Pharynx,
nasopharynx
Epipharynx
Oropharynx
Hypopharynx
Cervical interfascial spaces
1.abscesus in retropharyng. space, 2.v „dangerous space, 3. v prevertebral
space.
A superficial
cervical fascia
B carotic fascia
C middle cervical
fascia
D alar fascia
E prevertebral
fascia
Immune-specific function
of Waldeyer´s Ring
Palatine tonsil:
l The tonsils ensure controlled and protected
contact of the organism with environment,
immunologic surveillance
l The tonsils produce lymphocytes
l The tonsils expose B- and T-lymphocytes to
current antigenes
l The tonsils produce specific antibodies after the
production of the appropriate plasma cells.
l All types of immunoglbulins occur in tonsilar
tissue.
Main symptoms indicating disease of
the mouth and pharynx I:
Pain on eating, chewing, or swallowing
Frequent cause: inflammations, tumors, foreign bodies
Dysphagia
inflammations(glossitis, abscesy, angionerutický edém, edém
vchodu do hrtanu)
Neurogenic aetiology (disorder of n vagus a glossopharyngeus,
amyotrophic lateral sclerosis, bulbar amd pseudobulbar
paralysis, sclerosis multiplex, diabetic and alcoholic neuropathy)
Mechanical obstruction (f.b., diverticulosis, striktury, tumor)
Miscelanea (epithelitis post actinotherapiam, xerostomy, fractures
of mandibule and maxilla, disorder of chewing muscles)
Burning of the tongue
toxic stomatitis, various diseases of GIT, xerostomy, syndroma
Plummer-Vinson, Diabetes mellitus, food allergy,
mukoviscidosis, psychogenic glossodyna
Main symptoms indicating disease of
the mouth and pharynx II: - superfitialis
laesions of the tongue
Red tongue (anemia, scarlett fever, hepatic
cirrhosis, hypertension, allergy, Sjögren´s
syndroma)
Gray smooth tongue (st.p. radiotherapiam,
vitamin A deficiency, lichen planus)
Black hairy tongue (antibiotics, mycosis
Fissured tongue (lingua plicata, MelkerssonRosenthal
syndrome)
Coated tongue (mycosis, non-specific
inflammation, reduced food intake, fever,
malhygiene of oral cavity)
Brownish plaques (uremy in renal insufficiency)
Presence of blood in saliva, sputum
Bleeding in paradentosis, injury, foreign bodies, varices in base of
the tongue, tumors.
Differential diagnosis: epistaxis, hemoptysis (coughing of blood
from lower airways, hematemesis (bleeding from swalloving
ways)
Foetor ex cavo oris (Oral Fetor)
teeth, gingiva- caries dentium, parodontosis, stomatitis,
exulcerated tumors
Pharynx - inflammation (acute, chronic, specific), foreign bodies,
tumors
Airway – atrophis rhinitis, ozaena, purulent rhinosinusitis,
bronchiectasies
Digestive tract – esophageal diverticulum, disorder of stomach etc.
Metabolic cause- diabetes mellitus (acetone), renální insufficiency
(urine), liver coma (sweet aromatic smell)
l Trismus
Inflammation of the teeth or mandible,
temporomandibular joint, oropharynx
(peritonsillar absces) infury, muscle spasm
from neurologic origin, tumors of oropharynx
and around the temporomandibular joint,
congenital ankylosis of temporomandibular
joint
l Disorder of salivary secretion
xerostomy -dehydratation, st.p.RT, Sjögren´s
syndroma, sialoadenosis, sialorrhea psychogenic
factors, gravidity; …
l Disorder of speech
dysartry - bulbar and pseudobulbar palsy, …etc
Methods of investigation
l Inspection - indirect, direct endoscopy
l Palpation
l Investigation of inervation
– tongue motoric inervation (n. hypoglossus –
lying tongue -the tip to the sound side,
tongue out – to the disease side
– Sensitive
– Senzoric (anterior 2/3 n. V., posterior 1/3 n.
IX), elektrogustometry
Oropharynx- normal finding
Tonsillar pin
the crypts usually contain cell debris, bacteria, lymphocytes that
smell extremely foul when released and can cause bad
breath.
Inflammation of pharynx
- division according to site of disorder
• Tonzillitis inflammation of lymphoepithelial
tissue of pharynx.
• Pharyngitis inflammation of mucose
membrane of pharynx.
• Tonsillo-pharyngitis inflammation of mucose
membrane of pharynx and also
lymphoepithelial tissue.
