DISEASES OF ADENOIDS,TONSILS AND PHARYNX.pptx

Adenoid hypertrophy mainly occurs in children 3-5years

1. DISEASES OF ADENOIDS,TONSILS AND PHARYNX DR.KAKANDE

2. Anatomy Pharynx is a conical fibromuscular tube forming upper part of the air and food passages . It is 12-14 cm long extending from the bse of the skull ( basiocciput and basissphenoid ) to the lower border of cricoid cartilage where it becomes continuous with the esophagus. The width of the pharynx is 3.5cm at pharyngo- oesophageal junction,which has the narrowest part of digestive tract apart from the appendix The structure of the pharyngeal wall consists of 4 layers;Mucous membrane,Pharyngeal aponeurosis ( pharyngobasilar fascia), muscular coat , Buccopharyngeal fascia

3. Killian’s Dehiscence Inferior constrictor muscle has 2 parts; Thyropharyngeus with oblique fibres and cricopharyngeus with transverse fibres . Between this 2 parts exists a potential gap called Killian’s dehiscence . It is also called “gateway of tears” as perforation can occur this site during esophagoscopy . This is also the site for herniation of pharyngeal mucosa in cases of pharyngeal pouch

4. Waldeyer’s ring Also known as the pharyngeal lymphoid ring is a ringed arrangement of thr lymphoid organs to form masses in the pharynx. Waldeyer’s ring surrounds the naso and oropharynx with some of its tonsillar tissue located above and some below the soft palate (and to the back of the back of the mouth cavity The masses are; Nasopharyngeal tonsil or the adenoids Palantine tonsils Lingusl tonsils Tubal tonsils (in fossa of Rosenmuller ) Lateral pharyngeal bands Nodules (in posterior pharyngeal wall)

5. Pharyngeal spaces There are two potential spaces in relation to the pharynx where abscess can form ; Retropharyngeal space situated behind the pharynx and extending from the base of the skull to the bifurcation of trachea and Parapharyngeal space situated on the side of pharynx . It contains carotid vessels, jugular vein , last 4 cranial nerves , and cervical sympathethic chain The pharynx is divided into 3 parts ; Nasopharynx Oropharynx Hypopharynx or laryngopharynx

6. ADENOIDS Also known as Lushka’s tonsils,Nasopharyngeal tonsils Hypertrophy of lymphoid tissue sufficient to produce symptoms Commonly between age 3-7 years Its etiology can be physiological or pathological Physiological ; Occurs due to marked immunological activity Gradually regresses in size with the increase in size of the nasopharynx to become atrophic at puberty Persistence of adenoids into adult life is uncommon Pathological ; Due to recurrent UTI Recurrent rhino- sinustis

7. Anatomy The nasopharyngeal tonsils is commonly called adenoids is situated at the junction of the root and posterior wall of the nasopharynx It is composed of vertical ridges of lymphoid tissue separated by deep clefts Covering epithelium is of 3 types ; ciliated pseudostratified columnar, stratified squamous and transitional. Unlike palantine tonsils,adenoids have no crypts and no capsule Adenoid tissue is present at birth,shows physiological enlargement up to the age of 6 years and then atrophy at puberty and almost completely disappear by the age of 20

8. Blood supply adenoids receive it from ; Ascending palantine branch of facial , Ascending pharyngeal branch of external carotid, Pharyngeal branch of the 3 rd part of maxillary artery and the ascending cervical branch of inferior thyroid artery of thyrocervical trunk Lymphatics from the adenoid drain into upper jugular nodes directly or indirectly via retropharyngeal and parapharyngeal nodes Nerve suppky is through CN IX and X , they carry sensation. Referred pain to ear due to adenoiditis is also medicated through them

9. Clinical features Symptoms and signs depend not merely on the absolutr size of the adenoid mass but are relative to the available space in the nasopharynx Enlarged and infected adenoids may cause nasal aural or general symptoms Nasal symptoms; Nasal obstruction-Commonest symptom. This leads to mouth breathing. Nasal obstruction also interferes with feeding or suckling in a child. As respiration and feeding cannot take place simultaneously , a child with adenoid enlargement fails to thrive

