2 pdf - pharynx - Muhadharaty

Lecture ( 2) pharynx Dr. Sa'ad Y. Sulaiman

Anatomy of the oral cavity

The  oral  cavity  extends  from  the  vermilion  border  of  the  lips  (i.e.  the
junction  between  the  skin  which  is  keratinizing  and  the  mucus  membrane
which  is  non-  keratinizing  and  pink) to the oropharyngeal isthmus, i.e. up to
the anterior  pillar  of tonsils.

Common disorders of oral cavity

 Ulcers of oral cavity

Causes

1. Infections

Viral: e.g. Herpangina (Coxsackie virus) and herpes simplex;
multiple small vesicles which rupture to form small ulcers.

ii.

Bacterial: Vincent’s infection **, TB, syphilis.

iii.

Fungal: Candidiasis. **

2. Immune disorders:

Aphthus ulcer **
Behcet’s syndrome **

3. Trauma

i. Physical: cheek bite, ill-fitting denture.

ii. Chemical: silver nitrate, phenol, aspirin burn.

iii. Thermal: hot food or fluid

4. Neoplasms: squamous cell CA, minor salivary glands’ CA
5. Skin disorders: Erythema multiforme, lichen planus, bullous

pemphigoid, lupus erythematosus.

6. Blood disorders: Leukaemia, agranulocytosis.
7. Drug allergy: Systemic administration of drugs like penicillin,

tetracycline, sulpha …etc., or contact stomatitis due to local reaction to
mouth washes, tooth paste, prosthetic dental materials …etc.

8. Vitamin deficiencies.
9. Miscellaneous: radiation mucositis, cancer chemotherapy, diabetes

mellitus, uraemia.



Miscellaneous lesions of the tongue

Median rhomboid tongue:

developmental anomaly seen as red

rhomboid area, devoid of papillae on the dorsum of the tongue.

Geographical tongue

Erythematous areas, devoid of papillae

surrounded by an irregular keratotic white outline

Hairy tongue:

This is characterized by a hairy black- brown or yellow

aspect  of  the  dorsal  surface  of  the  tongue  due  to  chromogenic  bacteria.
Smoking seems to be a promoting factor. Treatment is by scraping the lesion
with  tongue  cleaner,  application  of  half-strength  hydrogen  peroxide,
improving  the  general  nutritional  status  by  vitamins  and  removal  of
causative factors if known.

Fissured tongue:

It may be congenital or seen in cases of syphilis,

deficiency of vitamin B complex or anemia.

Ankyloglossia (Tongue tie):

congenital anomaly characterized by the

presence  of  elongated  lingual  frenulum  tethering the entire oral tongue to the
floor  of  the  mouth  and  alters  the  mobility  of  the  tongue.  Early  surgical
treatment  is required to avoid delay in speech and trouble with eating.

Fordyce’s spots:

They are aberrant sebaceous glands present under the

buccal or labial mucosa and shine through it as small yellowish-brown
granules.

 Tumours of Oral Cavity

I. Benign tumours

(a) Solid tumours: papilloma, fibroma, haemangioma, pyogenic

granuoloma, pregnancy granuloma and minor salivary gland
neoplasm.

(b) Cystic lesion

 Mucoele: retention cyst of minor salivary glands.

 Ranula: It is a cystic translucent lesion seen in the floor of mouth on

one side of the frenulum and pushing the tongue up. It arises from the
sublingual salivary gland due to obstruction of its duct. Some ranulae
extend into the neck (plunging type).

Treatment is complete surgical excision if small, or marsupialisation, if
large.

II.

Premalignant lesions



Leucoplakia: this is diagnosed clinically. White patches on the oral

mucosa are abnormal. Aetiology is unknown. Treatment is by
excision and this is best performed using the KTP laser.



Erythroplakia: is a red patch on the mucosal surface and has a high

malignant potential. It should always be widely removed and a split-
thickness graft applied.



Melanosis and mucosal hyperpigmentation: Benign pigmented

lesions of oral mucosa may transform into malignant melanomas.

III.

