INFLAMMATORY DISORDERS OF THE PHARYNX

Dr. Mohamed Abdel-Haleem , Asst. Prof.OTORHINOLARYNGOLOGY, HEAD& NECK SURGERY DEPARTMENT

COLLEGE OF MEDICINE

TAIBAH UNIVERSITYMEDINAH, KSA

Anatomy of the pharynxCompartments

• Nasopharynx

• Oropharynx

• Laryngopharynx

(Hypopharynx)

Seen from behind

Diseases Of The Waldeyer’s Ring

• The adenoid tissue arises at the junction of the roof and the

posterior wall of the nasopharynx ( Luska’s pouch ), and is

composed of vertical ridges of lymphoid tissue. The enlarged

mass is a subepithelial lymphoid aggregate (hypertrophy)

sufficient to produce symptoms. The adenoid has only efferent

but no afferent.

• Age : - it is a disease of childhood ( 2-12) then gradual

involution and atrophy at puberty. Occasionally, detected in

adolescents and adults.

• Aetiology:

• Related to repeated upper respiratory tract infection. In

debilitated childern, and in nurseries.

Adenoid

• C/P:

• I ) effects of hypertrophy

• 1)- Bilateral nasal obstruction : a- mouth breathing , noisy respiration

in awake child and snoring during sleep.( obstructive sleep apnea in

marked hypertrophy ) . B- difficult feeding and suckling in infants. –

loss of voice tone. –bilateral mucoid nasal discharge . – foeter oris.

• 2)Eustachian tube obstruction: a-secretory Otitis media → CHL (

hearing loss) b- recurrent AOM.

• 3) Adenoid facies: open dry mouth - narrow pinched anterior

nares.

- Prominent incisors - elevated upper lip - high ( Gothic) palate. -

underslung lower jaw . - mucoid secretions over the upper lip. -

apathetic expressionless look.

- N.B. Adenoid facies develop s in long standing cases.

• II)- Recurrent infections

• 1- recurrent rhinitis & sinusitis 2-Recurrent acute otitis media.3- postnasal discharge & irritative cough. 4- recurrent phryngitis 5-cervical L.M.

• III)- General manifestations:

• 1- marked hypertrophied adenotonsillitis . 2- obstructive sleepapnea.

• 3- mental dullness and apathy. 4- may nocturnal enuresis.

• Examination:

• 1- Adenoid facies.

• 2- ears: retracted T.M. - 2ry o.m . -CHL

• 3-Anterior Rhinoscopy : a) vertical slit apeature of the nose b)narrowed nasal chambers. C) mucoid or mucopurulent nasaldischarge.

• 4- Mouth & oral cavity: a) distorted, dry & decayed teeth(overcrowded ).

• B) inflammed spongy gums. C) high arched palate. D) enlargedfaucial tonsils. E) discrete patches of lymphoid tissue on post.Pharyngeal wall. F) egg white postnasal discharge may be seen.G)sometimes lower edge of adenoid seen during examination of theoral cavity. H) foetor oris.

• 5) flexible nasopharyngoscopy shows adenoid tissue as lobulatedmass.

• 6) in the past, posterior rhinoscopy in old children & digitalpalpation.

Acute Tonsillitis

• N.B. Manifestations of prolonged nasal obstruction and hypoxia are : a) adenoid facies. B) sleep apnoea syndrome. C) pigeon chest.

• Investigations:

• 1- plain x-ray ( soft tissue lateral view nasopharynx ) shows radiopaque soft tissue shadow of post. wall and narrowing of nasopharyngeal air column.

• 2- audiogram & tympanometry.

• Treatment: removal of the adenoid tissue ( adenoidectomy) .

Definition: Acute inflammation of the palatine tonsils.

Incidence : age: any, but much more in children.

Aetiology: Causative organisms: streptococcus beta-

haemolyticus ( commonest) , streptococcus

pneumoniae and Haemophilus influenza.

Mode of transmission: droplet infection.

