ANATOMY OF THE PHARYNX

Pharynx is fibro-muscular tube extending from the base of the skull to be continuous
with esophagus at level of lower border of 6th cervical vertebrae (about 12.5 cm in
adults).
 The pharynx
It is divided into 3 parts:
1- Nasopharynx:
- Behind nose in front of C1, extending from the skull base above to the soft palate
below.
- Contains nasopharyngeal tonsil (adenoid).
2- Oropharynx:
- Behind mouth in front of C2, C3 extending from the soft palate above to the tip of
epiglottis below.
- Contains: palatine tonsils and tongue base.
3- Laryngopharynx (hypopharynx):
- Behind the larynx in front of C3, C4, C5, C6 cervical vertebrae, extending from the
tip of epiglottis to the inlet of esophagus.
- Consists of 3 parts :
a-Pyriform fossa: Laterally (Thyroid cartilage and thyrohyoid membrane), Medially
(Cricoid cartilage and aryepiglottic fold).
b-Postcricoid area: Extends from the arytenoids cartilage above to the lower
border of cricoid cartilage below.
c- Posterior pharyngeal wall.
Structure of the pharynx :
Formed of FOUR laryers :
1-Inner mucosal layer: stratified squamous epithelium except upper 1/2 of the
nasopharynx (pseudostratified columnar ciliated).
2-Subepithelial connective tissue layer (pharyngeal aponeurosis) contains
Waldeyer's ring :
a-Composed of collections of lymphoid tissues, each collection called tonsil which
differs from lymph gland (it has only efferent lymphatic and incomplete capsule).
 b-The ring consists of :
- One nasopharyngeal tonsil in the roof and posterior wall of the nasopharynx,
when enlarged called the adenoid.
- Two tubal tonsils one on each side of the nasopharynx around pharyngeal
ends of Eustachian tube.
- Two palatine (faucial) tonsils : one on each side of the oropharynx.
- Two lingual tonsils : one on each side of the base of the tongue.
c- The ring is drained to the upper deep cervical lymph nodes.
3-Muscle layer :
Formed of TWO layers:
a-External formed of 3 constrictors muscles (superior, middle and inferior
constrictors). The inferior constrictors is divided into 2 parts :
- The thyropharyngus (oblique).
- The cricopharyngus (transverse) : the mouth of the esophagus.
** The space in between 2 parts called Killian dehiscence which is the site of
herniation of pharyngeal mucosa in pharyngeal pouch.
b-Internal: formed of 3 muscles (palatopharyngus, salpingo-pharyngus and
stytopharyngus).
 4-Buccopharyngeal fascia: thin connective tissue coat attached posteriorly to the
prevertebral fascia.
Lymph drainage of the pharynx:
Nerve supply:
1-Motor: The vagus nerve through the pharyngeal plexus.
2-Sensory :
a-The nasopharynx: the trigeminal nerve.
b-The oropharynx: the glossopharyngeal nerve.
c- The hypopharynx: the vagus nerve.

Blood supply :
Arteries: Branches from the external carotid
artery (ascending pharyngeal tonsillar and
ascending palatine from facial artery,
descending palatine from maxillary artery and
lingual artery).
Veins : Drain into the pharyngeal plexus which
drains into the internal jugular vein.
Anatomy of the tonsil :
The tonsil is a mass of lymphoid tissue lying between two folds the anterior pillar
(palatoglossus muscle) and the posterior pillar (palatopharyngeus muscle) one on
each side of the oropharynx.
The medial surface is covered by stratified squamous epithelium lining 12-15 crypts.
The largest crypt lies just below the upper pole of the tonsil (crypta magna).

SPACES IN RELATION TO THE PHARYNX

 FUNCTIONS OF THE PHARYNX
1-Deglutition : Sharing in the second stage of deglutition, mixing food with saliva.
Transfer bolus of food to the esophagus through perstaltic waves of the constrictors
muscles.
2-Respiratory channel.
3-Vocal resonance.
4-Articulation of speech.
5-Taste.
6-The subepithelial lymphoid tissue is a part of the reticulo-endothelial system and
plays a role in :
- Protection of the respiratory and digestive systems.
- Production of antibodies.
- Formation of lymphocytes.
 SYMPTOMS OF PHARYNGEAL DISEASES
(A) Nasopharynx :
1-Nasal symptoms :
- Big mass → nasal obstruction, discharge and nasal tone of voice (rhinolalia
clausa).
- Vascular mass → epistaxis.
2-Ear symptoms : otitis media with effusion due to Eustachian tube obstruction.
3-Neurological symptoms : due to involvement of the skull base.
4-Cervical lymph nodes : the pharynx is one of the silent areas.
(B) Oropharynx :
1-Sore throat. 2- Dysphagia.
3-Big mass → respiratory distress and change of voice e.g.quinsy.
4-Lymph nodes in the neck.
(C) Hypopharynx (Laryngopharynx) :
1-Sense of lump in the throat.
2-Dysphagia.
3-Respiratory distress, change of voice and referred ear ache if a tumour extend to
the larynx.
4-Lymph node in the neck.
 EXAMINATION OF THE PHARYNX
a. Local examination:
(A) Nasopharynx :
- Posterior rhinoscopy.
- Endoscopic examination.
(B) Orpharynx :
- Inspection: Examine through the open mouth with the use
of a tongue depressor to inspect: Faucial pillars, tonsils,
posterior pharyngeal wall and movements of the palate.
- Palpation: Digital examination of the above areas.
(C) Hypopharynx:
- External examination.
- Moure's sign : loss of laryngeal click due to the presence of a mass between the
thyroid cartilage and a mass in the hypopharynx.
- Indirect laryngoscopy.
- Flexible laryngoscopy.
 b. Cervical lymph nodes examination.
c. Investigations :
1- Radiography :
- Plain x-ray : demonstrate the lumen of the pharynx.
- Ba swallow : demonstrate the lumen of the hypopharynx, it can be used with contrast
(fluoroscopy) to assess motility of the pharyngeal muscles.
- CT scan : accurately demonstrates the pharynx, surrounding structures and cervical
lymph nodes.
2- Direct hypo-pharyngoscopy:
Direct visualization of the hypopharynx by rigid hypo-pharyngoscope.
