PHARYNGITIS

Definition
• Inflammation of pharyngeal mucosa is known as
pharyngitis.
• Divided into nonspecific and specific pharyngitis.
• Nonspecific pharyngitis is extremely common and is
caused by viruses, bacteria, fungi and several other factors
like post nasal drip, gastroesophageal reflux, spices,
condiments, hot or cold drinks, immunosuppression etc.
• Nonspecific pharyngitis is again divided into
• Acute pharyngitis
• chronic pharyngitis.
 1. Acute pharyngitis
• Acute inflammatory
condition of the
pharynx.
 Etiopathology
• Acute pharyngitis is very common and occurs
due to different etiological factors like viral,
bacterial, fungal or others.
• Viral causes are more common.
• Acute streptococcal pharyngitis (due to group
A beta-haemolytic streptococci) has received
more importance because of its etiology in
rheumatic fever and post streptococcal
glomerulonephritis.
 Clinical features:
• Acut pharyngitis may occur in different degrees of
severity.
• Mild infections present with discomfort in the throat,
malaise and low grade fever. Pharynx in these cases is
congested but there is no lymphadenopathy.
• Moderate and severe infections present with pain in
throat, dysphagia, headache, malaise and high grade
fever. Pharynx in these cases shows erythema,
exudate and enlargement of tonsils and lymphoid
follicles on posterior pharyngeal wall.
• Very severe cases show edema of soft palate and
uvula with enlargement of cervical lymph nodes.
• It is not possible on clinical examination, to
differentiate viral from bacterial infections.
• Viral infections are generally mild and are
accompanied by rhinorrhoea and hoarseness
while the bacterial ones are severe.
• Gonococcal pharyngitis is mild and may even be
asymptomatic.
 Investigations
• Culture of throat swab is helpful in the diagnosis
of bacterial pharyngitis.
• It can detect 90% of group A streptococci.
• Diphtheria bacillus is cultured on special media.
Swab from a suspected case of gonococcal
pharyngitis should be cultured immediately
without delay.
• Failure to get any bacterial growth suggests a
viral etiology
 Treatment
1. General measures:
• Bed rest,
• Plenty of fluids,
• Warm saline gargles
• Analgesics
• Local discomfort in the throat in severe cases
can be relieved by lignocaine before meals to
facilitate swallowing
 2. Specific treatment
• Streptococcal pharyngitis (group A, beta-haemolytic
streptococcus) 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 i.m. for
patient < 60 lb in weight and 1.2 million units once i.m. for
patient > 60 lb.
• In penicillin sensitive individuals, erythromycin 20-40 mg/kg body
weight daily, in divided oral doses for 10 days is equally effective.
• Diphtheria is treated by diphtheria antitoxin and administration
of penicillin or erythromycin.
• Gonococcal pharyngitis responds to conventional doses of
penicillin or tetracycline.
 Viral infections causing pharyngitis

• Herpangina
• Infectious mononucleosis
• Cytomegalovirus
• Measles
• chickenpox
 2. Chronic pharyngitis
• It is a chronic inflammatory condition of the
pharynx.
• It is characterized by hypertrophy of mucosa,
seromucinous glands, subepithelial lymphoid
follicles and even the muscular coat of the
pharynx.
• It is of two types;
1. Chronic catarrhal pharyngitis.
2. Chronic hypertropic (granular) pharyngitis
 Etiopathology
• A large number of factors are responsible for
chronic pharyngitis.
These include;
a. Chronic irritants (smoking, chewing tobacco,
pan, drinking)
b. Laryngopharyngeal reflux
c. Postnasal discharge.
d. Environmental pollution.
e. Mouth breathing
 Clinical features
1. Discomfort or pain in the throat is the commonest
presentation. Specially noticed in the morning.
2. Foreign body sensation in the throat leads to a constant
desire to swallow or clear his throat to get rid of this
“foreign body”.
3. Cough: Throat is irritable and there is tendency to cough.
4. 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.