Malignant lesions

Carcinoma of oral cavity
Non-squamous malignant lesions

Minor salivary gland tumours

Melanomas
Lymphomas

 Stomatitis

Is a general term used to describe an inflammation of the whole lining of
the mouth. The following are the most common types:



Aphthus ulcer (recurrent  aphthus ulcer RAU,
recurrent  aphthus stomatitis  RAS, recurrent
oral ulcer   ROU):

Definition: Benign, recurrent ulceration of the oral mucosa, which appear
as painful white or yellow ulcer surrounded by bright red area.

Incidence: common form of mouth ulcer, affecting women more than men.
They may occur at any age, but usually first appear between the age of 10
and 40.

Aetiology: The cause is unknown and currently there no preventive
measure. The following factors may be suggested:

1. Autoimmune process (attack of mucous membrane by the own body’s

immune system).

2.  Hereditary.  The patient often has positive family  history.
3.  Nutritional  deficiency (vitamin  B 12, folic acid and iron).
4.  Physical or emotional  stress.
5.  Viral  or bacterial  infection.
6.  Food allergies.
7.  Hormonal changes related  to menstrual  cycles.

Classification: They are of two types

1. Minor aphthus ulceration.
2. Major aphthus ulceration.

Minor Aphthus ulcerations

Major Aphthus Ulceration

More common

Less common

2-10mm in size

2-4 cm in size

Multiple

Usually single

Painful

painful

They heal in about 7-10 days
without leaving a scar

They heal in about 3-6 weeks with a
scar

Treatment:

Minor ulcer: treatment is symptomatic as most ulcer s heal spontaneously.

Patients should avoid oral trauma

, for

example, from hard foods and

acidic foods or drinks that may exacerbate pain or perhaps precipitate
ulcers.

Topical analgesics (such as lidocaine).

Topical  steroids  may  be  effective  in  aborting  progression  of  ulcer  e.g.
1%    triamcinolone  dental  paste  (Kenalog  in  Orabase)  that will cover the
ulcer , enhance healing  and not affected by saliva.

Antimicrobial mouth washes to prevent secondary infection and improve
oral hygiene e.g. (mouthwashes containing chlorhexidine gluconate).

Major aphthus:
Treatment is more aggressive. Steroid and antibiotic mouthwashes are
useful and a short course of systemic steroid may be effective e.g.

one-week

course of 30 to 60 mg of oral prednisolone.

Any persistent ulcer should be biopsied to exclude malignancy.



Vincent’s

infection

(

acute

necrotizing

ulcerative gingivitis)

This  is  a  highly  infectious  ulcerative  lesions  affecting  the  gingivae  and
tonsils,  caused  by  two  gram  negative  organisms  (fusiform  bacillus  and  a
spirochaete  ).  It  was  common  during  the  First  World  War  due  to  lack  of
hygiene  in cleaning  of eating and drinking  utensils.
Diagnosis: swab from the affected area will  show the causative organisms.
Treatment:

1. Systemic antibiotic:  Penicillin  or Erythromycin and metronidazole.
2. Frequent mouth washes (with  sodium bicarbonate mouth solution).
3. Attention  to dental hygiene.



Fungal ulcers ( moniliasis or thrush)

Occur  in cases of prolonged antibiotic therapy, in poorly nourished children
and  in  patients  suffering  from  debilitating  illness. Presented  as creamy-white
plaque  on  the  tongue,  buccal  and  pharyngeal  mucosa  which  are  easily
removed with slight bleeding.
Treatment:  topical  application  of  nystatin  or  clotrimazole  or  1% of aqueous
solution of gentian  violet  after each feed.



Behcet’s Syndrome (occulo-oro-genital
syndrome)

It  is  characterized  by  triad  of  (1)  aphthus-like  ulcers  in  the  oral  cavity  (2)
genital  ulceration  and  (3)  uveitis.  There  may  also  be  vasculitis  of  the  skin,
synovitis  and  meningoencephalitis.  It  is  a  relapsing  condition  of  unknown
aetiology.

