ADENO TONSILLITIS

Dr. A. KARUNAGARAN, M.S. D.L.O,

Anatomy
Waldeyer`s inner ring consists collection
of sub epithelial lymphoid tissue Adenoids Palatine tonsil Tubal tonsil Lingual tonsil

Anatomy tonsil
Bilateral ovoid masses of lymphoid tissue Almond shape Partly covered by capsule Medial surface has 15 20 crypts, biggest
is crypta magna Mucosal folds in superior pole plica semilunaris, in inferior pole plica triangularis

Anatomy adenoids
Present at the junction of roof and
posterior wall of nasopharynx Has furrows and ridges Appear like bunch of banana Feels like bag of worms

Anatomy
Blood supply - Tonsils
Facial a.
Tonsillar branch Tonsil (main branch)

Ascending palatine

Tonsil

Lingual a. Dorsal lingual Tonsil Ascending pharyngeal Tonsil Maxillary Lesser descending palatine Tonsil

Anatomy
Blood supply Adenoids

Ascending palatine branch of facial a. Ascending pharyngeal a. Pharyngeal branch of IMAX. Ascending cervical branch of thyrocervical
trunk.

Differences between tonsils and adenoids

Tonsils
Paired structure Present in lateral wall of oro pharynx Covered by non keratinizing stratified sqamous epithelium Covered by capsule on the lateral wall Has crypts Almond shaped

Adenoids
Solitary structure Present in naso pharynx Coverd by ciliated columnar epithelium No capsule No crypts, only furrows Bunch of banana

Both afferent and efferents present

no afferent only efferents present

Infecting Organisms
Aerobic Bacteria Strep pyogenes (Gr A beta-hemolytic) Strep pneumoniae Strep viridans & other Streptococci Staph aureus H. Influenzae Diphtheroids Neisseria spp.

Infecting Organisms
Anaerobic Bacteria

Bacteroides
Peptococcus Peptostreptococcus

Veillonella
Fusobacteria

Infecting Organisms
Viruses Epstein-Barr Cytomegalovirus Adenovirus Herpes simplex Influenza A and B Parainfluenzae

Microbiology of Tonsillitis
Group A beta-hemolytic Is most recognized - associated with a risk of rheumatic fever and glomerulonephritis Beta-lactamase producing organisms Are of particular importance. Produced by Staph aureus, M. catarrhalis & H.influenzae Protect Group A Streptococci from eradication with penicillins Accounts for 39% of all cultured organisms

Who gets Tonsillitis ?

Most often occurs in children all experience at least 1 episode Rarely in children younger than 2 yr Viral tonsillitis in younger children Streptococcal tonsillitis in children aged 5-15 yr Poor socioeconomic status & over crowding

Pathophysiology

Viral Infections Bacterial Infections Inflammatory exudates of the crypts Epithelial keratinisation Deep-seated multiple abscess formation with increasing germ centers Parenchyma destruction Immunologic Factors

Unanswered Questions
Do virus infections in the pharynx and tonsils
predispose to bacterial infection? Is it possible to have an infective condition involving the pharyngeal lymphoid tissue without affecting the tonsils? Is there such a condition as chronic tonsillitis? Why are some patients susceptible to acute pharyngitis and acute tonsillitis and others not? Does the tonsil become irreversibly diseased after many episodes of acute tonsillitis?

Acute Tonsillitis
Symptoms:
Fever Sore throat Dysphagia or Odynophagia Airway Obstruction Lethargy / malaise

Acute Tonsillitis - Signs

Enlarged
Erythematous Exudative forming at
times pseudomembrane

Enlarged neck nodes

Grading the Size of Tonsils

Grading system: A. 0 tonsils in fossa B. +1 tonsils less than 25% C. +2 tonsils less than 50% D. +3 tonsils less than 75% E. +4 tonsils greater than 75%

Features of adenoid facies

Open mouth and mouth breathing Pinched nostrils Crowded teeth andhyper plasia of gums Loss of naso labial fold Under slung mandible High arched V shaped palate Short upper lip Hypo plasia of maxilla Vacant expression Pectus excavatum Rouned shoulders Voice changes- nasal and lifeless

Lingual Tonsils
Hyperplasia is the most common abnormality of the lingual

tonsil. Lingual tonsils sit on the base of the tongue and extend to the vallecula and do not have a capsule. Can be visualized by indirect mirror or flexible laryngoscopy Clinically, infection is marked by erythema and enlargement of tonsillar tissue. Suspension microlaryngoscopy with removal by CO2 laser, sharp dissection or hot knife cautery are some of the treatments available.

