OTOLARYNGOLOGY – HEAD AND NECK SURGERY

Lectured by: Mary Jane Mallillin, MD, FPOHNS

February 2, 2016
FEU−NRMF Institute of Medicine

ORAL CAVITY, OROPHARYNX AND SORE THROAT

I. ANATOMY OF THE ORAL CAVITY AND OROPHARYNX

ORAL CAVITY
LYMPHATIC DRAINAGE
 Submandibular nodes
 Submental nodes

NERVE SUPPLY
 Infraorbital nerve: sensory innervation of the upper lip
 Mental nerve: sensory innervation of the lower lip

TEETH
 White, small, hard substances that can be found in the mouth
 Used to mechanically break foods into smaller pieces in
 Lips and oral cavity comprise the initial part of the upper preparation for digestion
digastric tract.  Important role in speech
 Designed for mastication of food  The alveolar ridges inferiorly and superiorly support the teeth
 Helps in speech production  Two sets of teeth are the deciduous, replaced by permanent
teeth
BOUNDARIES (MUST KNOW!)  Adult teeth are composed of the following, occupying the
ANTERIOR Lips and teeth maxilla and mandible
POSTERIOR Anterior tonsillar pillars - 2 incisors
ROOF Hard and soft palate - 1 canine
FLOOR Mucosa overlying the sublingual and - 2 premolars
submandibular glands - 3 molars
LATERAL WALL Buccal mucosa  The roots of the upper 2nd premolar and the 1st molar are
located near the maxillary sinus
In between the anterior and posterior pillars are the tonsils
PALATE
CONTENTS (MUST KNOW!)  Made up of the hard palate anteriorly and soft palate
 Alveolar process of the teeth posteriorly
 Anterior tongue to circumvallate papilla, orifice of the  Palatine process of the maxilla forms the hard palate anteriorly
parotid gland (Stensen’s Duct) in buccal mucosa opposite and the horizontal plates of the palatine bones posteriorly
the 2nd molar  Soft palate
 Orifice of the submandibular gland (Wharton’s Duct) in - Composed of a strong, thin, fibrous sheet, palatine
anterior floor of the mouth aponeurosis
 Orifices of the sublingual glands - Tensor veli palatini and levator veli palatini form the
muscle of the soft palate
LIPS - Tensor veli palatini: elevates the soft palate during
 Composed of orbicularis oris muscle and the mucosal side lined deglutition to prevent the food from entering the nose
by nonKkeratinized squamous epithelium - Other muscles of the soft palate are the palatoglossus and
 Vermilion: is red because of the thin squamous epithelial the palatopharyngeus muscles
covering  Uvula: small projection that hangs free from the posterior of
 Nasolabial fold: separates the lips from the cheek the soft palate

BLOOD SUPPLY TONGUE

 Superior and inferior labial arteries arising from the facial  Mobile muscular organ that occupies most of the oral cavity
artery  Mucosa of the tongue is composed of numerous papillae that
give the characteristic roughness on the surface
VENOUS DRAINAGE  Papillae are projections on the surface; Types are:
 Facial vein - Filiform
- Fungiform
- Vallate

Kate Michal Tan 1

[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
 - Foliate

Kate Michal Tan 2

[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
BLOOD SUPPLY (Tongue and Floor of the Mouth)
 Lingual artery
 Sublingual artery

VENOUS DRAINAGE
 Facial vein to the internal jugular vein

LYMPHATIC DRAINAGE
 Ipsilateral and contralateral submental and submandibular
lymph nodes

NERVE SUPPLY
 Hypoglossal nerve 3. HYPOPHARYNX
 Chorda tympani: supplies taste to the anterior 2/3  Extends from the superior border of the epiglottis to the
 Glossopharyngeal nerve: supplies the posterior 1/3 of the inferior border of the cricoid cartilage of the larynx where
tongue it joins with the esophagus
 Lies inferior to the epiglottis
FUNCTIONS
 Speech
 Moves food in bolus in chewing and swallowing

PHARYNX

3 DIVISIONS OF THE PHARYNX

1. NASOPHARYNX
 Extends from the posterior choanae of the nose to the soft
palate inferiorly
 Contents: (MUST KNOW!)
- Adenoid tissues BLOOD SUPPLY
- Orifice of the Eustachian tube  Branches of the facial artery
 Not accessible to direct inspection  Maxillary artery
 Examined by nasopharyngeal mirror or optical instrument  Ascending pharyngeal artery
 Lingual artery
 Superior thyroid artery from the external carotid artery

