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Anatomy and Investigation of Pharyngeal Diseases and Diseases Of The Nasopharynx and Tonsils
ENT Head and Neck Surgery

1 Part

 

Anatomy and Investigation of pharyngeal diseases

 

Embryology:-  primitive foregut

 

Anatomy:-

 

Nasopharynx:-

Anterior:  Nasal fossa (choana and nasal septum).

Superior:  Base of the skull (lies inferior to body of sphenoid).

Inferior:  Soft palate.

Lateral: Eustachian tube and fossa of Rosenmuller.

Posterior: 1st cervical vertebra.

 

 

 

 

 

Oropharynx:-

Structures to identify:

  1. Vestibule/Anterior/labial sulcus
  2. Hard palate
  3. Soft palate
  4. Uvula
  5. Posterior faucial pillars/Palatoglossal arch
  6. palatine tonsil
  7. Anterior faucial pillars/Palatopharyngeal arch- VIP for Pharyngeal Swallowing triggering
  8. Posterior wall of oropharynx
  9. Lateral/buccal sulcus/Pterygoid hamulus
Superior: Soft palate.

Anterior: Oral cavity (palatoglossus)

Posterior:  2nd and 3rd cervical vertebra.

Inferior: hyoid bone and upper border of epiglottis.

 

    Hypopharynx:-

 

Superior: upper border of epiglottis

Inferior: upper end of oesophagus

Posterior:  4th, 5th, 6th cervical vertebrae.

It consist of piriform sinus ,post cricoid region and posterior pharyngeal wall.   

 

Nerve supply

Nasopharynx   V nerve.

Oropharynx     V and IX nerve.

Hypopharynx   IX and X nerve.

Structure of pharynx:-

  1. Mucous membrane:-

        Ciliated columnar epithelium (nasopharynx)

        Stratified squamous epithelium (oro and hypopharynx)

  1. Pharyngeal aponeurosis:

        Pharyngobasilar fascia.

  1. Muscular coat:

        External:

 

        Internal:

Stylopharyngeus from styloid process to the pharynx.

Salpingopharyngeus:- from cartilage of Eustachian tube to blend with palatopharyngeus in the pharynx.

Palatopharyngeus:- from the hard palate to join salpingopharygeus in the pharynx.

 

  1. Buccopharyngeal fascia:-
    • Cover outer surface of constrictors.

 

 Investigation of pharyngeal disease:-

 

History:-

Pain: commonest complaint.

Difficulty in swallowing:

  • True dysphagia due to hypopharyngeal or oesophageal obstruction.
  • Feeling a lump mainly in premenapausal women (globus histericus) but serious pathology should be investigated before reaching this diagnosis.

Regurgitation of food in pharyngeal pouch diseases.

Speech problems if the tumour extends into the larynx.

Post nasal problems:

        Nasal obstruction

        Nose bleed

        Cranial nerve involvement.

        Deafness.

Neck lump. (mass if the tumour metastasize to the neck.)

 

Questions to ask in pharyngeal symptoms.

 

Pain:

        Site would indicate the position of the disease.

        Localized or referred.

        Constant or intermittent usually referred with more serious pathology.

        Fever, usually involved in infection.

        Progressive diseases usually accompanied in carcinomas.

 

Dysphagia

  • Where is the obstruction?
  • True dysphagia or sensation of lump.
  • Weight loss usually accompanied with carcinomas due to swallowing difficulties.
  • Associated hoarseness of voice with involvement of the larynx.
  • Associated regurgitation.

 

Post nasal obstruction

  • Unilateral or bilateral.
  • Nose bleed
  • Nasal discharge

 

Examination:

Nasopharynx:-

  • Tongue depressor and small mirror.
  • Nasoendoscopy (rigid telescope, 0 to 30 degrees).
  • Under General Anaesthetic to inspect the post nasal space clearly.

 

 Oropharynx:

Tongue depressor to see:-

  • Tonsils, soft palate, posterior pharyngeal wall, retromolar triangle.

With mirror examination to see:-

  •  Base of the tongue, vallecula.

Fibre optic laryngoscope or 70 degrees telescope could be used if available. 

Hypopharynx:-

  • Laryngeal mirror (Indirect Laryngoscopy with L.A).
  • Fibre optic laryngoscopy introduced through the nose under L.A.
  • Rigid telescope. (70 degrees) introduced through the mouth
  • Direct Laryngoscopy under G.A maybe indicated.

