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L.2 Diseases of the pharynx

1. Congenital diseases:

A. Cleft palate:
Its defined as a malformation in the roof of the mouth
(primary &/or secondary palate) due to defective closure of the lateral
maxillary process with the medial nasal process which may be complete or
incomplete, associated with cleft lip or not. It’s important to correct these
abnormalities at the exact time to prevent the complication of this condition
(otitis media, sinusitis, pharyngitis& rhinitis).
Treatment: at 3rd month lip repair & at 6-12 month palatal repair, this
treatment is preceded by parents’ reassurance & teaching how to feed the baby
until the time for surgical repair.

B.ChoanalAtresia:

It’s the commonest congenital anomaly in
the nose, occurs due to persistent bucconasal membrane leading to closure of the
posterior aperture of the nose. It could be unilateral or bilateral, membranous
or bonny & could be associated with (CHARGE: coloboma, heart disease, atresia of
choana, retarded growth, genital hypoplasia in male & ear deformities). The
bilateral condition is a pediatric emergency because the newborn is an obligate
nasal breather, the patient is diagnosed by introduction of a soft red rubber
catheter into both nasal cavities or definitely by axial CT scan, its treated by
drilling the obstruction site & putting a rubber tube for 4-6 weeks to prevent
reclosure.


2.TraumaticDiseases:
Its rare in the in this
region , but could occur &its either physical chemical trauma.

A. Physical trauma: Its caused by foreign body, its common in children 2-3 yr.

Age that predict to put things in their mouth, previously the coin swallowing,
in elderly trauma occurs due to denture that make the elderly senseless to the
presence of bones in the food (fish or chicken) this bone may lodge in the
(tonsil, post.1/3 of tongue,valleculae,pharyngeal wall, pyriform
fossa,larynx,post cricoid area &esophagus).The patient is unable to swallow or
even to drink water with choking & spillover of food in to the larynx leading to
cough & irritation.The patient should have lat.&PA views x-ray of the neck, if
nothing appear then barium swallow is used in which we see filling defects
either complete (Ba not passing) or partial (on the wall of FB).Treatment: It
must be urgent by using of direct laryngoscope &/or the esophagoscope
immediately or one day after consultation, under GA by using grasping forceps
through the endoscope & take it out , if the FB is fixed & we are unable to
remove it then we push it downwards towards the stomach where its digested &
getout with stool , surgery may be used to remove the FB , if the FB is not
removed after one day it may lead to secondary infection,that causes difficulty
in removing the FB & its important not to cause any trauma (iatrogenic)during
anesthesia or endoscopy.
B.Chemical trauma:
It’s either caused by hot drinks or chemicals (erosive) substances as acid or
base (which is the most dangerous substance) that may be used in suicide or
accidentally. It affects the esophagus more than the pharynx causing stricture &
dysphagia treated by frequent dilatation.

3.Inflammatory diseases:

Non-specific pharyngitis:

Its either acute or chronic inflammation, it’s a common condition

that may affect the adult but its more in children. The causative agent is
usually a virus that predisposes to secondary bacterial infection &/or a
fungal infection, sometimes the condition is started as primary bacterial
infection. The viral agents responsible are (RCV, adenovirus&rhinovirus) the
bacterial agents are (staph, hemolytic & nonhemolytic strept, h.influenze &
branhamella catarrhalis). The B-hemolytic strept is very important because it
can cause rheumatic fever or glomerulonephritis in strept sensitive persons.