• Symptoms: 1-General symptoms: rapid onset of fever, headache, anorexia, & malaise. 2-pharyngeal symptoms: rapid onset of sever sore throat & referred otalgia and bad mouth odour ( Halitosis).

• Signs: 1- General signs: high fever and flushed face . Febrile convulsions may occur in children.

2-Pharyngeal signs:

a) Acute follicular tonsillitis: the crypts are full of purulent exudate → the surface of the tonsil has yellowish spots → Spotted appearance.

b) Acute membranous tonsillitis : the yellowish spots coalesce → form yellowish true ( non-adherent) membrane.

c)Acute parenchymatous tonsillitis: markedhyperaemia & enlargement of the tonsils.

3- cervical signs : enlarged tender jugulo -digastric lymph nodes.

• Complications:

• 1- Local complications: a) pharyngeal suppurations → peri -tonsillar abscess, para- pharyngeal abscess& retro-pharyngeal abscess.

• B) laryngitis c) Otitis Media.

• 2-Systemic complications: ( rare)

• A) Rheumatic fever → carditis and arthritis.

• B) Acute glomerulo-nephritis.

• This occurs by an autoimmune reaction.

• Treatment:

• 1) Antibiotic therapy for 10 days.

• 2) Supportive and symptomatic measures → rest, ample fluid intake, analgesics, antipyretics and gargles (as warm tea with lemon).

Chronic TonsillitisDefinition: Chronic inflammation of the palatine tonsils

Aetiology: It follows acute tonsillitis → as a result of :1- Organism factor: Repeated attacks of acute tonsillitis.2- Treatment factor: Inadequate dose or short course of antibiotics

therapy.3- Patient factor: Low patient′s resistance e.g. malnutrition.

Symptoms: 1- History of repeated attacks of acute tonsillitis.2- Sense of throat irritation → frequent hawking & hemming to clear the

throat.3- Bad mouth odour (halitosis) →due to accumulation of pus in the crypts.4- Difficult swallowing → if hypertrophic.5- Snoring and obstructive sleep apnea → if hypertrophic. Signs: 1)Pharyngeal signs: *size: Inequal size of both tonsils. Shape : a)

Hyperaemia of the anterior pillars →in the absence of acute infection. b) Irregularity of the surface of the tonsils → due to fibrosis. Squeezing : the crypts ooze pus on pressure by a tongue depressor.

2) Cervical signs: Persistent enlargement of the jugulo-digastric lymph nodes.

Treatment: Tonsillectomy operation →when chronic tonsillitis is symptomatic.

Inflammatory Disorders Of The Pharynx

• Definition : inflammation of the mucosal lining of the pharynx.

• Types:

• 1) Acute pharyngitis.

• 2) Chronic pharyngitis.

• 3) Pharyngeal manifestations of systemic diseases.

• 1-Acute Pharyngitis• Definition : acute inflammation of the mucosal lining of the pharynx.

• Types:

• 1- Non-specific Acute Pharyingitis:

• A) acute simple pharyngitis.

• 2- Specific Acute Pharyingitis:

• I) Bacterial: b) Diphtheria c) Vincent's angina.

• II) Fungal : d) Monailiasis ( candidiasis )

• III) Viral : e)Infectious mononucleosis ( glandular fever).

f) Acquired immuno -deficiency syndrome (AIDS)

A) Acute simple pharyngitis.Aetiology : mostly 1ry viral infection. In association with common

cold & influenza. May be followed by bacterial infection with streptococcus hemolyticus &

pneumoniae. Mode of transmission : Droplet infection.

Symptoms: 1-General symptoms: rapid onset of fever, headache, anorexia, & malaise. 2- pharyngeal symptoms: rapid onset of sever sore throat & referred otalgia.

Signs: 1- General signs: high fever and flushed face .2-Pharyngeal signs: a) diffuse hyperaemia of the pharyngeal

mucosa. b) a yellowish non- adherent true

membrane.3- cervical signs : enlarged tender upper deep cervical lymph

nodes.Complications: spread of infection ( OM & Laryngitis). Treatment: 1- antibiotics therapy.

