Chapter 17: Diseases of the Nasopharynx and Oropharynx Flashcards
1
Q
Regions of pharynx
A
- Nasopharynx
- Oropharynx
- Laryngopharynx/hypopharynx
2
Q
Respiratory portion of the pharynx
Immobile except for the lower soft palate
A
Nasopharynx
3
Q
Extends from the inferior border of the soft palate to the lingual surface of the epiglottis
Includes the palatine tonsils with their pillars and the lingual tonsils located on the base of the tongue
A
Oropharynx
4
Q
Represents the region of the separation of the upper airway from the upper digestive pathway
A
Laryngopharynx/hypopharynx
5
Q
Posterior wall extending toward the vault of the nasopharynx
A
Adenoid tissue
6
Q
Recessus pharyngeus
A
Rosennüller’s fossa
7
Q
Reflection of pharyngeal mucosa over the rounded protrusions of the cartilaginous portion of the ET projects as a thumblike intrusion into the lateral wall of the nasopharynx just above the attachment of the soft palate
A
Torus tubarius
8
Q
Posterior choanae of the nasal cavity
A
Nasopharynx
9
Q
Close proximity and can be involved by extension of nasopharyngeal disease
A
Cranial foramina (jugular foramina)
10
Q
Important vascular structures in the immediate in the nasopharynx
A
- Inferior petrosal sinus
- Internal jugular vein
- Meningeal branches from the occipital and ascending pharyngeal arteries
- Hypoglossal foramen
11
Q
Is in the proximity to the lateral portion of the roof of the nasophatynx
A
- Petrous portion of the temporal bone
2. Foramen lacerum
12
Q
Ostium of the sphenoid sinuses
A
Nasopharynx
13
Q
Permits direct visualization of the nasopharynx and torus tubarius
A
Nasopharyngoscope
14
Q
Circumferential ring of lymphoid tissue
A
Waldeyer’s ring
15
Q
Other parts of the ring
A
- Lymphoid tissue
- Palatine/faucial tonsils
- Lingual tonsils
- Lymphoid follicles on the posterior pharyngeal wall
16
Q
Has its lymphoid structures arranged in folds
A
Adenoid/pharyngeal tonsils
17
Q
Has its lymphoid arrangement around cryptlike formations
A
Palatine tonsils
18
Q
- Becomes diseased frequently than any of the other components of the ring
- More tortuous in the upper pole of the tonsils
- Become plugged with food particles, mucus, desquamated epithelial cells, leukocytes and bacteria
- Excellent place for the growth of pathogenic bacteria
A
Palatine tonsils
19
Q
Have small crypts that are not particularly tortuous or branched
A
Lingual tonsils
20
Q
Serves as a divider between the oropharynx and the hypopharynx
A
Epiglottis
21
Q
- Includes the pyriform sinuses, posterior pharyngeal wall and post cricoid cartilage
- Funnel-shaped
A
Hypopharynx
22
Q
Results from the embryologic failure of the bucconasal membrane to rupture prior to birth
A
Congenital choanal atresia
23
Q
Results in the persistence of a bony plate (90%) or membrane (10%) obstructing the posterior nares
A
Congenital choanal atresia
24
Q
Congenital choanal atresia
A
Unilateral: asymptomatic
Bilateral: emergency
25
Diagnostic for congenital choanal atresia
Inability to pass a soft catheter through the nose into the pharynx
26
Emergency treatment for congenital choanal atresia
Inserting a plastic oral airway into the infant's mouth
27
Alternative treatment for congenital choanal atresia
Tape a rubber baby bottle nipple (McGoven nipple) with a large opening on the tip into position in the infant's mouth (permitting both breathing and feeding)
28
Blindly perforating the bony plate or membrane is prohibited because of the...
Narrow nasopharynx
29
Atresia plate can be approached surgically by...
