MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU
„TVOŘÍME BUDOUCNOST MEDICÍNY“
Oral cavity and Pharynx
KOCHHK FNUSA
Ass.prof. P. Smilek, MD, Ph.D.
ENT Clinic of Masaryk university, Brno
Faculty St. Ann Hospital
Head: Ass.prof. Gál Břetislav, MD, Ph.D.
Pekařská 53, Brno , 656 91
Anatomy - oral cavity
▪ Lips (m.orbicularis oris)
▪ Cheek (m.buccinator, d.Stenoni)
▪ Processus alveolaris maxillae et mandibulae,
teeth (adult 32, child 20)
▪ Hard palate
▪ Base of the oral cavity (m.geniohyoideus, m.myohyoideus) –
gl.sublingualis, ductus Warthoni (gl.submandibularis)
Anatomy - oral cavity
Tongue – intraglossal and extraglossal („deep“) muscles (m.styloglossus,
m.palatoglossus, m.genioglossus, m.hyoglossus)
Anatomy - pharynx
Muscular-fibrous tube, from
skull base to C6
(cricopharyngeal sphincter)
– Tunica Adventitia
– Tunica Muscularis
– Tunica Mucosa
– lymphatic subepithelial tissue
Epipharynx
Oropharynx
Hypopharynx
plane interlaced with hyoid
plane interlaced with soft palate
Pars laryngea (hypofarynx)
– from superior edge of hyoid bone (vallecula glossoepiglottica) to
inferior edge of cricoid cartilage (C6)
- piriform recess – bordered medially by
aryepiglotic fold, laterally internal
space of thyroid cartilage,
posteriorly posterior wall
of hypopharynx
- anteriorly - postcricoid region
Waldayer´s lymphoepithelial ring (system of the
Pharynx)
Lies at the opening of the upper aerodigestive tracts. Lymphatic
tissue surrounds the upper aerodigestive tract in vertical and
horizontal planes. Tonsila:
▪ pharyngea (epipharynx)
▪ tubariae (epipharyngeal opening of tuba Eustachii)
▪ palatinae
▪ lingualis (tongue)
▪ lymphatic tissue on lateral pharyngeal walls
▪ lymphatic tissue on posterior pharyngeal walls
▪ lymphatic tissue in ventriculus laryngis
Immune-specific function of Waldeyer´s Ring
Lymphoepithelial tissue, reticulohistiocytic system.
Lymphoepithelial organ – tonsils (lymphatic follicles,
interfollicular tissue, lymphatic vessels, vains).
• The tonsils ensure controlled and protected contact of
the organism with environment, immunologic
surveillance
• The tonsils produce lymphocytes
• The tonsils expose B- and T-lymphocytes to current
antigens
• The tonsils produce specific antibodies after the
production of the appropriate plasma cells.
• All types of immunoglobulins occur in tonsillar tissue.
1. Continuus squamous
epithelium
2. Reticular epithelium
3. Secondary nodes
4. Basic lymphoid tissue
5.,6. Arterioles and
venules
Main symptoms indicating disease of the mouth
and pharynx I:
Pain on eating, chewing, or swallowing
Frequent cause: inflammations, tumors, foreign bodies
Dysphagia (difficult swalloving)
Inflammations (glossitis, abscess, angionerutic edema, edema of introitus
laryngis)
Neurogenic etiology (disorder of n. vagus a glossopharyngeus, amyotrophic
lateral sclerosis, bulbar amd pseudobulbar paralysis, sclerosis multiplex,
diabetic and alcoholic neuropathy)
Mechanical obstruction (foreign body, diverticulosis, stricture, tumor)
Miscelanea (epithelitis post actinotherapiam, xerostomy, fractures of mandibula
and maxilla, disorder of chewing muscles)
Burning of the tongue
toxic stomatitis, various diseases of GIT, xerostomia, syndrome Plummer-Vinson,
Diabetes mellitus, food allergy, mucoviscidosis, psychogenic glossodynia
Main symptoms indicating disease of the mouth and pharynx
II: - superfitialis laesions of the tongue
Red tongue (anemia, scarlet fever, hepatic cirrhosis,
hypertension, allergy, Sjögren´s syndrome)
Gray smooth tongue (st.p. radiotherapiam, vitamin A
deficiency, lichen planus)
Black hairy tongue (antibiotics, mycosis
Fissured tongue (lingua plicata, Melkersson-Rosenthal
syndrome)
Coated tongue (mycosis, non-specific inflammation,
reduced food intake, fever, malhygiene of oral cavity)
Brownish plaques (uremia 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 swallowing ways)
Foetor ex cavo oris (Oral Fetor)
teeth, gingiva- caries dentium, parodontosis, stomatitis, exulcerated tumors
Pharynx - inflammation (acute, chronic, specific), foreign bodies, tumors
Airway – atrophic rhinitis, ozaena, purulent rhinosinusitis, bronchiectasis
Digestive tract – esophageal diverticulum, disorder of stomach etc.