2- supportive and symptomatic measures ( rest, fluid intake, analgesics, antipyretics & gargles.

B)Diphtheria • Incidence: rare due to compulsory vaccination programs.• Age: 2-5 years • Aetiology : corynebacterium diphtheriae.• Mode of transmission: droplet infection.• Incubation period : 2-5 days.• Pathology: the organism remains in the pharynx & produce exotoxins.• 1- locally: the exotoxins cause necrosis of the surface epithelium →

ulceration of the pharyngeal mucosa. The ulcer is covered with a false membrane.

• 2-Systemically: the exotoxins are absorbed into the circulation → toxaemia. The exotoxins have a high affinity to the renal, cardiac and neural tissues.

• Symptoms: 1- General symptoms: gradual onset of fever, headache, anorexia and malaise.

• 2- Pharyngeal symptoms: a) mild sore throat and referred otolgia. B) bad mouth odour ( Halitosis).

• Signs: 1) General signs :a) mild fever b) sever toxaemia → pallor and rapid pulse out of proportion to temp.

• 2- pharyngeal signs: formation of a false membrane ( pseudo-membrane ) which :

• A) is unilateral B) exceeds the limits of the tonsil → to the pillars. • C) has a dirty grayish color. D) has offensive odour. E) is adherent to the

underlying tissue. F) reforms rapidly after removal. 3- Cervical signs : marked enlarged tender deep cervical lymp nodes → Bull neck appearance.

• Investigations: A swab from membrane

• 1- is examined by direct film → for diphtheria bacilli ( Chinase-letters appearance). 2- is cultured on Tellurite agar or Loeffler’s serum.

• Differential Diagnosis:

• A- true membranous lesions ( mucoid or purulent exudate i.e dead and living organisms & polymorph nuclear leucocytes) non -adherent as in

• 1- Acute follicular tonsillitis. 2- acute simple pharyngitis. 3-Moniliasis.

• B- False membranous lesions ( necrotic epithelial cells ,dead and living organisms & polymorph nuclear leucocytes + thick fibrinous exudate) adherent as in:

• 1- Vincent’s angina. 2- infectious mononucleosis.

• 3- Agranluocytosis. 4- Acute leukaemia.

• . Faucial diphtheriaAcute follicular tonsillitis

- Gradual insidious onset.- Low grade fever ( 38 c)- Sever toxaemia- pallor- weak Rapid pulse - Vomiting is not uncommon- false membrane ( adherent).- unilateral.- Throat swab is +ve for diphtheria.

- Acute onset.- High fever ( 39-40)- Mild toxaemia- Flushed face - Full Rapid pulse - Vomiting is uncommon- True membrane ( non- adherent).- Bilateral.- Throat swab is –ve for diphtheria.

• Complications:

by 1- local spread of the membrane. 2- systemic effect of theexotoxins.

• What: 1- renal : acute nephritis → albuminuria.

• 2- Cardiac complications : Heart failure may be due to: a) toxicmyocarditis (early 1st week). B) vagal neuritis (late 3rd week). 3-Neurological complications: start after 2-3 weeks

• - paralysis of the palatal muscles ( nasal regurgitation, speech hypernasality & deviation of the uvula to healthy side.

• - paralysis of the pharyngeal muscles → dysphgia to fluids.

• - paralysis of the laryngeal muscles → hoarseness of voice and stridor.- paralysis of the ocular muscles → diplopia

• - paralysis of the diaphragm & intercostal muscles → respiratoryfailure.

• 4- respiratory complications: a) laryngeal obstruction →spread of themembrane. B) lung collapse → inhalation a piece of the membrane

Treatment:

1- hospitalization & isolations until 3 successive daily – ve swab cultures.

2- rest in bed for 3 weeks.

3- Antibiotic therapy → penicillin 0.5 – 1 million IU/day for 10 days.

4- Anti- toxin serum: to neutralize the circulating exotoxins.