What to examine:-

  • Pyriform fossa, posterior pharyngeal wall, post cricoid region.
  • Larynx should be seen (not part of discussions).

 

Neck Examinations:-

Inspection: from front

Palpation: stand from behind the patient.

Auscultations using stethoscope to examine any vascular abnormalities in the neck like A.V fistula.

How to examine the neck:

 

To start examining the neck, we start by examining the mastoid process, then examining the posterior trinagle from the anterior end of trapizius muscle, then examine the end of posterior sterno mastoid, then examine the anterior triangle, and finish with examining the sub mental and sub mendibular triangle.

Other areas to examine:-

  1. Ear drum.
  2. Larynx.

 

Investigations:-

  1. Laboratory:-

F.B.C:- Leukemia very high white cell count

Paterson-Brown Kelly syndrome (serum iron and iron binding capacity) and   usually accompanied with anaemia characterized by Dysphagia, post cricoid    web, finger clubbing and it is precancerous.

E.S.R:- increase in lymphoma.

Monospot test: Positive in Glandular fever virus infection (enlarged posterior triangle glands).

Electrolyte: reduced potassium in dysphagia (hypokalemia).

T.F.T: check T3 and T4.

 

  1. Radiology:-

Plain X-ray: soft tissue neck X-ray to exclude possibility of foreign bodies.

OPT for any teeth or pharyngeal tumour extension.

Chest X-Ray for TB, lymphoma and carcinoma metastasis.

Contrast:-

Barium study: for hypopharyngeal problems.

Scans:

Thyroid isotope

CT scan

MRI.scan to check any tumour extension.

 

  1. Biopsy:-

Under G.A.

Nasopharyngeal: biopsy from fossa of Rosenmuller.

Oropharyngeal: tonsil removal or wedge biopsy.

Hypopharyngeal using biopsy forceps.

 

Diseases of Nasopharynx

 

  1. Neoplastic

Benign: - 

Nasopharyngeal angiofibroma.

Hemangioma.

 

Malignant:

Squamous cell carcinoma most common.

Lymphoma.

 

Nasopharyngeal angiofibroma:-

Commonest benign tumour (rare)

Pathology:-

Arises from lateral wall of nasopharynx

Spread:

Anteriorly: nose, orbit, ethmoid

Inferiorly: oropharynx

Superiorly: base of the skull.

Gross: tougth rubbery tumour with degree of vascularity.

Histology: vascular space with no contractile elements, surrounded by fibrous tissues.

Incidence: virtually all males.

Age: at puberty but could vary.

 

Clinically:-

Symptoms:

        Nasal obstruction.

        Nose bleed.

        Otitis media with effusion.

Signs: Mass which is smooth, lobulated and hard.

 

Investigations:-

Lateral view plain X-ray: mass in the nasopharynx, should be differentiated from adenoid and antrochoanal polyps.

 

Angiography: would show vascular picture.

CT scan: shows the extent of the diseases.

MRI scan: Best with Gadolenium enhancement.

Biopsy is risky.

 

Treatment:-

Major task

Embolization: to reduce the vascularity preoperatively.

 

 

Surgery: treatment of choice cross match for several untis of blood.

 

Transpalatal approach

Transantral approach

Craniofacial approach

 

How staging helps the treatment:

Stage I: Tumour limited to nasopharynx

Stage II (A) Tumour spread to ethonoid, sphenoidsinus.

(B)     Lateral spread to pterego palates fossa, infra temporal fossa, cheek.

 Stage III Superior and lateral spread.

 Stage IV Intra cranial extension craniotomy.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nasopharyngeal carcinoma:-

Commonest tumour of the nasopharynx, common in Chinese race accounting for up to 18% of all malignancy in China.

Aetiology multifactorial:

1.      Genetically determined susceptibility HLA A2.

2.      EB virus (Epstein-Berr Virus) infectious in early life.

3.      The integration of the genomes of the virus into chromosomes in the nasopharynx.

4.      Some environmental neoplastic transformations that gain entry into infected cells. (Salt fish ingestion in China.) Nitrosamine.

 

Incidence:

male: female   =  2:1

Age: 5th decade.

 

Clinically:

30% nasal symptoms: obstruction, bleed.

