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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
Infections
Viral: e.g. Herpangina (Coxsackie virus) and herpes simplex; multiple small vesicles which rupture to form small ulcers.
Bacterial: Vincents infection **, TB, syphilis.
Fungal: Candidiasis. **
Immune disorders:
Aphthus ulcer **
Behcets syndrome **
Trauma
Physical: cheek bite, ill-fitting denture.
Chemical: silver nitrate, phenol, aspirin burn.
Thermal: hot food or fluid
Neoplasms: squamous cell CA, minor salivary glands CA
Skin disorders: Erythema multiforme, lichen planus, bullous pemphigoid, lupus erythematosus.
Blood disorders: Leukaemia, agranulocytosis.
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.
Vitamin deficiencies.
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.
Fordyces 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

Benign tumours
Solid tumours: papilloma, fibroma, haemangioma, pyogenic granuoloma, pregnancy granuloma and minor salivary gland neoplasm.
Cystic lesions:
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.
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.

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:
Autoimmune process (attack of mucous membrane by the own bodys immune system).
Hereditary. The patient often has positive family history.
Nutritional deficiency (vitamin B 12, folic acid and iron).
Physical or emotional stress.
Viral or bacterial infection.
Food allergies.
Hormonal changes related to menstrual cycles.

Classification: They are of two types

Minor aphthus ulceration.
Major aphthus ulceration.

Minor Aphthus ulcerationsMajor Aphthus Ulceration1More common

Less common
22-10mm in size
2-4 cm in size
3 Multiple
Usually single
4Painful
painful
5They heal in about 7-10 days without leaving a scarThey 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.

Vincents 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:
Systemic antibiotic: Penicillin or Erythromycin and metronidazole.
Frequent mouth washes (with sodium bicarbonate mouth solution).
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.
Behcets 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

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.
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
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.
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 Kopliks 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:
Viral: Infectious mononucleosis.
Bacterial: Diphtheria and scarlet fever.
Fungal: Candidiasis. mentioned previously
Spirochaetes: Vencents angina.
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.


Investigation
Swab for bacteriological examination including part of the membrane.
Complication
Laryngeal obstruction and stridor Tracheostomy.
Myocarditis and neuritis.
Treatment
Antitoxin: Intravenous 20,000-100,000 units depending on the severity of the infection.
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
Fever, headache with sore throat and halitosis.
Diffuse grayish membrane with superficial ulceration.
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
Specific: T.B. and syphilis
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:
Recurrent attacks of acute pharyngitis (sore throat).
Chronic sinusitis with post-nasal drip
Irritants such as tobacco, alcohol and industrial fumes
Gastro-Esophageal reflux disease (GERD)
Mouth breathing.


Clinical Picture
Discomfort and pain in the throat without fever. There is none of the malaise of tonsillitis and the condition persists for weeks or months.
Foreign body sensation in the throat and tendency to clear the throat, which results from postnasal drip bathing the posterior pharyngeal wall.
Tiring of voice( not hoarseness)
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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NOTE: Pharyngeal membranes are of two types:
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
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