According to course
Ø acute
Ø chronic
Types of tonsillitis according to
various criterion
l Anatomic (site)
l Microbiologic
l Patogenetic
l Pathology- anatomy
Site of disorder – acute tonsillitis
Ø angina palatina
Ø angina retronasalis
Ø angina pharyngis lateralis
Ø angina lingualis
Microbiology
o bacterial infection : 30-40 % of all infections,
Streptococcus pyogenes 90% of bacterial
origin, Haemophillus influenzae,
Staphylococcus aureus, Mycoplasma
pneumoniae
o viruses – adenoviruses, parainfluenza,
enteroviry, coxackie, etc.
o mycosis – rarely in immunocompromised
patients (imunosupression, HIV, tumors)
Patogenetic division
Acute tonsillitis
l suppurative
l symptomatic – local symptom of general
disease with bacteriemia or viremia
l Secondary in immunodefficiency
(agranulocytosis, leukemia etc.)
Pathology-anatomy
Acute tonsillitis
o cataral
o lakunar
o Follicular
o Vesiculous
o Pseudomembranous
ulceromembranous
o Phlegmonous and gangrenous
Tonsillitis ac. cataral
Bilateral odynophagy
redness, swelling of
tonsills, febris
Tonsillitis ac. lacunar
Bilateral odynophagy,
increasing in swalloving,
irradiated into ears
infiltrated, reddened,
enlarged tonsills with
plagues in openning of
tonsillar crypts,
sometime confluenting
(angina confluens), not
spreading to tonsillar
pillars, fever
Tonsillitis ac. lacunaris
Tonsillitis ac. follicular
Bilateral odynophagy,
increasing in
swallowing,
irradiated into ears
microabscessus in
follicles visible
through mucosa
membrane on the
tonsillar surface
Herpangina (angina
vesiculosa) - Coxsakie virus
Marked generalized symptoms, sucfh as
high fever, headache, pains in the neck,
loss of appetite, stomatitis, vomiting
Vesicles form initially, particularly on the
anterior faucial pillar, than small flat
ulceration covered in milky white
plaques,
Herpangina
Pseudomembranos tonsillitis
(in mononucleosis infectiosa)
Epstein-Barr virosis
Bilateral odynophagy, headache
fever 38-39, marked lymphadenopathy, tonsil
is swollen, covered with a fibrinous exudate
or membrane, hepatosplenomegaly, marked
feeling of being unwell, leukocytosis,
mononuclear cells and atypical lymphocytes
Higher transaminasis (ALT,AST), positive
antibody against EB virus and positive PaulBunnel
reaction.
Pseudomembranos tonsillitis
Pseudomembranos tonsillitis
Tonsillitis ac. retronasal
Pain feeled in depth behind the nose,
blocked nose, running nose
Closed mumbleness, hearing disorder
(bad functio of Eustachian tube), pus
in posterior wall of oropharynx
Tonsillitis ac. of the tongue
odynophagy increasing with movement of
tongue
in laryngeal mirror- the finding as in
tonsillitis ac. lacunaris
Plaut-Vincent angina
in superior part of one
tonsill ulceration covered
with a gray membrane,
halitosis (foetor ex ore),
bad teeth bakteriology:
Bacillus fusiformis and
Spirocheta buccalis,
feeling of foreign body, scratching, no general
symptoms
Syphilis, Lues
primary ulcer gray coated
syphilitic angina mucous plaques or hazy,
smoke-colored mucosal lesions
gummose stage swelling with ulceration
typical bacteriology, serology
and histology evaluation
Lues
primary ulcer on soft palate in 21
old male
syphilitic angina mucous
plaques
Syphilis
II. st.
pharynx
male
29 let
cook in
public
catering
Primary source: pharynx
Abscessus et phlegmona
peritonsillaris
Abscessus et phlegmona
parapharyngealis
Sepsis tonsillogenes (angina septica,
sepsis post anginam, trombophlebitis v. jug.
int.)
Phlegmona
base of the
oral cavity
„Angina
Ludowici“
tongue pain, odynophagy,
fever with shivering fit,
symtomps of sepsis
elevation of base of oral
cavity, tongue not moving,
infiltration in submandibular
region
Complications during and
after tonsillitis
Phlegmona et abscessus
peritonsillaris
Ü Localisation - supratonsillar, retrotonsillar,
infratonsillar, lateral
Ü Increasing diffculty in swallowing occurs after
a symptomfree interl of a few days after
tonsillitis
Ü Fever not too high
Ü Sever pain to to diseased side, spreading to
the ear, patient refuses to eat,
Ü Differentila diagnossis :tonsilogenic sepsis,
dentitio diffitilis tertii mollaris inferioris
Ü Treatment- punctio, incisio, dilatation,
antibiotics
Peritonsillar phlegmon and
abscess
Clinical picture of swelling,
redness and protrusion fo
the tonsil, faucial arch, the
palate and the uvula,
marked tenderness of the
tonsillar area, trismus
Typical side for incision:
X midpoint between the uvula
and the last molar
2) Arteria carotis interna
3) Vena jugullaris int.