Symptoms of Pharyngeal Disease

1) Sore throat:

This  is  described  by  the  patient  as  discomfort  or  raw  sensation  in  the
throat.  It  is  commonly  due  to  inflammatory  causes  as  pharyngitis  and
tonsillitis,  but  may  be  due  to  tumor.  Pain  of  tonsillitis  is  made  worse  by
swallowing  and  is  typically  referred  to  the  ear.  Persistent  pain  specially
when associated with trismus suggests either quinsy or cancer.

2) Dysphagia:

  It  is  difficulty  in  swallowing  and  it  must  be  differentiated  from
odynophagia  which  is  painful  swallowing.  True dysphagia is a real difficulty
in swallowing resulting in food coming back to mouth. It means the presence
of  cancer  of  hypopharynx  or  esophagus  until  proved  otherwise.  It  usually
starts  as  dysphagia  to  solid  food  then  progress  to  fluid  and  even  to  the
patient's own saliva. Dysphagia due to neurological causes is more severe to
fluid  than to solid food, e.g. in CVA

3) Difficulty in speech:

Muffled speech can occur due to pharyngeal tumors of big size. Paralysis
of  the  soft  palate  can  lead  to  abnormal  speech  called  rhinolalia  aperta
(hypernasality).  This  is  in contrary to  rhinolalia clausa (hyponasality) when
there  is  nasal  obstruction  by  anything  like  common  cold  or  nasal  polyp  or
tumor.

4) Difficulty in breathing:

Some pharyngeal diseases are likely to impede the airway leading to
stridor e.g. retropharyngeal abscess and Ludwig's angina.

5) Cervical lymphadenopathy: may be infective or malignant.

Infections of The Pharynx

(PHARYNGITIS)

In  the  pharynx  the  most  common  site  involved  in  an  infection  is  the
oropharynx.  Nasopharyngitis  occurs  in  early  stages  of  coryza,  but  is  of
no  significance,  and  infections  of  hypopharynx  are  unknown.  In  the

oropharynx  the  area  involved  are:  The  lateral  wall  (tonsillitis),  the
posterior wall (Pharyngitis), the  floor (Lingual  tonsillitis). The roof
(The soft palate) is rarely infected.

Acute pharyngitis

This is the more frequent variety,

occurring primarily during the winter

months and less often in autumn and spring. It precedes the common
cold,

and

may

accompany

influenza,

measles,

infectious

mononucleosis, scarlet fever, typhoid fever or small pox.

Symptoms:

Sore  throat  which  ushers  in  the  coryza  is  accompanied  by  a  feeling  of
coldness,  a  slight  pyrexia,  headache,  backache  and  joint  pain.  The
throat  feels  dry,  raw,  uncomfortable  or  painful  especially  on
swallowing.  There  may  also  be  some hoarseness. These symptoms last
for a day or two.

Signs:    on  examining  the  throat  there  is  an  obvious  redness,  and
sometimes  swelling,  of  the  mucosa  of  the  soft  palate,  tonsils  and
posterior  pharyngeal  wall.  The  cervical  lymph  nodes  are  palpable  and
tender.  In  children  the  mouth  should  be  examined  for  Koplik’s  spots  in
case the pharyngitis  is the precursors of measles.

Treatment:  Simple  acute  pharyngitis  is  usually  a  self-limiting disease,
lasting  for  3-4  days;  so  treatment  is  only  symptomatic:  bed  rest,
analgesic  (paracetamol)  and  warm  fluids  by  mouth.  If  the  attack  is
prolonged  or  the  constitutional  symptoms  are  severe  antibiotics  are
prescribed: Penicillin or erythromycin.

Membranous Pharyngitis

Causes:

1. Viral: Infectious mononucleosis.
2. Bacterial: Diphtheria and scarlet fever.

3. Fungal: Candidiasis.

mentioned previously

4. Spirochaetes: Vencent’s angina.
5. Blood dyscrasia: agranulocytosis, and leukaemia.

Diphtheria

Is  a  specific  infection  of  Corynebacterium  diphtheria  which  is
disseminated  by  droplets  and  coughing. Children mostly affected with a
mortality  of 10%.