10. Nasal discharge it is partly due to choanal obstruction as the normal nasal secretions cannot drain into nasopharynx and partly due to associated chronic rhinitis. The child often jhas a wet bobbly nose Epistaxis Voice change Sinusitis AURAL SYMPTOMS; Tubal obstruction (Adenoid mass blocks Eustachian tube) Recurrent attacks of acute otitis media Serous otitis media

11. General symptoms; Adenoid facies Pulmonary hypertension Aprosexia DIAGNOSIS; Examination is possible in some young children and an adenoid mass can seen with a mirror. A rigid or flexible nasopharyngoscope is also useful to see details of nasopharynx in a cooperative child. Soft tissue lateral radiograph of nasopharynx will reveal the size of adenoids and also the extent to which nasopharyngeak air space has been compromised

12. Treatment When symptoms are not marked, breathing exercises, decongestant nasal drops and antihistamines for any coexisting nasal allergy can cure the condition without resort to surgey When symptoms are marked adeinodectomy is done.

13. Acute nasopharingitis Acute infection of the nasopharynx may be an isolated infection confined to this part of the generalized upper airway infection It may be caused by viruses (common cold,influenza,parainfluenza , rhino or adenovirus) or bacteria ( streptococcus,pneumococcus or H.influenza ) Clinical features ; Dryness and burning of the throat above the soft palate Pain and discomfort localized to the back of the nose Difficulty on swallowing Pyrexia Enlarged cervical lymph nodes Examination reveals white exudate congested and swollen mucosa in the nasopharynx

14. Treatment Mild cases clear up spontaneously Some analgesic may be required for pain and discomfort In severe cases with general symptoms,systemic antibiotics or chemotherapy

15. Chronic nasopharyngitis It is often associated with chronic infections of nose paranasal sinuses,and pharynx Commonly seen in smokers drinkers and those exposed to dust and fumes Clinical features; Postnasal discharge and crusting with irritation at the back of the nose. Patient has a desire of to clear the throat by hawking or inspiratory snorting Examination shows congested mucosa and mucopus or dry crusts

16. Treatment Chronic infections of the nose paranasal sinuses and oropharynx should be attended to Excessive smoking and drinking should be corrected Preventive measure should be taken to avoid dust and fumes Alkaline nasal douche helps remove crusts and mucopus Steam inhalations

17. Pharyngeal Bursitis( Thornwaldt’s disease ) It is infection of the pharyngeal bursa which is a median recess representing attachment of notochord to endoderm of the primitive pharynx. Clinical features ; Persistent postnasal discharge with crusting in the nasopharynx Nasal obstruction due to swelling in the nasopharynx Obstruction to Eustachian tube and serous otitis media Dull type of occipital headache Recurrent sore throat Low grade fever On exam will reveal a cystic and fluctuant swelling in posterior wall of the nasopharynx Treatment is antibiotics given to treat infections and marsupialization of the cystic swelling and adequate removal of its lining membrane

18. Acute Pharyngitis Occurs due to viruses,bacterial,fungal Viral causes are more common Acute streptococcal pharyngitis has received more importance because of its aetiology in rheumatic fever and post streptococcal glomerulonephritis Clinical features; Milder infections may present with discomfort in throat,malaise and low grade fever. Pharynx is congested but no lymphadenopathy Moderate and severe infections presents with pain in throat,dysphagia,headache,malaise,and high fever. Pharynx shows erythema ,exudate and enlargement of tonsils and lymphoid follicles on posterior pharyngeal wall Very severe cases shows edema of soft palate and uvula with enlargement of cervical nodes Viral infections aremild and accompanied by rhinorrhea and hoarseness while bacteria ones are severe. Gonnococcal pharyngitis maybe asymptomatic Diagnosis is through culture of throat swb

19. Treatment General measures ; Bed rest Plenty of fluids Warm saline gargles Analgesia Specifc measures; Strep pharyngitis – Penicilin G 200,000-250000 UNITS orally 4 times a day for 10 days Diptheria – Diptheria antitoxin and adm of penicillin or erythromycin Gonnococal pharyngitis – Conventional doses of penicillin or tetracyclin