Indications :
A- Diagnostic: - To examine the hypopharynx. - To take a biopsy.
B- Therapeutic:
1-Removal of a hypo-pharyngeal foreign body.
2-Dilatation of the crico-pharyngeal sphincter in case of pharyngeal pouch.
3-Excision of hypo-pharyngeal benign tumours.
Contraindications:
Cervical spine deformities as severe kyphosis.
 DISEASES OF THE NASOPHARYNX
Adenoids :
Hypertrophy of the nasopharyngeal tonsil sufficient to produce symptoms. Normally it
start to diminish in size at the age of 7-8 years and disappears in adult hood.
Etiology (Causes of hypertrophy) :
1-Physiological : commonest cause, usually occurs at the age of 3-8 years and
usually occurs in association with hypertrophy of the palatine tonsils.
2-Repeated attacks of upper respiratory tract infection.
3-General factors : bad hygiene, crowding.
Clinical picture :
A- Symptoms due to size.
B- Symptoms due to infection.
C- General symptoms.
D- Reflex symptoms.
A- Symptoms due to size : (enlargement)
I- Nasal obstruction :
 In infancy and early childhood :
1-Difficult suckling.
2-Noisy breathing, snoring and may be sleep apnea.
3-Nasal tone of voice (Rhinolalia clausa).
 In late childhood (due to prolonged nasal obstruction)
1-Adenoid face :
- Open mouth and thick lips.
- High-arched palate due to loss of moulding and adaptation of the palate over
the tongue during palatal growth.
- Crowded teeth with prominent incisors.
- Receding back lower jaw due to loss of negative intrabuccal pressure.
2-Chest deformities : as a result of nasal breathing against resistance because
nasal breathing is instinct :
- Pigeon chest.
- Harrison's sulcus.
- Retraction of lower end of sternum.
3-Retarded growth.
II- Eustachian tube obstruction : Leading to secretory otitis media with conductive
deafness.
B- Symptoms due to infection :
1- Nose : Rhinitis and sinusitis.
2- Ear : otitis media (suppurative or non-suppurative).
3- Nasopharynx: chronic nasopharyngitis with post-nasal discharge.
4- Digestive symptoms as loss of appetite, indigestion and morning vomiting due to
swallowed mucous.
C- General symptoms :
Mental dullness as a result of :
1-Lack of concentration due to conductive deafness.
2-Hypoxia during sleep due to airway obstruction.
3-Recurrent illness e.g.rhinitis, bronchitis.
D- Reflex symptoms :
1- Nocturnal enuresis and nightmares due to hypoxia.
2- Nervous symptoms as chorea, convulsions and tics.
3- Respiratory symptoms as reflex cough, asthma, laryngismus stridulus & bronchitis.
4- Obstructive sleep apnea.
Investigations :
 X-ray nasopharynx, lateral view (soft tissue shadow narrowing the airway).
 Nasopharyngoscope (Flexible).
 Audiogram and tympanogram.
Treatment :
 Conservative: For infant or with mild symptoms :
- Diet rich in calcium.
- Decongestant nasal drops.
 Surgical removal: Adenoidectomy.
 NASOPHARYNGEAL TUMOURS
(A) Benign :
Fibroma, papilloma, adenoma, chondroma and mixed salivary tumours.
Nasopharyngeal fibroma :
 It is the most common benign tumour of the nasopharynx.
 It is histologically benign but clinically it is an aggressive tumour.
Pathogenesis :
Most probably hormonal (oestrogen-androgen imbalance) because :
 It is mainly a disease of male (juvenile fibroma).
 It is limited to the age group 10-20 years (age group undergoing endocrine
changes).
 It may regress after the age of 25 years.
Pathology :
 Firm, lobulated swelling arise from periosteum of the sphenopalatine foramen.
 Histologically : (a) fibrous tissue, fibroblasts; (b) blood vessels of 2 types :
- Vascular spaces without a muscle coat and are the cause of severe bleeding.
- Feeding vessel : mainly from maxillary artery.
Clinical picture :
 Unilateral (early), bilateral (late) nasal obstruction with foeted discharge.
 Recurrent attacks of severe epistaxis (anaemic patient).
 Nasal tone (rhinolalia clausa).
 Anterior and posterior rhinoscopy: show lobulated pink mass, bleeds on touch.
 Signs due to extensions (late) :
- To the nose leading to broadening of the nasal bridge, to the cheek leading to
facial swelling and to the orbit leading to proptosis (frog-face deformity).
- To the Eustachian tube leading to secretory otitis media
Investigations :
 CT scan to detect site, size and extension.
 Angiography to show feeding blood vessel to do preoperative embolization.
 Biopsy : contraindicated due to severe bleeding.
Treatment :
Surgical excision : Is the treatment of choice for operable cases.
 Trans-palatal approach, if the tumour is confined to the nasopharynx.
 Lateral rhinotomy approach, if the tumour extends to the nose and sinuses.
 Preoperative embolization of the feeding vessels to decrease bleeding during
operation.
(B) Malignant :
 Squamous cell carcinoma is the most common tumour of nasopharynx.
 Other rare tumours are lymphoepithelioma, lymphoma, adeno-carcinoma and
mixed salivary tumours.
Squamous cell carcinoma :
Etiology :
 Tobacco smoking and wood dust.
 Genetic : common in China.
 Epstein-Barr virus infection.
Pathology :
 The fossa of Rosenmuller (just above and behind the Eustachian tube orifice) is
the commonest site of origin.
Clinical picture :
 Enlarged cervical lymph nodes (from metastases) in old male patient is often the
presenting sign.
 Nasal symptoms :
- Nasal obstruction and discharge.
- Epistaxis (slight, intermittent).
 Aural symptoms : Unilateral secretory otitis media in old age is supicious.
 Symptoms of cranial nerve involvement :
- 3rd, 4th, 6th cause ophthalmoplegia.
- 5th causes trigeminal neuralgia.
- 10th causes vocal cord paralysis.
- 11th causes paralysis of the palate.
- 12th causes paralysis of the tongue.
*** Trotter's triad :
The 3 main symptoms due to local invasion by nasopharyngeal carcinoma :
- Unilateral facial pain (Trigeminal nerve).
- Unilateral conductive deafness (Eustachian tube).