 Chronic catarrhal pharyngitis
• Congestion of posterior pharyngeal wall with
engorgement of vessels.
• Faucial pillars may be thickened.
• Increased mucous secretion which may cover
pharyngeal mucosa.
Chronic hypertrophic (granular) pharyngitis

• Pharyngeal wall appears

thick and edematous with
congested mucosa and
dilated vessels.
• Posterior pharyngeal wall
may be studded with reddish
nodules (hence the term
granular pharyngitis).
• Lateral pharyngeal bands
become hypertrophied.
• Uvula may be elongated and
appear edematous.
 Treatment
1. Etiological factor should be sought and removed.
2. Benzydamine mouth washes/warm saline gargles
3. Mandl’s (compound iodine) paint may be applied to the
pharyngeal mucosa.
4. Cautery of lymphoid granules. Throat is sprayed with
local anesthetic and granules are touched with 10-25%
silver nitrate. Electrocautery or diathermy of nodules
may require general anesthesia.
5. 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.
ADENOIDITIS
 Scenario
• A 07 years old girl presented with mouth
breathing, recurrent upper respiratory tract
infections and nasal discharge for last 06
months. X-ray lateral view neck showed a soft
tissue mass in the nasopharynx.
• 1. What is the most probable clinical diagnosis?
• 2. How will you confirm your diagnosis?
• 3. How are you going to manage this patient?
 Definition
• Inflammation of the
nasopharyngeal tonsils,
sufficient to produce
symptoms.
 Etiopathology
• Adenoids are also known as nasopharyngeal tonsils.
• Physiological enlargement of adenoids usually starts
between the ages of 5-7 years. Most of the lymphoid
tissue atrophy with the onset of puberty e.g. thymus.
• Atrophy of adenoids usually begins by the age of 10
years and is complete before the age of 15-16 years.
• Recurrent episodes of rhinitis, sinusitis or tonsillitis
may lead to adenoid hypertrophy.
 Clinical features
• May be due to simple enlargement,
inflammation or both.
• Size of the adenoids relative to the
nasopharyngeal space that is of importance
and not its absolute size.
• Clinical manifestations of adenoids may be
nasal, aural or general.
 A. Nasal manifestations
1. Nasal obstruction leads to mouth breathing, noisy
breathing, snoring and toneless voice. There may even
be obstructive sleep apnea syndrome.
2. Nasal discharge is due to associated rhinosinusitis and
choanal obstruction.
3. Epistaxis can occur due to acute infection of adenoids.
4. Adenoid facies may develop in long standing cases i.e.
dull looking triangular face, open mouth posture,
prominent crowded upper teeth, broad upper lip,
pinched nose and high arch palate.
 B. Aural manifestations
1. Eustachian tube obstruction leads to hearing
loss.
2. Otitis media, which may be in the form of
serous/acute/recurrent/ chronic otitis media
 C. General manifestations
• Mental dullness,
• Lack of concentration (aprosexia),
• Apathy,
• Nocturnal enuresis,
• Sleep apnea,
• Night terrors and
• Pulmonary hypertension leading ultimately to
cor pulmonale.
• Posterior rhinoscopic examination is usually
diagnostic in patients over the age of three
years.
• Flexible nasopharyngoscopy or zero degree
endoscopy may reveal status of adenoids
 Investigations
• X-ray soft tissue nasopharynx lateral view for
adenoids, may show narrowing of the
nasopharyngeal air space.
 Treatment
A. Conservative:
1. Removal of underlying cause such as allergy,
immunity deficiency should be corrected.
2. Antibiotics,
3. Nasal decongestant drops
4. Patient should be instructed in nose blowing
and nasal douching
 B. Surgical
1. Adenoidectomy is performed under general
anesthesia, when medical treatment fails or
symptoms are very severe.
2. Myringotomy with or without grommet
insertion may be considered if patient has
got otitis media with effusion.
