vessels: Anterior maxillary artery or
External carotid artery
Fig. 9. Malignant tumor Endoscopy. (middle pic) fungating tumor

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Fig. 10. Endoscopy
showing the tumor in the
nasopharynx
® Otoscopy: unilateral tympanic membrane retraction and
middle ear effusion as a result of impaired eustachian tube
ventilation
® EBV titer
® MRI / CT scan: MRI is the best test to confirm
Fig. 11. MRI and you can see here
your tumor which is almost bulging
through your eustachian tube
II. DISEASES OF THE OROPHARYNX AND
HYPOPHARYNX
A. INJURIES AND FOREIGN BODIES
SCALDS AND CORROSIVE INJURIES
• Etiology
® Accidental drinking of hot liquids
® Corrosive injuries more common in adults die to ingestion
of caustic liquids with suicidal intent
• Symptoms
® Severe pain
® Increased Salivation
• Diagnosis
® Initially, the mucosa appears erythematous
® Blistering then formation of a whitish fibrin coating
® Exclude injuries in lower levels of alimentary tract
o Ex. Ingestion of muriatic acid
o Liquefaction
® Chest X-ray to rule out widening of mediastinum due to
esophageal perforation
® Early endoscopy
o Delayed endoscopy can lead to esophageal perforation
• Treatment
® Rinse the oral cavity with cold water
® If lips are affected: corticosteroid-containing ointment
® Severe injuries: systemic corticosteroids, antibiotics and
analgesics
® Nasogastric feeding tube- start early (as early as the first 24
hours or first few hours) especially if there is ingestion of
acid to avoid perforation of the esophagus

• Treatment FOREIGN BODIES

® Primary high-voltage radiotherapy because most of the • Most commonly located in the tonsils and at the tongue base
tumors are very radiosensitive
• Fish bone and bone fragments
o Hence,it is very difficult to surgically removed everything
• Well-localized pain on swallowing
in your nasopharynx because you have to go through a
lot of structures to get inside and the morbidity would be • Removal
debilitating to the patient • Vallecula: the area between the tongue and the epiglottis

D. CONGENITAL CHOANAL ATRESIA (VIVA)

• (Theory) Results from the embryologic failure of the

bucconasal membrane to rupture prior to birth
• Results in the persistence of the bony palate (90%) or
membrane (10%) obstructing posterior nares.
• Unilateral obstruction may not be symptomatic at birth but later
will cause chronic unilateral nasal drainage in childhood
• Bilateral forms at birth resents emergency situations. Fig. 12. Endoscopy showing fishbone injury
Newborns are obligate nasal breathers.
• Inability to pass a soft catheter through the nose is diagnostic B. ACUTE INFLAMMATION
• Unilateral choanal atresia is corrected at an older age
• Atresia plate can be approached surgically by: ACUTE TONSILITIS
® Transnasal • Etiology
® Transeptal ® Bacterial inflammation of the palatine tonsils
® Transpalatal ® Group A β-hemolytic streptococci
® Staphylococci
E. NASOPHARYNGEAL BURSITIS (VIVA) ® Haemophilus influenza
® Pneumococci
• A.k.a Thornwaldt’s disease
• Pathology (ViVa)
• Is a form of unusual postnasal discharge that is produced by
® General inflammation and swelling of the tonsil tissue
mucoid drainage from a pocket (pharyngeal bursa) in the
uppermost part of the posterior pharyngeal wall ® With accumulation of leukocytes, dead epithelial cells,
pathogenic bacteria in the crypts
• Corrected by incision
® Pathologic phases includes
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o Simple inflammation at the tonsil area ® Tonsils are greatly swollen with a deep red color
o Formation of the exudate ® Diagnosis by clinical picture and positive rapid
o Cellulitis of the tonsils and its surrounding area streptococcal test
o Formation of the peritonsillar abscess ® Penicillin
o Tissue necrosis ® Mild antiseptic solution gargles
• Symptoms ® Pain reliever
® Sore throat
® dysphagia DIPTHERIA
® High fever (104F) • Etiology
® Fetid breath ® Caused by Corynebacteium diptheriae
® Otalgia (referred pain) ® Droplet inhalation
® Odynophagia ® Skin-to-skin contact
® Swollen tonsillar lymph nodes (spotted with at times grayish ® Incubation period: 1-5 days
or yellow exudates) • Pathogenesis
® Muffled speech ® Special endotoxin that causes cell necrosis and ulcerations
• Diagnosis • Clinical Manifestations
® Swollen, bright red, coated tonsils ® Two main forms:
® Leukocytosis o Local, benign pharyngeal diphtheria
® Culture o Primary toxic, malignant diphtheria
® Rapid immunoassay ® Begins with moderate fever and mild
swallowing difficulties
® Fully developed in ~ 24 hours with
severe malaise, headache, and
nausea
• Diagnosis
® Grayish-yellow pseudomembranes
firmly adherent to the tonsils and may
spread to the palate and pharynx
® Tissue bleeds when coating
Fig. 13. Diagnostic features of Acute Tonsillitis removed Fig. 15. Diagnostic feature of
® Slightly sweet breath smell Diphtheria