- 40.000 – 100.000 units i.m. or i.v. → according to the severity of toxaemia and extension of membrane. ( when diphtheria is suspected clinically antitoxin serum done after skin test for sensitivity which if occurred immediate corticosteroids and calcium must be done ).

- In sensitive patient : use another animal serum or de-sensitizations by reapted doses.

Prophylaxis: 1- active immunizations against diphtheria: compulsory , using diphtheria toxoid vaccine triple ( D.P.T.) against diphtheria, pertussis & tetanus at age 2, 4 & 6 months. Booster doses at 18 months & 5 years.

2- passive immunizations against diphtheria (5000- 10000) units for contacts of anti-toxin serum.

C- Vincent’ angina• Aetiology: causative organisms: 2 anaerobic organisms

which act in symbiosis→ Borrella vincentii & spirochaeta denticolata.

• Predisposing factor : dental carious.

• Symptoms : 1- General symptoms: gradual onset of fever, headache, anorexia and malaise. 2- pharyngeal symptoms: :a) sever sore throat and referred otolgia. B) bad mouth odour ( Halitosis).

• Signs: : 1) General signs : mild fever

• 2- pharyngeal signs: necrotic ulceration & false membrane formation on oral and pharyngeal mucosa.3-Cervical signs : enlarged tender upper deep cervical lymph nodes.

• Investigations: A swab from the membrane is examined by direct film for the causative organisms.

• Treatment: 1- Antibiotics: Penicillin is the drug of choice.

• 2- Mouth wash & gargle with hydrogen peroxide → provide an oxygenated medium not suitable for anaerobic organisms.

D)- Monailiasis (candidiasis or thruth) • Aetiology: causative organism: Candida albicans.

• Predisposing factors: debilitating diseases ( AIDS , malignancy & D.M. ) and prolonged use of systemic antibiotics or steroids.

• Symptoms: 1- General symptom : no fever.

• 2- pharyngeal symptoms : mild sore throat.

• Signs: 1- General signs: no fever.

• 2- pharyngeal signs: a) diffuse hyperaemia of pharyngeal mucosa.

• B) the oral and pharyngeal mucosa is covered with multiple small milky white patches. Removal of these patches reveals superficial mucosal ulcers.

• 3- cervical signs : No enlarged cervical lymph nodes.

• Treatment: 1- Local anti-fungal : as miconazole or nystatin.

• 2- treatment of the cause.

E) Infectious mononucleosis• Aetiology : Epstein Barr virus.

• Symptoms: 1- General symptoms: rapid onset of fever, headache, anorexia and malaise. 2- pharyngeal symptoms: sever sore throat and referred otolgia.

• Signs: 1- General signs: a)high fever. B) Generalized lymphadenopathy & splenomegaly.

• 2- pharyngeal signs: bilateral formation of a false membrane .

• 3- cervical signs : enlarged tender deep upper cervical lymph nodes.

• Investigations :

• 1- Blood picture : monocytosis and lymphocytosis.

• 2- serological tests : +ve Monospot test & +ve Paul- Bunnell’s test ( patient’s serum can agglutinate sheep’s red blood cells.)

• Treatment: 1- Antibiotics therapy (to avoid 2ry ifections & avoid ampicillin → may cause skin rash).

• 2- supportive and symptomatic measures → rest , antipyretics & gargle.

• 3- systemic steroids in sever cases.

F) Acquired Immuno-Deficiency Syndrome(AIDS)

• AETIOLOGY : Causative organism ( Human immuno-deficiency virus) ( HIV)

• CLINICAL PICTURE: 1- General manifestations: poor general condition.

• 2-Pharyngeal manifestations: a) hypertrophy of the pharyngeal tonsils.

• B) recurrent and sever candidiasis and aphthous ulcers .

• C) hairy leukoplakia: white mucosal patches

• D) Kaposi’s sarcoma: Red plaque or nodule. It is malignant mesenchymal tumour. It consists of aberrant slit-like vascular spaces surrounded by dense atypical spindle cells.

• 3- Cervical manifestations: enlarged deep cervical lymph nodes.