Metabolic cause- diabetes mellitus (acetone), renal insufficiency (urine),
liver coma (sweet aromatic smell)
Trismus
Inflammation of the teeth or mandible, temporomandibular joint,
oropharynx (peritonsillar abscess) injury, muscle spasm
from neurologic origin, tumors of oropharynx and around the
temporomandibular joint, congenital ankylosis of
temporomandibular joint
Disorder of salivary secretion
xerostomia - dehydration, st.p.RT, Sjögren´s syndrome, sialoadenosis,
sialorrhea - psychogenic factors, gravidity; …
Disorder of speech
dysarthria - bulbar and pseudobulbar palsy, …etc.
Methods of investigation
• Inspection - indirect, direct endoscopy
• Palpation
• Investigation of innervation
✓ tongue motoric innervation (n. hypoglossus – lying tongue the
tip to the sound side, tongue out – to the disease side
✓ Sensitive
✓ Sensorics (anterior 2/3 n. V., posterior 1/3 n. IX),
elektrogustometry
Oropharynx – normal finding
retchingat rest
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
• Tonsillitis inflammation of lymphoepithelial tissue of
pharynx.
• Pharyngitis inflammation of mucosa membrane of
pharynx.
• Tonsillo-pharyngitis inflammation of mucosa
membrane of pharynx and also lymphoepithelial tissue.
According to course
• acute
• chronic
Types of tonsillitis according to various
criterion
• Anatomic (site)
• Microbiologic
• Pathogenetic
• Pathology- anatomy
• angina palatina
• angina retronasalis
• angina pharyngis lateralis
• angina lingualis
Site of disorder – acute tonsillitis
Microbiology
• bacterial infection : Streptococcus pyogenes 90% of
bacterial origin, Haemophillus influenzae,
Staphylococcus aureus, Mycoplasma pneumoniae
• viral – adenoviruses, parainfluenza, enteroviry,
coxsackie, etc.
• fungal – rarely in immunocompromised patients
(imunosupression, HIV, tumors)
Distinguishing between viral and bacterial
infections
• Cultures; CRP
• Rapid strep test
• "strep score" - diagnostic scoring scheme for streptococcal infections: if achieved an overall
score of 5-6, a diagnosis of streptococcal infection is likely, and up to 80% can be beta hemol can
be cultured. In 80-80% of cases streptococcal infection can be detected. The administration of
antibiotics is indicated.
Age (5-15 year) 1 point
Season (november – may) 1 point
Temperature (above 38 degree) 1 point
Lymphnode enlargement 1 point
Inflammation of pharynx 1 point
Without symptoms of infection of upper airways 1 point
Acute tonsillitis
• suppurative
• symptomatic – local symptom of general disease with
bacteriemia or viremia
Secondary tonsillitis
• in immunodefficiency (agranulocytosis, leukemia etc.)
Pathogenetic view
Pathologic - anatomy view
Acute tonsillitis
According the grades of severity and
pathomorphology
• catarrhal
• follicular
• lacunar
• vesiculous
• pseudomembranous
• phlegmonous and gangrenous
Tonsillitis ac. catarrhal
Bilateral odynophagy
redness, swelling of
tonsills, febris
Tonsillitis ac. follicular
Bilateral odynophagia,
increasing in swallowing,
irradiated into ears
Micro-abscessus in follicles
visible through mucosa
membrane on the
tonsillar surface
Tonsillitis ac. lacunar
Bilateral odynophagia, increasing
in swallowing, irradiated into
ears
infiltrated, reddened, enlarged
tonsils with plagues in opening
of tonsillar crypts, sometime
confluent (angina confluens),
not spreading to tonsillar pillars,
fever
Herpangina (angina vesiculosa) - Coxsackie
virus
Marked generalized symptoms, such 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
Pseudomembranous tonsillitis
(mononucleosis infectiosa)Epstein-Barr virus's
Bilateral odynophagia, 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 transaminases (ALT, AST), positive antibody
against EB virus (positive Paul-Bunnel reaction),
PCR detection of virus.
