Sore Throat

Anatomy, phisiology, examination and illnesses of

the throat

Head of otolaryngology department

Prof. Alexander I. Yashan

Sagital section

Anatomy of mesopharynx (oropharyngoscopy)

Anatomy of epypharynx (epypharyngoscopy)

Anatomy of hypopharynx (hypopharyngoscopy-laryngoscopy)

EXAMINATION of the THROAT(bacteriological)

EXAMINATION of the THROAT(palpation)

PHISIOLOGY of the THROAT

• Breathing

• Swallowing

• Separating (channelization)

• Speech (articulation)

SWALLOWING• Normal mechanism - 3 stages

– 1st Stage - Oral (Voluntary) - tongue pushed against palate, forcing food into pharynx, triggering reflex stages

– 2nd Stage - Pharyngeal involuntary lasts 1-2 seconds Food in pharynx stimulates receptors with afferents in V and IX leading to the medulla. Reflex efferent signals travel via V, IX, X, and XII to:

• Elevate soft palate to seal off nasopharynx • Move palatopharyngeal walls medially • Close glottis and depress epiglottis • Larynx moves superiorly, and anteriorly under base of tongue to shield

larynx and widen hypopharynx • Relax cricopharyngeus • Close superior constrictor as bolus passes into esophagus

– 3rd Stage - Esophageal (Involuntary) • Liquids usually fall by gravity • Peristaltic waves push solids. Innervated by vagi and myenteric

plexus.

Examination Scheme

External: Lips

Oral vestibule

Teeth and gums

Hard & soft palate

Palatal mobility

Tongue dorsal, ventral surfaces,

Floor of mouth

Tongue mobility

Put Tongue Depressor & examine:

Tonsils

Ant. & post. Pillars

Tongue Posterior 1/3

Post. Pharyngeal wall

& its mobility

Examination

Tongue Depressors

Taste Sensation & Electrogustometry

INFLAMMATORY DISORDERS OF THE PHARYNX

• Inflammatory disorders of the pharynx most commonly present as throat or neck pain. Disphagia, odynophagia, and airway obstruction are other frequent complaints. The pharynx is a dynamic conduit for inspired air and ingested matter, responsible for diverting each into the trachea or esophagus, respectively. This process may be impaired by anything which obstructs or restricts the mobility of the pharynx. The following outline is directed toward a systematic approach to the evaluation of the patient with sore throat, odynophagia or disphagia.

EVALUATION • Key historical considerations

– Age of patient – Onset and duration – History of recent trauma (including possible foreign

body) – Inflammatory symptoms - fever, pain, malaise,

malodorous breath – Status of nasal airway: congestion, obstruction,

rhinorrhea, purulent discharge, allergic history, snoring – Reflux symptoms such as heartburn or water brash – Associated ear pain – Disphagia or odynophagia – Dyspnea or stridor – Other associated symptoms – Recent exposure to infectious discharge – Cancer risk factors: smoking history, ETOH abuse

Key considerations of physical examination for patients with throat pain:

– Ears - The patient's ears need to be examined for primary ear pathology, as acute otitis media and serous otitis media are often preceded by pharyngitis and nasal congestion. Conversely many patients with pharyngeal inflammation or tumor will have referred ear pain in which case otoscopy will be normal.

– Nose - The nose should be examined for any evidence of obstruction, purulence, or excessive secretions. Mouth breathing leads to drying of pharyngeal mucosa; this is a very common cause of chronic sore throat. Excessive secretion may cause the patient to clear his throat frequently, which traumatizes the larynx; and infected drainage from sinusitis may cause irritation in the pharynx.

– Pharynx - Examination of the throat for asymmetry, injection, erythema, exudate, swelling, or pooling of secretions. Also, careful inspection and palpation of any ulcerations, lesions, mucosal or submucosal masses.

– Neck - Careful palpation and inspection of the neck for lymphadenopathy, swelling, tenderness, induration or fluctuance. Large, firm, non-tender masses suggest neoplasia, while multiple small nodes are often seen in chronic recurrent infections.

Acute Viral or Bacterial Pharyngitis • Pharyngitis is caused by a variety of microorganisms. Most

cases are viral and include the virus causing the common cold, flu (influenza virus), adenovirus, mononucleosis, HIV among various others. Bacterial causes include Group A streptococcus which causes strep throat (15% of cases), in addition to Corynebacterium, Arcanobacterium, Neisseria gonorrhoeae, Chlamydia pneumoniae and others. In up to 30% of cases, no organism is identified.

• Most cases of pharyngitis occur during the colder months -- during respiratory disease season. Spread among household members is common. The medical importance of recognizing strep throat as a cause of pharyngitis stems from the need to prevent its complications which can include acute rheumatic fever, kidney dysfunction and severe disease such as bacteremia and rarely streptococcal toxic shock syndrome.

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Symptoms   • sore throat • additional symptoms are dependent on the underlying

microorganisms • step throat may be accompanied by fever, headache,

swollen lymph nodes in the neck • viral pharyngitis may be associated with runny nose

(rhinorrhea) and postnasal discharge • severe cases of pharyngitis may be accompanied by

difficulty swallowing and rarely difficulty breathing• Signs and tests    A physical exam with attention to the

pharynx to assess whether drainage/coating (exudates) are present, as well as skin, eyes, neck lymph nodes is frequently done.

Oropharyngoscopy

•Swollen, erythematous mucosa of the oropharynx and hypopharynx, often with edema of the uvula and soft palate.•Swollen cyanotic lymphatic follicles on the posterior wall•Mucous or purulent discharges on the posterior wall

Complications   • complications of strep throat:

• rheumatic fever,

• glomerulonephritis (kidney inflammation),

• chorea,

• bacteremia (bloodstream infection) and rarely streptococcal shock syndrome

• in some severe forms of pharyngitis (e.g., severe mononucleosis-pharyngitis)

• airway obstruction may occur

• peritonsillar abscess, retropharyngeal abscess

Acute Tonsillitis

• The most common organism is beta hemolytic streptococcus, but viral organisms can also cause exudative tonsillitis. Other causative organisms include staphylococcus aureus, streptococcus viridans, and various hemophilus species.

General Symptoms • Rapid onset of throat pain with pain on

swallowing associated with

• Fever, often 38°-39° C

• Malaise

• fatigue

• Chill

• Pain in extremities, muscles and joints

The Tonsils

Catharal and Follicular Tonsilitis

•The tonsils are red, enlarged and painfulnesswith an exudate or studded with white follicles. •Tender, firm cervical adenopathy is often present.

Tonsillectomy

Tonsillectomy

Secondary infection

Adenoidal facies

Adenotomy

• Adenoid grades

TonsilsEffect of tongue depressor on size

Tonsillar hypertrophy

Large kissing tonsils Asymmetrical tonsils

Acute tonsillitis

In mononucleosis the tonsils are hyperaemic and pusaccumulates in the tonsillar crypts. The debris in the crypts coalesces to form a purulent membrane. The

clinical picture resembles of that in streptococcal tonsillitis

Right peritonsillar abscess; the peritonsillar space, the soft palate and

the uvula are swollen. The uvula is displaced to the contralateral side

Peritonsillar Abscess Quinzy

Infectious Mononucleosis

Keratosis Concretions, exudate

Tonsil cysts

Tonsil Tumours

Papilloma Carcinoma

Deep lobe of parotid pushing tonsil medially

Hypertrophy of post pillar after tonsillectomy

Pharyngitis

Chronic Pharyngitis

Epiglottitis