• INVESTIGATIONS: Enzyme-linked immuno-sorbent assay (ELISA) → to detect antibodies to HIV.

• TREATMENT: the patient must be referred to specialized hospital.

2- Chronic pharyngitis• Definition: Chronic inflammation of the mucosal lining of the

pharynx.

• Types:

• 1- Non-specific chronic pharyngitis:

• a) Chronic simple pharyngitis.

• b) chronic pharyngo- oesophagitis.

• 2-Specific chronic pharyngitis:

• c)syphilis

• d) tuberculosis.

• e) Scleroma

a) Chronic Simple Pharyngitis.

• Aetiology:

• 1- Recurrent attacks of acute pharyngitis.

• 2- Mouth breathing ( due to nasal obstruction).

• 3-Smoking, spirits and spices.

• 4- Gastro- oesophageal reflux.

• Symptoms:

• 1-History of repeated attacks of acute pharyngitis.

• 2- Sensation of throat irritation.

• Signs:

• 1-Catarrhal chronic pharyngitis: mild hyperaemia of pharyngeal mucosa.

• 2-Hypertrophic chronic pharyngitis: scattered small nodules on the posterior pharyngeal wall( due to hypertrophy of the subepithelial lymphoid tissues )→ granular appearance.

• Treatment: of predisposing factors.

b) Chronic Pharyngo- Oesophagitis.• SYNONYMS : Plummer-Vinson’s syndrome

• Incidence: common in middle-aged females.

• Aetiology: unknown. May be iron deficiency or vitamin deficiency.

• Pathology: atrophy of the pharyngeal, oesophageal and gastric mucosa.

• Symptom: gradual progressive dysphagia.

• Signs: 1- General signs: a) pallor due to anaemia

• b- spoon-shaped nails ( koilonychia). c- splenomegaly.

• 2- Pharyngeal signs: a) angular stomatitis → fissured mouth angles.

• b) Glossitis → smooth tongue due to loss papillae.

• c) Atrophic glazed mucosa of the hypopharynx.

• Investigations: 1- Blood picture: hypochromic anaemia.

• 2- Gastric secretions: Achlorhydria.

• Complications: 1- submucosal fibrosis → web formation. 2- pre-cancerous → post-cricoid carcinoma.

• Treatment: 1-iron& vitamins supply. 2- repeated endoscopic dilatation( stenosis). 3- Regular follow up to exclude post cricoid carcinoma.

C) Syphilitic Pharyngitis • Aetiology: congenital or acquired.

• Clinical picture:

1- Primary syphilis ( chancre): very rare single painless pinkish indurated papule.

2- Secondary syphilis: Hyperaemia of the pharyngeal mucosa with multiple painless white mucous patches may ulcerate.

3-Tertiary syphilis ( Gumma): single or multiple painless pinkish rubbery ulcerating swellings. The ulcers has deep punched-out edges and necrotic dirty yellow floor ( wash- leather appearance)

• Treatment: anti-syphilitic therapy.

d) Tuberculous Pharyngitis.

• Aetiology: Most commonly 2ry to pulmonary tuberculosis.

• Clinical picture: 1- pallor of the pharyngeal mucosa.

• 2- painful shallow ulcers, with undermined edges and caseous pale yellowish floor.

• Treatment:

• Anti- tuberculous therapy.

e) Pharyngo- Scleroma

Aetiology: Most commonly 2ry to rhinoscleroma.Clinical picture: 1- Active stage: a) atrophic form: glazed atrophic dry pharyngeal mucosa.b) Nodular form: painless pinkish non-ulcerating indurated nodules.2- Fibrotic stage: Submucosal fibrosis →shortening of the soft palate.Treatment: similar to rhinoscleroma.

3-Pharyngeal Manifestations of Systemic Diseases

Definition: Inflammatory disorders of the mucosal lining of the pharynx due to systemic diseases.

Types:

1- Blood diseases:

a) Agranulocytosis.

b) b) Acute leukemia.