Pseudomembranous tonsillitis
Pseudomembranous tonsillitis
Tonsillitis ac. retronasal
Pain experienced in depth behind the nose, blocked
nose, running nose
Closed mumbling, hearing disorder (bad function of
Eustachian tube), pus in posterior wall of
oropharynx
Tonsillitis ac. of the tongue base
odynophagy increasing with movement of tongue
in laryngeal mirror- the finding as in tonsillitis ac.
lacunaris
Plaut-Vincent angina
(ulceromembranous pharyngitis)
in superior pole of one tonsil
ulceration with fibrin coatings,
halitosis (foetor ex ore), bad
teeth. Bacteriology: 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, smokecolored
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.
oropharynx
male
29 let
cook in public
catering
Serious complications of inflammatory
disease of tonsills
„Internal“
▪ Febris rheumatica, sterile consequences of streptococcic infection,
autoimmunity
▪ Sepsis tonsillogenes (angina septica, sepsis post anginam,
trombophlebitis v. jug. int.)
„Surgical“
– Abscessus et phlegmona peritonsillaris
– Abscessus et phlegmona parapharyngealis
– „Deep inflammation of neck soft tissues“, Phlegmona colli
Complications during and after tonsillitis
Phlegmona et abscessus peritonsillaris
Localization: supratonsillar, retrotonsillar, infratonsillar, lateral
Symptoms:
• Increasing difficulty in swallowing occurs after a symptom
free interval of a few days after tonsillitis
• Fever not too high
• Sever pain on diseased side, spreading to the ear, patient
refuses to eat,
Differential diagnosis: tonsilogenic sepsis, dentitio diffitilis tertii
mollaris inferioris
Treatment: absces drainage - puncture, incision, dilatation,
antibiotics
Abscessus infratonsillaris
Peritonsillar phlegmona and abscess
Clinical picture of swelling, redness and
protrusion of the tonsil, faucial pillar,
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.
Phlegmon base of the oral
cavity „Angina Ludowici“
tongue pain, odynophagy, fever with
shivering fit, symptoms of sepsis
elevation of base of oral cavity,
tongue not moving, infiltration in
submandibular region
Phlegmon and abscess parapharyngeal
• Spreading infection from tonsils into the parapharyngeal
space, borderline – the wall of pharynx
• Symptoms: Fever, pain, trismus, torticollis, swelling of
external neck, swallowing of hypopharynx
• Risk of infection spreading into the mediastinum
• Treatment: incision, drainage of infection focuses,
antibiotics – broad spectrum in sufficient dosage,
external approach
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
• Source: odontogeneses origin (80 %), infection of paratonsillar and retromolar
region (20 %), injury of oral cavity base, pharynx or cervical esophagus.
Cofactor - reduced immunity (diabetes mellitus, alcohol abuse)!
• Visceral spaces of the neck have no distal boundary with mediastinum.
• Clinical picture – fever, usually septic, dysphagia, pain in the neck, back
(intrascapular), retrosternal pain
• Inflammatory infiltration of the neck without boundary, fluctuation, special
palpation feeling; by spread into the mediastinum – dysphagia and even
dyspnoe
• Treatment – surgical opening of space surrounding great neck vessels,
collateral mediastinotomy, treatment of primary source, general treatment
aimed against sepsis, thrombosis, kidney failure etc.
• Bad prognosis, high mortality
Fasciitis necrotisans,
60 year female
60y female, caries teeth, submandibular fistula and phlegmon of soft tissues of neck and
anterior mediastinum, death as consequence of sepsis next day after surgery.
Genesis of tonsillogenic (internal)
complications (sepsis)
1) Extension through veins
2) Extension through lymph
vessels
3) Internal jugular vein
4) Regional lymph nodes around the VJI
5) Extension in continuity via the
cervical soft tissue
Sepsis tonsillogenes
Angina septica – thrombophlebitis of small veins occurring
during tonsillitis – spreading into internal jugular vein.