 Differential diagnosis
1. Foreign body nose
2. Meningoencephalocele
3. Angiofibroma
4. Thornwald’s cyst
 Differential diagnosis of a pediatric
nasopharyngeal mass:
1. Teratoid e.g. dermoids, teratoma, epignathi
2. Neuroectodermal e.g. encephalocele, brain
heterotopia, meningioma
3. Dysontogenetic e.g. chordoma,
craniopharyngioma
4. Miscellaneous e.g. cysts, haemangioma,
hamartoma, rhabdomyosarcoma
 Scenario
• A 07 years old girl presented with mouth
breathing, recurrent upper respiratory tract
infections and nasal discharge for last 06
months. X-ray lateral view neck showed a soft
tissue mass in the nasopharynx.
• 1. What is the most probable clinical diagnosis?
• 2. How will you confirm your diagnosis?
• 3. How are you going to manage this patient?
 ADENOIDECTOMY
• Indications:
1. Nasal obstruction and nasal discharge due to
recurrent or chronic adenoiditis
2. Acute/recurrent/chronic/serous otitis media
3. Recurrent epistaxis due to adenoiditis
4. Recurrent rhinosinusitis due to adenoiditis
 Contraindications
1. Acute upper or lower respiratory tract
infections
2. Cleft palate (to avoid nasal twang and nasal
regurgitation of food and fluids)
3. Hemostatic diathesis
a. Bleeding disorders e.g. thrombocytopenia b.
Clotting disorders e.g. hemophilia
 Procedure
• After orotracheal intubation for general anesthesia, patient is
made to lie supine on the table (head and neck should not be
extended).
• Boyle Davis mouth gag applied.
• Throat (epilaryngeal) pack placed.
• A Nelton catheter passed through the cavity and delivered
out through the oral cavity and the soft palate retracted.
• Inspection of adenoids and nasopharynx is done through
warm indirect laryngoscopic mirror.
• Palpation of the adenoids and nasopharynx is done to
differentiate adenoids from other pathologies like
meningocele and chordoma.
• Adenoid curette with guard is inserted into nasopharynx
till it touches posterior border of the nasal septum.
• Adenoids tissue is engaged in adenoid curette and a
single central and two lateral sweeps are made.
• These sweeps usually curette out whole the adenoids.
Postnasal space is packed with ribbon gauze for 6-8
minutes.
• Posterior nasal pack is removed and hemostatis
ensured. Nelton catheter and throat pack (also known as
epilaryngeal pack) is removed.
• Boyle Davis mouth gag is removed. A simple way of
removing the adenoids is FESS (Functional Endoscopic
Sinus Surgery) and microdebrider.
 Complications
1. Hemorrhage usually indicates inadequate removal. So
adenoids should be removed thoroughly. Perioperative
haemorrhage is managed by placing a pack for a few minutes.
Postoperative haemorrhage is managed by nasal
decongestant drops. If bleeding is severe, it is managed by
placing a post nasal pack in the nasopharynx under general
anesthesia.
2. Injury to pharyngeal opening of eustachian tube may occur.
3. Dislocation of the atlantoaxial joint (if vigorous curettage of
adenoids is performed).
4. Palatal insufficiency may occur if adenoidectomy is
performed in a patient with submucous cleft palate.
5. Nasopharyngeal stenosis as a result of scar formation.
TONSILLITIS
 Scenario
• 10 years old child has recurrent attacks of acute
tonsillitis more than 05 attacks per year for last 02
consecutive years. Examination shows anterior faucial
flare, debris coming out of crypts and enlarged jugulo-
digastric lymph nodes.
1. What is your clinical diagnosis?
2. What is the treatment of this patient?
3. What are other indications of the same operation?
4. What is primary haemorrhage, secondary haemorrhage
and reactionary haemorrhage?
 Definition
It is defined as an inflammation of palatine
tonsils (also known as pharyngeal tonsils).