1. Transnasal
2. Transeptal
3. Transpalatal (more definitive)
30
1. Is a form of postnasal discharge that is produced by mucoid drainage from a pocket (pharyngeal bursa) in the uppermost part of the posterior pharyngeal wall
2. Unusual cause of postnasal drainage
3. Corrected by excision
Nasopharyngeal bursitis
31
Symptoms of nasopharyngeal tumor
1. Posterior epistaxis
2. Postnasal discharge
3. Nasal obstruction
4. Hearing loss
5. Late sign: paralysis of CN 3, 6, 9, 10, 11
6. Serous otitis media
32
1. Uncommon tumor occurs exclusively in adolescent boys
2. Symptoms: epistaxis, nasal obstruction
3. Can invade the surrounding vital structures with eventual invasion of the base of the skull
Juvenile nasopharyngeal angiofibroma
33
Treatment modalities for juvenile nasopharyngeal angiofibroma
1. Radiation ( for residual disease or when surgery is not possible)
2. Surgery (preferred treatment when feasible)
3. Hormonal therapy
34
Evaluation of juvenile nasopharyngeal angiofibroma
1. CT scan
| 2. Arteriography
35
Highly vascular tumors obtain their blood supply from
1. Ascending pharyngeal artery or
2. Internal maxillary artery
Additional: branch of the internal carotid artery (tumor transcends into the anterior or middle cranial fossa)
36
Diagnosis of juvenile nasopharyngeal angiofibroma
1. History
2. Exam
3. CT
4. Arteriogram
5. Biopsy (not necessary and is hazardous)
37
Most common presenting sign of nasopharyngeal carcinoma
Posterior high cervical lymph node
38
Virus that is associated with nasopharyngeal carcinoma
Epstein-Barr virus
39
An accumulation of lymphoid tissue along the posterior wall of the nasopharynx above the level of the soft palate
Adenoids
40
Adenoids
Hypertrophy: childhood (normal), greatest size in the preschool and early school-age years
Spontaneous resolution: 18-20 years
41
Related to ET obstruction and resultant serous otitis media as well as recurrent and repeated episodes of acute otitis media
Adenoid hypertrophy
42
Can interfere with nasal breathing if theres obstruction
Adenoid hypertrophy
43
May lead to some changes in dental structure and malocclusion
Adenoid hypertrophy
44
Can interfere with the normal respiratory process--->cor pulmonale or sleep apnea-type syndromes
Adenoid hypertrophy
45
Indications for adenoidectomy
1. Chronic upper airway obstruction with resultant sleep disturbances, cor pulmonale or sleep apnea syndrome
2. Chronic purulent nasopharyngitis despite adequate medical management
3. Chronic adenoiditis or adenoid hypertrophy associated with production and persistence of middle ear effusion
4. Recurrent acute suppurative otitis media that has not responded to medical management with prophylactic antibiotics
5. Certain cases of chronic suppurative otitis media in children with associated adenoid hypertrophy
6. Suspicion of nasopharyngeal malignancy
46
Most common and preferred treatment for chronic serous otitis media that is refractory to medical management with antibiotics and other forms of conservative treatment
Insertion of ventilation tubes through the TM (may remain in place only 6-12 months)
47
Serves as a flag to warn of possible submucous palatal cleft
Bifid uvula
48
Oropharyngeal disorder can be divided into those that cause...
1. Acute sore throat
| 2. Chronic sore throat
49
Common organisms found in acute pharyngitis
1. Streptococci
2. Pneumococci
3. Influenza bacillus
50
Stages of acute pharyngitis
Hyperemia--->edema--->increased secretion
| Exudate at first is serous but becomes thicker or mucoid--->become dry and may adhere to the pharyngeal wall
51
Signs and symptoms of acute pharyngitis
1. Dryness or scratchiness of the throat
2. Malaise
3. Headache
4. Fever
5. Exudate in the pharynx
6. Hoarseness
7. Dysphagia
8. Cervical adenopathy and tenderness
9. Pharyngeal wall is reddened
52
Acute suppurative bacterial tonsilitis is most often caused by
```
Beta-hemolytic Streptococcus group A
Others:
Pneumococci
Staphylococci
Hemophilus influenzae
```
53
General inflammation and swelling of the tonsil tissue with an accumulation of leukocytes, dead epithelial cells and pathogenic bacteria in the crypts
Acute suppurative bacterial tonsilitis
54
Pathologic phases: acute suppurative bacterial tonsilitis
1. Simple inflammation of the tonsil area
2. Formation of exudates
3. Cellulitis of the tonsil and its surrounding area
4. Formation of a peritonsillar abscess
5. Tissue necrosis
55
Symptoms of acute suppurative bacterial tonsilitis
1. Sorethroat
2. Dysphagia
3. Fever
4. Otalgia
5. Tender cervical lymphadenopathy
6. Enlarged and inflamed tonsils with/out exudates
56
Lukewarm gargling solution in acute suppurative bacterial tonsilitis
1st: warm
| 2nd and 3rd: even warmer
57
Drug of choice for acute suppurative bacterial tonsilitis
Penicillin
58
If group A beta-hemolytic streptococci are cultured, it is important to...