Lingual Tonsil
History and Physical:
Sore throat Globus sensation Speech change Dysphagia Obstructive sleep apnea in adults Pediatric airway obstruction Often discovered incidentally during intubation in preparation for surgery that is unrelated to the ear, nose, and throat.

Lingual Tonsils
Differential diagnosis
lingual thyroid tissue thyroglossal duct cyst dermoid cyst lymphangioma angioma adenoma fibroma papilloma lymphoma squamous cell carcinoma minor salivary gland tumors on the base of the tongue

Lingual Tonsils
Hypertrophy of lingual tonsils in 62% of persons
with laryngoscopic signs of reflux and in 75% of persons with pharyngolaryngeal symptoms of LPR. Although the lymphoid tissue in Waldeyer's ring tends to decrease with advancing age, the lingual tonsil may increase in size. The most important cause of lingual tonsil hypertrophy is the occurrence of compensatory hyperplasia following adenotonsillectomy.

Differential Diagnosis of pseudomembranous tonsillitis

Infectious Mononucleosis
Cheesy exudates
covering tonsil

Lymphadenopathy of
neck, axilla & groin

Hepato/Spleenomega
ly

Oral Thrush
Painful throat White candidiasis

patches when removed leaves erythematous ulcer Immunosuppressive state

Keratosis tonsils
Incidental finding May cause slight

discomfort Yellow horny outgrowths in the crypts

Agranulocytosis
Halistosis, fever,
headache & dysphagia Single , multiple or coalesce necrotic slough covered ulcers Leucopenia H/O causative drugs intake

Diphtheria
Malaise, fever &

headache Greyish green membrane across tonsils to larynx Tender bilateral cervical lymphadenopathy

Vincents angina
Fetor oris, pyrexia Tonsillar deep ulcers with
grey slough in its base Necrotising gingivitis Enlarged tender cervical adenitis Smear:

Spirochaetes & Fusiform bacilli

Acute lymphatic leukemia

Fever, anaemia &

bleeding disorders Slough covered membrane forming ulcerations Cervical lymphadenopathy Exaggerated leucocytosis

Recurrent Acute Tonsillitis

Same signs and
tonsillar erythema symptoms as acute Smooth glistening tonsil with dilated Occurring in 4-7 blood vessels on the separate episodes surface per year Debris in crypts 5 episodes per which are few due year for 2 years to loss of tonsil 3 episodes per architecture year for 3 years

Ant pillar peri

Chronic Tonsillitis
Chronic sore throat Malodorous breath Presence of tonsilliths Peritonsillar erythema Persistent cervical lymphadenopathy Lasting at least 3 months

Local Complications
Respiratory obstruction Quinsy Acute retropharyngeal abscess Parapharyngeal abscess Neck space infections Acute otitis media

Retropharyngeal abscess
Dysphagia, fever Pharynx either

normal or smooth bulge of posterior pharyngeal wall Airway obstruction Neck rigid

Peritonsillar Abscess
Abscess formation

outside tonsillar capsule Signs and symptoms:

Fever Sore throat Dysphagia/odynophagia Drooling Trismus Unilateral swelling of soft palate/pharynx with uvula deviation

Peritonsillar Abscess
Incidence: estimated 30 cases
per 100,000 in US. Diagnosis is usually by physical exam but other modalities have been used such as US and CT. Widely accepted that Staphylococcus aureus is the most common organism causing the infection and origin is usually from the superior pole of the tonsil (from minor salivary gland - AKA: Weber gland).

Peritonsillar Abscess
Quinsy tonsillectomy vs. Interval tonsillectomy
Quinsy tonsillectomy can be a treatment option in pediatric patients to young to withstand bedside aspiration or I&D for recurrent PTA. Quinsy tonsillectomy can be surgically easier than interval tonsillectomy as fibrosis has not had time to set into the tonsillar capsule. Review by Johnson, discussed interval tonsillectomy for recurrent PTA with prevalence of 10%. Interval tonsillectomy can be considered after successful abscess drainage, usually from recurrent PTA after 6 weeks.

