Acute pharyngitis

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 Outline
 Acute pharyngitis is an acute
inflammation of the pharyngeal
mucosa, even the submucosa and
lymphatic tissues also are suffered
from.
 It is usually resulted from the acute
tonsillitis and the acute rhinitis
or is frequently part of an upper
respiratory tract infection.
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 Causes
1.Viruses: Coxsakie
viruses 、 Adenoviruses 、
Rhinoviruses and influenza viruses.
2.Bacteria: E-hemolytic Streptococci 、
Hemophilus influenzae etc.
3.Environmental factor: such as high
temperature, dust, smoke and irrigate
gases etc.
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 Clinical manifestation
 1.Severe pain in the throat, particularly
odynophagia. The pain can refer to the ears.
 2.Clinical findings are comparatively mild.
 3.Mild to moderate hyperemia and edema
 4.Mild enlargement of the lymph nodes
might occur.
 5.The leukocyte count is not elevated and
might actually be depressed.
 6.If no complication occurs, the period usually is
one week.

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 Treatment
 General measures. Bed rest, plenty of
fluids, warm saline gargles or pharyngeal
irrigations and analgesics form the
mainstay of treatment.
1.Gargling with warm,diluted salt
water or Dobell’s solution.
2.Analgesics:e.g.,aspirin,10 mg or
acetaminophen, 360 mg three times
daily.
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Treatment
 3.Antiviruses or antibiotics. Specific
treatment. Streptococcal pharyngitis (Group
A, beta-haemolyticus) is treated with penicillin
G, 200,000 to 250,000 units orally four times
a day for 10 days or benzathine penicillin G,
600,000 units once Lm. for patient <60 lb in
weight and 1.2 million units once i.m. for
patient >60 lb. In penicillin-sensitive
individuals, erythromycin, 20 to 40 mgfkg
body weight daily, in divided oral doses for 10
days is equally effective.

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Treatment
 Diphtheria is treated by diphtheria
antitoxin and administration of penicillin
or erythromycin.
 Gonococcal pharyngitis responds to
doses of penicillin or tetracycline.
 4.If possible, swab the pharynx for
culture before treatment begins.

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Chronic pharyngitis

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 Outline
 Chronic pharyngitis is a wild-
spreading inflammation of the
pharyngeal mucosa 、 submucosa
and lymphtic tissues and is frequently
part of an upper respiratory tract
chronic infection.
 Major in adult, the period is long,the
symptom is not cured easily.
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classification
 Chronic pharyngitis is of two types:
 Chronic catarrhal pharyngitis
 Chronic hypertrophic (granular)
pharyngitis.

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 Causes
1.local reasons:
a. Acute pharyngitis occurred repeatedly.
b. Various rhino disease and chronic
respiratory tract inflammation.
c. Excessive drinking and smoking, dust,
stimulation of the harmful gases and pungent
food etc.

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Aetiology

 A large number of factors are responsible:

 1. Persistent infection in the neighbourhood.
In chronic rhinitis and sinusitis, purulent
discharge constantly trickles down the
pharynx and provides a constant source of
infection. This causes hypertrophy of the
lateral pharyngeal bands.
 Similarly, chronic tonsillitis and dental sepsis
are also responsible for chronic pharyngitis
and recurrent sore throats.

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Aetiology

 Mouth breathing. Breathing through

the mouth exposes the pharynx to air
which has not been filtered, humidified
and adjusted to body temperature thus
making it more susceptible to infections.

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Aetiology
 Mouth breathing is due to:
 Obstruction in the nose, e.g. nasal
polypi, allergic or vasomotor rhinitis,
turbinal hyper­trophy, deviated septum
or tumours,
 Obstruction in the nasopharynx, e.g.
adenoids and tumours,
 Protruding teeth which prevent
apposition of lips,
 Habitual, without any organic cause.

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Aetiology

 2.Chronic irritants. Excessive smoking,

chewing of tobacco and pan, heavy drinking,
highly spiced food
 Environmental pollution. Smoky or dusty
environ­ment or irritant industrial fumes may
also be cause.
 Faulty voice production. Less often realised
but an important cause of chronic pharyngitis
in the faulty voice production.

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Aetiology
3. Whole reasons: such as anaemia,
dyspepsia, cardio-vascular disease, deficient of
vitamin and immune dysfunction et al.

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Clinical manifestation
 Discomfort or pain in the throat. This is
especially noticed in the mornings.
 Foreign body sensation in throat. Patient has a
constant desire to swallow or clear his throat to
get rid of this "foreign body".
 Tiredness of voice. Patient cannot speak for long
and has to make undue effort to speak as throat
starts aching. The voice may also lose its quality
and may even crack.
 Cough. Throat is irritable and there is tendency to
cough. Mere opening of the mouth may induce
retching or gagging.
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 sign
 Chronic catarrhal pharyngitis.
 In this, there is a congestion of posterior
pharyngeal wall with engorgement of vessels;
faucial pillars may be thickened. There is
increased mucus secretion which may cover
pharyngeal mucosa.