Symptoms: fever, shivering fit, palpation pain before
anterior edge of sternocleidomastoid muscle. Possibility of
spreading into the intracranial space.
Sepsis post anginam – symptoms free interval of a few
days after tonsillitis, normal finding on tonsils; Lymphatic
way: lymph node – periadnitis -periphlebitistrombophlebitis
VJI
Thrombophlebitis v. jug. int. – treatment :surgery,
removal of inflam. focus, suture of VJI and resection in
extension of thrombosis, antibiotics
Fasciitis necrotisans
inflammation of soft
tissues of the neck with
fast spreading in fascial
compartments without
borders, with necrosis
Incision, drainage
Chronic pharyngitis
▪ Frequent disease in adult population
▪ Part of chronic inflammation of breathing pathways
▪ Etiology – chronic inflammation , long lasting nasal blockage, breathing
through mouth, fume and dust, extreme temperatures, spicy food, hard
alcohol, smoking, GERD – gastro-esophageal-reflux-disease
Hyperplastic
Atrophic
Chronic hyperplastic pharyngitis
▪ symptoms: strange sensation in the pharynx with compulsive
throat-clearing and swallowing, little better after income of food
▪ Objective finding: the mucosa of posterior pharyngeal wall is
thickened and granular, prominent solitary follicles, venous
telangiectasis and secretion
▪ Therapy: reduction of hyperplastic mucosal areas with 2-4% silver
nitrate, removal of focuses in
breathing ways
Chronic atrophic faryngitis
▪ Etiology: stay in dry or extremely humid environment, frequently in diabetes mellitus
and after tonsillectomy
▪ Symptoms: feeling of foreign body, burning sensation and dryness feeling;
▪ Objective: posterior pharyngeal wall is dry and glazed, often with dry crusts of
secretion. The mucosa is smooth, pink
▪ Therapy: moisturizing the pharyngeal mucosa
with steam inhalation, saline solution,
„vincentka“, a change of climate, air humidity,
seaside stay
Nicotin, alcohol mentol, chamomile, sage must be avoided,
Chronic atrophic pharyngitis
Chronic tonsillitis
▪ Focal inflammation in tonsillar tissue
▪ Frequent disease in population
▪ Etiology: mixed bacterial infection in tonsillar crypts Streptococcus
β-hemolyticus gr. A, less B,C,G, gold
staphylococcus)
▪ Symptoms: strange feeling in pharynx, feeling of foreign body,
foetor ex ore, higher level of ASLO, sometimes subfebrilie. After
exercising fevers, pain in muscles… repeated use of antibiotics
Chronic tonsillitis
Objectively: hypertrophic / atrophic tonsils; tonsils
are fixed to theirs base, tonsillar surface is fissured or
scared, watery pus and grayish-yellow material can be
pressed out of the openings of the crypts
Therapy:
▪ Conservative – antibiotics
(uncertain effect – bad spreading into crypts)
local antiseptics, autovaccines,
immunostimulants
▪ Surgery : tonsillectomy
Tonsillectomy - indication
▪ Recurrent tonsillitis according to Pittsburg protocol (7/y in 1st y, 5/y in 2 x, 3/y in 3 y)
▪ Chronic tonsillitis
▪ Tonsillar hypertrophy with sleep apnea syndrome
▪ Peritonsillar (or parapharyngeal) abscess
▪ Suspicion on tumor
▪ Tonsillogenic septicemia, Angina septica
▪ Focal infection – „metatonsilar troubles“ (pain in joints, trouble in cardiology, urology)
▪ Branchial cleft fistulas (2nd branchial arch)
▪ Processus styloideus elongatus with dysphagia
▪ Part of plastic treatment of palate cleft
Principples of tonsillectomy
▪ Performed under intubation anesthesia,
▪ introduced McIvor gag
▪ „cold“ vs. „hot“ technics
▪ Infiltration of tonsillar pillars, combination of blunt and sharp
dissection
▪ Bleeding – bipolar electrocoagulation,
Tonsillotomy
Tonsils are removed only partly
- Laser
- coblation technique
- Radiofrequency surgery
▪ simple tonsillar hypertrophy in children (with clinical
symptoms – breathing, swallowing etc.),
▪ sleep apnea syndrome in children
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
• Posterior indirect rhinoscopy
• Direct epipharyngoscopy
• Rtg, CT
• (Palpation)
Evaluation of Eustachian tube
• Epipharyngoscopy
• Politzeration
• Catheterization - murmur
• Normal dry, filled
• In stenosis – discontinuous, abrupt
• In liquid in middle ear cavity– moist fennomen's
• In perforation of ear drum – high, whistle
• Tubometry – even in perforated ear drum (Valsalva, Toynbee),
Vegetationes adenoideae (tonsila
pharyngea)
Adenoidectomy
under general anesthesia
under local anesthesia
Benign tumors of epipharynx –
juvenil angiofibroma
▪ Frequent benign tumor of epipharynx, usually arises from the
pterygomaxillary fissure (foramen sphenopalatinum), spreading into
epipharynx, or nasal cavity , paranasal sinuses, orbit and base of the skull.