VENOUS DRAINAGE
 Internal jugular vein

LYMPHATIC DRAINAGE
 Retropharyngeal lymph nodes
 Parapharyngeal lymph nodes or deep cervical nodes

TONSILLAR RING
 aka WALDEYER’S RING
 Composed of lymphatic tissues that encircle the respiratory and
2. OROPHARYNX alimentary tracts
 Extends from soft palate superiorly to the upper margin of  Lymphoepithelial tissue found in the pharyngeal recess and in
the epiglottitis inferiorly the lateral bands on the posterior wall of the oropharynx and
 From soft palate superiorly to vallecula inferiorly (lecture) nasopharynx
 Communicates anteriorly with the oral cavity  Includes the following:
 Contents: tonsils (MUST KNOW!) 1. Pharyngeal tonsil (Adenoids)
 Boundaries:  Regresses or becomes smaller during adulthood
 Lateral: tonsillar pillars composed of the  If present during adulthood: patients usually have
palatoglossus anteriorly and palatopharyngeus adenoid facies
posteriorly 2. Tubal tonsils of Gerlach
3. Palatine tonsils
 Has important immunologic importance among the
tissue of tonsillar ring
 Most commonly removed tonsils

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[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
  Largest tonsils
3. PARAPHARYNGEAL SPACE
4. Lingual tonsils at the base of the tongue
 An inverted pyramidal space
5. Lymphoid aggregates of lateral pharyngeal bands,
 Boundaries
oropharynx and laryngeal ventricles
 Superior: base of the skull
 Inferior: hyoid bone
 The styloid process divides this space into 2
1 – ADENOIDS
compartments:
2 – TUBAL
 Prestyloid compartment: muscular
3K PALATINE
 Postyloid: contains neurovascular structures
4 – LINGUAL
4. MASTICATOR SPACE
 Collection of spaces by splitting of the investing layer of
deep cervical fascia
Is it okay to remove the
 Contains the following:
tonsils? Yes! Because you still
 Masseter
have other tonsils.
 Lateral and medial pterygoid
 Ramus and posterior body of the mandible
THE NECK  Tendon of insertion of temporalis muscle
 To be able to treat deep neck infections, one must have  Inferior alveolar nerve
knowledge in the neck spaces and the fascial spaces  Internal maxillary artery

NECK SPACES 5. PAROTID SPACE contains the following:

 Parotid gland
 Facial nerve
 External carotid artery
 Posterior facial vein

6. PERITONSILLAR SPACE
 Composed of loose connective tissue lying between the
capsule of the palatine tonsil and superior constrictor
muscle

7. SUBMANDIBULAR SPACE/ SUBMAXILLARY SPACE

 Divided into sublingual and submaxillary spaces by the
mylohyoid muscle
 Interconnected with each other and also communicate with the  Submandibular gland lies within both spaces
mediastinum so that infections can spread easily to a variety of
areas TRIANGLES OF THE NECK
 These spaces are present in the neck between the layers of
cervical fascia 1. Anterior Cervical Triangle
 Common microorganisms in neck space infections:  Submaxillary
- Staphylococcus aureus  Carotid
- S. pyogenes  Muscular
- Peptostreptococcus  Submental triangle
- Bacteroides melaninogenicus
- Fusobacterium 2. Posterior Cervical Triangle
 Occipital
1. VISCERAL SPACE contains the following:  Subclavian triangle
 Pharynx
 Esophagus FASCIA
 Larynx  Divided into superficial and deep cervical fascia
 Trachea  Anatomic landmarks for surgery
 Thyroid gland  Potential spaces of infection
 What is the importance of knowing the fascial spaces of
2. RETROPHARYNGEAL SPACE the neck? It is important to know the fascial spaces of the
 Space containing lymph nodes that lies anterior to the alar neck because these are potential spaces for neck
fascia and posterior to pharynx and esophagus infections. The infection could spread to involve this space
 Boundaries and to spread along these spaces to involve other areas
 Superior: base of the skull like the mediastinum.
 Inferior: superior mediastinum

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[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
1. SUPERFICIAL CERVICAL FASCIA
PHYSIOLOGY OF SWALLOWING
 Lies beneath the skin and superficial to the platysma
 Supports physiology of deglutition
muscle of the neck
 Normal swallow requires that ALL VALVES and PRESSURE
GENERATORS operate normally and in correct sequence
2. Deep Cervical Fascia
 3 Subdivisions
 Normal/Competent Throat Functions
 Superficial/ Investing Fascia surrounding the
 Airway maintenance
sternocleidomastoid, trapezius muscle and strap
 Swallowing
muscles
 Voice production
 Middle layer or the visceral layer
- Envelops the trachea, larynx and hypopharynx
 Upper Digestive Tract:
 Deep layer or Prevertebral Fascia
 Oral cavity
- Runs posterior to the esophagus and great
 Pharynx
vessels
 Larynx
- Ensheaths the prevertebral musculature
 Valves & Pressure Generation
 Critical components of normal, efficient and safe operation
of the upper aerodigestive tract during deglutition