Phlegmona and
parapharyngeal abscess
Ü Spreading infection from tonsill into the
parapharyngeal space
Ü Fever, pain, trismus, torticollis, swelling
of external neck, swallowing of
hypopharynx
Ü Risk of infection spreading into the
mediastinum
Ü treatment – incision, drainage of
infection focuses, antibiotics – broad
spectrum in sufficient dosage
A. Retrotonsilar abscess
B. peripharyngeal abscess
VC = great vessels
Carotic sheath
between deep and
superficial cervical
fascia
Neck fascial spaces
1.abscess in retropharyngeal space, 2. in „dangerous space, 3. in prevertebral
space.
A superficial
fascia
B carotic
sheath
C middle leaf of
deep neck fascia
D alar fascia
E prevertebral
fascia
Phlegmona colli, Mediastinitis
Ü Source –infection of paratonsillar a retromoral
region, injury of oral cavity base, pharynx or
cervical oesophagus. Visceral spaces of the neck
have no distal boundery with mediastinum.
Ü Clinical picture – fever, usually septic, dysphagia,
pain in the back (intrascapular), retrosternal pain
Ü Inflammatory infiltration of the neck without
boundery, fluctuation, speciall palpation feeling;
by spread into the mediastinum – dysphagia and
even dyspnoe
Ü Treatment – surgical opening of space
surrounding great neck vessels, collateral
mediastinotomy, treatment of primary source,
general treatment aimed against sepsis,
thrombosis, kidney failure etc.
Ü Bad prognosis, high mortality
Genesis of tonsillogenic
sepsis
1) Extention by veins
2) Extention by lymph
vessels
3) Internal jugular vein
4) Regional lymph nodes around
the VJI
5) Extention in
continuity via the
cervical soft tissue
Sepsis tonsillogenes
Angina septica – trombophlebitis of small
vains occuring during tonsillitis – spreading
into internal jugular vein, and . Symptoms:
fever, shivering fit, palpation pain before
anterior edge of sternocledomastoid muscle.
Possibility of spreading into the intracranium
Sepsis post anginam – symptoms free
interval of a few days after tonsillitis, normal
finding on tonsils; Lymphatic way: lymphnode
-periadnitis-periphlebitis-trombophlebitis VJI
Trombophlebitis v. jug. int. – treatment
:surgery, removal of inflam. focus, suture of
VJI and resection in extention of thrombosis,
antibiotics
Fasciitis
necrotisans
inflammation of soft
tissues of the neck
with fast spreeding
in fascial
compartments
without borders,
with necroses
Incision, drainage
Chronic pharyngitis
Hypertrophic – pharyngeal paresthesis,
increasing in swallowing, hypertrophic
changes of subepithelial tissue
Atrophic - feeling of foreign body, burging
and dryness feeling; pharyngeal mucos
membrane is thin, dry, glossy, sometimes
covered with secretion
Chronic pharyngitis
Hypertrophy of palatinal tonsils
(indication to TE)
Diphtery
tumors of oropharynx
history – long lasting: pain,
feeling of foreign body,
bleeding, halitosis
asymetric changes in istmus
facium, ulceration,
hyperkeratosis, bleeding,
tough tonsil, exofytic growth –
histology !
foreign bodies
onside pain, feeling of foreign body
History- sudden onset during eating,
finding of foreign body.
evaluation of epipharynx
l posterior rhinoscopy
l Palpation
l Direct epipharyngoskopy
l Rtg, CT
Evaluation of Eustachian tube
l Epipharyngoscopy
l Politzeration
l Cathetrisation
– Normal rustle dry, filled
– In stenosis – discontinuous, abrupt
– In liquid in middle ear cavity– moist
fenomens
– In perforation of ear drum – high,
l Tubometry – even in perforated ear
drum (Valsalva, Toynbee),
Vegetationes adenoideae
(tonsila pharyngea)
Tonsillitis ac. retronasalis
Adenotomy
soft palate carcinoma
oropharyngeal cancer with
metastasis on the neck
oropharyngeal cancer
Evaluation of salivary glands
l Inspection
l Palpation
l Ultrasound
l Sialography, CT, NMR
l FNB = fine needle biopsy
l Endoscopy of drainige system
Sialography