PHARYNGITIS

Non Specific ACUTE PHARYNGITIS CHRONIC PHARYNGITIS ACUTE NON-SPECIFIC PHARYNGITIS (SORE THROAT) - mostly dt self-limiting viral infection - may be bacterial infection Viral, Bacterial - Catarrhal - Hypertrophic - Atrophic CHRONIC NON-SPECIFIC PHARYNGITIS predisposing factors: 1. Smokers 2. Chronic rhinosinusitis 3. Environmental/industrial pollution exposure Specific Diphtheria, Vincents Angina - Scleroma -TB - Syphilis - Fungal infection DIPHTHERIA acute fibrinous inflammation of URT Corynebacterium Diphtheriae (KlebsLoeffler bacillus) - rare nowadays dt obligatory DPT vaccine immunization - spread = secretion from nose & throat of patients - IP = 2-7 days - marked generalized toxemia + moderate fever, pallor, rapid weak pulse - diphtheric membrane = 1. grayish yellow irregular membrane covering tonsils + spread beyond tonsils to palate & pharyngeal wall 2. adherent to underlyg tissue leave bleeding point on stripping! - bilateral tender enlarged upper deep cervical LNs Bull neck appearance - isolation & 3 weeks strict bed rest guard HF - general measures (IV glucose, throat gargle, Vit Bcomplex-neuritis) - diphtheria anti-toxin - procaine penicillin - treatment of complications VINCENTS ANGINA (TRENCH MOUTH) pharyngeal infection + ulcerative gingivitis by : - Borellia Vincentii (spirochete) - Fusiform Bacilli (gram ve bacilli) predisposing factors: 1. Poor oral hygiene 2. Smoking 1. Punched-out, ragged gingival & pharyngeal ulcerations covered with grayish membranous sloughs 2. Enlarged tender cervical LNs

Etiology

C/P

1. Sore throat may refer to ear 2. Variable fever 3.Exam = generalized hyperemic throat + cervical lymphadenitis

1. Recurrent sore throat 2. Repeated hawking + sense of irritation in the throat 3. Exam = Chronic dusky red mucosa + viscid catarrhal mucus on the surface Chronic scattered hypertrophic hypertrophic nodules of lymphoid tissue granular appearance Chronic atrophic dry glazed Atrophic mucosa - avoid predisposing factors - mild throat gargles or lozenges

Treatment

- viral self-limiting, requires only general conservative measures, mouth gargles or lozenges - bacterial antibiotics

Complications: 1. Respiratory obstruction (dt spread of membrane to larynx) 2. Myocarditis + respiratory failure 3. CN palsies palatal paralysis + diplopia 4. Respiratory muscle paralysis 5. Acute interstitial nephritis

TONSILITIS
ACUTE TONSILITIS VIRAL incidence etiology adenovirus * MCC of sore throat in infants & small children GLANDULAR FEVER (INFECTIOUS MONONUCLEOSIS) - self-limiting - Epstein-Barr virus - in adolescents & young adults - result of contact with infected saliva (kissing fever)

Diff. diagnosis: 1. Diphteria 2. Other causes of sore throat 3. Other causes of membrane over tonsils (inf.mononucleosis, Vincent angina, leukemia, agranulocytosis

BACTERIAL any age - in children & young adults - group A B-hemolytic streptococci + pneumococci + h.influenzae +staphylococci - spread = droplet infection + share of towels, glasses Acute catarrhal - infection limited to epithelial covering of tonsils - tonsils : congested, NO pus Acute follicular - crypts with PUS spotted appearance - spots coalesce together form false membrane = 1. can be stripped out easily w/out leaving bleeding point 2. strictly limited to the surface of tonsils Acute - tonsils : swollen & congested, parenchymatous NO apparent pus formation 1. high fever, malaise, prostration * rapid, full pulse in proportion to pyrexia 2. throat pain referred otalgia 3. dysphagia & fetor oris 4. *infants may be rigors, febrile convulsions or vomiting 5. exam = Acute catarrhal congestion of tonsils & pharyngeal wall Acute follicular - congested & studded with yellow spots - false grayish/dirty yellow membrane form over, & limited to the tonsil surface Acute congested & swollen with NO parenchymatous accumulation of pus inside the crypts 6. tongue = appear coated/furry 7. enlarged jugulo-digastric LN

