Sore throat

1
Sore throat

2
Anatomy of pharynx
3
(No Transcript)
4
Nasopharynx

• Anterior ?????? posterior choana
• Inferior pharyngeal isthmus
• Posterior and lateral ?????? vertebra
  ,Rosenmüller fossa(nasopharyngeal recess)
  ,Eustachian tube opening
• Superior sphenoid ,occipital bone ,adenoid gland

5
Oropharynx

• Superior nasopharynx
• Anterior oral cavity ,anterior limiting at
  anterior pillar

6
Hypopharynx

• ???????? tip of epiglottis ??? cricoid cartilage
• Superior ?????? oropharynx
• Inferior ?????? pyriform sinus
• Anterior ?????? larynx

7
(No Transcript)
8
Waldeyers ring
- Adenoid gland - Palatine tonsils - Lingual
tonsils - Lymphoid nodules(Post.pharynx)
9
Nerve supply

• Sensory
• glossopharyngeal (IX to oropharynx region )
• vagus (X) to remainder of pharynx
• Motor CN IX
• glossopharyngeal (IX)
• vagus (X) and spinal accessory (XI)
• recurrent laryngeal

10
Blood supply

• External carotid
• Superior thyroid artery
• Facial artery
• Internal maxillary artery
• Subclavian artery
• Thyrocervical artery
• Inferior thyroid artery

11
Venous drainage

• Superior thyroid vein Lingual vein

Internal jugular vein
12
Lymphatic drain

• Deep cervical nodes

13
Acute Sore throat
14
Acute sore throat

• Sudden onset
• Severe
• High fever

15
Acute sore throat

• Acute pharyngitis
• Pharyngeal infection
• Viral Infection
• Infectious mononucleosis
• Diphtheria
• Vincents angina
• Tonsillitis
• Scarlet fever
• Lingual tonsilitis
• Keratosis of tonsilitis
• Fungal infection

16
1. Acute Pharyngitis
17
Acute Pharyngitis

• ?????????????? Hemolytic streptococcus
• Other e.g. Staphylococcus, pneumococcus, virus
  etc.
• Symptom
• Sudden onset
• Soreness and dryness
• Dysphagia
• High fever

18
Acute Pharyngitis

• Sign
• Mucous-membrane hyperemia
• Hypertrophic and proliferation of lymphoid tissue
• Edema of uvula
• Treatment
• Specific Penicillin groups antibiotics
• Supprotive
• Hydration
• Rest
• Antipyretic

19
(No Transcript)
20
Acute sore throat

• Acute pharyngitis
• Pharyngeal infection
• Viral Infection
• Infectious mononucleosis
• Diphtheria
• Vincents angina
• Tonsillitis
• Scarlet fever
• Lingual tonsilitis
• Keratosis of tonsilitis
• Fungal infection

21
2. Pharnygeal infection
22
Pharyngeal infection

• Pharyngitis ????????????? Cold weather season
• Child 6 mo. ? Immune decrease ? Upper respiratory
  viral infection (esp. Day care center)

23
(No Transcript)
24
Pharyngeal infection

• Viral infection
• Infectious mononucleosis
• Diptheria
• Vincents angina

25
Viral infection

• Adenovirus ? tonsillitis
• Enterovirus ? Common cold
• Cosakie viruses ? Herpangina (Acute febrile
  illness)
• Malaise
• Sore throat
• Hemorrhagic and small vessel engorgement at
  palate and anterior pillars (recover in 48 hr)

26
(No Transcript)
27
(No Transcript)
28
Viral infection

• Rhinovirus, RSV and myxoviruses ? Croup
• Treatment
• Nonspecific and symptomatic treatment
• ATB (secondary bacterial infection)
• Prophylaxis
• Polyvalent vaccines

29
Infectious mononucleosis

• ?????? Severe attack of tonsillitis
• Manifestation
• High fever
• Large, swollen, dirty gray membrane-covered
  tonsils
• Malaise
• Sore throat
• Dysphagia
• Odynophagia