VALVES PRESSURE GENERATION

Lips 2nd major component of
Tongue swallowing
Velum to back of the tongue The tongue exerts pressure on
Velopharynx the palate  rolls bolus into the
Larynx oropharynx  pharyngeal
PT – PRETRACHEAL FASCIA Upper esophageal sphincter pressure generators are
PV – PREVERTEBRAL FASCIA triggered, constrictors contract
IF – INVESTING FASCIA  pharyngeal diameter narrows

ESOPHAGUS Tongue base retraction acts like

a piston
PHYSIOLOGIC CONSTRICTIONS OF THE ESOPHAGUS (MUST KNOW!)
*During swallowing, valves *During swallowing, pressure is
adjust to direct food from exerted on food to move it
mouth through pharynx and into rapidly and cleanly
esophagus

1. UPPER
 Area of the esophageal inlet between the cricoid cartilage
and the cricopharyngeal part of the constrictor pharyngis
1. Preparatory phase where chewing of food occurs
inferior muscle
 Narrowest portion; where foreign bodies most commonly 2. Oral Phase − food is broken down and moistened to form a
bolus that is moved toward the oropharynx
lodge
3. The food is pressed against the hard palate.
2. MIDDLE 4. Pharyngeal Phase − The velum is elevated to close the
 Where the aortic arch crosses over the tracheal bifurcation nasopharynx and the larynx is sealed off by elevation of
epiglottis
3. LOWER: 5−6. Esophageal Phase−there is peristaltic wave to move the
bolus into the stomach.
 Where the esophagus pierces the diaphragm

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[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
1. ORAL PREPARATORY PHASE
3. PHARYNGEAL PHASE
 Food in the oral cavity is chewed and formed into “bolus”
 Airway is closed to prevent food from entering the lungs
 There is lip closure and lingual manipulation, lateral
 Sensory stimulus: Bolus and tongue movement
rotatory movement of mandible with lateral rolling of the
 Pharyngeal swallow is triggered as the bolus passes the
tongue
back of the tongue
 Rapid and finely coordinated movements bring the bolus
 Occurs in < 1 second
 Where the pleasure of eating occurs
 Aspiration may occur if there is a delay in pharyngeal
swallow
2. ORAL PHASE  Larynx should be closed, if not −> it leads to aspiration
 Prior to oral stage, the bolus in on the floor of the mouth  Upper ES must be open to receive the bolus
or between tongue and palate
 Epiglottis acts to direct food into the esophagus
 At the start, the tongue elevates bolus against palate,
rolling and squeezing it posteriorly
4. ESOPHAGEAL PHASE
 Bolus passes the faucial arches and back of the tongue
 After the food travels from pharynx to esophagus, muscle
then enters the pharynx
contractions move the food from upper esophagus thru
 Combination of tongue movements and stimulation from
the lower esophageal sphincter and into the stomach
the initiate a series of muscle contractions that prepare
 Ends when the food reaches the stomach
the pharynx for the next stage

