The pharynx

الدكتورسعد يونس سليمانكلية طب نينوى

Peri-tonsillar AbscessParapharyngeal AbscessRetro-pharyngeal Abscess(Acute & Chronic)Ludwig’s Angina

Parapharyngeal Abscess

Def What is parapharyngeal space?
Collection of pus in the PARA-PHARYNGEAL Space
A connective tissue space which: Lies on the lateral side of the nasopharnx and oropharynx Extends from skull base to hyoid bone Contains: Internal carotid artery Internal jagular vein Last 4 cranial nerves Cervical sympathetic trunk Deep cervical lynph nodes


Etiology: Acute Tonsillitis or peritonsillar abscess or after tonsillectomy Infection &extraction of last lower molar tooth Infection of the parotid salivary gland Extension of mastoid infection ( Bezold's abscess). - Spread from retropharyngeal abscess.
The infection passes through the Superior constrictor muscle
Symptoms Occurs mostly in adolescents and adults The patient is feverish, ill and toxic. Acute sore throat.

Signs: General; fever Pharyngeal: Cervical

- The lateral pharyngeal wall & tonsil are pushed medially - Trismus due to spasm of ptrygoid muscles
A unilateral diffuse tender swelling : Below & behind the angle of the mandible Deep to the anterior border of the sternomastoid The neck is tilted to the diseased side
Investigations: CBC S.Urea &electrolyte FBS Lateral soft tissue neck radiograph, CT & MRI.


ComplicationsSpread to- Skull base  meningitis carotid sheath thrombophlebitis of IJV with septicaemia and erosion of carotid arteryMediastinum MediastinitisLarynx laryngeal edemaRupture into the pharynx aspiration Bronchopneumonia Cranial nerves and sympathetic chain involvement  Horner's syndrome.

Treatment Medical: massive antibiotic therapy and, Surgical drainage

A vertical incision at the anterior border of the sternomastoid muscle
Sternomastoid

Acute Retropharyngeal Abscess

Collection of pus in the retropharyngeal space
BuccoPharyngeal Fascia
Prevertebral fascia
The Retropharyngeal space
It is a connective tissue space between : the buccopharyngeal fascia & pre-vertebral fascia It extends from the skull base to the posterior mediastinum The space is divided into 2 compartments by a fibrous raphe (spaces of Gillette). Each space contains retropharyngeal lymph node one on each side The Retropharyngeal LN atrophy at the age of 5


Age: below the age of 5 (The Retropharyngeal LN atrophy at the age of 5) Site: at one side of the midline (The two fasciae are attached to each other at the midline by median raphe.) Etiology
Upper Rrspiratory Tract Infection with suppuration of Retropharyngeal LN After Adenoidectomy operation Impacted FB or penetrating injury of posterior pharyngeal wall.


Symptoms In A child below 5 years General: High pyrexia. Pharyngeal: Severe sore throat Dysphagia Difficult breathing, stridor and croupy cough
Abscess


Normal PatientLateral view of the Neck
Look forThe vertebral column ( for any destruction e.g in Pott’s disease)The pre-vertebral space (3/4 the width of the body of the vertebra)The airway

Investigations: plain X ray & CT scan

Widening of prevertebral space
Normal vertebral bodies
Complications:Spread to mediastinummediastinitisRupture………….

Treatment Medical: massive antibiotic therapy and, Surgical drainage Tracheostomy if indicated
Incision in the posterior pharyngeal wall with the patient in the Trendlenberg position Why?
In this position the head is lower than the chest to avoid aspiration of pus

Chronic Retropharyngeal Abscess(Pre-vertebral Abscess or Pott's Abscess )

What is the pre-vertebral space? A space between: The cervical vertebrae The pre-vertebral fascia
Formation of a cold abscess in the pre-vertebral space


Etiology:Pott’s Disease i.e tuberculosis of cervical vertebrae  the abscess rupture through the prevertebral fascia  the abscess reaches the Retropharyngeal space prevertebral fascia



Symptoms In an adult General: Tuberculous Toxaemia Pharyngeal: Pharyngeal discomfort rather than pain. Mild dysphagia. Cervical: limited painful neck movement

-Night sweets -Night fever -Loss of weight -Loss of appetite

Signs: The patient looks pale with low grade fever and loss of weight. Painless swelling lies in the midline of the posterior pharyngeal wall. Enlarged painless cervical lymph nodes.

Investigations Plain X ray & CT scan

Widening of the Prevertebral space
Destruction of the cervical vertebrae

Treatment: Medical: Antituberculous therapy Surgical Drainage Orthopedic Management

Through a vertical incision along the posterior border of the sternomastoid muscle
The drainage should never be through the mouth to avoid secondary infection.