30
Infectious mononucleosis

• May be
• liver damage
• Skin rash
• Petichial palate
• Splenomegaly
• Cause
• EBV (e.g. CMV)

31
(No Transcript)
32
(No Transcript)
33
Infectious mononucleosis

• Specific diagnosis procedure
• Differential blood count ? 50 lymphocyte, 10
  atypical lymphocyte
• Serologic study ? monospot and serum heterophil
  antibody titer
• Heterophil antibody titers (Bunnell-Davidson or
  Ox-cell hemolysis test ? gt 1/56 diagnostic
• X-ray
• Marked enlargement of adenoid, tonsil or
  prevetebral cervical soft tissue

34
(No Transcript)
35
(No Transcript)
36
Infectious mononucleosis

• Treatment
• Symptomatic
• Not use ampicillin ? rash
• Upper airway obstruction ? Short term high dose
  steroid therapy, Tonsillectomy and adenoidectomy
  or Tracheotomy

37
3. Diphtheria
38
Diphtheria

• Dirty gray membrane at tonsils, tonsillar
  pillars, soft palate and uvula
• Remove membrane ? bleeding
• Bull neck appearance ? cervical adenopathy
• ?????????????????? ???????????????????????????
  upper airway obstruction and cardiac toxicity

39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
Diphtheria

• Identified ? Klebs-loeffler bacillus
• Fluorescent antibody studies
• Gram stain
• Culture
• Treatment
• Penicillin in high dose
• Treat carriers
• Tracheostomy (Airway obstruction)

43
Vincents angina

• Cause by Spirochaeta denticolata and Vincents
  fusiform bacillus (Borellia vincentis)
• Slow progressive, ??????????????
• ???????????????????

44
(No Transcript)
45
Vincents angina

• Sign and symptom
• Malaise
• Headache
• Sore throat
• Jugulodigastric lymph node enlargement
• High fever
• Membrane on tonsil ??? ? ????????? involve tissue
  (resolve 7-10 d)

46
Vincents angina

• Treatment
• Penicillin
• Oral hygiene

47
Acute sore throat

• Acute pharyngitis
• Pharyngeal infection
• Viral Infection
• Infectious mononucleosis
• Diphtheria
• Vincents angina
• Tonsillitis
• Scarlet fever
• Lingual tonsilitis
• Keratosis of tonsilitis
• Fungal infection

48
3. Tonsillitis
49
Tonsillitis

• Acute tonsillitis ???????? 5-6 yr, gt 50 yr
• Predisposed of tonsillitis
• Low resistance
• Abnormal tonsils form previous recurrent
  tonsillitis
• Generalize pharyngitis
• Secondary of viral infection
• Overcrowding, poor nutrition, inadequate
  ventilation
• Fatigue and exposure to cold

50
tonsillitis

• Symptom
• Dry throat
• Thirst
• Malaise
• Fever
• Fullness in the throat
• Odynophagia
• Dysphagia
• Pain radiating to the ears

• Symptom (cont.)
• Altered speech
• Headache
• Limb and back pain
• Swelling of regional lymph node
• Shivering

51
Tonsillitis

• Sign
• Dry tongue
• Swollen red tonsils
• Yellow white spots
• Purulent exudate (Severe)

52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
Tonsillitis

• Diagnosis
• Clinical grounds
• Culture
• Common cause
• 40 Group A beta hemolytic streptococcus
• Other e.g. Alpha, gamma streptococci,
  diptheroids, anaerobes

56
Tonsillitis

• Treatment
• Bed rest
• Good fluid intake
• Analgesics
• ATB e.g. penicillin, clindamycin or oxacillin

57
Acute sore throat

• Acute pharyngitis
• Pharyngeal infection
• Viral Infection
• Infectious mononucleosis
• Diphtheria
• Vincents angina
• Tonsillitis
• Scarlet fever
• Lingual tonsilitis
• Keratosis of tonsilitis
• Fungal infection