The fungal agent is mostly due to candida (monilia) which causes what

is known as oral thrush, this infection occurs in children that may be not
aggressive, it also affect immunocompramised patient as (DM, AIDS, leukemia,
chronic liver disease).
The viral infection usually affect young school age children due to
crowding & communication with other children that may lead to spread of
infection easily, the bacterial infection is uncommon in children due to factors
related to immunity.
The most important predisposing factor for pharyngitis & tonsillitis
is the weather changing (weather localized or systemic) from hot to cold or vice
versa will activate certain inert bacteria in the oral cavity & pharynx as in
drinking cold water eating ice-cream which causes localized temperature change
in the area & then activation of inert bacteria leading to infection, this can
occur in systemic change in the weather as in getting out of bathroom or
sleeping under the air conditioner.
Clinical features:
Simple infection:
1. .Irritation or itching in the area in the first few hours or days.
2. . Pain is started leading to dysphagia & odenophagia(pain during swallowing)
or even during speaking.
3. .Systemic symptoms (fever 38c, tiredness, weakness, lassitude, and
predilection to sleep in bed & sometimes headache). The fever is very important
in children where it might cause hypothalamus sensitization impulse generation
to whole brain causing febrile convulsions, that’s why its important to give
drugs to lower the temperature in addition to antibiotics.
Notes:
- Patient with valvular heart disease may develop infective
endocarditis after simple pharyngitis.
- -Patient with kidney disease may develop glomerulonephritis after simple or
mild sorethroat.
- -In fungal infection of the pharynx we must think of immunocompramised patient
for any reason.
Investigation:
- -Throat swab as in diphtheria or resistant microorganisms.
- - Blood tests that show increased WBC count (neutrophilia in bacterial
Infection & lymphocytosis in viral infection) OR decreased WBC count in typhoid
fever.
- -Serological tests to differentiate the condition from infectious
mononucleosis.
Treatment:
1. Rest in bed for few days to encourage cure & to prevent spread of the
infection to the community.
2. .Analgesia simple analgesia is required especially in viral infection, which
is either local (lozenges, sprays & paints) or systemic (aspirin &
paracetamole).
3. .Antibiotics it’s better to be given even in viral infection to prevent
secondary bacterial infection. Broad-spectrum antibiotics as penicillin,
cephalosporins, erythromycin & spiromycin. The route of administration depend on
the severity of the condition, in sever cases we start parentral antibiotics for
3 days followed by 7 days orally, while in mild cases we give oral AB for 7 days
only.
4. Feeding is important especially in children.


Specific pharyngitis

1. .Acute specific pharyngitis:


Diphtheria: The most important specific infection in the pharynx, it is
caused by G+ve bacillus corynebacterium diphtheriae that can
produce an exotoxin responsible for the systemic effects of the disease
(myocarditis, cardiac conduction defect, arrythmias& fatal
thrombocytopenia)these effects are the major cause of death in this infection.
Clinical features:
Usually affect children <10 yr. old, it was a common infection
previously but nowadays it becomes rare due to the development of vaccination,
the incubation period of the disease is 2-7 days. It starts gradually as
malaise, pyrexia &headache. Its characterized by the formation of a
pseudomembrane on the tonsils, soft palate, posterior pharyngeal wall & even the
nasopharynx, its gray in color (may be white to dark brown in color) this
membrane is firmly attached to the mucosa & if we remove it then it bleeds.
There is also tender bilateral cervical lymphadenopathy, if it affect
the larynx or trachea it may lead to respiratory obstruction & stridor
especially in children < 5 yr. Age because of narrow airways.
Diagnosis:
1. .Clinical features.
2. .Throat swab, which is diagnostic in 100% of the cases.
Treatment:
1. .Antibiotics as penicillin or erythromycin.
2. .Antitoxin is also given especially in children in a dose of 10000-80000 IU.



2. Chronic specific pharyngitis:

a. .Tuberculosis(TB) :

It’s a rare disease, usually associated with pulmonary TB, but sometimes
especially in the tonsils the infection is caused by ingestion of infected milk.

Its characterized by cervical lymphadenopathy (LAP), which are (enlarged,
multiple, painless, rubbery, unilateral) but when an abscess develop it becomes
tender. On examination the tonsil is usually normal, but could be enlarged.
Diagnosis:
1. .Clinical features.
2. .Blood examination: anemia (IDA), lymphocytosis (40-60%), high ESR (15-20
mm/hr).
3. .Throat swab examined by Ziel Nelson stain.
4. .Chest x-ray to identify pulmonary TB.
5. .Lymph node biopsy: when the diagnosis is not established, histopathological
study shows granuloma (epithelial cells, peripheral lymphocytes, and giant cells
with central caseation. Sometimes ZN stain is used to identify the acid-fast
bacilli.
Treatment:
By anti TB drugs with surgical removal of LAP or even the tonsils.


b. .Syphilis:
It’s a rare disease & consist of 3-stages:
1. Primary: characterized by chancre in the (lips, cheek, or tonsils). Its
highly infectious (don’t touch it), there may be cervical LAP.
2. Secondary: more common & forming mucous patches (single or multiple) may
ulcerate forming snail like ulcer covered by dirty gray colour membrane like
burn.
3. Tertiary: forming tumor like mass & usually occur after prolong period
after the infection & usually in elderly.
Diagnosis:
1. .Clinical features.
2. .Swab must be examined immediately.
3. .Serological test: Wassermann test (not specific) & treponema pallidum
immobilization test (specific).
Treatment:
Penicillin is used & directed to the stage of the disease.