Maintain adequate antibiotic therapy for 10 days to reduce the possibility of nonsuppurative complications such as RHD and nephritis
59
1. Present in the tonsil is capable of producing beta-lactamase
2. This may explain persistent positive cultures after apprpriate treatment
Branhamella catarrhalis
60
Do not have the complex arrangement of the faucial tonsils nor are they as large
Lingual tonsils
61
More common in tonsillectomized patients and in adults
Lingual tonsilitis
62
Signs and symptoms of lingual tonsilitis
1. Soreness on swallowing
2. Sense of lump in the throat
3. Malaise
4. Slight fever
5. Cervical adenopathy with tenderness
6. Reddened, swollen lingual mass with whitish spots dotting the surface of the tonsils
63
Membranous pharyngitis
1. Vincent's (or Plaut's) angina
| 2. Diphtheria
64
Caused by fusiform bacilli and spirochetes normally present in the oral cavity
Vincent's infection or trench mouth
65
Diagnosis of Vincent's angina
Presence of numerous fusiform bacteria seen with Fontana stain
66
Treatment of Vincent's angina
1. Supportive measures
2. Sodium perborate or hydrogen peroxide mouthwash
3. Specific penicillin therapy
67
Remains the most common site for diphtheria
Pharynx
68
Occurs more frequently in unimmunized or inadequately immunized individuals
Diphtheria
69
Most common initial complaints of diphtheria
Sore throat
70
Examination in patient with diphtheria
1. Membrane present over the tonsillar area with spread to adjacent structures
2. Membrane appears dirty and dark green and may even obstruct the view of the tonsils
3. Bleeding occurs with elevation of the membrane
71
Treatment of diphtheria
1. Use of a specific antitoxin
| 2. Elimination of the organism from the oropharynx
72
1. Acute infectious disease characterized by fever, malaise, somnolence, lymph node enlargement (posterior cervical region)
2. Lymphocytosis with appearance of abnormal lymphocytes
Infectious mononucleosis
73
Lead to erroneous diagnosis of lymphoma
Biopsy of a cervical lymph node during an acute episode of infectious mononucleosis
74
Complications of infectious mononucleosis
1. Ruptured spleen
2. Guillain-Barré ascending paralysis
3. CN paralysis
75
1. Infections of the tonsils proceed to a diffuse cellulitis of the tonsillar area extending onto the soft palate
2. Usually unilateral and is more common in older children and young adults
Peritonsillar abscess
76
Symptoms of peritonsillar abscess
1. Fever
2. Sorethroat
3. Trismus
4. Cervical adenopathy
77
1. Suppurative infiltration of the peritonsillar tissue occurs most often in the supratonsillar fossa
2. Causes edema of the soft palate on the involved side and displacement of the uvula across the midline
3. Swelling extends to adjacent soft tissues, causing painful swallowing and trismus
Peritonsillar abscess
78
Throat culture may be negative in presence of an abscess
Peeistonsillar abscess
79
Bacterial recovered in peritonsillar abscess
1. Primary: S. pyogenes
| 2. Less: S. aureus
80
Peritonsillar abscess
Regardless of method preferred, ALL peritonsillar abscesses are drained
81
History peritonsillar abscess or a history of repeated episodes of pharyngitis...