II. DISEASES OF THE ORAL CAVITY AND OROPHARYNX

DYSPHAGIA VS. ODYNOPHAGIA

 Conversely, many patients with pharyngeal inflammation
 Dysphagia – difficulty swallowing
or tumor will often have referred ear pain in which case
 Odynophagia – painful swallowing
otoscopy will be normal
EFFECT: Disruption of normal deglutition
2. NOSE
 The nose should be examined for any evidence of
EVALUATION OF PATIENTS
obstruction, purulence or excessive secretions
 Mouth breathing leads to drying of the pharyngeal
HISTORY
mucosa, which is a very common cause of chronic sore
 The following are important historical considerations in a
throat
patient complaining of sore throat and dysphagia
 Excessive secretions may cause the patient to clear his
 Age of the patient
throat frequently, which traumatizes the larynx causing
 Babies: loss of appetite
hoarseness
 Elderly: complains of dryness of the throat  Infected drainage from sinusitis may cause irritation in the
 Adults: sore throat pharynx
 Onset and duration of symptoms
 History of recent trauma (including possible foreign body) 3. PHARYNX
 Inflammatory symptoms like fever, pain, malaise,  Examination of the throat for asymmetry, erythema,
malodorous breath exudates, swelling, or pooling of secretions.
 Status of nasal airway  Inspection and palpation of the oral cavity to look for any
 Reflux symptoms such as heartburn ulcerations, lesions, mucosal and submucosal masses
 Presence of associated ear pain
 Via the Jacobson’s nerve 4. NECK
 Dysphagia or odynophagia  The neck should be inspected and palpated for the
 Dyspnea or stridor presence of lymphadenopathy, swelling, tenderness,
Otolaryngologic emergency induration or flatulence
 Recent exposure to infections  Large, firm, nonKtender masses suggest neoplasia
 Cancer risk factors like smoking history, alcohol abuse  Multiple small nodes are often seen in chronic recurrent
infections
PHYSICAL EXAMINATION
 The following are key consideration of PE for patients with 5. LIPS AND ORAL CAVITY
sore throat and dysphagia:  Any swelling, hyperemia, ulcerations, masses and changes
in color should be noted
1. EARS Torus Palatinus – smooth benign mass of the palate
 Patients ears should be examined for primary ear
pathology, as otitis media and serous otitis media are Other diagnostic procedures include the following:
often preceded by pharyngitis and nasal congestion  Ultrasonography
 Otoscopy will reveal hyperemic or retracted tympanic  CT scan
membranes  MRI
 Endoscopy and swallowing studies
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[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
 APTHOUS ULCERS HERPETIFORM ULCERS

a. Minor Apthous Ulcers

 Round to oval superficial ulcerations
 2K5 mm in size
SORE THROAT  Covered by white grayish fibrinous exudate
 Associated symptoms:  persists for 1 week and heals spontaneously
- Mild difficulty of breathing
- Drooling of saliva b. Major Apthous Ulcers
- Dysphagia  Deeper and larger ulcerations
- Rash  1K2 cm in size, single or multiple ulcerations found on
- Muffled voice or hoarseness the lips, buccal mucosa, tongue, soft and hard
- Halitosis palates, and tonsillar pillars
- Swollen lymph nodes  Usually accompanied by tender cervical lymph nodes
 Patients complain of difficulty and painful swallowing
INFECTIONS OF THE ORAL CAVITY AND PHARYNX  Heals in 2K4 weeks
 Inflammatory disorders of the oral cavity and pharynx present
as throat or neck pain.  Treatment (Symptomatic)
 Other frequent complaints include: - NSAIDs
- Dysphagia - Oral antiseptics
- Odynophagia - Mouth rinses
- Drooling of saliva - Topical application of steroid gel may help in alleviating
- Muffled voice or hoarseness pain
- Halitosis - Vit B, folic acid and iron may also help if there is deficiency
- Swollen lymph nodes
- Airway obstruction B. HERPES ZOSTER (SHINGLES)
 PHARYNX  Neurotropic reactivation of chickenpox virus
- A dynamic conduit for inspired air and ingested matter  Virus persists in the ganglion cells after the patient’s initial
- Responsible for diverting each into the trachea or exposure to the virus and reactivated when the immunity
esophagus, respectively is decreased like in cases of trauma, stress, neoplasia or
 The process may be impaired by anything, which obstructs or massive infection
restricts the mobility of the pharynx  Incubation period: 4K20 days
 sSarts as pain and itching on the affected dermatome
A. RECURRENT APTHOUS STOMATITIS followed by appearance of vesicle
 Common inflammatory lesion of the oral cavity mucosa  SelfKlimited and mild cases resolve even without
 aka Apthae or Canker Sores intervention
 Common among the 2nd and 3rd decade of life  ZOSTER OPHTHALMICUS and ZOSTER OTICUS or RAMSAY
 Apthous ulcers usually bleed when scraped from the HUNT SYNDROME
mucosa  Pain is very severe
 Usually appear on the buccal mucosa  Accompanied by fever and nausea
 Do not occur in the tonsils  Cervical lymphadenitis may develop
 Unknown etiology but a number of precipitating factors  More diffuse lesions on the oral cavity mucosa
have been identified such as:  Vesicles may appear on the buccal mucosa, palate,
- Trauma to the mucosa uvula, gingiva, floor and lips
- Hormonal changes (premenstrual)  Diagnosis: History and PE
- Autoimmunity  Conservative Management
- Vit B, iron and folic deficiency - Analgesics
 Herpetiform Ulcers - Anti−inflammatory drugs
- Associated with STD (Ask patients if they have a - Burrow’s solution and lotions
history of STD)  Oral Treatment
 ACYCLOVIR or FAMCYCLOVIR for 5K7 days
 Antibiotics for secondary bacterial infection

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[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
C. CANDIDIASIS
- Rest
- Antibiotics for bacterial infections
- Supportive for viral infections