- Unilateral palatal immobility.
Diagnosis :
 CT scan of the nasopharynx and skull base to detected tumour extension and
bone erosion, MRI to detect intracranial extension.
 Biopsy is essential.
Treatment :
 Radiotherapy is the treatment of choice as the tumours are radiosensitive.
 Surgery are usually limited to radical neck dissection for recurrence after
irradiation.
 DISEASES OF THE OROPHARYNX
Acute tonsillitis :
Acute inflammation of the palatine tonsils.
Aetiology :
 Organisms :
- Mainly by B-haemolytic streptococcus.
- Less commonly staph. aureus and pneumococcus.
- Usually these organisms are secondary invaders following a virus infection.
Clinical picture :
 Symptoms :
- General : Malaise, fever (may be accompanied with convulsions especially in
infants) and generalized bodyache.
- Local : sore throat, dysphagia, foetor oris and earache.
 Signs :
- Temperature : 39-40C.
- Full rapid pulse.
- Flushed face.
- Enlarged tender jugulo-digastric lymph nodes.
- Tonsils : according to type of tonsillitis :
a-Catarrhal type : Congestion of the tonsils and the adjacent pharyngeal
mucosa.
b-Follicular type : The crypts are full of pus and epithelial debris (follicles) which
may coalesce to form a membrane which confined to the tonsils (bilateral) and
does not spread to the palate, pharynx or larynx.
c- Parenchymatous type : There is diffuse enlargement and swelling of the whole
tonsil.
Complications :
 Local :
- Peritonsillar abscess (quinsy).
- Parapharyngeal abscess.
- Retropharyngeal abscess.
- Chronic tonsillitis.
 Near by :
- Acute otitis media.
- Laryngitis.
 General :
- Rheumatic fever.
- Nephritis.
Differential diagnosis :
Other causes of membrane on the tonsils : Diphtheria, vincente's angina,
agranulocytosis, leukaemia, glandular fever and fungal infection (moniliasis).
Treatment :
 Bed rest, soft diet ample fluid intake and warm antiseptic gargles.
 Systemic antibiotics for 10 days and analgesics.
Chronic tonsillitis :
 Chronic inflammation of the tonsils due to recurrent attacks of acute tonsillitis and
insufficient treatment of acute tonsillitis.
 It is more common in children between 4-15 years.
 Usually associated with enlargement of the nasopharyngeal tonsil (Adenoid).
 It may be hypertrophic or atrophic (from fibrosis).
Symptoms :
 Local :
- Persistent or recurrent sore throat.
- Bad mouth odour (due to pus in the crypts).
- Irritating cough.
- Snoring (sleep apnea), dysphagia and speech difficulties (if large).
 General : Symptoms of septic focus
- Fatigue, low grade fever, headache (due to chronic toxaemia) anorexia (due to
swallowing of septic tonsillar materials).
- Skeletal system : arthritis, myositis, backache and joint pains.
- Cardiovascular system : carditis, anaemia and increased sedimentation rate.
- Urinary system : Nephritis.
 - Skin : eczema and psoriasis.
- Eye : Iridocyclitis.
Signs :
 Persistent congested anterior faucial pillars.
 Persistent enlargement of the jugulodigastric lymph glands (tonsillar gland).
 Inequality of both tonsils and irregularity of the crypts.
 Intratonsillar abscess.
 Squeezing of pus from the crypts on pressure on the tonsils (sure sign).
Treatment : Tonsillectomy.
 TONSILLECTOMY
Excision of the palatine tonsils.
Indications :
A- Inflammatory :
1- Repeated acute attacks (more than 3-4 times per year for at least 2 years).
2- One attack of quinsy.
3- Chronic non specific tonsillitis either atrophic or with marked enlargement interfering
with swallowing or breathing (obstructive sleep apnea).
4- Chronic specific tonsillitis :
 Diphtheria carrier.
 Primary tuberulosis.
 Fungus infection.
B- Traumatic :
 Impacted foreign body tonsil which cannot be removed (unilateral tonsillectomy).
C- Neoplastic : (Unilateral tonsillectomy).
 Benign : Papilloma.
 Malignant : Carcinoma, very early (excional biopsy).
D- Adjacent septic focus :
 Recurrent otitis media.
 Persistent cervical adenitis especially if T.B is suspected (as the tonsils are the
portal of entry of T.B bacilli).
E- Distant septic focus :
 Rheumatic fever.
 Nephritis.
F- Step in other surgical procedure :
As a part of UVPP (uvulo palatophryngoplasty) and 9th nerve neurectomy.
Contraindications :
Absolute :
 Bleeding disorders : e.g. haemophilia, purpura and leukaemia.
 Advanced heart, kidney and chest diseases.
Relative :
 Acute tonsillitis, to avoid haemorrhage.
 Upper respiratory infection to avoid postoperative anaesthetic complications.
 Epidemics of poliomyelitis for fear contracting polio.
 Anaemia, hypertension, diabetes to avoid complications of these diseases.
  High sedimentation rate (active rheumatic fever) to avoid subacute bacterial
endocarditis.
 Pregnancy to avoid abortion or premature labour.
 Menstruation to avoid bleeding.
Preoperative preparations :
1- History : to exclude any contraindications as bleeding tendency.
2- General examination : to evaluate the general condition of the patient and exclude
any contraindication for anaesthesia.
3- Investigations :
a- Blood examination : CBC, bleeding time, clotting time, prothrombin time, Hb % (do
not do the operation if Hb % is less than 70%) and ESR.
b- Urine for sugar (Diabetes) and albumin (nephritis).
c- Chest x-rays.
d- ECG in adults and in suspected cardiac patients (penicillin for 4 days before the
operation to avoid subacute bacterial endocarditis).
e- Fasting for at least 6 hours before surgery to avoid inhalation of vomitus during
recovery from anaesthesia.
Anaesthesia : general
Postoperative care :
1- Position of the patient :
- Post tonsillectomy position : The patient lies on one side, the lower limb near the bed
is flexed till the chest while the other lower limb is extended, put a small pillow infront
of the patient chest for support, the bed side upper limb is flexed while the other upper
limb is extended over the pillow.
- This position allows early detection of bleeding, any vomitus can easily get out,
avoids falling back of the tongue and allow observation of the colour (cyanosis).