Parapharyngeal abscess
Fever, dysphagia & airway obstruction Swelling below soft palate over the pharynx Tender firm swelling in the upper part of neck

Acute otits media

Preceding URI &

blocked ear Severe otalgia Bulging congested ear drum Eustachian catarrh

Systemic Complications
Acute rheumatic fever Acute glomerulonephritis Bacterial endocarditis Dermatitis Septicemia Septic abscesses Septic arthritis Menigitis

Investigations

CBC & serum electrolytes Crypt swab culture & sensitivity 60% specificity Crypt aspiration culture & sensitivity ed specificity A rapid antigen detection test (RADT) has 95% specificity Serum examined for anti-streptococcal antibodies ASO titre - Useful for documenting prior infections in acute rheumatic fever, glomerulonephritis or other complications Monospot serum test

Medical Management of Acute Tonsillitis

Largely supportive Adequate hydration and caloric intake Control pain Antibiotics Penicillin 1st line treatment Macrolides, Cephalosporins, Clindamycin Vancomycin and Rifampin are also used

Current Indications for Tonsillectomy

Recurrent tonsillitis Chronic persistent tonsillitis Hypertrophic obstructive Tonsillitis not responding to

medicine causing dysphagia or OSA Diphtheria carrier state Rec Peritonsillar abscess +/_ Rec tonsillitis Unilateral tonsillar hypertrophy Benign tumours of tonsil like papilloma, adenoma Chronic tonsillolith As an approach to IX nerve, elongated styloid process

Adenoidectomy-Indications
Recurrent or chronic sinusitis or adenoiditis
Poorly understood - possibly caused by obstructive adenoid tissue causing stasis of secretions predisposing the nasal cavity to infection.

Otitis media
Proximity of adenoid tissue to eustachian tube Adenoidectomy can be recommended on 1st set of tubes if nasal obstruction and recurrent rhinorrhea is present or on 2nd set of tubes if needed.

Contra indications for adeno tonsillectomy

Epidemic of polio Age below 3 years Acute infections Blood dyscrasiasis: hemophilia, purpura Uncontrolled systemic diseases like diabetes and heart diseases Velopharyngeal insufficiency
Overt cleft palate, submucous (covert) cleft Neurologic or neuromuscular abnormality leading to impaired palate function

Anemia

Cold steel Instruments

Complications of Tonsillectomy

Haemorrhage Haematoma & oedema uvula Infection Pulmonary complications Remnant tonsils Referred otalgia Post operative scarring causing voice change or nasal regurgitation

Complications
Noniatrogenic complications after adenoidectomy
Regrowth of adenoid tissue, particularly in very young children, which may require revision (secondary) adenoidectomy. Hypernasality, because of temporary pain splinting. Persistent hypernasality is rare and probably caused by unrecognized pre-existing velopharyngeal weakness. Atlantoaxial subluxation (Grisels syndrome), which presents with persistent torticollis 1-2 weeks after surgery. Iatrogenic complications after adenoidectomy include Dental injury, from intubation or the mouth gag Nasopharyngeal stenosis, caused by excessive tissue removal. Eustachian tube injury

The Modern Tonsillectomy

 History Indications Innovative Techniques and Comorbidites

Intracapsular tonsillectomy Harmonic scalpel Laser Coblation

Adjuvant Therapy
Local Anesthesia: Bupivacaine Postoperative Antibiotics

History
Aulus Cornelius Celsus
1st Century AD the tonsils are loosened by scraping around them and then torn out with a finger Used vinegar and medication for postoperative hemostasis 6th Century AD Hook and knife method

Aetius of Amida

Philip Syng Physick (Father of American

surgery)

Mackenzie

First to develop the tonsillotome Late 1800s Made tonsillotome use common

Innovative Techniques
Intracapsular

Tonsillectomy Harmonic Scalpel Laser Coblation

Guiding Principle:
reduce morbidity
Hemorrhage Pain Diet Activity Cost

Intracapsular Tonsillectomy
Tonsillar hypertrophy causing sleep disordered breathing Intracapsular tonsillectomy
Microdebrider at 1500 rpm in oscillating mode Hemostasis with suction cautery