Tonsillectomy is performed either immediately or as inyerval tonsillectomy 6 weeks later
82
Mucosa appears thin and glistening or glazed, with an absence of all but a few of the lymphoid collections that are seen in an average pharynx
Atrophic pharyngitis
83
1. Dryness is striking
2. Mucous coating is gluelike in consistency
3. Underlying mucous membrane has a dry, furrowed appearance
Atrophic pharyngitis/pharyngitis sicca
84
Caused by the air not being sufficiently warmed and humidified by the nasal mucosa, as occur in chronic mouth breathing
Atrophic pharyngitis
85
Symptoms of atrophic pharyngitis
1. Sense of dryness
2. Thickness in the upper pharynx
3. Hoarseness
4. Fetor
86
Treatment of atrophic pharyngitis
1. Mandl's paint (stimulate secretion)
2. Potassium iodide
3. Breathing of warm moist air (20-30 minutes 2x a day)
87
1. Dry troublesome throat
2. Mild soreness, difficulty with marked pharyngitis sicca
3. Dry, shiny and hyperemic pharyngeal mucosa
4. Management: complete avoidance of smoking
Pharyngitis associated with tobacco
88
Most common of all recurring throat diseases
Chronic tonsilitis
89
Category of chronic tonsilitis
1. Tonsil is enlarged with evident hypertrophy and scarring. The crypts seem partially stenosed, but an exudate, often purulent. One or two crypts are enlarged and a considerable of cheesy or putty-like material can be expressed
2. Small tonsils, usually recessed and often referred to as "buried" in which the margins are hyperemic and a small amount of thin, purulent secretion can be often expressed
90
Does not necessarily correlate with severity of the problem
Size of the tonsils in chronic tonsilitis
91
Treatment of chronic tonsilitis
1. Removal of tonsils
2. Prolonged courses of penicillin
3. Daily throat oral irrigating device
92
Has been performed frequently in an effort to control recurrent pharyngeal disease, upper airway obstruction and chronic otitis media
Tonsillectomy with or without adenoidectomy
93
Commonly performed in young adults who have suffered repeated episodes of documented tonsilitis, peritonsillar cellulitis or perironsillar abscess
Tonsillectomy
94
Absolute indications for tonsilectomy
1. Development of cor pulmonale by chronic airway obstruction
2. Tonsil or adenoid hypertrophy with sleep apnea syndrome
3. Hypertrophy to the extent of causing dysphagia with associated weight loss
4. Excisional biopsy for suspected malignancy (lymphoma)
5. Recurrent peritonsillar abscess or abscess extending into adjacent tissue spaces
95
Most widely accepted indications for tonsillectomy in children
1. Documented recurrent bouts of tonsilitis (despite adequate medical management)
2. Tonsilitis associated with persistent and pathogenic streptococcal cultures (carrier state)
3. Tonsil hyperplasia with functional obstruction
4. Hyperplasia and obstruction remaining 6 months after infectious mononucleosis
5. Rheumatic fever history with heart damage associated with chronic recurrent tonsilitis and poor antibiotic control
6. Persistent chronic tonsil inflammation that does not respond to medical management
7. Tonsil and adenoid hypertrophy associated with orofacial or dental abnormalities that narrow the upper airway
8. Recurrent or chronic tonsilitis associated with persistent cervical adenopathy
96
Contraindications for tonsillectomy
1. Repeated URTI
2. Systemic or chronic infection
3. FUO
4. Enlarged tonsils without obstructive symptoms
5. Allergic rhinitis
6. Asthma
7. Blood dyscrasias
8. General inability or failure to thrive
9. Poor musculat tone
10. Sinusitis
97
Tonsillectomy can be performed in individuals who have a cleft palate deformity. However...
There should be extenuating circumstances to indicate this operative procedure and the patient must be informed of the possible effect on voice quality of the operative procedure
98
Structure of 2 pillars
1. Palatoglossus muscle (anterior pillar)
| 2. Palatopharyngeus muscle (posterior pilla)
99
Lateral boundary of the tonsillar fossa
Superior constrictor muscle
100
Blood supply of tonsils
1. Dorsalis linguae from the lingual artery
2. Ascending palatine from the external maxillary
3. Tonsillar from the external maxillary
4. Ascending pharyngeal from the external carotid
5. Descending palatine from the internal maxillary
101
Main lymphatic drainage from the palatine tonsils...
Leaves the fibrous trabeculae of the tonsil to pass through the capsule to the superior constrictor muscle of the pharynx
102
Post operative bleeding (tonsillectomy)
1. Immediate
| 2. Delayed
103
Generally handled by reanesthetizing the patient and controlling by ligature or suction electrocautery
Immediate persistent postoperative bleeding
104
1. May be handled in an outpatient situation, particularly if the youngster or adult is cooperative
2. Occur up to the 10th postoperative day
Later bleeding of significance
105
Sources of deep neck infections
1. Dental
2. Pharyngeal
3. Trauma
106
Pharyngeal space infection
1. Dental
2. Oral cavity
3. Tonsils
4. Parotid gland
5. Traumatic
6. Mastoid
107
Funnel-shaped, with its base located at the base of the skull on each side to the jugular foramen and its apex at the great horn of the hyoid bone
Pharyngomaxillary (parapharyngeal) space
108
Inner boundary of pharyngomaxillary space
Ascending ramus of the mandible and its attached medial prerygoid muscle and the posterior portion of the parotid gland
109
Dorsal boundary of pharyngomaxillary space
Prevertebral muscle
110
Each fossa is divided into unequal compartments
1. Anterior (prestyloid) compartment
| 2. Posterior compartment
111
1. Larger
2. May become involved in a suppurative process as a result of infected tonsils, some form of mastoiditis or pertrositis, dental caries and surgery
Anterior (prestyloid) compartment
112
1. Smaller
| 2. Contains the internal carotid artery, jugular vein, vagus and sympathetic nerve
Posterior compartment
113
When infection extends from the pharynx into pharyngomaxillary space, patient will develop...