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sign
 Chronic hypertrophic (granular) pharyngitis
 Pharyngeal wall appears thick, oedematous, congested
mucosa & dilated vessels.
 Posterior pharyngeal wall may be studded with red­dish
nodules (hence the term granular pharyngitis). These
nodules are due to hypertrophy of subepithe­lial lymphoid
follicles normally seen in pharynx
 Lateral pharyngeal bands become hypertrophied.
 Uvula may be elongated and appear oedematous

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Treatment
 In every case of chronic pharyngitis,
aetiology factor eradicated.
 Voice rest and speech therapy is
essential for those with faulty voice
production. Hawking, clearing the throat
frequently or any other such habit should
be stopped.

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 Treatment
 Warm saline gargles, in the morning, are
soothing and relieve discomfort.
 Mandl's paint may be applied to
pharyngeal mucosa.
 Cautery of lymphoid granules is
suggested. Throat is sprayed with local
anaesthetic and granules are touched
with 10-25% silver nitrate.
 Electrocautery or diathermy of nodules
may require general anaesthesia.
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PALATINE TONSIL

 Palatine tonsils are two in number, ovoid

mass of lymphoid tissue situated in the lateral
wall of oropharynx between the anterior and
posterior pillars. Actual size of the tonsil is
bigger than the one that appears from its
surface as parts of tonsil extend upwards into
the soft palate, downwards into the base of
tongue and anteriorly into palatoglossal arch.
A tonsil presents two surfaces-a medial and a
lateral, and two poles-an upper and a lower.

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PALATINE TONSIL
 Blood Supply
 The tonsil is supplied by five arteries.
 Tonsillar branch of facial artery. This is the
main artery.
 Ascending pharyngeal artery from external
carotid.
 Ascending palatine, a branch of facial artery.
 Dorsal linguae branches of lingual artery.
 Descending palatine branch of maxillary
artery

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Lymphatic drainage

 Lymphatics from the tonsil pierce the

superior constrictor and drain into upper
deep cervical nodes particularly the
jugulodigastric (tonsillar) node situated
below the angle of mandible.

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Nerve Supply

 Lesserpalatine branches of
sphenopalatine ganglion (CN V) and
glossopharyngeal nerve provide
sensory nerve supply.

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Functions of Tonsils

 Like other lymphoid masses of Waldeyer's

ring, palatine tonsils have a protective role
and act as sentinels at the portal of air and
food passage. The crypts in tonsils increase
the surface area for contact with foreign
substances. Tonsils are larger in childhood
and gradually diminish near puberty. They
are removed when they themselves become
the seat of disease.

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Acute tonsillitis

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Causes:
 Acute tonsillitis often affects school-
going children, but also affects
adults.
 Haemolytic streptococcus is the
most commonly infecting organism.
Other causes of infection may be
staphylococci, pneumococci or H.
influenzae.

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 Pathology
It can be classified into three types:
1.Acute catarrhal tonsillitis:it is aroused
usually by viruses, the inflammation is
limited to the surface of the tonsil.
2.Acute follicular tonsillitis:the inflammation
involves the lymph follicle of the tonsillar
substance.
3.Acute lacunar tonsillitis:tonsil is congestive
and bulgy.The crypts show collection of
pussy material. 32
 Clinical
manifestation

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Symptom
 The symptoms vary with severity of
infection.
 Sore throat.
 Difficulty in swallowing. The child may
refuse to eat anything due to local pain.
 Fever. It may vary from 38 to 40°C and
may be asso­ciated with chills and rigors.

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Symptom
 Earache. It is either referred pain from the
tonsil or the result of acute otitis media which
may occur as a complication.
 Constitutional symptoms. They are usually
more marked than seen in simple pharyngitis
and may include headache, general body
aches, malaise and constipation. There may
be abdominal pain due to mesenteric
lymphadenitis simulating a clinical pic­ture of
acute appendicitis.

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 Sign
 Often the breath is foetid and tongue is
coated.

 There is hyperaemia of pillars, soft palate

and uvula.

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sign
 Tonsils are red and swollen with yellowish
spots of purulent material presenting at the
opening of crypts (acute follicular tonsillitis)
or there may be a whitish membrane on the
medial surface of tonsil which can be easily
wiped away with a swab (acute membranous
tonsillitis). The tonsils may be enlarged and
congested so much so that they almost meet
in the midline along with some oedema of the
uvula and soft palate (acute parenchymatous
tonsillitis).

