Pharynx [للقراءة فقط]fac.ksu.edu.sa/sites/default/files/pharynx_1.pdf · Pharynx •...
Transcript of Pharynx [للقراءة فقط]fac.ksu.edu.sa/sites/default/files/pharynx_1.pdf · Pharynx •...
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PharynxDr. Dr. AbdulrahmanAbdulrahman HagrHagr
MBBS MBBS FRCS(cFRCS(c))
http://http://www.drhajr.comwww.drhajr.com
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Pharynx• Anatomy (deep spaces)• Physiology• Pathology
– Adenoid– Snoring & sleep apnea– Acute infection– Complication of Infections– Chronic Pharyngitis
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NasopharynxNasopharynx
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NasopharynxNasopharynx• Respiratory function• Anterior: choana (posterior nasal aperture)• Posterior: superior constrictor muscle• Superior: basilar portion of occipital bone• Inferior: soft palate
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Adenoid = الناميات
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OropharynxOropharynx
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Orophaynx= الحلقوم
)فلوال إذا بلغت الحلقوم و أنتم حينئذ تنظرون (
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OropharynxOropharynx• Respiratory & Digestive function• Anterior: anterior tonsillar pillar• Posterior: superior & middle constrictors• Superior: soft palate• Inferior: base of tongue, superior epiglottis• Laterally:
– Palatoglossal– Palatopharyngeal arches– Parapharyngeal space
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Tonsil = لوزة
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HypopharynxHypopharynx
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HypopharynxHypopharynx• Digestive function • Lies posterior to the larynx• Superior: superior border of epiglottis and
pharyngoepiglottic folds• Inferior: inferior border of the cricoid• Posterior/lateral: middle & inferior
constrictors, bodies of C4-C6• Anterior: laryngeal inlet
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Piriformآمثرى =
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Pharyngeal muscles
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Pharyngeal muscles• External circular and internal longitudinal
(opposite in remainder of GI tract)
• External: 3 constrictors constrict wall of pharynx during swallow
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Pharyngeal musclesPharyngeal musclesInternal: • Elevate pharynx and larynx during speech/swallow
1. Palatopharyngeus2. Salpingopharyngeus3. Stylopharyngeus4. Levator veli palatini
• Tenses soft palate & opens ET during yawn/swallowTensor veli palatini (V3)
• Approximates tongue and soft palate Palatoglossus (CN XI via X)
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Hyoid = المي
أي الجمع من آل اتجاه ) وتأآلون التراث أآال لما (
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Pharyngeal muscles
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Pharyngeal lymphatic drainage• Nasopharynx Retropharyngeal space• Oropharynx Parapharyngeal space• Hypopharynx Neck
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Jugular = وداجي
."انتفخت أوداجه"
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Pharyngeal vessels
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Parapharyngeal space (PPS)
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The parapharyngeal space (PPS)
• Cone shaped– Base at temporal bone– Apex at the hyoid bone
• Between – Pharyngeal – Lat + med pterygoid muscles
• Most frequently involved with infections
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Contents• Loose fibrofatty tissues• Carotid artery• Internal jugular vein• Cranial nerves IX, X, XI, and XII; • Cervical sympathetic chain• Lymph nodes
– Nasal cavity, paranasal sinuses– Nasopharynx and oropharynx, – Mastoid tip
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Communication• Submandibular
• Retropharyngeal
• Parotid spaces
• Masticator
• Peritonsillar
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Retropharyngeal space
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Retropharyngeal space• Between
– Prevertebral fascia – Posterior pharyngeal wall and esophagus fascia
• From– Skull base – Tracheal bifurcation
• Major route mediastinum.