2- Diseases of Unknown Aetiology:

a)Recurrent aphthous ulcers.

b) Behcet’s disease.

a) Agranulocytosis

Aetiology: Depression of the bone marrow, which may beidiopathic or due to drugs →antibiotic as chloramphenicol,anti-mitotic as methotrexate, anti-emetic aschlorpromazine.

Clinical picture:1- General manifestation: Recurrent infection →due to

leucopenia.2- Pharyngeal manifestations : a) Sore throat and referred

otalgia.b) Extensive necrotic ulceration& false membrane formation

on the pharyngeal mucosa.The ulcers are not surrounded by red inflammatory reaction.Investigations: 1- Blood picture →marked leucopenia,

particularly the granulocytes.2- Bone marrow aspirate ( sternal puncture) →diagnostic.Treatment: 1- Immediate withdrawal of the causative drug.2- Hospitalization, isolation and systemic antibiotics →to

prevent secondary infection. 3- Repeated fresh bloodtransfusion.

B) Acute leukemia

Aetiology: Neoplastic proliferation of the precursors of the white blood cells in the bone marrow.

Clinical picture: 1- General manifestations: a) Pallor →due to anaemia.

b) Bleeding tendency →due to thrombocytopenia. c) Recurrent infections → because most leucocytes are non functioning immature cells.

d) Generalized lymphadenopathy and splenomegaly. e) Sternal tenderness.

2- Pharyngeal manifestations:

a) Sore throat and referred otalgia. b) Extensive necrotic ulceration& false membrane formation on the pharyngeal mucosa. c) Multiple haemorrhagic petechiae on the pharyngeal mucosa.

Investigations:

1- Blood picture →marked leucocytosis (with many immature blast cells), anaemia and thrombocytopenia.

2- Bone marrow aspirate (sternal puncture) →diagnostic.

Treatment: 1-Hospitalization, isolation and systemic antibiotics →to prevent secondary infection. 2- Repeated fresh blood transfusion.

3- Chemotherapy and bone marrow transplantation.

C- Recurrent aphthous ulcersIncidence: commonest cause of oral and pharyngeal

ulceration.Aetiology: unknown. May be vitamin deficiency,

immunological disturbance or stress.Clinical picture: 1- General manifestations: good general

condition.2- pharyngeal manifestations: Recurrent single or

multiple variable-sized painful oral pharyngeal ulcers which are surrounded with marked hyperaemia. They heal spontaneously within 1-2 weeks.

Treatment: Local corticosteroids

D) Behcet’s Disease

Aetiology : Unknown. Most probably an auto-immune disease.Clinical picture: 1- General manifestations: a) iridio - cycllitis. B) Genital ulcers. C) progressive sensori -neural hearing loss. 2- pharyngeal manifestations: Recurrent multiple small painful oral and pharyngeal ulcers, which occur in groupsTreatment: Local and systemic corticosteroids.

Infections Of The Pharyngeal Spaces.

• 1- Peri-tonsillar abscess ( Quinsy ).

• 2- Para-pharyngeal abscess.

• 3- retro-pharyngeal abscess.(Acute- Chronic).

• 4- Ludwig’s angina.

1- Peri-tonsillar abscess ( Quinsy ).

Definition: collection of pus in the Peri-tonsillar space.Incidence: age adults side: unilateral site: above & lateral to the tonsil.Aetiology: Acute tonsillitis. The infection passes outside the tonsil throughcrypta magna.Symptoms:1- General manifestations: fever , headache, anorexia and malaise.2- Pharyngeal manifestations: after an attack of acute tonsillitis .a) Sever unilateral sore throat & referred otalgia. On pus formation →throbbing pain.b) Sever dysphgia → inability to swallow even saliva → drooling.c) Bad mouth odour ( Halitosis).

• Signs: 1- General manifestations: high fever.

• 2-Pharyngeal manifestations: a) a pharyngeal swelling →

• In the soft palate above and lateral to the tonsil.

• Pushes the adjacent tonsil downward & medially.

• Pushes the uvula to the opposite side &

• On pus formation → the swelling pits on blunt probing.