Clinically it is divided into;
A. Acute tonsillitis
B. Chronic tonsillitis
 A. Acute tonsillitis
• Etiopathology:
• Acute tonsillitis is a disease of children and
young adults although it may present at any age.
• Rare in infants and after 50 years of age.
• Caused by viruses or bacteria.
• Commonest causative organisms is Beta
hemolytic Streptococcus.
• Less common causative organisms are
Staphylococci, Pneumococci and H. influenzae.
Acute inflammation of the tonsil is classified as follows;
1. Acute catarrhal tonsillitis: In this infection is limited
to the surface epithelium of the tonsil.
2. Acute follicular tonsillitis: In this infection spreads
into crypts of the tonsil. Openings of the crypts are
visible as whitish or yellowish dots, where exudate
from the crypts coalesce to form a membrane on the
surface and is then known as membranous tonsillitis.
3. Acute parenchymatous tonsillitis: In this infection
spreads into the substance of the tonsil and the
tonsil is enlarged.
 Clinical features
These vary with the severity of infection.
1. Sore throat is the commonest presentation.
2. There may be complaint of odynophagia.
3. General symptoms like fever, anorexia, malaise and
bodyaches may also occur. Occasionally referred
earache may occur due to stimulation of
glossopharyngeal nerve.
• Abdominal symptoms due to mesenteric
lymphadenitis secondary to swallowed infected
saliva. This may mimic acute appendicitis.
 On examination
1. Tonsils may be red, containing whitish or
yellowish spots on the opening of the crypts
or a membrane covering the tonsils.
2. Jugulodigastric lymph nodes may be
enlarged and tender.
 Complications
A. Local complications:
1. Chronic tonsillitis. In acute tonsillitis, infection may persist
in the tonsil and may change into chronic tonsillitis.
2. Peritonsillar abscess,
3. Parapharyngeal abscess,
4. Retropharyngeal abscess
5. Acute otitis media
B. Distant complications:
1. Rheumatic fever
2. Acute glomerulonephritis rarely.
 Investigations
• Diagnosis of acute tonsillitis is usually clinical.
• Throat swab is sent for culture and sensitivity
in doubtful or resistant cases.
 Treatment
1. Bed rest is advised.
2. Antibiotics like penicillin or erythromycin are
given for 7-10 days.
3. Analgesics and antipyretics are given to
relieve pain and fever.
 Differential diagnosis
1. Diphtheria:
• It is slow in onset as compared to acute tonsillitis.
• Sore throat is also less as compared to acute tonsillitis.
• In cases of diphtheria, membrane extends beyond the
tonsil on to the faucial pillars and soft palate whereas in
acute tonsillitis, membrane is localized only to the
tonsils.
• In cases of diphtheria, membrane is dirty grey in color
and tightly adherent. Removal of the membrane leaves a
bleeding surface.
• Smear and culture of throat swab/membrane shows
Corynebacterium diphtheriae.
 2. Infectious mononucleosis
• Synonyms:
• Glandular fever, Kissing fever
• It is a disease of lymphoreticular system.
• Appearence of the tonsil is similar to that of
acute tonsillitis.
• All the cervical, axillary, inguinal lymph nodes
and spleen are enlarged.
• Blood smear shows more than 5% lymphocytes.
Paul- Bunnel (monospot) test is positive.
 3. Agranulocytosis
• There is widespread ulcerative and necrotic
lesions in the oral cavity and oropharynx.
• Patient is debilitated and severely ill.
• Total leukocyte count is reduced to less than
2000 per cubic millimeter
Differential diagnosis of white patch on the
tonsils
1. Membranous tonsillitis
2. Diphtheria
3. Infectious mononucleosis
4. Agranulocytosis
5. Leukemia
6. Aphthous ulcers
7. Malignancy of tonsil
8. Candida infection of tonsil
 B. Chronic tonsillitis
• Etiopathology:
• Long standing infection of the tonsils may occur
as a result of;
1. Subclinical infection of the tonsil
2. Complication of acute tonsillitis
• Chronic post nasal discharge secondary to
chronic sinusitis is usually a predisposing factor.