2- Observation of :
- Colour : cyanosis (respiratory obstruction) and pallor (hemorrhage).
- Pulse : rapid (hemorrhage).
- Blood pressure : drop (hemorrhage).
- Vomiting and hemorrhage (reactionary).
- Frequent swallowing movement (hemorrhage).
3- Feeding :
- 2-3 hours after the operation to avoid vomiting.
- The 1st day : cold soft foods and fluids.
- 2nd day : semi solid food.
- 3rd day : normal diet, avoid hard and spicy foods.
4- Medications :
Antibiotic (for one week) and analgesics.
Complications :
1-Complications of general anaesthesia.
2-Hemorrhage : the commonest complications :
a-Primary hemorrhage : hemorrhage during operation :
Causes :
- Improper preparation of the patient.
- Bad dissection (not in the proper plane).
- Fibrosed tonsillar bed e.g. quinsy.
Treatment :
- Ligation of the bleeding vessels and diathermy.
- Suture the pillars with or without pack.
- If not controlled : blood transfusion and ligation of the ext. carotid artery.
b- Reactionary hemorrhage :
- Hemorrhage during the first 24 hours after the operation.
- Due to :
 Failure to ligate all bleeding vessels.
 Slipping of a ligature.
 Dislodging of a thrombus by coughing or straining.
 Rising of blood pressure during recovery from anaesthesia.
- The condition is diagnosed by spitting fresh blood, pulse is increasing, blood
pressure is decreasing, frequent swallowing, vomiting of dark altered blood and
shock (in severe cases).
Treatment :
Mild cases :
- Remove the blood clots from the tonsillar bed and apply pressure with a cotton
swab soaked in a solution of hydrogen peroxide and ephedrine.
Severe cases :
- Ligate the bleeding vessels under general anaesthesia.
- Suturing of the pillars may be needed.
- If not controlled ligation of ext. carotid artery.
- Blood transfusion and anti-shock measures.
c-Secondary hemorrhage : Occurs between 3rd to 10th day after the operation due
to infection of tonsillar bed.
Treatment :
- Antibiotic injection.
- Local gurgle with H2O2 or pressure with gauze soaked in H2O2.
- If bleeding continue : suturing of the pillars on a pack for 2 days.
3-Injury : Teeth, tongue, lips, palate (nasal regurge) and dislocation of jaw from
mouth gag.
4-Infection :
 Local sepsis : causing dysphagia, bleeding and foetor oris.
 Near by :
- Otitis media.
- Cervical lymphadenitis.
 - Parapharyngeal abscess.
 General : Bacteraemia causing flaring up of rheumatic activity, nehritis and
endocarditis in susceptible patients (prophylactic penicillin should be give pre-
and post-operation).
5-Incomplete removal.
6-Pulmonary complications :
a-Respiratory obstruction : due to
- Extubation spasm of the vocal cords (suction of blood or secretion on cords and
give oxygen).
- Falling back of the tongue (pull the mandible forwards, put an air way)
- Inhalation of blood clots, vomitus tonsillar tissue or piece of gauze (bronchoscopic
removal).
b- Aspiration pneumonia, lung abscess.
 INFLAMMATION OF THE PHARYNX
Types :
a-Acute pharyngitis.
b-Chronic pharyngitis.
c- Pharyngeal manifestations of blood diseases.
ACUTE PHARYNGITIS :
Acute inflammation of the mucosal lining of the pharynx.
Types :
 Non-specific acute pharyngitis :
Acute simple pharyngitis.
 Specific acute pharyngitis :
a-Bacterial :
- Diphtheria.
- Vincent's angina.
b- Fungal :
- Moniliasis (candidiasis or thrush).
c-Viral :
- Infectious mononucleosis (glandular fever).
- Acquired immuno-deficiency syndrome (AIDS).
ACUTE SIMPLE PHARYNGITIS :
Etiology :
 Causative organisms :
- Mostly primary viral infection. In association with common cold and influenza.
- May be followed by bacterial infection with Streptococcus haemolyticus
(commonest) Streptococcus pneumoniae and Haemophilus influenzae.
 Mode of transmission : Droplet infection.
Symptoms :
 General symptoms : Rapid onset of fever, headache, anorexia and malaise.
 Pharyngeal symptoms : Rapid onset of severe sore throat and referred otalgia.
Signs :
 General signs : High fever and flushed face.
 Pharyngeal signs :
- Diffuse hyperaemia of the pharyngeal mucosa.
 Cervical signs : Enlarged tender upper deep cervical lymph nodes.
Complications :
 Spread of infection : otitis media and laryngitis.
Treatment :
 Antibiotics therapy. rest, ample fluid intake, analgesics, antipyretics and gargles.
DIPHTHERIA :
- An acute membranous inflammation caused by corynebacterium diphtheria.
- Usually affects the pharynx (faucial diphtheria). It may involve the larynx or the nose.
Children are particularly affected, especially between 2-5 years.
Incidence :
- The incidence of faucial diphtheria has fallen markedly in the last few decades due
to the vaccination programmes.
- The organism is transmitted by droplet infection and has an incubation period of 2-5
days.
Pathology :
The organism remains localized on the mucous membrane and secretes a powerful
exotoxins which cause necrosis of the epithelium and circulate in the blood causing
complications. A false membrane is formed of the necrotic epithelium, blood cells, pus
and thick fibrinous exudates.
Symptoms :
 General symptoms : gradual onset of fever, headache, anorexia and malaise.
 Pharyngeal symptoms :
- Mild sore throat and referred otalgia.
- Bad mouth odour (halitosis).
Signs :
 General signs :
- Mild fever.
- Severe toxaemia : pallor and rapid pulse out of proportion to temperature.
 Pharyngeal signs: Formation of a false membrane (pseudo-membrane) which :
- is unilateral,
- exceeds the limits of the tonsil to the pillars,
- has a dirty grayish color,
- has an offensive odour,
- is adherent to the underlying tissues → leaves a bleeding raw surface on removal
and reforms rapidly after removal.
 Cervical signs : Markedly enlarged tender deep cervical lymph nodes (Bull neck
appearance).
Differential diagnosis :
From causes of membrane on the tonsil and pharynx e.g.acute tonsillitis, Vincent
angina, scarlet fever, infectious mononucleosis, a granulocytosis and moniliasis.