58
4. Scarlet fever
59
Scarlet fever

• Cause form acute streptococcal tonsillitis or
  pharyngitis by endotoxin
• Sign and symptom
• Erythematous rash
• Severe lymphadenopathy
• Sore throat
• Vomitting
• Headache
• Fever
• Bright red tonsils and pharynx

60
Scarlet fever

• Sign and symptom (cont.)
• Yellow membrane on tonsil, pharynx, nasopharynx
• Strawberry tongue rash enlarge papillae ?
  good prognosis
• Investigation
• Culture
• Treatment
• IV penicillin G

61
(No Transcript)
62
(No Transcript)
63
(No Transcript)
64
Acute sore throat

• Acute pharyngitis
• Pharyngeal infection
• Viral Infection
• Infectious mononucleosis
• Diphtheria
• Vincents angina
• Tonsillitis
• Scarlet fever
• Lingual tonsilitis
• Keratosis of tonsilitis
• Fungal infection

65
5. Lingual tonsillitis
66
(No Transcript)
67
Lingual tonsillitis

• Most affect 1 tonsil
• ?????????????????????, ??????????????
• Diagnostic
• Acutely inflamed and tender tissue mass
• White exudate at base of tongue

68
Lingual tonsillitis

• DDX
• Lingual thyroid
• Thyroglossal duct cyst
• Varicosities
• Dermoid cyst
• Tumor
• Treatment
• ATB e.g. penicillin

69
Lingual tonsillitis

• Complication
• Lingual quinsy
• peritonsillar abscess in the loose connective
  tissue outside the capsule of the tonsil
• microorganisms manage to escape from the capsule
  and infiltrate the infratonsillar cleft.
• Epiglottitis
• Otitis and laryngitis

70
Acute sore throat

• Acute pharyngitis
• Pharyngeal infection
• Viral Infection
• Infectious mononucleosis
• Diphtheria
• Vincents angina
• Tonsillitis
• Scarlet fever
• Lingual tonsilitis
• Keratosis of tonsilitis
• Fungal infection

71
6. Keratosis of tonsils (Keratosis pharyngeus)
72
Keratosis of tonsils (Keratosis pharyngeus)

• Cause by metabolic disturbance
• Most in young adults
• Excessive cornification of epithelial lining of
  crypts of tonsil ? Wide horny projection from
  tonsil

73
(No Transcript)
74
(No Transcript)
75
Keratosis of tonsils (Keratosis pharyngeus)

• Sign and symptom
• ???????? Foreign body in neck ? Cough, ????
• Treatment
• Removal
• Improving oral hygiene

76
Acute sore throat

• Acute pharyngitis
• Pharyngeal infection
• Viral Infection
• Infectious mononucleosis
• Diphtheria
• Vincents angina
• Tonsillitis
• Scarlet fever
• Lingual tonsilitis
• Keratosis of tonsilitis
• Fungal infection

77
7. Fungal infection
78
Fungal infection

• Candida albican ?????? Neonates, older, ATB,
  Immunocompromised pateint
• Sign and symptom
• White mucosal patches
• Dysphagia
• Odynophagia
• Diagnosis
• Pharyngeal scraping

79
(No Transcript)
80
(No Transcript)
81
Fungal infection

• Nystatin
• Fluconazole, Ketoconazole ? Immunocompromised
  patient

82
Complication of infections of tonsils and
adenoids
83
Complication

• Local
• Systemic

84
Local complication

• Peritonsillar abscess (Quinsy)
• ??????????????????????? recurrent tonsillitis
  ???????????????????? chronic tonsillitis ???
  inadequately treated
• ???????????????? ??????????????????????????? ??
  drooling ??? odynophagia ??? dysphagia
• ?? dehydration ??? cervical lymphadenopathy ,
  trimus , tilting of neck to the same side , ?????
  , malaise

85
Local complication

• Peritonsillar abscess (Quinsy)
• Culture ?? mixed bacteria ???? aerobic ???
  anaerobic
• Management needle aspiration , surgical
  drainage ??? quinsy tonsillectomy