The adenoids

Definition:
A mass of lymphoid tissue in the junction of the roof & posterior wall of the
nasopharynx called nasopharyngeal tonsil, which undergo hypertrophy sufficient
to produce symptoms between 3-7 yr. of age. It contains no crypts & no capsule
unlike the palatine tonsil, but is composed of vertical ridges of lymphoid
tissues separated by a bout 5-deep clefts.
The adenoids can produce antibodies locally (IgA) & systemically (IgG, IgM).


Symptoms of adenoid diseases:

1. .Symptoms due to hypertrophy:

a. .Nasal obstruction: which lead to:
1. .Mouth breathing.
2. .Feeding problems especially in infants.
3. .Snoring.
4. .Hyponasal speech & toneless voice.
b. .Eustachian tube obstruction: which lead to deafness by:
1. .Retraction of the drum (early).
2. .Otitis media with effusion (late).
c. .adenoid facies: characterized by
1. .Open mouth.
2. .Facial elongation.
3. .High arched palate.
4. .Open anterior bite with protrusion of the upper incisors.
5. .Flattened midface.
2. Symptoms due to inflammation:
a. .Nasal discharge due to mechanical obstruction & secondary rhinitis.
b. .Post nasal drip.
c. .Cough.
d. .Sinusitis.
e. .Otitis media (OM with effusion, acute OM, chronic OM).
f. .Generalized mental disturbances.


Signes of adenoid diseases:
1. .Anterior rhinoscopy: show congested mucosa, hypertrophy of the inferior
turbinate & high amount of secretion.
2. .Posterior rhinoscopy: can be done in older children (more than 6 yr.). It
shows a lobulated mass covered with mucous membrane & postnasal discharge.
3. . Otoscopic examination & hearing assessment by tuning fork:
a. .Retraction of the TM.
b. .Signes of OM (OM with effusion, acute OM, chronic OM.
c. .Conductive deafness.
d. .TM mobility by seigle pneumatic apparatus.
4. .Neck examination: upper deep cervical lymph node enlargement.
5. .Signes of adenoid facies.

Diagnosis:

1. .PTA (pure tone audiometry) & tympanometry.
2. .Lateral x-ray of the neck to show the postnasal space.

Treatment:

a. .Conservative treatment:
1. .Non-irritant decongestant nasal drops& systemic decongestant.
2. .Treatment of sinusitis & allergy.
3. .Breathing & postural exercises.
4. .Good nutrition & diet.
b. .Surgery: by adenoidectomy.
Indications of adenoidectomy:
1. .Nasal obstruction: evaluated by clinical & radiological findings.
2. .Otitis media with effusion due to adenoid hypertrophy.
3. .Recurrent acute otitis media.
4. .Sleep apnea.
5. .Biopsy in suspected cases of lymphoid system neoplasia.


Contraindications of adenoidectomy:
1. .Recent upper respiratory tract infection.
2. .Bleeding disorders.
3. .Cleft palate.
4. .Submucous cleft palate.
5. .Congenitally short palate.

Complications of adenoidectomy:

1. .Hemorrhage:
a. .Primary: occur during the operation.
b. .Reactionary: occur during the first 24 hrs.
c. .Secondary: occur between 4-10 day post operatively.
2. .Trauma: to the soft palate, Eustachian tube & cervical spine.
3. .Hypernasal speech.
4. .Scarring of the nasopharynx.
5. .Remnant of adenoid tissue.
6. .Acute otitis media.
7. .Retropharyngeal abscess.
8. .Cervical cellulitis.
9. .Septicemia.





رفعت المحاضرة من قبل: Mostafa Altae
المشاهدات: لقد قام 7 أعضاء و 105 زائراً بقراءة هذه المحاضرة








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