 Acute follicular tonsillitis Diphtheria
Age Any age 2-5 years
Onset Rapid Gradual
Pain Severe Slight
Face Flushed Pale
Fever High 39-40 Moderate 37.5 to 38
Pulse Rapid proportionate with the Very rapid disproportionate to the rise of
rise of temperature and full temperature thready feeble (toxic
myocarditis)
Toxaemia Moderate the patient is Severe the patient is flabby
irritable
Local The membrane is not Spreads beyond the tonsil e.g.to the palate,
examination extending beyond the tonsil posterior pharyngeal wall, adherent and
can be easily separated leaves bleeding surface on stripping
Lymph Moderate swelling The whole neck is swollen
nodes
Blood P.N.Ls and leucocytosis Slight lymphocytosis
Swab Haemolytic streptococci Positive for diphtheria bacilli
Albumin in Uncommon Common
urine
Complications :
Early complications : In the first week
 Due to effect of the membrane :
- On the larynx (by extension) causing laryngeal obstruction.
- On the lungs (by inhalation) causing lung collapse.
 Due to effect of the exotoxins :
- On the heart causing toxic myocarditis.
- On the kidney causing acute nephritis.
Late complications :
 After 2 to 3 weeks.
 Due to peripheral neuritis (caused by the exotoxins) affecting :
- 3rd, 4th, 6th cranial nerves leading to eye muscles paralysis (diplopia and
ophthalmoplegia).
- 9th, 10th, 11th cranial nerves leading to :
a-Palatal paralysis (regurgitation of food from the nose and deviation of uvula to
the normal side). The commonest and the earliest neurological
complications.
b-Laryngeal paralysis (hoarseness and aspiration).
 c- Pharyngeal paralysis (dysphagia).
d-Chest muscles paralysis (respiratory failure).
e-Affection of the cardiac muscles (heart failure).
Treatment :
A- Curative treatment :
 Isolation in a fever hospital until 3 successive swabs are –ve.
 Absolute rest in bed to prevent heart failure.
 Antitoxic serum 30,000 to 100,000 I.U (according to age and severity) is given I.M
or I.V should be given once diphtheria is suspected (if toxins fix into the tissues, it
can no longer be neutralized by the antitoxins) :
- Intradermal sensitivity test should be done to the patient before the administration
of the antitoxic serum.
- If the patient is sensitive (raised red indurated patch), descensitization is done by
repeated injections of gradually increasing doses of the serum.
- If allergic reactions occur after administration of the antitoxic serum, use
cortisone, antihistamine, calcium and adrenaline.
 Penicillin (drug of choice for corynebacterium diphtheria) 0.5-1 million I.U is given
for 10 days.
B- Prophylactic treatment :
 Active immunization : The triple vaccine (D.P.T) for immunization against
diphtheria, pertussis and tetanus is given I.M in 3 successive doses, compulsory to
infants at the age of 3,4,5 months. A booster dose is given at school age.
 Passive immunization : a dose of 3,000 – 10,000 I.U of antitoxic serum is given to
contacts.
 Tonsillectomy for carriers.
Treatment of complications :
a-Cardiovascular : rest, raise foot of bed, oxygen.
b-Palate and pharynx paralysis : nasogastric tube.
c- Respiratory muscle paralysis : mechanical ventilation.
d-Stridor : tracheostomy.
e-Renal failure : dialysis.
VINCET'S ANGINA
Acute ulcerative inflammation of the pharynx affecting tonsils, fauces and gums.
Etiology :
 Causative organisms : Gram –ve fusiform bacilli and borrelia vincenti (spirochaeta
denticola).
 Predisposing factors : prolonged use of antibiotics, bad oral hygiene (carious
teeth).
Symptoms :
 General : absent or very mild fever.
 Local : sore throat (pain is marked), fetor oris and unilateral tender cervical lymph
node.
Signs :
 Unilateral ulcer on tonsil covered by grayish yellow membrane, non adherent,
easily removed leaving an excavating ulcer with irregular edge.
Investigations : Throat swab : film shows organisms.
Treatment :
 Hydrogen peroxide mouth wash.
 Penicillin or Erthromycin and Metronidazole.
MONILIASIS (Thrush)
Fungus infection of the pharynx by Candida albicans.
Predisposing factors :
 Debilitating conditions.
 Prolonged use of broad spectrum antibiotics or corticosteroids.
 Immune deficiency states e.g. AIDS, diabetes, malignancies and chronic
debilitating diseases.
Symptoms :
No fever, sore throat and severe dysphagia.
Signs :
White patches of thin membrane which can be easily removed, appear over the
mucosa of the pharynx and cheek.
Treatment :
 Stop the used drugs.
 Vitamins.
 Nystatin or amphotericin suspension paint or gentian violet 1% paint.
CHRONIC PHARYNGITIS
Non specific :
Aetiology :
 Recurrent attacks of acute pharyngitis.
 Nasal obstruction (mouth breathing) and sinusitis.
 Teeth and gums infections.
 Excessive use of tobacco.
 Reflux oesophagitis.
Symptoms :
 Irritation in the throat (sore throat).
 Hawking (frequent clearing the pharynx).
Signs :
The pharyngeal mucosa may show one of the following clinical types :
 Catarrhal : red congested mucosa with enlarged uvula.
 Hypertrophic : small nodules of lymphoid tissue are scattered over the pharyngeal
wall, giving a granular appearance.
 Atrophic : dry and glazed mucosa with some viscid mucous on the surface (usually
accompanied by atrophic rhinitis).
Treatment :
 Treat the predisposing factors.
 Local applications e.g. gurgle, lozenge, spray.
Chronic Specific :
A- Syphilis :
 Very rare now.
Primary :
- Chancre : Painless nodule affect the tonsils.
- Cervical adenitis.
Secondary :
- Mucous patch : grayish rounded area over the tonsils, tongue and cheek.
- Skin rash.
- Generalized lymphadenopathy.
Tertiary :
- Gumma : hard mass on the palate, post. Pharyngeal wall. It ulcerates giving
ulcer with deep punched out edge, indurated base and necrotic yellowish floor
(wash-leather appearance).
- It infiltrates the palate causing perforation.