Total tonsillectomy
Subcapsular

 Conclusions
Intracapsular tonsillectomy is safe and efficacious in children under 3 years for tonsillar hypertrophy and sleep disordered breathing without need for admission Retrospective study Uneven distribution Long term results of tonsillar regrowth unknown

Limitations

Harmonic Scalpel Tonsillectomy

Ultrasonic dissector and coagulator Vibratory energy
Cutting: sharp blade with frequency of 55.5 kHz over distance of 80 m Coagulating: vibration breaks H-bonds, thermal energy 50 100 C Electrocautery 150 400 C

 Operative time statistically significant No significant difference in intraoperative blood

Harmonic scalpel 8 min 42 sec Electrocautery 4 min 33 sec

loss and postoperative ability to eat and drink Level of activity for the first postop day significantly lower in harmonic scalpel group Postoperative pain scores tended to be lower in harmonic scalpel group Postoperative bleeding
Harmonic scalpel: 6 Electrocautery: 3 Not statistically significant

Laser Tonsillectomy
Compared the use of KTP laser tonsillectomy versus cold dissection and snare
KTP 532 laser at 10W, continuous beam Outcomes measured Operative time Operative bleeding Postoperative pain Postoperative advancement to diet

 Results

Operative time: Laser 12 min Dissection 10 min Not statistically significant Intraoperative blood loss Laser 20 mL Dissection 95 mL Statistically significant Laser group with higher postop pain scores Laser group with greater difficulty resuming postoperative diet Readmission for delayed hemorrhage was 8% in the laser group and 4% in the dissection group Not statistically significant

 Conclusion
KTP laser provides little benefit over dissection tonsillectomy except to minimize intraoperative bleeding

Limitations
Technical expertise Electrocautery not included

Coblation Tonsillectomy
Bipolar radiofrequency energy transferred to

sodium molecules to create an ion or plasma field This thin layer of plasma is utilized to ablate tissues at molecular level No need for electrocautery for hemostasis Temperature from 40 to 85 C Electrocautery at 20W: above 400 C

 Coblation
From surface out laterally Coblate 9 setting to ablate tissues Coblate 5 setting to coagulate Capsule not penetrated

Electrocautery

Outcomes measured
Questionnaire

Bovie set to 20 W

Pain Analgesics Nausea/vomiting Diet Activity

Complications

Coblation Tonsillectomy
Future considerations
To evaluate coblation for intracapsular tonsillectomy, a fair study would use another intracapsular technique such as powerassisted tonsillectomy with a microdebrider

 Technique
Monopolar electrocautery used most often Greatest for otolaryngologists in practice < 20 years Hemostasis Sharp dissection most common for group in practice > 20 years Decreased pain Method of hemostasis not mentioned

Local Anesthetic evenly distributed

Conclusions
Tonsillectomy is a surgical procedure that
carries significant postoperative morbidity To minimize postoperative morbidity various techniques and adjuvant therapies have been studied There are many options available and it behooves an otolaryngologist to stay as up to date as possible

THANK YOU

DISEASES OF TONSILS & ADENOID

ACUTE TONSILLITIS
Etiology : Viral followed by
secondarily invaded by Hemolytic streptococcus Staph aureas H.influenza Dipl. Pneumoniae Age : Commonest <9yrs

 Spread : Droplet infection Types:

Ac Ac Ac Ac cattarhal parenchymatous follicular membranous

Acute membraneous tonsillitis

Acute parenchymatous tonsillitis

ACUTE TONSILLITIS:CLINICAL FEATURES

SYMPTOMS Sore throat Fever Malaise Odynophagia Thick speech Earache

SIGNS Pyrexia,halitosis. Furred tongue. Enlarged congested tonsil. Others signs according to type. Tender & enlarged J-D nodes.

ACUTE TONSILLITIS : TREATMENT

Bed rest : Isolation
Mouth gurgles : How it helps ? Analgesics : Antibiotics :

Medical Therapy
First Line
Penicillin/Cephalosporin for 10 days Injectable forms for noncompliance

Macrolides
Penicillin allergy Erythromycin/Clarithromycin 10 days Azithromycin (12mg/kg/day) 5 days

DYNAMICS OF TONSILLITIS
Viruses Other aerobic and anaerobic bacteria

Group A Streptococci Penicillin Rx Cure Nonseptic complications Recurrence Persistence Septic Complications

ACUTE TONSILLITIS COMPLICATIONS :