• Treatment ® Smear findings

® 10 – 14 days treatment of Penicillin V • Treatment
® Macrolides or oral cephalosporins ® Isolation
® Analgesic ® Diphtheria antitoxin 200-1000IU/kg body weight/ IV or IM
® Gargles (in question but clinical experience indicates that (after a negative skin test)
gargling adds px comfort) ® Penicillin G
® B. catarrhalis present in tonsils is capable of producing ® Discharge after 3 consecutive 1-week interval smears show
Blactamase. This may explain persistent positive culture negative results
after appropriate treatment ® 2% may continue to carry the bacterium and should
undergo tonsillectomy
SCARLET FEVER ® Vaccination
® Group A β-hemolytic streptococci ® Bleeding upon removal of pseudomembrane
® Exotoxin • Complications
® Rash (begins on the trunk) ® Toxic myocarditis (usually with the primary toxic malignant
® Perioral pallor form): can be fatal
® Raspberry tongue (bright red tongue with glistening surface ® Interstitial nephritis
and hyperplastic papillae) ® ECG and urinalysis follow-ups should be continued for at
least 6 weeks after onset of disease

TUBERCULOSIS
• Epidemiology
® Usually in advanced organ tuberculosis
® Very rare
• Clinical Manifestations
® Primary complex
o Commonly in children
o Typical ulcerative lesion of the oral mucosa and tonsil with
regional cervical lymphadenopathy
® Organ tuberculosis with ulcerative mucocutaneous lesions
o In regions that may come into contact
Fig. 14. Raspberry tongue
® Organ tuberculosis with ulcerative mucocutaneous lesions

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o Lesions may appear as mucosal ulcerations on the lips • Clinical Manifestations
and dorsum of the tongue or as slightly raised, nodular ® Systemic disease but commonly presents as tonsillitis as
eruptions on the palate the initial or cardinal symptoms
o Skeletal involvement (“cold abscesses”) causing bulging ® Fatigue, anorexia and moderate temperature elevation
of the posterior wall of the pharynx (like retropharyngeal ® Severe pain on swallowing
or parapharyngeal abscess). ® Headache
® Limp pains
® Very hard to differentiate from other diseases
® Weakness is very common
® Adenoids are enlarged

• Diagnosis: Clinical Examination

® Tonsillar, nuchal, axillary and inguinal nodes are enlarged
® Liver, spleen enlargement
® Tonsils are bright red, swollen, and covered with grayish
fibrin coating

Fig. 16. Diagnostic Feature of Tuberculosis

• Miliary tuberculosis
® Hematogenous spread, appearing as multiple pinhead size
papules, some hemorrhagic, that form on the oral mucosa
• Diagnosis
® Acid-Fast bacilli smears, sputum, bronchial secretions,
gastric juice, or biopsy material
® Biplane chest radiograph
® Tuberculin skin test
® Calcifications by ultrasound in enlarged cervical lymph
nodes (pathognomonic) Fig. 17. Diagnostic feature of Infectious Mononucleosis
® Cervical lymph node biopsy
• Treatment
® Inpatient anti-tuberculous polychemotherapy • Diagnosis: Laboratory Tests
o Triple or quadruple regimen ® Initially leukopenia followed by leukocytosis
® 80-90% atypical lymphocytes
ACUTE VIRAL PHARYNGITIS ® EBV serology
• Etiology ® Hepatic enzymes
® Influenza or parainfluenza viruses ® Upper ultrasound and ECG
® Sudden onset of dryness or “scratchiness” of the Throat • Treatment
fever, sore throat and headache ® Symptomatic relief of pain and fever
® Malaise and headache common o Aspirins not recommended as they cause bleeding
® Coughing and catarrhal symptoms (usually differentiates problems if tonsillectomy is required
from bacterial) ® Antibiotics
® Cervical adenopathy o Ampicillin and amoxicillin avoided since they frequently
® Early stage is hyperemia to edema to inc. secretion induce a pseudo allergic rash
® Lateral pharyngitis-when lateral wall involvement, when ® Tonsillectomy
isolated o Severe course
• Diagnosis
® Pharyngeal mucosa appears red and coated on mirror C. TONSILLOGENIC COMPLICATIONS
examination
® If bacterial etiology is suspected ~ rapid streptococcal PERITONSILLAR ABSCESS
test • Unilateral inflammatory process that includes the peritonsillar
® If viral, do RT-PCR Test to rule out COVID-19 tissue
• Treatment • Pronounced unilateral redness and swelling of the soft palate,
® Supportive muffled speech, and possible trismus
® Analgesics, cold compresses, warm liquids • Uvular edema
® If with poor response- antibiotic • May involve tongue base and lateral pharyngeal wall