- It cause adhesions between the palate and posterior pharyngeal wall.
B- Tuberculosis (T.B) :
 Primary or secondary to pulmonary T.B.
 It gives small tubercle on the tonsil and palate which ulcerate giving painful ulcer
with undermined edge and pale granulations in the floor.
C- Scleroma :
 Associated with rhinoscleroma.
 Glazed atrophic mucosa with crustation but without ulceration.
 It cause adhesions between the palate and posterior pharyngeal wall.
 PHARYNGEAL MANIFESTATIONS
OF BLOOD DISEASES
I- Infectious mononucleosis :
Acute pharyngitis caused by Epstein Barr virus.
Symptoms :
 Sore throat and dysphagia.
 Fever, headache and malaise (Febrile type).
Signs :
 Generalized lymphadenopathy and splenomegally (glandular type).
 Pharyngeal ulcers surrounded by congested area and covered by whitish
membrane (anginose type).
Investigations :
 Blood picture : monocytosis and lymphocytosis with atypical lymphocytes.
 Serological test : positive paul Bunnell's test i.e patients serum can agglutinate
sheep RBCs (due to presence of abnormal antibodies).
Treatment :
 Antibiotics therapy to avoid secondary bacterial infection.
 Supportive and symptomatic measures as rest, ample fluid intake, analgesics,
antipyretics and gargles (as warm tea with lemon).
 Systemic steroids in severe cases.
II- Agranulocytosis :
A grave condition characterized by marked reduction in the neutrophil polymorphs, due
to bone marrow depression.
Etiology :
 Primary : idiopathic.
 Secondary to :
- Drugs containing the benzene ring e.g. sulphonamides, cytotoxic drugs or
chloramphenicol.
- Irradiation.
- Terminal stage in renal and hepatic failure or malignancy.
Clinical picture :
 Sore throat of sudden onset.
 Necrotic ulceration (without red inflammatory reaction around) in the oral and
pharyngeal mucosa which later become extensive and form gangrenous
stomatitis.
 Malaise with prostration which may be terminal.
Diagnosis :
 Blood picture shows leucopenia down to 2000 cells/ml and neutrophils down to
400 cells/ml.
 Sternal puncture.
Treatment :
 Stop the causative drug.
 Blood transfusion and vitamin B12.
 Systemic antibiotics for secondary infection.
 Bone marrow transplantation.
III- Acute leukaemia :
Neoplastic disease of the bone marrow leading to marked increase in the number of
immature blast white blood cells.
Clinical picture :
 Hypertrophied bleeding gums.
 Generalized lymphadenopathy and splenomegaly.
 Sternal tenderness.
 Sore throat with extensive necrotic ulcers and pseudo-membrane on the
pharyngeal mucosa.
Investigations :
 Blood picture : marked leucocytosis (with many immature blast cells), anaemia
and thrombocytopenia.
 Bone marrow aspirate (sternal puncture) : diagnostic.
Treatment :
 Hospitalization, isolation and systemic antibiotics to prevent secondary infection.
 Repeated fresh blood transfusion.
 Chemotherapy and bone marrow transplantation.

ULCERS OF THE OROPHARYNX

I- Local causes :
1- Traumatic :
 Mechanical e.g. ill fitting denture, cheek biting and jagged teeth (ulcers have
punched out serrated edges, soft base, red granulations in the floor, heals in few
days).
 Thermal : too hot foods or drinks.
 Chemical : corrosives, tobacco (hyperkeratosis).
 Radiotherapy : dryness of the oral mucosa (xerostemia).
2- Infective :
Bacterial :
 Acute specific :
- Diphtheria : dirty white grayish pseudomembrane.
- Vincent angina : deep ulcer.
 Chronic specific :
- T.B : undermined edge, superficial with pale granulation tissue.
- Syphilis : deep punched out, wash leather slough and indurated base.
 Fungal : Moniliasis.
 Viral :
- Herpes simplex : herpetic stomatitis with vesicles on the buccal mucosa which
rupture giving painful shallow ulcers with red edematous margin.
- Herpes zoster : vesicular eruption on palate, tonsils and posterior pharyngeal
wall with shallow ulcers, usually accompanied by herpes zoster otitis.
- Infectious mononucleosis.
- AIDS : caused by HIV, persistent oral thrush, moniliasis, herpetic ulcers and
cervical lymphadenopathy.
3- Malignant ulcer :
 Ulcer with everted edge, indurated base and necrotic floor.
II-Miscellaneous causes :
1-Blood diseases : acute leukaemia and a granulocytosis.
2-Dyspeptic ulcers : small punched out painful ulcer on the lips, cheek, and the
tongue. Usually related to gastrointestinal disorders.
3-Behcet's syndrome :
 Iritis with oropharyngeal and genital ulcers.
 Aetiology : unknown.
 Treatment : steroids (local and systemic).
4-Vitamin deficiency :
 Vit. B deficiency: it gives painful red swollen glazed tongue.
Vit. C deficiency (scurvy): gives swollen easily bleeding gums.
5-Skin diseases :
 Pemphigus : the oral lesion is in the form bullae that rupture to form painful
ulcers.
 Lichen planus : the oral lesion is in the form erythematous lesions which form a
painful ulcers.
 Both diseases are treated by steroids.
6-Drugs : Hypersensitivity lead to vesicles which rupture give ulcers.
 7-Cancrum oris : occurs in immunocompromized patient, ulceration of the gum,
buccal mucosa with sloughing bone exposure and gangrene.
8-Recurrent aphthous stomatitis :
Commonest cause of oral and pharyngeal ulceration.
Etiology :
Unknown. May be vitamin deficiency, immunological disturbance or stress.
Clinical picture :
 General manifestations : Good general condition.
 Pharyngeal manifestations : Recurrent single or multiple small painful oral and
pharyngeal ulcers which are surrounded with marked hyperaemia. They heal
spontaneously within 1-2 weeks.
Treatment : Local corticosteroids.
 SUPPURATION IN SPACES RELATED
TO THE PHARYNX
(A) Peritonsillar abscess (Quinzy) :
Collection of pus in peritonsillar space i.e. between tonsil capsule and its bed (superior
constrictor muscle).
Pathogenesis :
 Repeated attacks of acute tonsillitis leads to fibrosis and obstruction of the
opening of the crypts especially crypta magna.