CHRONIC TONSILITIS
- older children - young adults - mixed aerobic & anaerobic bacteria - penicillin-resistant group A Bhemolytic streptococci - persistent sore throat for at least 3 months - tonsillar inflammation - when no other source can be identified (eg : sinuses/lingual tonsils)

pathology

C/P

- sore throat, fever, enlarged tonsils - malaise - lymphadenopathy - hepatosplenomegaly - atypical lymphocytes in peripheral blood - + serology/ Paul-Bunnell test

symptoms: - chronic sore throat - halitosis (malodorous breath) - fatigue signs: - UNequal size tonsils (asymmetry) - congestion of anterior pillars - enlarged tonsillar crypts filled with debris (irregularity of surface) - enlarged jugulo-digastric LN

treatment

COMPLICATIONS OF TONSILITIS: Local = peritonsillar/parapharyngeal/retropharyngeal cellulitis or abscess, acute OM, laryngeal edema Systemic = scarlet fever, ARF, post-strep GN, septicemia

- tonsillectomy (in severe symptoms) - long acting penicillin (in refused/ contraindicated surgery)

SUPPURATIONS OF SPACES AROUND THE PHARYNX

INTRA-TONSILLAR ABSCESS
defini tion

NO ABSCESS!!!

PERI-TONSILLAR ABSCESS
Suppuration in the PERITONSILLAR space ( between capsule + adjacent lateral pharyngeal wall)

PARAPHARYNGEAL ABSCESS
Suppuration in PARA-PHARYNGEAL space

RETRO-PHARYNGEAL ABSCESS CHRONIC ACUTE (Potts disease)

Abscess in RETROPHARYNGEAL space between posterior pharyngeal wall + prevertebral fascia - infants & young children - adults Cold abscess BEHIND PREVERTEBRAL FASCIA *cold abscess no sign of inflammation middle aged adults

LUDWIGS ANGINA
rapidly spreading, potentially fatal infection, involving SUBMANDIBULAR space Characteristics : 1. rapidly spreading cellulitis 2. NO tendency to PUS formation 3. involve both submaxillary & sublingual spaces 4. usually bilateral 5. DIRECT extension! 1. Dental or periodontal infection(70%) - esp 2nd & 3rd lower molar teeth 2. Penetrating injuries of the mouth floor 3. Mandibular fracture

Pus collection INSIDE the tonsil

incide nce

Rare! - usually in adult age

- in adult males - usually UNILATERAL

anatomy complications!

sup inf med lat

skull base hyoid bone superior constrictor - mandible - deep lobe of parotid - pterygoid ms

etiolo gy

1. Obstruction of one of the crypts, by: - recurrent infection - FB - accumulation of food inside tonsil 2. Rare complication of acute tonsillitis

follows an attack of acute tonsillitis infection travels to peritonsillar space (via crypta magna) resulting in cellulitis & pus formation Streptococcus Haemolyticus

1. Spread of infection from tonsils/quinsy (intra/peritonsillar) 2. Odontogenic infection (eg: extraction of 3rd molar tooth) 3. Middle ear infections with bony destruction of mastoid tip (BEZOLDS ABSCESS)

1. Suppuration of retro-pharyngeal lymph glands of Henle (each side!) (atrophy at 5th years of life infants & young children) 2. Transmission of infectinn from surrounding structures, (adults, esp immunocompromisd patient) may be 2ry to : - FB in post pharyngeal wall - trauma from endoscopic prodecures/endotracheal intubation

TB of cervical vertebrae

sympt oms

Mild - mild fever - mild pain - mild dysphagia

Severe form of acute tonsilitis symptoms: - high fever, malaise, headache - marked sore throat + referred otalgia (CN12) - marked dysphagia (to the degree that pt is unable to swallow his saliva) dribbling of saliva - trismus (difficulty to open mouth) - painful swelling under the jaw - halitosis (malodorous breath)

- high fever - sore throat - odynophagia - trismus (spams of masticator muscles)