20% deafness

20% Neck gland (metastasis)

10% pain

20% cranial nerve palsy IX, X, XI, XII

Check for push of the soft palate downwards, fluid in the ears, paralysis of the tongue, III, IV, VI eye movement, trismus and facial numbness.

Neck examinations distant spread to lungs, liver and bones.

 

Investgations:

1.      EBV sorology for high risk patient and IgA antibody for the VCA (viral capside Antigens)

2.      Radiography:-

Plain X-ray: destruction of base of skull 30% and chest X-ray indicated.

CT scan: showed soft tissue involvement into retropharyngeal and pharapharyngeal spaces, and also intracranial extension.

MRI scan: Best to detect intracranial extension.

3.      Biopsy: from fossa of Rosenmuller

 

Classification of SCC of nasopharynx:

Based on light microscopy                                                                   5 year survival.

 

Type I:  25% of NPC, well differentiated (keratinised)                          10%

Type II: 12% of NPC, variable differentiation (minimal keratinsation)        50%

Type III: 60% NPC, undifferentiated (Anaplastic).                                            60%

 

TNM classification

TX: primary tumour cannot be assessed.

T0: No evidence of primary tumour.

Tis:  Carcinoma in situ.

T1: tumour confined to nasopharynx.

T2: Tumour extends to soft tissue.

T2a: tumour extends to oropharynx and or nasal cavity without parapharyngeal extension.

T2b: any tumour with parapharyngeal extension.

T3: Tumour invades body structure/ paranasal sinuses.

T4: Tumour with intra cranial extension, cranial nerve involvement, infratemporal fossa, orbital involvement.

 

Treatment:-

Radiotherapy in the treatment of choice, neck should be included: dose 6500-7000 cGy.

 

Complication of radiotherapy:

  • Xerostomia.
  • Tooth decay.
  • Hypopituitism, hypothyroidsim.
  • Eye problems.
  • Skin problems.
  • Skull bone necrosis.
  • Osteoradio necrosis for the bone.

 

Surgery: for neck glands (radical neck dissections).

Biopsy nasopharynx for diagnosis.

Chemotherapy: mainly for palliative management.

Immune therapy: including vaccines in the future.

 

Prognosis:-

Depends on the stage of the tumour

(15% - 75%)

 

Other pharyngeal tissues:-

  • Lymphoma.
  • Salivary gland tumour.
  • Carcomas.

 

 

 

 

 

 

 

 

 

 

 

Adenoids:

Definition: hypertrophy of nasopharyngeal tonsil sufficient to produce symptoms (arises from the roof and posterior wall of nasopharynx. (ages 3-10).

What is the difference between palative tonsil and adenoids.

 

Pharyngeal tonsils the adenoid has:

  • No crypt.
  • No capsule.
  • Ciliated epithelium cover.

 

Problems with adenoid:

  • Hypertrophy
  • Adenoiditis

 

Symptoms of signs:

 

    1. Nasal obstruction:

In infants:

        Failure to thrive.

With older children:

        Breathing through the mouth.

        Snoring.

        Loss of tone in voice.

        Nasal discharge cough.

        Dental malocclusion.

 

    1. Eustachion tube obstruction:

Glue ears with deafness.

 

    1. Others:
      1. Rhinitis.
      2. Mental dullness.
      3. Nocturnal enuresis.
      4. Nightmares.

 

 

 

 

 

 

 

 

 

 

 

 

Investigations:-

1.      Rigid nasoendoscopy: small telescope (2.4mm) maybe suitable for older children.

2.      Post nasal space X-Ray not always helpful.

3.      Examination under G.A.

 

Treatment: -

Removal under G.A using adenoid curette

Complications:-

        Bleeding primary, reactionary and secondary.

        Recurrence

        Damage to the Eustachion tube.

        Hypernasality with nasal escape.

 

Tonsillar anatomy and disease

 

Definition: lymphoid tissue in the oropharynx

Relation:

Anteriotly: palatoglossal arch

Posteriorly: palatopharyngeal arch

Medially: free surface

Laterally within outward:-

Capsule.

Superior constrictor muscle, IX nerve, facial artery.

Buccopharyngeal fascia.

 

Blood Supply:-

Arteries:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Veins: forms a plexus which communicates above with pterygoid plexus and drains into common facial and internal Jugular vein.