 In acute tonsillitis pus accumulates within the obstructed crypts which rupture in
the peritonsillar space.
Clinical picture :
 Usually in adult (rare in children).
 Usually unilateral in fibrotic tonsils, it may occur over tonsillar remnants.
Symptoms :
Symptoms of acute tonsillitis becomes more severe.
 Fever (up to 41C), anorexia and malaise.
 Pain becomes unilateral, throbbing and radiates to the ear.
  Dysphagia becomes more severe up to the degree of drooling saliva.
 Speech becomes thickened (muffled).
 Trismus due to reflex spasm of the medial pterygoid muscle.
 Torticollis due to reflex spasm of the sternomastoid muscle.
 Foetor oris.
Signs :
 The soft palate is oedematous above and lateral to the tonsil (pitting oedema on
probing).
 The tonsil is pushed downwards and medially.
 The uvula is oedematous and pushed to the other side.
 The cervical glands are enlarged and tender.
Differential diagnosis :
 Tumours of the tonsil :
- No acute symptoms.
- No pus on aspiration.
- Biopsy is diagnostic.
 Aneurysm of the int. carotid artery :
- Pulsations are seen.
- Blood on aspiration.
 Parapharyngeal swelling (Bec's triad).
 Unilateral hypertrophied tonsil (no acute symptom and uvula is central).
Complications :
 Rupture with aspiration of pus → bronchopneumonia.
 Spread of infection to :
- Parapharyngeal space (parapharyngeal abscess).
- The larynx (laryngeal obstruction).
- Septicemia.
Treatment :
 Medical treatment :
Before pus formation i.e in the stage of peri-tonsillar cellulites by massive antibiotic
therapy.
 Surgical treatment :
A- Drainage of the abscess.
After pus formation i.e in the stage of peri-tonsillar abscess: as indicated by throbbing
pain, fever become hectic, pitting edema and aspiration brings pus.
- How ?
o Anaesthesia commonly surface with the patient sitting.
o The incision is performed with a guarded scalpel or better a quinsy knife in one
of these points :
a- Most pointing point. b- Crypta magna.
c- Midway between the last upper molar tooth and base of the uvula.
d- 1/2 cm lateral to the meeting point of two lines : a vertical line along the anterior
pillar and a horizontal line along the base of the uvula.
o The drainage is performed by a quinsy forceps; using Hilton's method i.e the
forceps is introduced closed → opened in the abscess → withdrawn out open.
 B- Tonsillectomy:After 4-6 weeks to avoid recurrence of quinsy.

(B) Parapharyngeal abscess :

Suppuration in the parapharyngeal space.
Causes :
 Quinzy, acute tonsillitis and after tonsillectomy.
 Infection of last molar teeth.
 Petrositis (petrous apex is the roof of this space).
 Suppuration in cervical lymph node.
 Sharp foreign body.
Clinical picture :
 As quinsy : fever, anorexia, headache, malaise, pain, dysphagia, trismus and
torticollis.
 Bec's triad (diagnostic) :
- External neck swelling below and behind the angle of the mandible deep to the
anterior border of sternomastoid.
- Internal swelling in the lateral wall of the pharynx (pushing the tonsil medially).
- Trismus : due to spasm of medial pterygoid muscle.
Investigations : CT is diagnostic.
Complications :
The infection may spread to :
 Base of the skull causing meningitis.
 Mediastinum causing mediastinitis.
 Internal jugular vein causing thrombophilibitis.
 The larynx causing laryngeal oedema.
Treatment :
 Systemic antibiotics, analgesic and antibiotic.
 Incision along the anterior border of the sternomastoid muscle and drainage of the
abscess.
(C) Reteropharyngeal abscess :
An abscess in the retropharyngeal space which may be acute or chronic.
I- Acute retropharyngeal abscess :
An abscess in one side of the midline of the pharynx between the buccopharyngeal
and the prevertebral fasciae (Space of Gilette).
Etiology :
 Suppuration of the retropharyngeal glands of Henle in children under the age of 5
years (later the glands atrophy).
 The glands are usually infected from due to infection in nose, pharynx and tonsils.
Symptoms :
 Fever, malaise and anorexia.
 Stridor and croupy cough.
 Dysphagia difficult suckling and drooling of saliva.
 Torticollis.
Signs :
 Swelling in one side of the midline of the pharynx.
 Enlarged tender cervical glands.
Investigations :
 Plain x-ray lateral view neck shows widening of the prevertebral space in cervical
region.
 CT is diagnostic.
Complications :
 Laryngeal edema and respiratory obstruction.
 Rupture leads to inhalation, suffocation and pulmonary complications.
Treatment :
 Antibiotics.
 Longitudinal incision is done from the mouth. Avoid inhalation of pus by cuffed
endotracheal tube and using an electric sucker.
 Tracheostomy if needed.
II- Chronic retropharyngeal abscess :
Etiology :
 T.B caries of the cervical vertebrae (Pott's disease). The cold abscess lies
centrally behind prevertebral fascia – seen in older children and young adults
usually secondary to pulmonary T.B.
  T.B. infection of the retropharyngeal lymph nodes due to spread of infection from
deep cervical lymph nodes. The abscess here lies laterally in the retropharyngeal
space i.e infront the prevertebral fascia.
Clinical picture :
 General: T.B toxaemia i.e loss of weight, night fever, sweating and cough with
expectoration and may be haemoptysis.
 Local :
- Sore throat and mild dysphagia.
- Swelling in the midline of the pharynx (laterally if due to T.B lymphadenitis).
- Tender cervical spine.
- Enlarged cervical lymph nodes.
Investigations :
 X-ray lateral view neck : widening of prevertebral space with destroyed vertebrae.
 CT is diagnostic.
 Investigations for T.B : as chest x-ray and sputum analysis.
Treatment :
 External surgical drainage : incision from outside along posterior border of
sternomastoid (not through mouth for fear of T.B enteritis).
 Anti-T.B drugs.

(D) Ludwig's angina :

Infection of the submandibular space :
 The submandibular space is divided by mylohyoid muscle into: (a) superior part i.e
sublingual space containing the sublingual gland; (b) inferior part i.e submaxillary
space containing the submandibular gland.