20. Viral infections causing pharyngitis Herpanagia Infectious mononucleosis Cytomegalovirus Pharyngoconjuctival fever Acute lymphonodular pharyngitis Measles and chickenpox

21. Fungal pharyngitis Candida infection of oropharynx can occur as an extension of oral thrush in pts with immunosurpressed debilitated or taking high doses of antimicrobials. Often complain of pain in throat with dysphagia Nystatin is DOC

22. Chronic pharyngitis Chronic inflammatory condition of pharynx characterixed by hypertrophy of mucosa , seromuccinous glands subepithelial lymphoid tissues and muscular coat of pharynx Two types; Chronic catarrhal pharyngitis and Chronic hypertrophic (granular) pharyngitis .

23. Aetiology Persistent infection in the neighbourhood Mouth breathing Chronic irritants Environmental pollution Faulty voice production

24. Symptoms Discomfort or pain in throat Foreign body sensation in throat Tiredness of voice Cough

25. Signs Chronic catarrhal pharyngitis ; Congestion of posterior pharyngeal wall with engorgement of vessels,faucial pillars maybe thickened and increased mucous secretions may cover pharyngeal mucosa Chronic hypertrophic pharyngitis ; Lateral pharyngeal bands become thickened,Uvula may be elongated and edematous, Pharyngeal wall appears thickened and edematous , posterior pharyngeal wall maybe studded with reddish nodule

26. Treatment In every case aetiology cause should be sought and eradicated Voice rest and speech therapy Warm saline gargles esp in mrng Mandl’s paint may be applied to pharyngeal mucosa Cautery of lymphoid granules is suggested. Throat is sprayed with locoal anesthesia and granules touched with 10-25% of silver nitrate

27. Atrophic pharyngitis A form of chronic pharyngitis often seen in patients of atrophic rhinitis.Pharyngeal mucosa along with its mucosa show atrophy . Scantity mucus production leads to crusts which letter gets to be infected and foul smell Clinical feature is dryness and discomfort in throat ,hawking and dry cough. Examination show dry and glazed pharyngeal mucosa often covered with crusts Treatment same as atrophic rhinitis

28. ACUTE TONSILITIS Tonsils are a pair of small, soft tissue masses located at the back of the throat, one on each side. Scientifically, tonsils are part of the lymphatic system and are classified as secondary lymphoid organs. The two main types of tonsils are the palatine tonsils, which are the ones commonly referred to as “tonsils,” and the pharyngeal tonsils, also known as the adenoids . The palatine tonsils are clusters of lymphatic tissue consisting of lymphocytes, macrophages, and other immune cells. They play a role in the immune system by helping to protect the body against infections. The tonsils contain germinal centers where immune cells are activated and antibodies are produced in response to pathogens, such as bacteria or viruses, that enter the throat

29. Anatomy of the tonsils Palatine tonsils are the largest member of the inner  waldeyer’s ring . They consist of paired aggregates of lymphoid tissue located in pocket formed between between the anterior (mucosal fold of palatoglossal muscle) and posterior tonsillar xtends superiorly into the soft palate, inferiorly into the tongue base and anteriorly into palatoglossal arch (formed by palatoglossal muscle). Tonsils may be larger in childhood and usually regress in size near puberty. Developmentally tonsils arise from the ventral po portion of the second pharyngeal pouch, i.e. ideally named as sinus tonsillaris .

30. Histologically they consist of lymphoid tissue with aggregates of lymphocytes arranged in follicular manner and embedded in a stroma of connective tissue. The tonsil has two surfaces – medial and lateral , and two poles – upper and lower

31. Tonsilar crepts The medial surface of tonsil has 10-15numbers of pits, which leads into blind ending, and are often highly branched, extending through whole thickness of tonsil – called crypts. Embryologically , they represent sinus tonsillaris . The largest crypt is called Crypta Magna / Intra-tonsillar cleft – represent the persistent part of the ventral portion of the second pharyngeal pouch. Secondary crypts: They arise from the main crypts within the substance of tonsil. Content of crypts: Crypts may be filled with microorganism, desquamated food debris etc. Sometimes they may get im mpacted in these crypts leading to development of a white material ( tonsillolith / tonsil stones) – which can be express ed out with pressure over the anterior tonsillar pillar. This can also lead to acute and recurring inflammation of tonsils (tonsillitis).