Nerves: IX and X

Lymphatic drainage: into upper Jugulo digastric nodes.

Structure:

 

 

 

 

 

 

 

 

 

 

 

Waldeyer's ring: (lymphoid tissue in the head and neck)

  • Lingual tonsils.
  • Posterior pharyngeal wall lymphoid tissue.
  • Lymphoid tissues in the fossa of Rosenmuller.
  • Nasopharyngeal tonsil.
  • Palatine tonsils.

 

Function:-

Group of secondary lymphatic organs which represent 0.2% of all lymphocytes in adult. It ceases to function after birth and the studies show that removing chronically inflamed tonsils would increase the IgA in the body which enhances the immune system.

 

Tonsillar diseases:-

Tonsillitis:

  1. Acute:

        Aetiology:

Haemolytic streptococci.

Viral infection.

Others: staphylococci, Haemophilas influenza.

 

        Symptoms:

Sudden onset

Temperature rises up to 40C.

Considerable swallowing problems.

Earache.

Abdominal pains due to mesenteric lymphadenitis

 

        Signs:

Enlarged red and swollen tonsils with crypt full of Fibrin turns into purulent and necrotic areas.

Enlarged cervical glands.

Increased pulse rate due to fever.

 

 

        Investigations:

Throat swobs. (controversal)

FBC

Mosospot test.

 

        Treatment:

Bed rest.
Pain killer: paracetomol with codein.

Non steriodal anti-inflammatory. (like voltarol)

Antibiotics: penicillin is the treatment of choice.

Avoid ampicillin as it causes rash.

Fluids.

 

        Complications:

Peritonsillar absess.

Parapharyngeal and retropharyngeal absess.

Septicaemia.

Others: larygeneal oedema, nephritis, chronic tonsillitis.

 

  1. Chronic tonsillitis:

Recurrent short-lived bouts of febride malaise with sore throat, red tonsils.

Indication for tonsillectomy:

1.      Recurrent tonsillitis at least 4-5 episodes per year in the past 3 years.

2.      Peritonsillar absess after 2nd episode.

3.      Unilateral tonsillar enlargement.

4.      Gross tonsil enlargement obstructive sleep apnea.

 

  1. Peritonsillar absess (Quinsy):-

Definition:

Suppuration (absess) outside the tonsillar capsule.

 

Incidence:

More unilateral and mainly in adults.

 

Symptoms:

Increased temperature with rigor 40C.

The patient looks ill.

Acute sore throat.

Ear ache, Foeter oris (bad breath).

Inability to swallow

 

Signs:

Trismus

Oedema of the uvula which is pushed to the other sides of the infection.

Enlarged cervical glands.

 

 

 

 

 

 

 

 

 

 

Treatment:

Drainage under L.A using scalpel or aspiration using 10ml syringe.

I.V antibiotics: penicillin is the choice.

 

Complications:

Parapharyngeal absess.

Haemorrhage.

Laryngeal obstruction, air way obstruction.

 

  1. Tonsillar tumour incuding oropharyngeal

Classification:

                  Benign adinoma, papilloma.

                  Malignant squameous cell carcinoma 75%.

                  Lymphoma 15%

                  Minor salivary glands 5%

 

Incidence:

                  M : F  =  10 : 1

 

Etiology:

                  Smoking and alcohol.

 

Clinical features:

      Symptoms:      

Sore throat.

                  Otalgia.

                  Disphagia.

                  Tonsillar bleeding.

 

Signs:

                  Squaemous cell carcinoma always ulcerated.    

                  Lymphoma causes unilateral enlargement of the tonsils.

 

 

 

 

 

Investigations:

                  Haemotological H.P for anaemia.

                  Radiological chest X-Ray

                                          OPT for bone involvement.

                                          CT scan to check tumour extent.

 

Classifications:

UICC:

T1 tumour less than 2cm

                        T2 2-4 cm.

                        T3 more than 4cm.               

                       

      Treatment:

                        Depends on the staging and the fitness of the patient.

                        In general surgery is highly indicated except for very small tumour where                                    radiotherapy is indicated.

 

       Surgery:

Commando procedure involves the removal of part of the soft palate, part of the tongue, part of the mandible with radical neck dissection and cover the defect with free flap (radial forearm flap).

 

 

                       

 

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