▪ Highly vascularized tumor, locally destructive, recurrent
▪ Occurs exclusively in males 15-25 let
▪ Vessels –
ACE (a.maxillaris, a.pharyngica asc.)
ACI (a.opthalmica, sin.cavernosus)
Nasopharyngeal angiofibroma
Etiology not sufficiently known
A) hormonal - adolescent male
B) other – disturbances in embryonal development
Classification according to Chandler
I) limited to nasopharynx
II) spreading into nasal or sphenoidal cavity
III) spreading into maxillary and ethmoidal cavities, fossa pterygopalatina or
infratemporalis, into orbit or face
IV) intracranial spreading
Nasopharyngeal angiofibroma
Symptoms: recurrent epistaxis, one sided or both sided nasal
ostruction, nasal discharge, rhinosinusitis, rhinolalia, hearing
disorder, headache, in advanced stage: diplopia, eye bulb
protrusion, liquorhea, loss of smell, deformaties of face, palate
Diagnossis
▪ rhinoendoscopy red-yellow soft, bleeding tissue on contact
▪ Imagination methods CT with contrast medium+angiogragphy,
NMR with contrast medium+angiogragphy, DSA
▪ Biopsy usually contraindicated for strong bleeding
Nasopharyngeal angiofibroma - therapy
Surgery
▪ Trans nasal endoscopic technique (small tumors)
▪ External approaches – medial maxillectomy from lateral rhinotomy,
transpalatinal, transantral, neurosurg. approaches
▪ Preoperative embolization of the feeding vessels – within 48 hours
before surgery (risk of CMP)
Actinotherapy - success rate 80 %
chemotherapy intraarterial – only advance, or palliative
Recurrences in 20-50% - uncomplete removal
Nasopharyngeal cancer
▪ South-east asia; in European rare
▪ WHO classification:
– I. Spinocelular cancer with keratinization
– II. Small differentioted Spinocelular cancer without keratinization
– III. Not-differentiated cancer
▪ Type I – local spred into base of the skull, less frequently regional or distant
metastasis, low chemo and radiosenzitivity
▪ Typ II a III (lymphoepithelioma, nasopharyngeal type cancer)
- usually both large regional metastasis and distant metastasis, good chemoradiosensitivity,
is thought to be due to the Epsttein-Barr virus
Symptoms
– 1st symptom frequently – enlarged, not painful bilateral neck lymph
nodes
– Ear - Eustachian tube dysfunction from obstruction- conductive hearing
loss, tinnitus, middle ear effusion
– Nasal obstruction, bloodstained purulent nasal discharge
– Neurology typical for advanced tumors (n.VI, n.V – diplopia, disorder of
face sensitivity, n.IX-XI), Trotterova trias: palate paresis, neuralgia n V.,
conductive hearing loss
Diagnosis
– rhinoepipharyngoscopy
– Biopsy
– CT (bone destruction) a MR (intracranial spread)
Nasopharyngeal cancer
▪ Radiotherapy
▪ Advanced primary tumor - Radiotherapy + chemotherapy
(neoadjuvant, concomitant)
▪ Surgery only in case persisting neck metastases after non
surgical treatment – neck dissection
▪ Lymphoepithelioma
(Schmincke-Regaud) 5y survival rate 40 %
other malignant tumors in this region 20 %
Nasopharyngeal cancer