INFECTIOUS MONONUCLEOSIS
• Overview
® Epstein-Barr virus
® Adolescents and young adults Fig. 18.. Edematous Uvula

® Incubation period: 7-9 days

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• Peritonsillar infections may readily spread to the
parapharyngeal space

Fig. 21. CT Scan showing abscess on the parapharyngeal space

• Danger Space
Fig. 19. Pharyngeal Spaces
® Potential Space
o dangerous for rapid inferior spread of infection to the
posterior mediastinum through its loose areolar tissue
® Treatment
o Removal or incision of the affected tonsil under antibiotic ® Routes of entry
coverage (6-8weeks post infection) o Retropharyngeal
o Drainage and antibiotics. Follow up the patient because it o Parapharyngeal
o prevertebral spaces
has a high rate of recurrence.
o “Hot potato voice”: common sign

TONSILLOGENIC SEPSIS
• Rare
• Immune-compromised patients
• Hematogenous or lymphogenous route
• Arise from any inflammation of the pharynx

RETROPHARYNGEAL AND PARAPHARYNGEAL

ABSCESS
• Inflammation or abscess from prevertebral or parapharyngeal
lymph nodes or by hematogenous spread as a result of minor
foreign-body injury or upper respiratory inflammation
• Clinical hallmarks
® severe pain on swallowing, progressive dysphagia, muffled Fig. 22. Danger Space

speech and possible trismus and dyspnea

• Routes of entry • Treatment
® direct spread from the parapharyngeal space, or lymphatic ® Surgical incision and drainage under general endotracheal
spread from the paranasal sinuses or nasopharyngeal anesthesia
region ® Transoral or external approach
® Antibiotics
® Steroids
® Intubation or tracheostomy

CHRONIC PHARYNGITIS
• Etiology
® Long term exposure to various noxious agents (nicotine,
alcohol, chemical, gaseous irritants)
® Chronic mouth breathing due to nasal obstruction
® Accompanying feature of chronic sinusitis
® Recurrent pharyngitis
• Symptoms
® Dry-throat sensation with frequent throat clearing and
Fig. 20. Routes of Entry drainage of viscous mucus
® Dry cough and foreign-body sensation in the pharynx
• Diagnosis
® Pronounced swelling in the oropharynx or hypopharynx
usually at prevertebral or parapharyngeal region
® Leukocytosis
® Contrast CT scan Fig. 23. Chronic Pharyngitis’ diagnostic
feature

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• Diagnosis ® Hyperplastic palatine tonsils
® History ® Nasal obstruction
® Pharyngeal mucosa appears red and “grainy” due to the o Sometimes the obstruction is anatomical
hyperplasia of lymphatic tissue on the posterior pharyngeal • Diagnosis: Flexible Transnasal Endoscopy
wall ® Muller Maneuver
® In some case, the mucosa may appear smooth and shiny o Perform endoscopy and ask the patient to swallow while
® Nasal examination to exclude nasal airway obstruction inhaling
• Treatment o Negative inspiratory pressure during the maneuver
o Avoid causing agents produces various collapse effects in the pharynx when
o Sage or chamomile in steam inhalation to moisten OSAS is present
o Surgery for those with nasal airway obstruction • Diagnosis: Objective Measuring Techniques
® Screening
CHRONIC TONSILITIS o Outpatient basis: oxygen saturation, respiratory sounds,
• Pathogenesis heart rate during sleep
® Recurrent inflammations of the tonsils and peritonsillar o Madaus Electronic Sleep Apnea Monitor (MESAM)
tissue can lead to permanent structural changes with o Not accurate since no EEG
scarring ® Confirming the diagnosis
® Bacteria can grow on cellular debris in poorly drained crypts o Polysomnography: gold standard
® The size of the tonsils does not necessarily correlate with o Inpatient procedure
severity of the problem o Additional thoracic and abdominal respiratory excursions,
• Symptoms transcutaneous PO2 and records an EEG evaluation:
sometimes the cause is arrhythmia
® Recurrent episodes of pain or asymptomatic
® Lethargy, poor appetite, bad taste in mouth and fetid breath
odor
• Diagnosis
® Reveals small, firm immobile tonsils with associated
peritonsillar redness
® Occasionally, purulent liquid “cheesy” or “putty-like” can
be expressed from the crypts
® Smears: group A β-hemolytic streptococci
® Tonsillar lymph nodes may be enlarged
® Anti-streptolysin titer >400 IU/ml
• Treatment
® Tonsillectomy
® Very hard to remove