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sign
 Thejugulodigastric lymph nodes are
enlarged and tender.

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 Diagnosis
 The diagnosis is generally easy and
depended on the typical clinical
manifestation.
 The differential diagnosis is
difficulty. We should differentiate it
from pharyngeal diphtheria,
Vincent’s angina, agranulocytic
angina, hypoleukocytic angina,
etc. 40
 Complications
Peritonsillar
abscess(Quinsy)

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 General complications
 Acute rheumatism
 Acute endocarditis
 Acute arthritis
 Acute nephritis
 Septicaemia
The occurrence of these complications
have something to do with Ⅲ type
allergic reaction which every target
organs produce to streptococcus.

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 Treatment
 Common treatment: rest, easily digestible
diet, laxative, analgesics, etc.
 Antibiotics: penicillin. culture and
sensitivity test. glucocorticoid
 Local treatment: gargling with Dorbell’s
solution (or compound sodium
borate solution).
 Traditional chinese medicine:
 Surgical treatment: This disease attacks
repeatedly, particularly having
complications.
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Chronic tonsillitis

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Outline
 Chronic tonsillitis results
from repeated attacks of
acute tonsillitis and pharyngitis
or bad drainage of the
tonsillar crypt.

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Aetiology
 It may be a complication of acute tonsillitis.
 Pathologically, micro abscesses walled off
by fibrous tissue have been.
 Subclinical infections of tonsils without an
acute attack.
 Mostly affects children and young adults.
Rarely occurs after 50 years.
 Chronic infection in sinuses or teeth may be
a pre­disposing factor.

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Causes
Streptococcus
Staphylococcus

Pathogenesis:
autoallergy

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Clinical
manifestation

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 Symptom
 History: repeated attacks of sore
throat which are due to attacks of acute
tonsillitis.
 Dryness and itch of throat, a feeling
of foreign body,irritant dry cough, etc.
 Difficulty in breathing and
swallowing, snore when sleeping (in
children), disturbance of speech
resonance, etc.
 Distant symptoms: the ear, the chest,
the abdomen, the cardiovascular system,
the urinary system, the locomotor system,
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 Sign
 Tonsils and palatoglossal arch show
chronic hyperemia, the mucosa is
deep red in color.
 When the palatoglossal arch is pressed,
fluid or caseous pus may be expressed
from the crypts.
 The tonsils may appear shrunken due to
fibrosis, the surface of tonsil is
cicatricial and irregular.
 The mandibular lymph nodes are
enlarged.
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 Diagnosis
Medical history
+ local examination

Historyof repeated attacks i

the main diagnostic basis.
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Differential diagnosis
1.Physical hypertrophy of
the tonsils
2. Keratosis of the tonsils
3. Tumor of the tonsils

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 Treatment
 Non-surgical treatment:
1.Immunotherapy or Antiallergic measure:
2.Increasing immunity: interferon,
immunoglubulin
3.Strengthen exercise to enhance
constitution:
 Surgicaltreatment:
tonsillectomy
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 tonsillectomy
 Thegolden rule: Healthy tonsils
should never be removed and
diseased tonsils should always
be removed.

When to remove the

tonsils?
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 Indication
 The chronic tonsillitis attacks
repeatedly or complicates with quinsy
many times.
 The tonsils are over-hypertrophy and
impede deglutition, respiration
and pronunciation.
 The chronic tonsillitis have become focus
which arouses pathologic of other organs
or associate with pathologic of adjacent
organs.
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 Diphtheria who is bacteria-carrier
and is invalid after conservative
treatment.
 All kinds of tonsillar benign tumor
can be removed with tonsils. But we
should adopt a prudent policy to the
tonsillar malignant tumor.

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 Contraindication
 Acute tonsillitis: we should excise the
tonsils when the acute inflammation is
extinct by 2-3 weeks.
 Disease of hemopoietic system and
who have the dysfunction of
coagulation: such as aplastic anemia,
purpura etc.
 Serious general disease: such as
active pulmonary tuberculosis,
rheumatic cardiac disease, arthritis,
nephritis, hypertension, psychosis, etc.
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 Acute infectious disease: such
as poliomyelitis, influenza etc.
 In and prior to female menstrual
period and pregnant stage:
 The morbidity of immunoglobulin
deficiency and autoimmune
disease in the patient’s relatives is
high; the leukocyte count is low.

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Surgical method
Tonsillectomy
by dissection
Method of
tonsillectomy guillotine
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Tonsillectomy
by dissection

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Peritonsillar abscess
 It is a collection of pus in the peritonsillar space which
lies between the capsule of tonsil and the superior
con­strictor muscle.
 Aetiology
 Peritonsillar abscess usually follows acute tonsillitis.
First, one of the tonsillar crypts, usually the crypta
magna, gets infected and sealed off. It forms an
intratonsillar abscess which then bursts through the
tonsillar capsule to set up peritonsiliitis and then an
abscess.
 Culture of pus from the abscess may reveal pure
growth of Strept. pyogenes, Staph. aureus or
anaerobic organisms.