Ludwig’s Angina Definition: Infection of submandibular space. What is submandibular space? A space lies between the mucus membrane of the floor of the mouth and tongue on one side and superficial layer of deep cervical fascia extending between the hyoid bone and mandible on the other. Divided into two compartments by the mylohyoid muscle: 1- Sublingual compartment ( above the mylohyoid) 2- Submaxillary and submental compartment (below the mylohyoid).
The Tongue


Etiology Infection of the floor of the mouth e.g: Lower teeth (the commonest 80%) Tongue Mandible Sublingual or submandibular salivary gland



SymptomsGeneral ; The patient is ill, toxic (fever > 38°C) Local:As the tongue is pushed upwards &Backwards  obsrtuct: The Air Passage & The Food PassageSevere Odynophagia with drooling of salivaSevere Dyspnoea There is varying degree of trismus.

Signs General:Fever Local: Swelling in the floor of the mouth which pushes the tongue upwards & backwards Cervical : Tender indurated swelling of both submandibular regions. Suppuration seldom occurs

Treatment

Medical: massive Antibiotic therapy Bed rest in semi-sitting position to avoid airway obstruction and, Surgical drainage: By a horizontal incision below the mandible Usually there is no or little frank pus Tracheostomy If indicated

Juvenile Nasopharyngeal Angiofibroma(JNA) Nasopharyngeal Carcinoma (NPC)

Juvenile Nasopharyngeal Angiofibroma(JNA)
Is a vascular tumor of the nasopharynx occurring almost entirely in adolescent males (7-19 years with a mean of 14 years). The tumor has a tendency to regress after puberty. Although the tumor is benign, it is locally invasive and behaves as malignant due to the anatomical structure of the nasopharynx.

Aetiology The exact cause is unknown. As the tumor is predominantly seen in adolescent males in the 2nd decade of life, it is thought to be testosterone dependent. Such patients have a hamartomatous nidus of vascular tissue in the nasopharynx and this is activated to form angiofibroma when male sex hormone appears.

Clinical picture The patient is nearly always a young boy with a mean age of 14 years. Repeated attacks of epistaxis which can be extremely profuse due to absence of muscular coat from the sinusoids. Progressive nasal obstruction. Nasal speech (Rhinolalia aperta). 5. Conductive deafness due to pressure on Eustachian tube.

Examination Posterior rhinoscopy: smooth, rubbery lobulated mass in the nasopharynx. Middle ear effusion. Mass in the nasal cavity or on the check if the tumor has extended anteriorly or laterally. Proptosis results from extension of the tumor to the orbit through the infraorbital fissure.

Investigation X-ray of the base of the scull and a lateral view of the skull. CT scan, MRI and MRA. External carotid angiography.
Biopsy is Contraindicated because of fatal bleeding.

Differential diagnosis Antrochoanal polyp. Nasopharyngeal carcinoma.

Treatment Surgical excision: Haemorrhage is the main danger of operation, so adequate blood should be prepared before operation. Embolization: is indicated preoperatively to control the vascularity of the tumor. Radiotherapy: should be reserved for patients with inoperable intracranial extension.

Nasopharyngeal Carcinoma (NPC) common in South East Asia especially in China. maximum age incidence is in the 5th decade males >females. Most tumors arise from fossa of Rosenmuller. Aetiology The exact etiology is unknown. The factors responsible are: Genetic: The Chinese have a higher genetic susceptibility to NPC. Viral: Epstein-Barr virus is closely associated with NPC. Environmental: Ingestion of salted fish and indoor cooking in homes without chimneys are common in china.

Spread of Nasopharyngeal Carcinoma Direct: Anteriorly: Into the nasal cavity and paranasal sinuses leading to nasal symptoms. Posteriorly: to the retropharyngeal space and lymph node of Rouviere. Laterally: into the parapharyngeal space involving the last 4 cranial nerves. Superiorly through the base of the skull involving the optic nerve and the cavernous sinus. Inferiorly to the oral cavity and retrotonsillar region. Lymphatic spread to the cervical lymph node, Blood born (rare).

Clinical picture Cervical lymphadenopathy: is often the presenting feature which may be unilateral or bilateral. Nasorespiratory symptom: nasal obstruction, nasal speech and epistaxis. Tinnitus and aural symptoms due to Eustachian tube obstruction. This may proceed to secondary otitis media. Neurological symptoms: the most frequently involved nerves are 5th, 6th, 9th and 10th cranial nerves. The latter two nerves paralysis leads to immobility of soft palate. Involvement of the sympathetic chain results in Horner's syndromes. Pain and headache due to intracranial extensions or sphenoidal sinusitis.

Examination Posterior rhinoscopy: a large exophytic tumor may be seen. The palate is pushed downward and paralyzed. The neck should be palpated for metastatic lymph nodes. Middle ear effusion. Parapharyngeal spread can cause trismus. Investigation Imaging: X-ray of the base of the skull ----bony destruction involving the petrus bone, foramen lacerum and carotid canal. CT scan and MRI: MRI is superior to CT scan in finding soft tissue. Biopsy under GA,

Treatment Radiotherapy is the treatment of choice because surgical removal of the primary growth is impossible. Chemotherapy as an adjuvant to radiotherapy is of contraverse. Surgery in form of radical neck dissection is reserved for patients where lymph nodes are not controlled by radiation or when enlarged lymph nodes appear after the primary tumor has been controlled.