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AnatomyAnatomy• Skull base
Cricoid cartilage anteriorly Inferior border of C6 posteriorly
• Widest portion (5cm) at hyoid• Narrowest portion (1.5cm) at caudal end• Divided into 3 parts:
– Nasopharynx– Oropharynx– Hypopharynx
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ContentsContains LN (<5Y) that receive from • Nose• Nasopharynx• Paranasal sinuses• Oropharynx• Middle ear
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Afferent innervation of
pharynx
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Afferent innervation of pharynx1975
Gag
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Pharynx• Anatomy (deep spaces)
• Physiology• Pathology
– Adenoid– Snoring & sleep apnea– Acute infection– Complication of Ix– Chronic Pharyngitis
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Physiology• Breathing (Inspiration + Expiration)• Speech (Expiration)• Swallowing (Expiration) 2000/day
• Ventilation (ME)• Immunity
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Pharynx• Anatomy (deep spaces)• Physiology
• Pathology–Adenoid– Snoring & sleep apnea– Acute infection– Complication of Ix– Chronic Pharyngitis
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Adenoid Adenoid
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Adenoid
• Child • Snoring• Mouth breathing• Nasal Tone• Bilateral OME• Bilateral nasal obstruction
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PreOpPreOp Evaluation ofEvaluation of Adenoid Adenoid DiseaseDisease
• Triad of – Hyponasality– Snoring– Mouth breathing
• Rhinorrhea• Nocturnal cough• Post nasal drip
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PrePre--Op Evaluation ofOp Evaluation of Adenoid Adenoid DiseaseDisease
“Adenoid face”• “Micky Mouse”• Overbite• Long face• Crowded incisors
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PreOpPreOp Evaluation of Adenoid Evaluation of Adenoid DiseaseDisease
Differential diagnoses• Allergic rhinitis• Sinusitis• GERD• DNS
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PreOpPreOp Evaluation of Adenoid Evaluation of Adenoid DiseaseDisease
Lateral neck films
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Pharynx• Anatomy (deep spaces)• Physiology• Pathology
– Adenoid–Snoring & sleep apnea– Acute infection– Complication of Ix– Chronic Pharyngitis
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Obstructive Sleep Apnea
1. Cessation of air flow
2. > 10 Seconds
3. Chest and abdominal effort
• 3 % children
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Pathophysiology• Desaturation• arousal with restoration of airway• sleep fragmentation hypersomnolence• core pulmonale
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Pathophysiology - complications
• Desaturation Polycythemia• Hypercapnia pulmonary hypertension• Systemic hypertension• Arrythmias
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Obstructive Sleep Apnea Syndrome • Snoring• Disturbance of sleep• Sleepiness, difficult arousal • Failure to thrive • Behavioral concerns • Impaired cognitive skills (school performance)
• Behavioral problems• Nocturnal enuresis
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Evaluation - physical exam
• Nose DNS, Turbinate
• Throat
• Fiberoptic examination
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PrePre--Op EvaluationOp EvaluationTonsil size (occupation of oropharynx)• 0 in fossa• +1 <25% • +2 25-50%• +3 50-75%• +4 >75% kissing
+1 +3+2 +40 10050 7525
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Complications• Growth• Cardiovascular• Gastrointestinal• Pulmonary• Behavioral• Neurologic• Surgical
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ComplicationsGrowth• Failure to thrive• Short stature• Impaired growth hormone releaseCardiovascular• Cor Pulmonale/Pulmonary hypertension• Polycythemia• Arrhythmia• Possible systemic hypertension
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ComplicationsGastrointestinal• Feeding difficulties• Gastroesophageal refluxPulmonary• Chronic aspiration• Pulmonary edema (Post operative)
• Pectus excavatum
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ComplicationsBehavioral• Developmental delay• Behavioral problems• School problemsNeurologic• Nocturnal enuresis• Lethargy/dull effect• Hypoxia induced headaches
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Nocturnal EnuresisSurgical removal of upper airway obstruction
led to a significant decrease in or complete
cure of nocturnal enuresis in 75% of
children studied
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Guidelines for evaluation Provisional diagnosisHistory/physicalScreening testsBrief observation in the clinicOvernight oximetryTests to diagnoseSleep studies.
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Treatment • Treat underlining cause• Adeno-tonsellectomy• ICU
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Pharynx• Anatomy (deep spaces)• Physiology• Pathology
– Adenoid– Snoring & sleep apnea
–Acute infection– Complication of Ix– Chronic Pharyngitis
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Acute Acute AdenotonsillitisAdenotonsillitis
Etiology• 70% viruses• 20% bacterial• 40% are beta-
lactamase-producing • GABHS
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S/S• Dysphagia, • Headache, • Painful cervical lymphadenitis, • Fever• Exudate, • Absence of cough, and hoarseness.
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Microbiology of Microbiology of AdenotonsillitisAdenotonsillitis
Most common organisms in chronic tonsillitis (recurrent/chronic infection, hyperplasia)
• Strept pyogenes (Group A beta-hemolytic) GABHS
• H.influenza• S. aureus• Streptococcus pneumoniae
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Acute Acute AdenotonsillitisAdenotonsillitisDifferential diagnosis
Infectious mononucleosisMalignancy: lymphoma, leukemia, carcinomaDiptheriaScarlet feverAgranulocytosis
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Other Other TonsillarTonsillar PathologyPathology
• Hyperkeratosis, mycosis leptothrica
• Tonsilloliths
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Diphtheria• Sore throat• Malaise• low-grade fever• Pseudomembrane• Airway obstruction• Unimmunized patient
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Vincent angina• Acute oropharyngeal ulcerative
• G-ve anaerobic
• Poor oral hygiene (fetid breath) malnutrition fatigue
• Pseudomembranous ulceration
• Cervical lymphadenopathy
• Penicillin and metronidazole
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Infectious mononucleosis• Fever• Fatigue• Cervical LN • Jaundice• Epstein-Barr virus• Atypical lymphocytes• “Monospot”
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Scarlet fever= الحمى القرمزية
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Thrush= السالق • Fungal infection
Candidiasis is the most common
• Pseudomembranouscandidiasis (thrush)
• DM or immunodeficiency
أي ضربه ضربا مبرحا إلى أن نزع جلده فبيض " : سلق الولد بالعصا ) فإذا ذهب الخوف سلقوآم بألسنة حداد ( .لدغه، آذاه" : سلقه بالكالم. "
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SyphilisSyphilis
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Retention CystsRetention Cysts
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Tonsillar Cleft
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Medical ManagementMedical Management• PCN is first line• Steroids• IV abx, • Recurrent, chronic tonsillitis or obstruction
tonsillectomy
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Complications• Nonsuppurative complications of GABHS
– poststreptococcal glomerulonephritis– acute rheumatic fever (ARF).