32. Structures of tonsillar bed from medial to  lateral Condensed capsule formed by the pharyngobasilar fascia and loose areolar tissue – The tonsil is virtually inseparable from its capsule, but the capsule is united by loose connective tissue to superior constrictor muscle. Hence in tonsillectomy the tonsillar dissection is carried out in this plane . Just under the capsule is the peritonsillar vein. The superior constrictor muscles. Buccopharyngeal fascia. The glossopharyngeal nerve and the stylohoid ligament pass downwards and forwards beneath the lower edge of the superior constrictor in the lower part of the tonsillar fossa.

33. Blood supply, Venous drainage and Nerve supply of tonsils Tonsillar branch of the facial artery is the main artery of the tonsil. It enters tonsil near its lower pole by piercing the superior constrictor just above the styloglossus muscle. Lingual artery through its dorsal lingual branches, Ascending palatine branch of facial artery, Descending palatine branch of maxillary artery Ascending pharyngeal vessels . Venous drainage occurs through the para tonsillar vein (external palatine), and the vessels also pass through to the pharyngeal plexus or facial vein after piercing the superior constrictor to IJV.

34. T he tonsils have no afferent lymphatics. Lymphatic vessels from the tonsil pierce through the buccopharyngeal fascia and pass to the  upper deep cervical group of nodes , particularly to the jugulodigastric group. The sensory nerve supply to tonsil is by: Lesser palatine branches from sphenopalatine ganglion of maxillary division of trigeminal nerve (CN V2). Glossopharyngeal nerve (CN IX).

35. Acute tonsilitis Acute infections of tonsils may involve; Acute catarhhal or superficial tonsillitis Acute follicular tonsillitis Acute parenchymous tonsillitis Acute membranous tonsillitis

36. Aetiology Oftens occurs in school going children and adults Rare in infants and >50yrs Hemolytic streptococcus is most commonly infecting org. Others,staph,pneumococcus,or H.influenza

37. Symptoms Sore throat Difficulty swallowing Fever Earache

38. Signs and treatment Foeted breath and tongue coasted Hyperemia of pillars soft palate and uvula Red tonsils and swollen with yellow spots of purulent material presenting at the opening of the crypts Juglodiastric lymph nodes are enlarged and tender Treatment ; Bed rest and fluids,analgesics (aspirin or paracetamol) , antimicrobial therapy (most infectious are due to streptococcus and pelican is drug of choice if allergic erythromycin) Antibiotics continued for 7-10 days

39. Complications Chorinic tonsillitis with recurrent acute attacks Peritonsilar abscess Parapharyngeal abscess Cervical abscess Acute otitis media Rheumatic fever Acute glomerulonephritis Subacute bacterial endocarditis

40. Faucial Diptheria Acute specific infection caused by gram positive bacillus C.Diptheria Spreads by droplet infection Incubation period is 2-6 days Clinical feature s;Oropharynx is more commonly involved and have a greyish white membrane forms over tonsils and spreads to the soft palate and post. Pharyngeal wall , jugulodigastric nodes are enlarged and tender presenting as “bull-neck”. Ptient is ill and toxaemic but fever seldom rises above 38degrees Complication ;Myocarditis,cardiac arrhythmias,acute circulatory failure,paralysis of soft palate,diaphragm and ocular muscles,airway obstruction.