86
left sided peritonsillar abscess
87
(No Transcript)
88
Local complication

• Parapharyngeal abscess
• ????????? infection ???? pus drain ??? tonsills
  ???? peritonsillar abcess ???? superior
  constrictor muscle
• Abcess ?? form ??????? superior constrictor
  muscle ??? deep cervical fascia
  ?????????????????????????? great vessels
• ????? pain in the throat and neck , ?? tender
  swelling of neck ??? angle of mandible

89
Local complication

• Parapharyngeal abscess
• ??? abcess extend ?????????? ?????? Ludwigs
  angina ??? extend ?????????? ???? infect carotid
  sheath
• ??????????? CT scan
• ???????? IV antibiotics , external drainage of
  mandible below submaxillary gland

90
Left parapharyngeal abscess
91
Local complication

• Retropharyngeal abscess
• ?????? dyspnea , dysphagia ??? large fluctuant
  mass ??? posterior wall of pharynx
• CT scan
• ???????? surgical drainage

92
Local complication

• Suppurative cervical adenitis
• ?????????? jugulodigastric lymph node
• ???????????? Staphylococcus aureus ??????????
  penicillin
• ???????? penicillinase-resistant antibiotic ???
  drain ?????????? abscess

93
Local complication

• Tonsillolith
• ???? calculus ??? tonsil ??????????????
  deposition ??? calcium carbonates ??? debris ??
  tonsil crypt ????????? hard mass
• ??????? discomfort , foul odor ????????
  ulceration
• ???????? removal with follow up examination for
  recurrences ?????? tonsillectomy

94
Tonsillolith
95
Local complication

• Tonsil cyst
• ??????????????? single ???? multiple white
• ??????????????
• ??????????????????
• ?????????? local discomfort ????? incision and
  drainage ????? recurrent ????? tonsillectomy

96
Systemic complication

• group A beta-hemolytic streptococi
• Bacteremia
• acute glomerulonephritis
• rheumatic fever
• Subacute bacterial endocarditis

97
Chronic Sore throat
98
Chronic sore throat

• Chronic pharyngitis
• Chronic adenoid and tonsillar disease
• Agranulocytosis
• Tuberculosis
• Syphilis

99
Chronic pharyngitis

• ?????????????? chronic infection
  ?????????????????? ???? local irritation ????
  ??????????????
• Symptoms ??????? ?????? ????????
• Signs Hyperemia , mucosal swelling, fibrosis,
  hypertrophic change
• Treatment ??????????? , supportive treatment

100
Chronic adenoid and tonsillar disease

• Local enlargement ??? lymphoid tissue
• ??????? chronic infection

101

• Chronic adenoid infection
• ????????? 3-6 ????????? hypertrophy
• Mucopurulent, anterior and posterior nasal
  discharge,
• ????? speech problem
• Adenoid facies

102
(No Transcript)
103

• Chronic tosillitis
• Inflammatory, constant feeling of sore throat
  ????? attack ??? acute tonsilitis
• Halitosis, dysphagia, bad taste
• P/E Cryptic tonsils with debris, voice
  muffling, fibrotic tonsils
• Treatment ATB ?????? tonsillectomy

104
(No Transcript)
105
Agranulocytosis

• ??????? toxic ???????? bone marrow
• Signs Necrotic ulceration ??? mucosa,
  ??????????????????, local hemorrhage
• Symptoms sudden onset of high fever, chills,
  jaundice, weakness and sore thoart Treatment
  - ????????????? ???? chloramphenical
  - Blood transfusion
• - ??????? secondary infection
• - Steroid

106
Agranulocytosis
107
Tuberculosis

• ?????? ?????????? primary infection ??????
• ????? ????????? tubercle ??? mucosa ??????????
  ???????????? infiltration ???????
  ????????????? ?????????
• ??????????????????? tubercle bacillus ??? smear
  ???? culture
• ???????? Anti TB drug

108
(No Transcript)
109
Syphilis

• ?????? pharynx ????????????????
• First stage ?? chancre
• Second stage ?? lesion ??? ????????? 2 ???????
  pharynx
• Tertiary ??????????
• ??????????? ?????????? treponema pallidum
  ?????? serologic test
• Treatment Benzathine penicillin