Etiology :
Spread of infection from lower premolar and molar teeth (80%), acute septic
pharyngitis and submandibular siloadenitis.
Clinical picture :
 Symptoms (like Quinzy) : The patient is toxic with fever, pain, trismus, severe
dysphagia and salivation.
 Signs (like parapharyngeal abscess) :
- External swelling in the submandibular region.
- Internal swelling : edema in the floor of the mouth leads to protrusion of the
tongue (backwards and upwards).
- Trismus.
Complications :
 Respiratory obstruction by extension of edema to the larynx or falling of the tongue
backwards.
Treatment :
 Antibiotics and analgesics.
 Drain the abscess with external
transverse curved incision
parallel to the mandible (in the
submandibular region).
 Tracheostomy may be needed.
 DISEASES OF THE HYPOPHARYNX
Pharyngeal pouch (Zenker's diverticulum)
Herniation of the pharyngeal mucosa through Killian's dehiscence (the space between
the oblique fibers "Thyropharyngus muscle" and circular fibers "Cricopharyngus
muscle" which together form the inferior constrictor muscle).
Etiology (pathogenesis) :
Normally, when the oblique part contracts, the transverse part relax to allow the bolus
to pass the oesophagus (second stage of deglutition). If there is contraction of both parts
at the same time due to neuromuscular in-coordination, the mucous membrane bulges
through the weak area. This usually occurs in elderly male.
Clinical picture :
 Small pouches are usually asymptomatic.
 Dysphagia is of long standing.
 Regurgitation of undigested food.
 Cough is caused by aspiration of fluid from the pouch
into the larynx.
 Swelling in the neck, usually on the left side under
sternomastoid, cystic and empty on external pressure.
Investigations :
 Barium swallow : the pouch appears with a smooth lower border (retort-shaped
swelling).
 Hypopharyngoscopy : froth in pyriform fossa and opening of the pouch may be
seen.
Complications :
 0.5 – 1% develops squamous cell carcinoma.
Treatment :
 Endoscopic treatment :
- Repeated dilatation of cricopharyngeal
sphincter.
- Endoscopic diathermy of the septum
between pouch and esophagus.
 Surgical :
- Cricopharyngeal myotomy.
- Excision of the pouch (diverticulectomy) with
crico-pharyngeal myotomy to prevent
recurrence.
Plummer Vinson syndrome
(Paterson-Brown Kelly syndrome, Chronic pharyngo-esophagitis).
Chronic atrophic inflammation of the hypopharynx and upper esophagus.
Etiology :
Unknown. Iron and vitamins deficiency may be the cause. It occurs most commonly in
females over 40 years of age.
Pathology :
Atrophy of mucosa of hypopharynx and esophagus with submucosal fibrosis leading to
web formation and even stricture.
Clinical picture :
 Dysphagia of long duration (first for solids, later for fluids).
 Angular stomatitis (fissures at angles of the mouth).
 Superficial glossitis.
 Koilonychia (spoon-shaped nails).
 Hypochromic microcytic anaemia (Pallor).
 Achlorhydria (from gastritis).
 Splenomegally in 50% of cases.
Complications :
 Precancerous condition, about 10% turns to postcricoid carcinoma suspected by
rapid progression of dysphagia, hoarseness of voice and cervical lymph node.
Investigations
 Blood : Microcytic anemia with decreased serum iron.
 Gastric secretion : Achlorohydria.
 Barium swallow : Post-cricoid web, stricture at upper esophagus.
 Oesophagoscopy : Smooth, atrophic mucosa, web or stricture.
Treatment :
 Iron and vitamins.
 Repeated endoscopic dilatation.
 Regular observation to exclude post-cricoid carcinoma.

TUMOURS OF THE HYPOPHARYNX

A- Benign : Rare, Fibroma, papilloma, angiofibroma.
B- Malignant : The most common is squamous cell carcinoma.
Malignant tumours of the hypopharynx:
Pathology :
 Squamous cell carcinoma.
 Sites:
1- Pyriform fossa (50%).
2- Postcricoid area (40%)
3- Posterior pharyngeal wall (10%)
 Predisposing factor: plummer Vinson syndrome predisposed to postcricoid
carcinoma in females.
 Silent area may give lymph nodes before local symptoms (poor prognosis).
Symptoms :
 Early : vague symptoms (sore throat), enlarged cervical lymph node may be the
presenting symptom.
 Dysphagia : progressive, first to solids then to fluids.
 Extension to the larynx leads to hoarseness and stridor especially postcricoid
carcinoma.
 Cancer cachexia.
Signs :
 Indirect laryngoscopy :
- Pooling of saliva in pyriform fossa carcinoma.
- Tumour mass or ulcer could be seen.
- Cord paralysis may be present.
 Moure's sign positive in postcricoid carcinoma (absent click which is normally
present due to friction of thyroid cartilage against vertebral bodies).
N.B. : Absence of normal laryngeal click may occur also in reteropharyngeal abscess and
perichondritis.
 Cervical lymph node enlargement.
Investigations :
 Plain x-ray lateral view head and neck :
- Widening of prevertebral space in postcricoid area.
- Soft tissue shadow in pyriform fossa.
 Ba swallow : detect the lower limit of the tumour.
 CT and MRI : detect extent, lymph node and pre-vertebral fascia involvement.
 Hypopharyngoscopy : to assess extent of tumour and take biopsy.
 General laboratory investigation to assess general condition of the patient for
surgery.
Treatment :
A- Curative : Early cases can be treated by surgery or irradiation. However
results of surgery are much better.
 Postcricoid carcinoma :
1-Total laryngopharyngectomy.
2-Repair of the pharynx by stomach pull-up or mycocutaneous flaps
e.g.pectoralis major.
 Pyriform fossa carcinoma :
1-Total laryngectomy.
2-Partial pharyngectomy.
3-Pharyngeal repair.
 Cervical lymph nodes : if present are treated by radical neck dissection.
B- Pallative treatment : For inoperable cases e.g.tumour fixed to the vertebral
column, fixed lymph nodes or distant metastasis.
- Pain killer e.g. morphine.
- Pallative irradiation.
- Gastrostomy for dysphagia.
- Tracheostomy for dyspnea.
- Radiotherapy or chemotherapy.