- fever - malaise - pallor - dysphagia (difficulty in swallowing & suckling) - stridor ( difficult, noise breathing)

- generalized TB toxemia( loss of weight) - mild fever (dt TB) *usually at night *excessive sweating - dysphagia (painful neck movement)

- young pt with poor dentition - UNIlateral neck pain & swelling soon Bilateral - edema & brawny induration of suprahyoid soft tissue & floor of mouth results in thrusting of tongue against palate respiratory probs - fever, neck rigidty, trismus & odynophagia - patient may progress from onset of symptoms to respiratory obstruction in 24 hrs!!

signs

yellowish, welllocalized, soft cystic swelling on the surface of tonsil

- pale yellowish area over the swelling = abscess maturation ( a point where it can rupture spontaneously) - torticollis (head tilted to diseased side dt SCM spasm) - high temp (39-40) & rapid strong bounding pulse - exam is difficult dt trismus (masseter & pterygoid spasm) - coated tongue & accumulated saliva - uvula: edematous & pushed to other (healthy) side - swelling of soft palate above & lateral to the inflamed tonsils - enlarged jugulo-digastric LN

- tender lateral

neck swelling +
inferior extend to hyoid bone - lateral pharyngeal wall & tonsil are displaced medially (pushed by pus)

- high temp, rapid pulse - pallor, toxemia - nuchal rigidity & torticollis (head tilted to healthy side) - pharyngeal congestion & swelling in post pharyngeal wall limited to one side of midline - enlarged tender cervical glands investigation (neck Xay) - abnormal thickening of prevertebral tissue (>50% or vertebral body) - reversal of normal cervical spine curvature - air in prevertebral soft tissue

- normal temp & pulse - tenderness along vertebrae - enlarged painless cervical LNs - midline cystic fluctuant swelling on post pharyngeal wall investigatn (neck radiograph) - caries of cervical vertebrae - calcified tuberculous LNs

compl icatio ns

*same as acute tonsillitis Local = -peritonsillar / parapharyngeal/ retropharyngeal cellulitis or abscess - acute OM - laryngeal edema Systemic = - scarlet fever - ARF - post-strep GN septicemia

- sudden rupture + inhalation chest complications - extension >lateral parapharyngeal abscess >inferior laryngeal edema + stridor - IJV thrombophlebitis - pyemia & septicemia (rare)

*rare but serious! [contents of carotid sheath!] - IJV thrombosis (Lemierres syndrome) - Rupture of carotid artery - Involvement of CN 9, 10, 11, 12 or sympathetic chain - Spread to mediastinum mediastinitis

- spontaneous rupture aspiration sudden death - laryngeal edema + stridor - spread to mediastinum mediastinitis

treat ment

1. Incision INTRAORAL (LA) 2. General antibiotics & antiseptic gargles 3. Tonsillectomy prevent recurrence (after cure- prevent massive bleeding & spread of infection)

PRESUPPURATIVE STAGE: 1. Bed rest 2. Antibiotics & analgesics 3. Soft nutritious diet (immunity) SUPPURATIVE STAGE 1. Incision INTRA-ORAL (LA) & drainage 2. General antibiotic 3. Tonsillectomy (1 month after all acute manifestations subside)

1. General treatment as peritonsillar abscess 2. Systemic antibiotics 3. Incision & drainage (externally (GA )along anterior border of sternomastoid )

1. Systemic antibiotics, analgesics & soft diet 2. Incision & drainage * vertical incision (PREORALLY) w/OUT anesthesia or LA (esp infants) in head-low position + use suction to prevent aspiration 3. Tracheostomy ( in airway compromised)

GENERAL 1. Full anti-TB drug therapy 2. Rest & good nutrition ( calcium + proteins) LOCAL - incision & drainage (externally (GA) thru neck) along posterior border of SCM - stabilization of spine (in spinal caries)

1. intensive IV antibiotic therapy 2. early airway maintenance (entotracheal tube/tracheotomy) 3. rapid surgical intervention - horizontal submental incision above hyoid - vertical incision of mylohyoid bilateral drainage of exudates (instead of pus) from submaxillary & sublingual spaces