110
(No Transcript)
111
Noninfectious causes of pharyngitis
112
Noninfectious causes

• Trauma
• Inflamation
• Irritation
• Allergy
• Tumor
• Iatrogenic
• Unknown
• Systemic

113
Trauma

• Foreign body ???? ????????? ???????
• ?????????????????????????? penetrating injury
  ???? non-penetrating injury ????????????????????
  ???????????????????????
• ??????????????????????????????????????????????????
  ????? myofascial dysfunction , joint pain

114
Trauma

• ????????
• ???????????
• ???????????????????? ???????????????????

115
Inflammation

• Child abuse
• Thermal burn ingestion , inhalation , caustic
  ingestion
• Gastroesophageal reflux (hypopharynx)

116
Irritation

• Outdoor air-borne pollution
• Cigarette smoke
• Indoor air quality
• ????????????????????????????????

117
Allergy

• ????????? target organ ??????????????????????
• ???????????????????? pollen , house dust ,
  temperature , humidity

118
Tumor

• Lymphoma
• ??????????????????????? ???? ?????????????????????
  ??? ????????????????
• Salivary gland tumor
• Leukemia
• Kaposis sarcoma

119
Iatrogenic cause

• ?????????????????????????? ???????????????????????
  ? ????????
• ??????????????????????
• ?????????????????????
• ???????????????????????????????????????????????

120
Systemic cause

• Behcets syndrome
• ??????????????? autoimmune ??????????????????????
  ????????????
• ??????????????
• ???????????????????????? ?????????????????????
  ???????????? ???????????? ???????????? ??????
  ??????????
• ???????????????? / ?????????????

121
Systemic cause

• Reiters syndrome
• ???????????????????? ?????????????????????????
  ????????????????????? ????????????????????????????
  ???????????????? ?????????????????????????????????
  ???
• ??????????????
• ????????????????????????? / ?????????????

122
Systemic cause

• Kawasakis disease
• (infantile acute febrile mucocutaneous lymph node
  syndrome)
• ?????????????????????????????? ??????? ???????
  ????????????? ?????????? ?????????????????????
• ???????????????? , ???????????????? LN
• ????????? aspirin ???????

123
Systemic cause

• Wegeners granulomatosis
• ?????????????
• ?????????????????????????????????
• ???????????
• ??????????????
• ????????? prednisolone ??? cyclophosphamide

124
Unknown cause

• Eagles syndrome
• ?????????????????? styloid ?????????????????
• ???????????????????????????? ?????????????????????
  ??????? ??????? ?????????????????????????????????
  ?????? ??? styloid process ???
• ???????????????????????????????????????? styloid
  ???

125
Miscellaneous

• Drug allergy
• ????????????????????????????
• Recurrent aphthous ulcer
• Progressive necrotizing ulceration
• Zenkers diverticulum

126
Tonsillectomy and adenoidectomy
127
(No Transcript)
128
(No Transcript)
129
Adenoid

• adenoidectomy

130
Indication of tonsillectomy

• Severe upper airway obstruction
• Peritonsillar abscess
• Suspicious of malignancy
• Adenoid and tonsillar hypertrophy with
  malocclusion

131
Relative indications
Recurrent episode of tonsillitis gt 6 time /year
or 3 time/ year more than two year Tonsillitis
associated with valvular heart disease,
febrile seizure Halitosis Chronic sore
throat Streptococcal carrier Obstructive sleep
apnea Snorer Dysphagia
132
Contraindication for tonsillectomy

• Recent upper respiratory tract infection
• Hematologic problem
• Bleeding tendency
• Uncontrolled systemic disease

133
Post operative tonsillectomy
134
(No Transcript)
135
Complication of tonsillectomy and adenoidectomy

• Hemorrhage
• Immediate within 24 hr.
• Delayed post op 5-7 days
• Airway obstruction from edema
• Eustachian tube injury
• Immunologic risk
• Infection
• Velopharyngeal insufficiency
• Nasopharyngeal stenosis

136
Thank you