د. حسين جاسم
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.