E. ACUTE PHARYNGITIS (MANUAL)

 Acute viral and bacterial pharyngitis affects all ages
 Characterized by diffuse sore throat and other symptoms
of URTI
 MC organisms include various organisms such as
- Streptococci
PUNCTATE CONTINUOUS - Pneumococci
- Influenza virus
 aka THRUSH or MONILIASIS  Viral infection cannot be reliably differentiated from
 Fungal infection most commonly seen in very young, bacterial infection on PE
elderly, immunosuppressed patients, or those with  First symptoms include dryness or throat itchiness
weakened immune system due to radiation or  Inflammation involves the larynx and the patient
chemotherapy, DM, long term antibiotics use, steroid complains of hoarseness
inhalations, leukopenia or HIV  Signs and Symptoms
 Patients usually have oral and pharyngeal pain - Malaise
 Diffuse pharyngeal erythema and edema with multiple - Headache
whitish plaques - Fever
- Can be easily scraped from the mucosa; - Dysphagia
 Removal of whitish material reveals superficially ulcerated - Referred pain to the ear
mucosa - Cervical lymphadenopathy
 Risk Factors - Pharyngeal wall appears hyperemic with mucoid
- Chemotherapy or radiation treatment secretions
- DM - Diffuse erythema and edema of the oral and
- Long−term antibiotic therapy nasopharyngeal mucosa
- Steroid use - Lymphoid follicles or plaques on the posterior
- Leukopenia pharyngeal wall
- HIV - Cervical lymph nodes may be enlarged
 Diagnosis: KOH preparation revealing budding yeast forms  Treatment (Supportive care)
 Treatment  Good oral hygiene
- Oral antiKfungal agents such as clotrimazole lozenges  Sdequate fluid intake
or nystatin oral suspension  Saline gargles
 Rest
D. PHARYNGITIS (LECTURE)  Snalgesics such as paracetamol
 Allergic  If bacterial infection is present, antibiotics will hasten
 Viral resolution and prevent complications
- Throat itchiness
- Severe coughing due F. ACUTE TONSILLITIS
to itchiness
- Frequent throat
clearing
 Acute or Chronic
 Symptoms
- Frequent throat clearing
- Post nasal drip
- Foreign body sensation to the throat
DIFFUSE PUNCTATE
- Dryness or throat itchiness
- Cough (because of itchiness)  Presence of erythematous and/or exudative tonsils with
- Hoarseness any of the following symptoms:
- Dysphagia - Sore throat
- Cervical lymphadenitis - Dysphagia
 PE: - Odynophagia
- Diffuse erythema and edema - Rever
- Lymphoid follicles  50% of cases are of viral in origin
 Treatment  Group A beta hemolytic Streptococcus: MC organism in
- Saline gargles cases of bacterial tonsillopharyngitis
- Analgesics
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[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
  Other causative organisms
TONSIL GRADING (MUST KNOW!)
- S. aureus
- S. viridans
- Various Haemophilus species
 It is important to differentiate whether the infection is
viral or bacterial in etiology
 Affects children, adolescents

Features suggestive of Features suggestive of

BACTERIAL etiology VIRAL etiology
- Sudden onset - Conjunctivitis
- Sore throat/dysphagia - Coryza
- Fever - Cough
- Petechiae - Hoarseness
- Headache - Diarrhea
- Nausea & vomiting
- Abdominal pain
- iIflammation of the
pharynx and tonsils GRADE 0 Surgically removed tonsils
- Patchy discrete exudates GRADE 1 Tonsils hidden within tonsil pillars
- Tender, enlarged anterior GRADE 2 Tonsils extending to the pillars
cervical nodes GRADE 3 Tonsils are beyond the pillars
- Age 5−15 years
GRADE 4 Tonsils extend to midline
- History of exposure
Signs & Symptomsx: dysphagia, foreign body
sensation, sleep apnea
 Examination of the Oral Cavity
- Swollen, erythematous mucosa of the oropharynx
and hypopharynx  muffled speech
- Edema of the uvula and soft palate
- Red, enlarged tonsils covered with an exudate or
studded with white follicles
- Tender, firm, cervical adenopathy
 Exudative tonsillitis: lesions appear on the tonsils
 Diagnosis
- Mirror exam GRADE 3 GRADE 4 or “KISSING TONSILS”
- Leukocytosis,  ESR,  CRP
- Culture, Rapid immunoassay G. CHRONIC TONSILLITIS
 Treatment  MC of all recurring throat diseases
 Antimicrobials (for bacterial)  Diagnosis depends on what the tonsils loop upon
- Antibiotics – for patients with acute bacterial inspection
tonsillitis based on clinical and epidemiological  Two Accepted Clinical Pictures
findings - Enlarged and hypertrophied tonsils: crypts are deep
- Penicillin − DOC for streptococcal pharyngitis and partly stenosed and a purulent exudate
 Other antibiotics: - Small but hyperemic margins with thin, purulent
 Cephalosporins secretions from crypts
 Erythromycin for patients allergic to penicillin  Treatment
AE: GI upset - Prolonged antibiotic therapy (penicillin)
Do not give unless patient is allergic to penicillin - Throat irrigations to clean the crypts
 Clindamycin for penicillin and erythromycin− - Surgical removal of tonsils if medical or conservative
intolerants given for 10 days management has failed
 If there is failure to resolve within 3−4 days,
shifting to augmented penicillins, clindamycin,
3rd generation cephalosporins or higher
generation macrolides
 Symptomatic/Supportive (for viral)
- Hydration
- Warm saline gargle
- Bed rest
- Use of analgesics and antipyretics GRADE 4 or “HYPERTROPHIC TONSILS”
- Maintaining good oral hygiene