41. Treatment Started on clinical suspicion. Dose of antitoxin given depend on duration and severity of disease Antitoxin is given by iv fusion Sensitivity to hoarse serum should be tested by conjunctival or intracutaneous test with diluted antitoxin and adrenaline should be at hand for any immediate hypersensitivity In presence of hypersensitivity desensitization should be done Antibiotics used are benzyl penicilin600mg 6 hourly for 7 days Erythromycin is used in penicillin sensitivity individuals (500mg 6hourly orally)

42. Chronic tonsillitis It maybe a complication of acute tonsillitis Subclinical infections of tonsils without an acute attack Mostly affects children and adults Chronic infection in sinuses or teeth may be a predisposing factor There are three types ; Chronic follicular tonsilliti s (here tonsillar crypts are full of infected cheesy material which shows on the surface as yellowish spots ), Chronic parenchymatous tonsillitis (there is hyperplasia of lymphoid tissue,tonsils are enlarged and may interfere with speech,deglutination and respiration,sleep apnea.Long standddding cases develop Cor pulmonale ) and Chronic fibroid tonsillitis ( tonsils are small but infected with history of repeated sore throats)

43. Clinical features Recurrent attacks of sore throat or acute tonsillitis Chronic irritation of throat with cough Bad taste in mouth and foul breath (halitosis) due to pus in crypts Thick speech,difficulty swallowing and choking spells at night

44. Examination Tonsils may show varying degree of enlargement ,sometimes meet in midline There maybe yellowish beads of pus on the medial surface of tonsils (chronic follicular type) Tonsils are small but pressure of anterior pillar expresses frank pus or cheesy material (chronic fibroid type) Enlargement of jugulodigastric lymph nodes

45. Treatment Conservative treatment consists of general attention to health,diet,treatment of coexistent infection of teeth nose and sinuses Tonsilectomy is indicated when tonsils interfere with speech,deglutination and respiration

46. Complications Peritoneal abscess Parapharyngeal abscess Tonsiloliths Tonsilar cysts Tonsiloliths (calculus of tonsils) seen in chronic tonsils when crypts is blocked with retention of debris ,salts and calcium are then deposited leading to formation of a stone. It may gradually enlarge and ulcerate throught the tonsils. They are seen more in adults and give rise to discomfort or foreign body sensation . Easily diagnosed by palpitations and treatment is removal of stone or tonsillectomy

47. Diseases of lingual tonsils Acute lingual tonsillitis –Gives rise to unilateral dysphagia or feeling of lump in throat. On exam;lingual tonsil may appear enlarged or congested .Cervical lymph nodes are enlarged and treatment Is by antibiotics Hypertrophy of lingual tonsils –Mostly it is compensatory hypertrophy of lymphoid tissue due to repeated infection in tonsillectomized patients . Usual complains are discomfort on swallowing,feeling of lump in throat dry cough or thick voice .Treatment is conservative,diathermy coagulation or excision of lingual tonsils has to be done Abscess of lingual tonsil -Rare condition but can follow acute lingualtonsilitis . Symptoms are severe unilateral dysphagia ,pain in tongue,excessive salivation , trismus,jugulodigastric nodes are enlarged and tender . Potentially dangerous as laryngeal edema can follow. Diagnosis is by mirror exam and palpation of the base of the tongue . Treatment is antibiotics, analgesia, hydration and incision and drainage of abscess

48. Friedman Grades of tonsillar hypertrophy Grade 0 No tonsils seen / Surgically removed tonsils. Grade 1 Within tonsillar fossa Grade 2 Visible beyond anterior pillars Grade 3 Extend 3/4th of way to midline. Grade 4 Completely obstructing airway i.e. Kissing tonsil.

49. dation of Tonsillar Enlargement Grade Definition Description Not visible Tonsils don’t reach tonsillar pillars / Surgically removed. 1+ Less than 25% Tonsils fill less than 25% of transverse oropharyngeal space measured between anterior pillars 2+ 25% to 49% Tonsils fills less than 50% of transverse oropharyngeal space 3+ 50% to 74% Tonsils fills less than 75% of transverse oropharyngeal space 4+ 75% or more Tonsils fills more than 75% of transverse oropharyngeal space

50. THANK YOU REFERRENCES; DISEASES OF EAR,NOSE AND THROAT & HEAD AND NECK SURGERY 6 TH EDITION TEACHMEANATOMY