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Peritonsillar abscess
 Clinical Features
 Peritonsillar abscess mostly affects adults and rarely
the children though acute tonsillitis is more common
in children. Usually, it is unilateral though
occasionally bilateral abscesses are recorded.
Clinical features are divided into:
 General. They are due to septicaemia and resemble
any acute infection. They include fever (up to 104°F),
chills and rigors, general malaise, body aches,
headache, nausea and constipation.

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Local

 Severe pain in throat. Usually unilateral.
 Odynophagia. It is so marked that the
patient cannot even swallow his own
saliva which drib­bles from the angle of
his mouth. Patient is usu­ally dehydrated.
 Muffled and thick speech, often called
"Hot potato voice".

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Local
 Foul breath due to sepsis in the oral cavity
and poor hygiene.
 Ipsilateral earache. This is referred pain via
CN IX which supplies both the tonsil and
the ear.
 Trismus due to spasm of pterygoid
muscles which are in close proximity to the
superior constrictor.

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Examination
 The tonsil, pillars and soft palate are
congested and swollen.
 Uvula is swollen and oedematous and
pushed to the opposite side.

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Examination
 Bulging of the soft palate and anterior
pillar above the tonsil.
 Mucopus may be seen covering the
tonsillar region.
 Cervical lymphadenopathy is seen. This
involves jugulodigastric lymph nodes.
 Torticollis. Patient keeps the neck tilted
to the side of abscess.

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Treatment
 HosPitalisation.
 Intravenous fluids to combat dehydration.
 Antibiotics. Suitable antibiotics in large i.v.
doses to cover both aerobic and anaerobic
organisms.
 Analgesics like paracetamol is given for
relief of pain and to lower the temperature.
 Oral hygiene should be maintained by
hydrogen per­oxide or saline mouth washes.

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 The above conservative measures may cure
peritonsil­litis. If a frank abscess has formed,
incision and drainage will be required.
 Incision and drainage of abscess. A
peritonsillar abscess is opened at the point of
maximum bulge above the upper pole of
tonsil or just lateral to the point of junction of
anterior pillar with a line drawn through the
base of uvula . With the help of a guarded
knife, a small stab incision is made and then
a sinus for­ceps inserted to open the abscess.

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 Interval tonsillectomy. Tonsils are removed
four to six weeks following an attack.
 Abscess or hot tonsillectomy. Some
people prefer to do 'hot' tonsillectomy instead
of incision and drainages Abscess
tonsillectomy has the risk of rupture of the
abscess during anaesthesia, and excessive
bleeding at the time of operation

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Complications

 Parapharyngeal abscess (a
peritonsillar abscess is a potential
parapharyngeal abscess).
 Oedema of larynx. Tracheostomy may
be required.
 Septicaemia. : Like endocarditis,
nephritis, brain abscess may occur .

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Complications
 Pneumonitis or lung abscess. Due to
aspiration of pus, if spontaneous rupture
of abscess has taken place.
 Jugular vein thrombosis.
 Spontaneous haemorrhage from
carotid artery or jugular vein.

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Adenoid hypertrophy

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Outline
Adenoid also is called the
pharyngeal tonsil which is
located at the midline of
nasopharyngeal vault. It is a
component of the pharyngeal
lymphoid inner ring. In normal
state, it becomes the biggest in
4 years old and atrophy after
puberty and disappears in adult.
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Ifthe adenoid is hypertrophic
and arouses corresponding
symptom, it is called adenoid
vegetation.

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Cause
Because of repeated
inflammatory irritation of
nasopharynx and it’s adjacent
area or adenoid itself, the
adenoid becomes pathological
hyperplasia.

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Clinical manifestation

adenoid face
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Local symptoms
Aural symptom:
Rhinal symptom:
The symptoms of pharynx
、 laryngnx and lower
respiratory tract:

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General symptoms
Symptoms of chronic toxic
and reflective neurosis ：
such as malnutrition, dysplasis,
obtuseness of reaction,
hypoprosexia, night-terrors,
enuresis, etc.

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Sign
 Adenoid face:
 It is usually companied with the
hypertrophic palatine tonsil:
 Anterior rhinoscopy:
 Palpation of the nasopharynx:
 Lateral nasopharyngeal radiograph
or CT scan:
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Adenoid face

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85
 Treatment
General treatment:
0.5%ephedrine nansal drip
Surgical treatment:
If conservative treatment is
invalid, we must take
adenoidectomy immediately.

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Adenoidectomy

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