Chronic tonsillitis usually occurs in children or
young adults.
 Clinical features
1. Recurrent episodes of sore throat.
2. Chronic irritation in the throat.
3. If the tonsils are large, there may be difficulty
in swallowing and choking sensation during
sleep.
4. Bad taste in mouth or foul breath (halitosis)
due to pus in crypts.
 On examination
• Signs of chronic tonsillitis
are positive i.e.
1. Tonsils are usually
enlarged.
2. Crypts are prominent.
3. Anterior faucial pillars give
an appearance of a flare
(also known as anterior
faucial flare).
4. Jugulodigastric lymph
nodes are enlarged.
 Investigations
• Diagnosis of chronic tonsillitis is mainly
clinical.
• No investigation is required for diagnostic
purposes.
• Investigations may be required for differential
diagnosis, identification of any complication or
fitness of the patient for general anesthesia
and surgery.
 Treatment
1. Removal of the underlying cause such as
rhinitis and sinusitis. Nutrition and hygiene
should be improved.
2. Tonsillectomy should be performed as a last
resort if the tonsils interfere with daily routine
life, deglutition, respiration and sleep.
TONSILLECTOMY
 Scenario
• A 20 years old boy after 07 days of his
tonsillectomy comes to emergency with
bleeding from mouth, fever and pain.
1. What is your diagnosis?
2. What investigations you will advise?
3. How will you treat this case?
 TONSILLECTOMY
Indications:
1. Chronic tonsillitis
2. Recurrent tonsillitis; If there are 4-5 episodes of acute
tonsillitis per year for last two consecutive years.
3. Peritonsiller abscess; Tonsillectomy is done 4-6 weeks after
resolution of peritonsiller abscess.
4. Enlarged tonsils if causing mechanical obstruction to
respiration and swallowing.
5. Doubtful malignancy (especially lymphoma) of tonsil (for
biospy purpose).
6. As an approach procedure (to reach the tonsillar bed);
a. Glossopharyngeal neurectomy in glossopharyngeal neuralgia.
b. For removal of styloid process in Eagle’s syndrome.
 Contraindications:
1. Acute respiratory tract infection
2. Haemoglobin below 10 g/dl 3. Hemostatic
diathesis;
a. Bleeding disorders e.g. thrombocytopenia
b. Clotting disorders e.g. haemophilia
4. Systemic diseases e.g. hypertension, diabetes,
bronchial asthma etc.
5. Active period of menstruation
 Complications of tonsillectomy
• Complications of tonsillectomy may be divided
into;
A. Peroperative complications
B. Postoperative complications
 A. Peroperative complications
a. Hemorrhage: Bleeding during surgery is
known as primary haemorrhage. It is because
of recent infection, previous peri-tonsillar
abscess, hemostatic diathesis, a large tonsillar
branch of the facial artery or an aberrant
internal carotid artery.
b. Trauma: Damage to carious teeth, dislocation
of temporomandibular joint and excessive
resection of mucosa of the soft palate.
 B. Postoperative complications
a. Immediate complications:
1. Hemorrhage: Bleeding which occurs within 24 hours of
surgery is known as reactionary haemorrhage but
usually occurs within first 6-8 hours.
• Managed by removal of blood clots from tonsillar fossa
and application of slight pressure with a gauze soaked in
1:1000 adrenaline. If bleeding does not stop, the patient
is prepared for second general anesthesia and the
bleeding points are re-stitched. If the patient is
hypovolumic, cross-matched blood should be transfused.
2. Aspiration: Blood, secretions or tissues may be
aspirated into lungs
 b. Intermediate complications
1. Hemorrhage:
• Bleeding which occurs after 24 hours of surgery is known as
secondary haemorrhage. Usually it occurs between 5th to
6th postoperative day.
• Cause of secondary haemorrhage is infection of the tonsillar
fossa.