Kate Michal Tan 9

[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
TONSILLECTOMY
 Surgical procedure in which the tonsils are removed
 May be recommended in patients with the following
conditions (manual):
 Tonsillar hyperplasia accompanied by one of the
following
 Upper airway obstruction
 Dysphagia
 Speech impairment
 Halitosis
 Peritonsillar abscess occurring in the background of
chronic tonsillitis
 Recurrent or chronic tonsillitis: 4 episodes in a year
 Cases with high ASO, both IgG and IgM subclasses  Examination of the Oral Cavity
 Normal titer: 200 IU - Diffuse erythema of the oropharynx and tonsils often
 Absolute Indications for Tonsillectomy (LECTURE) mimicking bacterial tonsillitis
 Obstructive Sleep Apnea Syndrome - Tonsils may appear necrotic
 Hypertrophy with Obstruction - Diffuse cervical adenopathy: present bilaterally as
 NOT recurrent tonsillitis well as tonsillar and inguinal nodes
 Contraindications  Diagnosis
- Abnormal clotting  Blood smear
 Complications  Lymphomonocytoid cells
- Hemorrhage  Pfeiffer cells
- Dehydration secondary to odynophagia  CBC: Leukopenia
- trismus and infection of the tonsillar bed manifested  On repeat CBC: leukocytosis
as fever  Paul−Bunnel test
- Lingual tonsillitis  Monospot test
- Streptococcal gingivostomatitis  Serologic test
- Sequelae: PSGN, ARF, rheumatic endocarditis  IgM, IgG
 Clinical
ADENOIDECTOMY  Enlarged tonsillar, nuchal, axillary and ingunal
 Beneficial to patients with obstructive adenoidal nodes
hypertrophy  Mirror exam
 Contraindications  Tonsils bright red, swollen with grayish fibrin
- Clotting disorders coat
- Submucosal cleft palate  Treatment
- Short soft palate  Supportive: for the relief of pain and fever
 Complications  Acetaminophen, ibuprofen
- Bleeding  Do not use aspirin
- Infection  Steroids: in severe cases with adenotonsillitis
- Velopharyngeal insufficiency with speech defect involvement which can lead to upper airway
and/or nasal regurgitation and scarring of Eustachian obstruction
tube orifice  Complications: Hepatitis (lecture)

H. INFECTIOUS MONONUCLEOSIS I. EPIGLOTTITIS

 aka Pfeiffer’s glandular fever, Kissing disease  Acute inflammatory condition
 Etiologic agent: EBV of the supgraglottic larynx
 Incubation period: 7K9 days  Otolaryngologic emergency
 Membranous type of tonsillitis  MC in children 3K5 y/o but also
 Primarily affects young adults, among adolescents occurs in adults
 Presents as non−specific malaise, fatigue, low−grade fever  Etiology: H. influenza
 Signs and Symptoms  Symptoms
- Bilateral CLAP - Rapid onset of sorethroat
- Hepatosplenomegaly and fever
- Body malaise - Pooling of saliva
- Pyrexia - Difficulty in breathing with
- Anorexia airway obstruction
- Palpable tonsillar, axillary and inguinal node
- Sore throat
- Tender cervical adenopathy