• B) trismus. ( spasm of pterygoid muscle).

• 3- Cervical manifestations: a) enlarged tender UDCL nodes.

• B) Torticollis ( spasms of the neck muscles).

• Complications:

• 1- spread of infection to→ parapharyngeal space

• → parapharyngeal abscess & to larynx → laryngeal oedema.

• 2- rupture of the abscess into the larynx → aspiration →broncho -pneumonia.

• Treatment: 1- massive antibiotic therapy ( before pus formation) 2-drainge of the abscess ( surface aneasthesia & sitting patient).

• 3- tonsillectomy : after 4-6 weeks to avoid recurrent quinsy.

2- Para-Pharyngeal Abscess• Definition: collection of pus in the Para-pharyngeal space.• The Para-pharyngeal space: is a connective tissue space.• Lies → on the lateral side of the naso-pharynx and

oropharynx.• Extends form → the base of the skull to → the level of hyoid

bone.• Limited laterally by : the mandible superiorly & the sterno-

mastoid muscle inferiorly.• Content: - internal carotid artery, internal jugular vein, last 4

cranial nerves, deep cervical lymph nodes & deep lobe ofparotid gland.

• Aetiology: 1- acute tonsillitis, peri-tonsillar abscess & infection after tonsillectomy . The infection passes through sup. Constrictor muscle of the pharynx. 2- infection of the last lower molar tooth.

• Symptoms:• 1- General manifestations: fever , headache, anorexia and

malaise.2- Pharyngeal manifestations: a)sever unilateral sore throat

and referred otolgia.On pus formation ( throbbing pain). B) sever dysphagia+

drooling of saliva.

• Signs:1- General manifestations: high fever.• 2-Pharyngeal manifestations: a) a pharyngeal swelling which

pushes the lateral pharyngeal wall and tonsil medially• B) trismus. ( spasm of pterygoid muscle). • 3- Cervical manifestations: a) a unilateral diffuse tender

swelling below & behind the angle of the mandible, deep to the ant. Border of the sterno-mastoid muscle. B) Torticollis ( spasms of the neck muscles).

• N.B. the pharyngeal swelling , trismus. & Torticollis → constitute BOECK’S TRIAD → diagnostic to para-pharyngeal abscess.

• Investigations: CT scan → diagnostic• Complications: 1- spread of infection to : a) skull base →

meningitis.• B) the carotid sheath → thrombosis of internal jugular vein and

rupture of the carotid artery. C) the mediastinum → mediastinitis. D) larynx → laryngeal oedema.

• 2- rupture of the abscess into the pharynx → aspiration → broncho-pneumonia.

• Treatment: 1- medical : massive antibiotic therapy.• 2- surgical: drainage of the abscess by vertical incision along the

ant. Border of the sterno -mastoid muscle. •

Retro- pharyngeal abscessChronic Acute Types

Formation of a cold abscess in the pre-vertebral space.

- Collection of pus in the retro-pharyngeal space .-Infection of adenoidectomy.

Definition :

T.B. cervical vertebrae ( cold abscess) rupture in the pre-vertebral space & then retro-pharyngeal

space.

-Suppuration of the retro-pharyngeal nodes. 2ry to URTI.

Aetiology:

Adults.- children, below the age 5 years. Age:

-1- General : T.B. toxaemia2- Pharyngeal : mild sore throat.3- cervical: painful limited neck movements.

1- General : T.B. toxaemia signs.2- Pharyngeal : pharyngeal swelling pushes post. Pharyngeal wall forewords in midline.3- cervical: tenderness cervical spine.

-1- General : fever, headache, anorexia & malaise.2- Pharyngeal : sever unilateral sore throat & otolgia.

-Throbbing pain - sever dysphgia + drooling.-- sever dysponea with laryngeal obstruction. 1- General : fever2- Pharyngeal : pharyngeal swelling pushes post. Pharyngeal wall forewords.3- cervical: Torticollis.