• Management is done by removing clots from the tonsillar
fossa and application of pressure with a gauze soaked in
1:1000 adrenaline.
• Systemic antibiotics (intravenous penicillin or erythromycin)
are given to treat the infection. Hemoglobin estimation
should be done and blood should be cross-matched.
2. Edema of the uvula.
3. Pulmonary complications may occur because of
inhalation of blood or secretions.
4. Subacute bacterial endocarditis: Tonsillectomy
leads to transient bacteremia at the time of surgery.
If the patient has an abnormal heart valve or a
septal defect, subacute bacterial endocarditis may
occur. So surgery in immediate and postoperative
period should be covered by systemic penicillins.
 c. Late complications:
• Postoperative scaring:
• Careless traumatic surgery with loss of the soft
palate may lead to scarring and limited
mobility of the soft palate.
• Nasal regurgitation of fluids and hypernasal
voice.
PERITONSILLAR ABSCESS (PTA)

Synonyms: Peritonsillar cellulitis,

Quinsy, Angina tonsillaris
 Scenario A
• An 18 years old male presented with severe sore
throat and odynophagia for last seven days. Pain was
mostly confined to left side of throat and there was
also difficulty in opening the mouth. Throat
examination revealed a rounded, reddish diffuse bulge
in the left supratonsillar region.
1. What is the most probable clinical diagnosis?
2. What usual complications are associated with this
condition?
3. How will you manage this case?
 Definition
• It is defined as a collection of pus between the
fibrous capsule of the tonsil (usually at its
upper pole) and the superior constrictor
muscle of pharynx
 Etiopathology
• Exact etiology is unknown.
• Complication of acute tonsillitis.
• Initially there is peritonsillar cellulitis but if left
untreated may proceed to peritonsillar
abscess.
• Beta haemolytic streptococcus and
anaerobes are usual causative organisms.
• Always unilateral.
• Rare in children
 Clinical features
1. History of previous episodes of acute tonsillitis
2. Severe pain in the throat on the side of
peritonsillar cellulitis.
3. Plummy quality of voice and intense salivation
with dribbling.
4. Ipsilateral referred earache. There is also rise in
the body temperature.
5. Fetid smell.
 On examination
1. Asymmetry of oropharynx
with hyperemia and
edema of the soft palate.
2. Medial displacement of
the tonsil.
3. Trismus caused by spasm
of medial pterygoid muscle
due to contact with pus.
4. Ipsilateral tender enlarged
cervical lymph nodes
 Complications
1. Airway obstruction may occur due to edema
of larynx.
2. Spread of infection to other spaces of the
neck especially parapharyngeal space may
occur.
 Investigations
1. Wide bore aspirate is sent for microbiology,
culture and sensitivity.
2. C T/MRI is carried out in case of suspected
complications such as spread of infection to
parapharyngeal space, retropharyngeal space
or mediastinum
 Treatment
1. In early stages of cellulitis, conservative treatment
is carried out with intravenous antibiotics for 48
hours.
2. In late stages, patient is admitted in the hospital for
I/V antibiotics and observation for any airway
obstruction.
3. Wide bore needle aspiration is often curative. It is
carried out at a point where a horizontal line drawn
from the base of uvula and a vertical line drawn
from medial border of anterior faucial pillar meet
together.
4. Incision and drainage of the abscess under local
anesthesia is carried out if wide bore aspiration
fails or insufficient. It is done with bistoury knife at
the point mentioned above. Efficient suction is
carried out at the same time.
• Taken into consideration the morbidity and
mortality associated with peritonsillar abscess,
tonsillectomy is carried out about one month
after the acute episode of peritonsillar abscess
has subsided. “abscess tonsillectomy” also known
as “hot tonsillectomy” (incision and drainage of
abscess plus tonsillectomy) is carried out by some
surgeons as a preferred method of treatment
 Differential diagnosis
1. Parapharyngeal abscess
2. Retropharyngeal abscess
3. Parapharyngeal tumor