Marked trismus
114
Pharyngomaxillary space abscess should be drained through a...
Cervical incision (transverse incision)
2 fingerbreadths below the mandible, gives access to the anterior border of the SCM
Submaxillary gland is identified as well as the posterior belly of the digastric muscle
115
Most serious complications of the phatyngomaxillary space infection involve the...
Surrounding vasculature
1. Septic thrombophlebitis of the jugular vein
2. Sudden massive hemorrhage from erosion of the internal carotid artery
116
If hemorrhage occurs when the abscess is drained...
Immediate ligation of the internal carotid artery or common carotid artery can be performed
117
Is a cellulitis of phlegmonous inflammation of the superior compartment of the suprahyoid space
Ludwig's angina
118
Potential space exists between the muscles attaching the tongue to the hyoid bone and the mylohyoid muscle
Suprahyoid space
119
Causes extreme firmness in the tissue of the floor of the mouth and forces the tongue upward and posteriorly and thus can potentially obstruct the airway
Ludwig's angina
120
Treatment of Ludwig's angina
Surgical incision through midline, thus interrupting the tightness that has formed in the floor of the mouth
121
Preparation before incision and drainage of Ludwig's angina
Possible tracheostomy
122
Potential space is in close proximity to the pharyngomaxillary space
Masticator abscess
123
Includes the internal pterygoid muscle, masseter muscle and ramus of the mandible
Masticator space
124
Most frequently involved secondary to infection of dental origin
Masticator space
125
Swelling and tenderness occur over the ramus of the mandible as well as firmness developing along the lateral floor of the mouth
Masticator abscess
126
Management of masticator abscess
1. Antibiotics
2. Drainage ( transverse cervical incision, 2 fingerbreadths below the mandible and carried down to the mandibular periosteum)
127
1. Occurs primarily in infants or small children under the age of 2
2. Older children/adults: secondary to spread from a paraphryngeal space abscess or traumatic interruption of the posterior pharyngeal wall lining by trauma from a foreign object or during instrumentation or intubation
Retropharyngeal abscess
128
In children there is an accumulation of pus between the posterior pharyngeal wall and prevertebral fascia which results from a suppuration and breaking down of lymph nodes in the retropharyngeal tissue
Retropharyngeal abscess
129
Symptoms of retropharyngeal abscess
```
Infant/child
1. Unexplained fever
2. Loss of appetite
3. Change in speech
4. Difficulty swallowing
5. Stridor (abscess becomes larger or edema extends downward to involve the larynx)
Adults
1. Dysphagia
2. Pain on swallowing
```
130
Safe intubation is required to avoid rupture of the abscess
Retropharyngeal abscess
131
Diagnosis of retropharyngeal abscess
Lateral soft tissue xray: reveal a marked increase in the soft tissue shadow between the pharyngeal airway and the bodies of the cervical vertebrae
Larynx and trachea: forward position
132
Treatment of retropharyngeal abscess
1. Drainage: head is lowered so that escaping pus will not be aspirated, and a small, pointed scalpel blade is used to make a short vertical incision at the point of greatest swelling
133
Complications of retropharyngeal abscess
1. Asphyxia
2. Hemorrhage (profuse: ligation of internal carotid artery)
Can extend to mediatinum--->mediatinitis
134
Results from the efforts of the heart and lungs to compensate for long-term chronic obstruction
Cardiopulmonary syndrome
135
Other findings associated with sleep apnea syndrome
1. Systemic hypertension
2. Polycythemia
3. Cardiac arrhythmia (bradycardia and ventricular tachycardia)
136
More common in patients with associated obstructive lung disease and daytime hypoxia
Right heart failure
137
Associated with an increased risk of sleep disordered breathing
1. Obesity
| 2. Increasing age