Kate Michal Tan 10

[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
  Manifestations in children (Trismus)
- Drooling
- Dysphagia
- High fever
- Inspiratory stridor
- Muffled “hot potato” voice
- Sudden onset of symptoms then rapid progression
- Sore throat
- Toxic appearance
- “Tripod” Positioning
 Diagnosis
- Based on the discovery a large swollen epiglottis
- On radiological examination, it shows a thumb sign
 Treatment
- Airway management (tracheostomy or tracheotomy)
- Antibiotics, usually 3rd generation
- Cephalosporins
- Humidified air

J. DIPHTHERIA
 Caused by Corynebacterium diphtheria, which produces
endotoxin that causes epithelial cell necrosis and
ulceration
 Transmitted by respiratory droplets
 Manifestations
- Local, benign pharyngeal diphtheria which begins
with fever and odynophagia  severe malaise,
headache and nausea
- Slightly sweet breath can also be noted
 Oral Cavity Examination
- Grayish−yellow pseudomembrane that is firmly
adherent to the tonsils and may spread to the palate
and oropharynx that usually bleed when removed
 Treatment
- Diphtheria antitoxin
- Pen G
 Complication
- Toxic myocarditis
- Interstitial nephritis
 Prevention
- Active vaccination

DEEP NECK INFECTIONS

A. QUINSY/PERITONSILLAR ABSCESS
 Develops by spread of bacterial tonsillitis to the
peritonsillar space which lies between the tonsillar capsule
and the superior constrictor muscle
 Infection of the tonsil proceeds to a diffuse cellulitis and
extends into the soft palate and leads into a peritonsillar
abscess
 Rapidly progressing disease, unilateral
 More common in older children and young adults
 Signs and Symptoms
- Progressively increasing pharyngeal pain often
unilateral and radiating to the ear on the affected
side
- Increasing dysphagia
- “hot potato” voice
- Difficulty handling secretions and opening mouth

Kate Michal Tan 11

[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
  Examination of the Oral Cavity - Sore throat
- Unilateral erythema - Neck pain
- Unilateral - Dysphagia
displacement of the - Swelling
soft palate - Frequently toxic with high fever
- Swelling of the
anterior tonsillar
pillar and soft palate
- Deviation of the
uvula to the
opposite side
- Bilateral

cervical adenopathy
- Severe trismus
 Management
 Needle aspiration or incision and drainage of
the peritonsilar space in an abscess
 Antibiotic coverage (penicillin) parenterally
followed by oral administration for at least 10
days
 Adjuctive measures
- Hydration
- Analgesics
- Good oral hygiene
 Tonsillectomy
- Recommended if the patient has prior
history of tonsillitis in which the abscess is
likely to recur

B. PARAPHARYNGEAL ABSCESS
 Frequently begins with bacterial pharyngitis,
acute tonsillitis, or dental abscess
 Etiology
- Suppuration of deep cervical LN
- Phlebitis
- Thrombosis of
deep neck
veins
 Signs & Symptoms
- Sore throat
- Neck pain
- Dysphagia
- Swelling
- Trismus
 Treatment
- IV antibiotics
- Incision and drainage

C. PHARYNGEAL SPACE INFECTIONS

 Infections extending into the deep neck structures
frequently begin with a bacterial pharyngitis, acute
tonsillitis or dental abscess
 May also follow surgical manipulation of the tonsils or
dental extraction
 Etiology
- Suppuration of the deep cervical lymph nodes
- Direct contamination by needle sticks
- Results of vascular inflammation such as phlebitis
or thrombosis of the deep neck veins
 Signs and Symptoms

Kate Michal Tan 12

[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
  Prominent symptom: trismus due to splinting of the
 Can occur at any age
pterygoid muscles
 MC seen in young children
 Characteristic finding: displacement of the lateral
 Etiology
pharyngeal wall without swelling or enlargement of - Suppuration of the retropharyngeal lymph nodes
the tonsil
- Injuries to posterior pharyngeal wall
 Treatment
 Symptoms
- Blood cultures
- Severe sore throat
- IV antibiotics
- Difficulty swallowing
- Incision and drainage: if the patient does not respond
- Possible airway obstruction
to therapy
 Clinical findings
- Erythema and edema of the oropharynx
D. LUDWIG’S ANGINA
- Bulging of the posterior pharyngeal wall
 Lateral soft tissue xKray of the neck
- Widening of the retropharyngeal space
 Management
- Incision and drainage under general endotracheal
anesthesia because of the risk of aspiration
- Followed by vigorous oral and appropriate antibiotic
coverage