• unclear pathogenesis ? immune mediated.
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Acute rheumatic fever• 2 major manifestations, or 1major and 2 minor • Major manifestations CASE
1. Carditis2. Polyarthritis3. Chorea4. Erythema marginatum5. Subcutaneous nodules.
• Minor manifestations FLAP1. Arthralgia2. Fever3. laboratory elevated ESR or C-reactive protein4. prolonged PR interval on
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Unilateral Unilateral TonsillarTonsillarEnlargementEnlargement
Apparent enlargement vs true enlargementNon-neoplastic: • Acute infective• Chronic infective • Hypertrophy• CongenitalNeoplastic
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Indications for TonsillectomyIndications for Tonsillectomy
AAO-HNS:• 3 or more episodes/year• Hypertrophy causing malocclusion• PTA unresponsive to non-surgical Mx• Halitosis, not responsive to medical therapy• UTE, suspicious for malignancy• Individual considerations
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Pharynx• Anatomy (deep spaces)• Physiology• Pathology
– Adenoid– Snoring & sleep apnea– Acute infection
–Complication of Ix– Chronic Pharyngitis
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Complication of Ix•• PeritonsillarPeritonsillar AbscessAbscess (Quinsy) PTAPTA• Parapharyngeal infection PPA• Retropharyngeal infection RPA• Ludwig’s angina
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PeritonsillarPeritonsillar AbscessAbscess
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Parapharyngeal abscess
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Parapharyngeal abscessclinical features
• Dysphagia• Trismus• Fever• Neck erythema• Neck swelling • Medial displacement of lateral pharyngeal
wall
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Parapharyngeal abscess
• Source of infection–Tonsils **Quinsy–Pharynx–Lower 3rd molar–Ear infection–Parotid deep lobe
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Parapharyngeal abscess
• Management:–Iv antibiotics–CT scan–I&D–?tracheostomy
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ParapharyngealParapharyngeal space massspace mass
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Retropharyngeal abscess
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Retropharyngeal abscess-Clinical features
• Fever• Dysphagia• Drooling• Neck rigidity• Unilateral posterior pharyngeal wall bulging• Hot potato voice• Airway compromise
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Retropharyngeal abcess
Source of infection• Infection of tonsils, teeth, pharynx, sinus• Retropharyngeal LN suppuration• Foreign body• Extension from other deep spaces infection
– Parapharyngeal space– Prevertebral space
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Retropharyngeal abscess
Management:• ABCD• Imaging• IV antibiotics• ?I&D
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Ludwig’s Angina
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Ludwig’s Angina• Extension of localized periapical infection
– Anterior mandibular → Sublingual– Posterior mandibular (molar) → Submandibular
• Fascial planes
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Historical clues• Recent dental extraction or work• Dental caries• Fever• Swelling of mouth, face, neck• Compromised host• Co-morbidities (diabetes)
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Physical exam• Toxicity• Brawny bilateral boardlike edema• Submandibular, submental, sublingual• Trismus• Tongue elevation• No fluctuance
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Etiology• Streptococcus• Staphylococcus• Mixed aerobic/anaerobic infection
–B. Fragilis• ß-lactamase resistance (40%)
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Diagnosis• Clinical• CT scan
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4 year with fever, irritability, and decreased oral intake x 24 hours. Swelling x 10 hrs
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Treatment• ABCD • Tracheostomy/ Intubation• Drainage and debridement• ICU• Extended spectrum or• Clindamycin + penicillins/ Cipro• Steroids
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Deep Neck Space Infections
Complications• Upper airway obstruction• Reinfection• Asphyxiation • Descending mediastinitis• Spread to other spaces• Death
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Pharynx• Anatomy (deep spaces)• Physiology• Pathology
– Adenoid– Snoring & sleep apnea– Acute infection– Complication of Ix
–Chronic Pharyngitis
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Chronic Pharyngitis• Nasal obstruction• Smoking• Sub-acute infection• Reflux• Allergy• Idiopathic
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