Symptoms:

Sings:

- plain x-ray & CT scan .- plain x-ray & CT scan Investigations:

-Fracture of spine-Spread → mediastinitis.-Rupture → aspiration→ broncho-pneumonia.

Complication:

Medical : Anti-tuberculous therapy.Surgical : drainage of the abscess- Orthopedic management of cervical spine.

-Medical : massive antibiotic therapy.-Surgical : drainage of the abscess( vertical incision in post. Pharyngeal wall).-tracheostomy. When needed.

Treatment

4- Ludwig’s Angina• Definition: bilateral diffuse cellulitis of the floor of the mouth. • The floor of the mouth is a connective tissue space which

divided by mylo-hoid muscle to submandibular and sublingual spaces.

• Aetiology: infection of the floor of the mouth e.g. lower teeth ( commonest) , mandible , tongue submandibular or sublingual salivary glands.

• Symptoms:• 1- General manifestations: fever.• 2- Pharyngeal manifestations: a) a swelling in floor of the

mouth → pushes the tongue upwards and backwards. b) trismus. ( spasm of pterygoid muscle).

• 3- Cervical manifestations: tender indurated swelling of both submandibular regions. Suppurations seldom occurs.

• Complications: spread of infection to larynx → laryngeal oedema.

• Treatment: 1- medical : a) massive antibiotic therapy. B) bed rest , in semi-sitting position to avoid airway obstruction.

• 2- surgical: drainage by horizontal incision below the mandible• B) tracheostomy when necessary.

Stomatitis and oropharyngeal ulcerations

• Classifications:

• I) Local causes:• 1- Trauma. A) Mechanical trauma due to fish bone, stiff a tooth

brush, accidental cheek biting, ill-fitting denture and jaggedteeth. The ulcer have punched out serrated edges, soft basewith red granulations in the floor. B) Thermal burns: due tointake of hot food ( ant. Palate tongue).

• C)- Chemical injuries ( corrosives) : forms multiple ulcerationwith yellowish sloughs.

• D) Tobacco smoking → inflammatory patches with excessivekertination.

• E) Radiotherapy : dryness of oral mucosa ( xerostomia) andulceration.

• Treatment:

• 1- Topical antibiotics with hydrocortisone.

• 2- coating of lips by lubricant e.g. liquid paraffin.

•

• 2- Infectious:• A) Bacterial:

-acute : ( pharyngitis , tonsillitis , Vincentangina and faucial diphtheria).

- chronic:-tuberculosis- syphilis.

• B) viral:- Herpes simplex( viral ulcers shallow,

rounded and symmetrical. Surrounded byinflammation).- Herpes zoster- Herpangina.-AIDS.

Treatment: topical anesthetic and anti viraldrugs.

• C) Fungal:-Monailiasis ( candidiasis).

• 3- Allergic stomatitis.( contact allergy e.g. lip stick, tooth paste

and mouth wash)

• 4- Malignant ulcer.

• 5- Dyspeptic ulcer. They related to

constipation, diarrhea and hyperacidity. The ulcersare small, superficial, painful with punched outedges. Occur in oral cavity and tongue.

• 6- precancerous lesions.• Leukoplakia: which appear as a raised white area

usually on the inner side of the check, dorsum of the tongue and the lower lip. It has ill-defined border and no surrounding inflammation.

• II) Miscellaneous causes • 1- Blood diseases: -Agranulocytosis - Acute

leukaemia.• 2- Vitamin deficiencies: - Vitamine A deficiency • - Vitamine C deficiency.• 3- Metabolic disorders: -Diabetes and Uremia.• 4- Skin diseases: • - pemphigus. • -bullous pemphigoid• - Erythema multiforme.• – Lichen planus. • –lupus erythematosis. • 5- Recurrent aphthous stomatitis.• 6- Behcet’s disease.• 7- Cancrum oris. ( rapid spreading ulcerations of gums,

buccal mucosa & tongue with sloughing & bone exposure in immunocompromized patient).

• 8- Stomatitis due to metals drugs. ( mercury, lead ,..)

Thank you