BENIGN TUMORS OF THE ORAL CAVITY

A. MUCOCOELE
 Causes
 Unusual inflammatory condition of the floor of the mouth - Trauma to the salivary
with pronounced edema and often abscess formation in gland
the sublingual space - Obstructed or rupture
 “woody” salivary duct
 Lead to fatal airway obstruction  aka Mucous Retention Cyst
 Presents as pain in the floor of the mouth and submental or Mucous Cyst of the oral
area mucosa
 Involved spaces in Ludwig’s angina (MUST KNOW!)  Benign, mucous−containing cystic lesion of the minor
 Sublingual space salivary gland consisting of a collection of fluid
 Submaxillary space  Fluctuant; size may vary from 1mm to several cm
 Etiology  Can be seen on the buccal mucosa, anterior ventral
- Trauma to the floor of the mouth tongue, and floor of the mouth
- Severe dental caries  Some resolve after a short time while others may persist
- Tonsillitis for several years and may require surgical removal
- Peritonsillitis  NOT A TRUE cyst: does not contain any epithelial lining
- Recent dental extraction  Lower lip – MC location
 Signs and Symptoms  Ranula – Term used when it is found on the floor of the
- Severe swelling mouth
- Induration of the floor of the mouth, gums and
B. AMELOBLASTOMA
tongue
 Rare benign odontogenic tumors
- Displacement of the tongue posteriorly and superiorly
- Oropharyngeal airway obstruction  Locally aggressive that arises from the mandible and
maxilla
- Drooling
 Comprising only 1% of the tumors and cysts of the jaws
 Patient initially notices a painless swelling on the jaw with
E. RETROPHARYNGEAL ABSCESS
facial deformity
 Progresses slowly causing loose teeth, ulcers and gum
diseases
 MC site – Ascending ramus of the Mandible
 Treatment
 Surgery – MC treatment of the tumor
 Excision of normal tissue near the tumor margin −
these tumors have the capacity to invade adjacent
structures

Kate Michal Tan 13

[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D
 SWALLOWING DISORDERS (LECTURE)
ACHALASIA GLOBUS PHARYNGEUS
 Dysphagia type:
- aka Cardiospasm  Can be found in the elderly
 Solid foods only
- neuromuscular disorder complaining of lump in the
 Liquid only
 Failure of esopahgoastric throat
 Both solid and liquid
junction to relax with  Feeling of lump in the throat
 Progressive (From solid  liquid)
deglutition resulting in the (subjective)
 Symptoms
proximal dialtation of the  Somatoform disorder
OROPHARYNGEAL ESOPHAGEAL
esphagus with absence of  Presents pseudoneurological
 Inability to initiate  Heartburn peristalsis symptoms relating to
swallowing  Chest pain  Patient then feels a need voluntary sensory or motor
 Nasal regurgitation  “Sticking” of food in to force the food down function
 Aspiration suprasternal or with water or other Presentation
 “sticking” of food in substernal location beverages to complete the - Lump in the throat not
upper neck swallowing related to eating
 Substernal fullness and - Sensation may be relieved by
regurgitation is common eating or drinking
 Other symptoms  Esophagoscopy should be - Symptoms may be triggered
- Odynophagia performed to rule out by stress
- Otalgia malignant obstruction Diagnosis of exclusion
- Vomiting Differential Diagnosis
- Weight loss - Cricopharyngeal web
 Diagnosis - Laryngopharyngeal reflux
 Cine−esophagography - Diffuse esophageal spasm
 Esophagoscopy - Neurological diseases
 ENT usually use RIGID esophagoscopy - Benign or malignant tumors
 Gastro usually use FLEXIBLE esophagoscopy Diagnosis
 Motility studies - Chest xray
 Biopsy - Endoscopy
 Treatment - Barium swallow
- Most important step toward successful treatment is an Management (Symptomatic)
accurate diagnosis - Psychotherapy
- Medical therapy - Behavioral therapy
- Rehabilitation therapy - Antidepressants
- Endoscopic and surgical therapy
 Cause
 FOREIGN BODIES

Sources:
 Otolaryngology – Head and Neck Surgery
A Textbook for Medical Students First Edition 2015
- Anatomy and Physiology of Oral Cavity and
Oropharynx (pp 81−87)
- Diseases of Oral Cavity and Oropharynx (pp 89−97)
 Lecture/ Recording
 Powerpoint

- Foreign bodies in the oropharynx are most commonly

located in the TONSILS (REMEMBER!) and at the tongue
base; Most commonly lodged at the cricopharyngeus
portion of the esophagus
- Typical foreign objects are FISH BONES (REMEMBER!) and
bone fragments
- Most patients describe well−localized pain on swallowing.
 Other causes (MUST KNOW!)
 Obstructive lesions
 Neuromuscular/myotonic lesions

Kate Michal Tan 14

[OHNS] Oral Cavity, Oropharynx & Sore Throat MD 2017 − 3D