Clinical picture

The disease has incubation period of 4 days. The patient is severely ill,
although the temperature seldom rises over 38C.

On examination The disease is characterized by:



The appearance of false membrane on the tonsils, soft palate and

posterior pharyngeal wall. The disease may spread to affect the nasal
cavity and nasopharynx. The membrane is usually grey in colour,
firmly attached to the mucosa and leaves bleeding surface when it is
removed.



Tender and enlarged cervical lymph nodes.

NOTE: Pharyngeal membranes are of two types:

1. TRUE MEMBRANE: Inflammatory reaction mucoid or purulent

exudate  cover the pharyngeal mucosa and form a True Membrane. The

underlying mucosa is intact So removal does not leave bleeding surface

2. FALSE MEMBRANE: Certain Inflammatory reaction Necrosis of

surface epithelium The subepithelial tissue produce fibrinogen
change to fibrin form the false membrane (with the necrotic epithelium)
The membrane covers the submucosa because the epithelium is destroyed

 removal leaves bleeding surface

Investigation

Swab for bacteriological examination including part of the
membrane.

Complication

o Laryngeal obstruction and stridor Tracheostomy.

o Myocarditis and neuritis.

Treatment

1. Antitoxin: Intravenous 20,000-100,000 units depending on the

severity of the infection.

2. Systemic I.V. Penicillin.

Agranulocytosis

A rare condition in which polymorph nuclear leukocytes are reduced in
number or disappear from the circulation.

Aetiology

 Idiopathic

 Hypersensitivity reactions to certain drugs like chloramphinicol and

sulphonamides.

 Cytotoxic agents bone marrow depression.

Clinical picture

o Fever, headache with sore throat and halitosis.

o Diffuse grayish membrane with superficial ulceration.

o The cervical lymph nodes are not usually involved.

Investigation: CBC and blood film.

Treatment

 Treat the cause and any causative drug is immediately withdrawn.

 Steroid and systemic antibiotic.

 Fresh blood transfusion is necessary.

Chronic pharyngitis

1. Specific: T.B. and syphilis
2. Nonspecific

Nonspecific

chronic pharyngitis

Chronic  irreversible  inflammation  of  the  mucus  membrane  of  the
pharynx  with  hyperplasia  of  its  various  elements.  Not  infrequently  the
normal  lymphoid  tissue  on  the  posterior  pharyngeal  wall  undergoes
hypertrophy  so  called  granular  pharyngitis.  A  frequent finding is thick
vertical  bands  of  lymphoid  tissue  on  the  posterolateral  wall  of  the
pharynx  behind  the  posterior  pillar  of  the  fauces-  the  so-called  lateral
pharyngeal band.
Aetiology
Exact  aetiology is unknown:
1.  Recurrent  attacks of acute pharyngitis  (sore throat).
2.   Chronic sinusitis with post-nasal drip
3.   Irritants such  as tobacco, alcohol and industrial fumes
4.   Gastro-Esophageal reflux  disease (GERD)
5.   Mouth  breathing.

Clinical Picture
1. Discomfort and pain in the throat without fever. There is none of the

malaise of tonsillitis and the condition persists for weeks or months.

2. Foreign body sensation in the throat and tendency to clear the throat,

which results from postnasal drip bathing the posterior pharyngeal
wall.

3.  Tiring of voice( not hoarseness)
4.  Fear of cancer may  be dominant  in patient's mind.
Examination
- Catarrhal  (simple  type): mild hyperaemia  of the  pharyngeal  mucosa.
-  Hypertrophic  type:    scattered  nodules  on  the  posterior  pharyngeal
wall giving a granular appearance.
Treatment



Cessation of smoking is the most important step.



Appropriate treatment of postnasal drip –if present- (by

intranasal steroid), and acid reflux (by proton pump inhibitor like
omeprazole and lansoprazole).



Reassurance by the exclusion of malignancy.



Soothing gargles such as crushed soluble aspirin may relieve the

condition transiently.

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