Peritonsillar abscess Parapharyngeal abscess Retropharyngeal abscess Oedema of larynx Cervical supp. Lymphadenitis

 Acute middle ear cleft infection Chronic tonsillitis Septicaemia Acute rheumatism

 Rheumatic heart disease Chorea S.B.E. Acute nephritis

ACUTE TONSILLITIS : d/ds

Infectious Mononucleosis Faucial diphtheria Agranulocytosis Scarlet fever Oral thrush ALL Vincents angina Tertiary syphilis

Differential Diagnosis of pseudomembranous tonsillitis

Infectious Mononucleosis
Cheesy exudates
covering tonsil

Lymphadenopathy of
neck, axilla & groin

Hepato/Spleenomega
ly

Oral Thrush
Painful throat White candidiasis

patches when removed leaves erythematous ulcer Immunosuppressive state

Keratosis tonsils
Incidental finding May cause slight

discomfort Yellow horny outgrowths in the crypts

Agranulocytosis
Halistosis, fever,
headache & dysphagia Single , multiple or coalesce necrotic slough covered ulcers Leucopenia H/O causative drugs intake

Diphtheria
Malaise, fever &

headache Greyish green membrane across tonsils to larynx Tender bilateral cervical lymphadenopathy

Vincents angina
Fetor oris, pyrexia Tonsillar deep ulcers with
grey slough in its base Necrotising gingivitis Enlarged tender cervical adenitis Smear:

Spirochaetes & Fusiform bacilli

Acute lymphatic leukemia

Fever, anaemia &

bleeding disorders Slough covered membrane forming ulcerations Cervical lymphadenopathy Exaggerated leucocytosis

FAUCIAL DIPHTHERIA

Definition
Diphtheria is an acute, toxin-mediated
disease caused by toxigenic

Corynebacterium diphtheriae ( ).

Its a very contagious and potentially lifethreatening bacterial disease.

Corynebacterium diphtheriae
Causative organism of diphtheria

Gram- positive bacillus Produces exotoxin at site of

infection Travels to heart and nervous system

 Spread by close contact via

droplets or contaminated articles Humans are the sole carriers of the organism More common in children < 10 years Rare occurrence today because of routine vaccination

C. diphtheria
Clinical manifestations Systemic symptoms from
exotoxin Fatigued Lethargic Tachycardic toxic

C. diphtheria
Clinical characteristics Pharynx grayish membrane (composed of
fibrin, leukocytes, and cellular debris) extends from pharynx to larynx Extensive cervical lymphadenopathy (bull neck)

Pharyngeal diphtheria

Pharyngeal diphtheria

Laryngeal diphtheria

C. diphtheria
Diagnosis

Isolation of the organism Culture from local lesion Grows on selective media

containing potassium tellurite Notify microbiology lab if diphtheria suspected

C. diphtheria
Treatment Started before culture
confirmation Airway Resuscitation Skin test for allergy to horse serum

 Administer diphtheria antitoxin

Have epinephrine available Antibiotics (erythromycin,
penicillin G, rifampin, or clindamycin) used to eradicate carrier state

C. Diphtheria
Prevention Vaccine Trivalent vaccine diphtheria toxoid,
tetanus toxoid and pertussis (DTP) 6 weeks of age, 2 more 4-8 weeks intervals, and 4th 6-12 months later.

Complications:
Myocarditis. Cardiac arrhythmias. Acute circulatory failure. Paralysis of soft palate,diaphragm & ocular
muscles. Laryngeal-airway obstruction.

Ac tonsillitis
Onset Membrane Acute Yellowish,easily separable High Proportionate +/-

Faucial diphtheria
Insidious Ashy gray ,bleeds on separation Low Disproportiona te ++ CBD / KLB ++

Fever Pulse Toxaemia

Throat swab Heam.strepto Urine: +/Albuminuria

Recurrent Acute Tonsillitis

Seven episodes in a single year Five or more episodes in 2 years Three or more episodes in 3 years

Chronic Tonsillitis
No true consensus on the definition. Symptoms greater than 4 weeks