PERIPHERAL OBSTRUCTIVE SLEEP APNEA

SYNDROME (OSAS)
• Etiology and Pathogenesis
® Tendency for the velum, oropharynx, and/or hypopharynx Fig. 24. Flow Chart for Sleep Apnea

to collapse during sleep narrowing airway and causing

• Treatment
periods of apnea or hypopnea
® Weight reduction
® Frequent arousal from sleep and gasping for air preventing
® Abstinence from alcohol and nicotine
normal sleep pattern
® Avoiding big meals
® Long-term effects due to reduction in blood oxygen levels
® Establish regular sleep-wake pattern
with potential for damage to the cardiopulmonary system
* Factors and Condition That Promote Snoring and Apnea See ® Splint
Appendix ® Occlusive splint that advances the lower jaw
• Signs in the patient’s history that are suggestive of OSAS ® Widens the airway
® Loud, irregular snoring ® Continuous positive airway pressure (CPAP)
o In severe OSAS or failed occlusive splint
® Periods of apnea during sleep (witnessed)
® Unusual daytime sleepiness or fatigue o Pneumatic splint
® Intellectual deterioration (poor concentration and impaired ® Surgery
memory) o Careful patient selection
o Uvulopalatopharyngoplasty (UPPP) with tonsillectomy
® Personality changes
o Intranasal surgery: septorhinoplasty, turbinate reduction
® Loss of libido, impotence o May cause oropharyngeal insufficiency due to decreased
® Nocturia, enuresis musculature
® Gasping of air
• Diagnosis D. BENIGN TUMORS
® Elongated uvula
® Narrow velopharyngeal passage • Overview
® Bulky soft palate with a small oropharyngeal lumen ® Can arise from all epithelial and mesenchymal tissues in the
® Hyperplastic tongue base head and neck region
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® Papilomas, pleomorphic adenoma
® Fibromas, lipomas, chondromas
® Hemangiomas and lymphangiomas
• Treatment
® Generally surgical
® Hemangiomas and lymphangiomas
o Due to high rate of spontaneous remission during first
years of life surgery is advised if tumor persists beyond
that period or there are already symptoms of dyspnea or
dysphagia
Fig. 26. Tonsillar Carcinoma

PRECANCEROUS LESIONS • Diagnosis

• Leukoplakia ® Tonsillar carcinoma may appear as exophytic lesions or an
® Most common precancerous lesion ulcerating infiltrating type
® Asymptomatic ® Occasionally not grossly visible
® Exogenous irritants such as denture pressure or ® CT and MRI
alcohol/nicotine abuse ® Biopsy
® Complete surgical removal
® Usually in smokers

Fig. 25. Leukoplakia

• Bowen’s Disease
® Chronic inflammatory disease caused by an intraepidermal
carcinoma
® Similar to leukoplakia

MALIGNANT TUMORS
• Overview
® Majority are squamous cell carcinoma
® 80% are located in the palatine tonsils or tongue base
® Less common sites are the soft palate and posterior wall of
the pharynx
• Etiology Fig. 27. Imaging of Tonsillar Carcinoma
® Chronic nicotine and alcohol abuse
® Smokeless tobacco use
• Treatment
® Betel nut use
® For most cases is surgical removal
® Reverse smoking
® Neck dissection
® Poor oral hygiene, ill-fitting dentures
® Postoperative radiation
® In elderly patients with dentures, make sure to reinforce
follow up with dentist from time to time ® Alternatively, primary radiotherapy or combined radiation
and chemotherapy
• Symptoms
® Some may remain clinically silent
® Depend on location and extent III. REFERENCES
® Dysphagia, odynophagia • Doc Uy’s Lecture
® Blood-tinged saliva • ViVa Trans
® Fetid breath odor • Boie’s 6th edition page 332-368
® Trismus

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IV. APPENDIX
CLASSIFICATION COMMON FACTORS

Pharyngeal Overweight and Obesity

Obstruction Adenoids
Tonsillar Hyperplasia
Tumors in oral cavity, pharynx, larynx,
neck
Dysgnathia
Acromegaly
Nasal Obstruction Septal deviation
Nasal polyps
Deformities of external nose
Tumors of the nose
Decreased Muscle Alcohol
Tone Nicotine
Drugs (sedatives, hypnotics, muscle
relaxants)
Sleep deprivation
Shift work
Hypothyroidism
Others Sex (male predominate)
Genetic predisposition
Sleeping in supine position
Table 1. Factors and Condition that Promote Snoring and Apnea

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