CHRONIC TOSILLITIS SYMPTOMS

RECURRENT PAIN

HALITOSIS COUGH SNORING SLEEP APNOEA ASYMPTOMATIC SEPTIC FOCUS

CHRONIC TONSILLITIS-SIGNS
LARGE TONSILS SMALL FIBROTIC IN

ADULTS ANTERIOR PILLAR CONGESTED SQUEEZE IRWIN MOORES SIGN LYMPHADENOPATH Y

JUGULODIGASTRIC LYMPH NODES

ADENOIDS
Normally regress by 10 yrs Etiology:
Age ; 3-4 years Physiological hypertrophy Infection Rarely tuberculosis

Predisposing factors

Adenoiditis : Clinical features

Associated with nasal obstruction :
Adenoid facies (develop gradually) Nose Pinched ,narrow Mouth - Remains open,dribbling of saliva,mouth breathing Teeth Protruded,irregular,crowded Lower jaw Undershot

Adenoid Hypertrophy

 Palate High arched. Feeding difficulties. Face - Loss of nasolabial furrow,dull

look. Chest Pigeon shaped. Pot belly.

 NASAL DISCHARGE.
SINUSITIS. EPISTAXIS. VOICE CHANGE.

Adenoid Hyperplasia
Triad
Hyponasality Snoring Open mouth breathing

Purulent rhinorrhea, post nasal drip,

chronic cough, and headache

Adenoiditis : Clinical features(contd)

Associated with E-T obstruction: ET cattarh,SOM,AOM,CSOM Associated with infection : Rhinitis,Sinusitis,URTI,

Tonsillopharyngitis. Lymphadenitis

General :
Nocturnal enuresis Deafness leads to mental
retardation

Adenoiditis :Diagnosis &Diff diagnosis

Diagnosis :
Clinical features: clinch diagnosis Posterior rhinoscopy: Digital palpation :--bag of worms X-ray nasopharynx soft tissue lateral view Nasal endoscopy , Nasopharyngoscopy

PreOp Evaluation of Adenoid Disease

Lateral neck films are useful only when history and physical exam are not in agreement. Accuracy of lateral neck films is dependent on proper positioning and patient cooperation.

Adenoiditis : Treatment
Conservative : in acute & mild cases
Antibiotics,Decongestants,Breathing exercises

Surgical :
Adeoidectomy-for persistent & rec. infection Precautions: Grommet insertion : in case of SOM

TONSILLECTOMY
INDICATIONS LOCAL FOCAL GENERAL

Chronic Tonsillitis Sleep apnoea Quinsy Tonsillolith Foreign body

JD lymphadenopathy

Middle ear disease

RHD SBE Glomerulonephritis RF RA

Benign tumor Diphtheria carrier Approach for Styloid Approach for IX

CONTRAINDICATIONS
AGE < 5 yrs Hb < 10 BLEEDING DISORDERS / BT CT EPIDEMIC OF POLIO HT DM

Preoperative evaluation
Most common lab test is a CBC Coagulation studies when the history or

physical examination suggests a bleeding disorder. Lateral Neck/Adenoid films

METHODS

DISSECTION GUILLOTINE ELECTROCAUTERY CRYOSURGERY LASER HARMONIC SCALPEL COBLATION MICRODEBRIDER

ROSES POSITION

INSTRUMENTS

TONSILLAR DISSECTOR

EVES TONSILLAR SNARE

DISSECTION METHOD

Adjuvant Therapies
Perioperative Steroids
Dexamethasone (0.15-1.0mg/kg) Two times less likely to have an episode of postoperative emesis, and more likely to advance to eating a soft diet. Reducing postoperative pulmonary distress, subglottic edema, pain reduction.

POST OP CARE

POSITION PULSE BP W/F BLEEDING DIET COLD FEEDS ANTIBIOTICS ANALGESICS GARGLES

COMPLICATIONS

HAEMORRHAGE PRIMARY REACTIONARY 48 hrs SECONDARY 5-8 days Trauma TM joint ASPIRATION VOICE CHANGE

Unilateral Tonsillar Enlargement

Apparent enlargement vs true enlargement Non-neoplastic: Acute infective Chronic infective Hypertrophy Congenital Neoplastic

Peritonsillar Abscess

Retention Cysts

Pleomorphic Adenoma

 Ca tonsil

ICA Aneurysm

Peritonsillar abscess
Abscess formation outside tonsillar capsule Signs and symptoms:
Fever Sore throat Dysphagia/odynophagia Drooling Trismus Unilateral swelling of soft palate/pharynx with uvula deviation

The End