Pediatric pharyngeal diseases

Ehab ZAYYAN, MD, PhD

Hacettepe University- Turkey Consultant and Head of ENT Department European Gaza Hospital Assist. Professor, School of Medicine Islamic University, Gaza

Anatomy of the pharynx

The pharynx
The pharynx is located behind the nasal cavities, the mouth and the larynx From the skull base till the C6 It is a musculumembranous wall that is deficient anteriorly.

Pharynx- posterior view

The lateral and posterior walls of the pharynx consist of 3 pairs of muscles which unite in the posterior midline at the pharyngeal raphe. 1. Superior constrictor muscle 2. Middle constrictor m 3. Inferior constrictor muscle.

Nasopharynx
It lies behind the nasal cavities, above the soft palate. The pharyngeal tonsil (adenoid): a collection of lymphoid tissue in the submucosa of this region

 The Eustachian tube orifice opens into the lateral wall of the nasopharynx Tubal tonsils: a collection of lymphoid tissue in the submucosa behind the opening of the auditory tube

Nasopharyngeal examination

Oropharynx
From the soft palate to the upper border of the epiglottis Roof: undersurface of the soft palate Floor: root of the tongue Anterior wall: oropharyngeal isthmus Posterior wall: C2, C3

Oropharynx lateral wall Palatoglossal fold Palatopharyngeal fold Uvula Palatinal tonsils

Palatine tonsils
Two masses of lymphoid tissue located in the tonsillar fossa. The tonsil is covered by mucous membrane and its medial surface is free projecting in the cavity of the pharynx Tonsillar crypts on the surface. Fibrous capsule covers the lateral surface of the tonsil. It separates it from the superior constrictor pharyngeal muscle.

Waldeyeres ring of lymphoid tissue

At the junction of the mouth and oropharynx and the nose with the nasopharynx there is a collection of lymphoid tissue: 1. Palatine tonsils 2. Lingual tonsils 3. Pharyngeal tonsils 4. Tubal tonsils

Hypopharynx (laryngopharynx)
From the upper border of the epiglottis till the lower border of the cricoid cartilage.

Lymph drainage of the pharynx

1. Nasopharynx retropharyngeal nodes 2. Tonsils and oropharynx upper deep cervical nodes, especially the jugulodigastric node which is called the tonsillar node. 3. Hypopharynx vessels thru the thyrohyoid membrane upper deep cervical nodes

Pharyngeal diseases

Acute pharyngitis
Mostly a viral infection Fever, sore throat, odynophagia, malasia Recovery within 5 7 days Tx: analgesics .

Acute tonsillitis
Very common in pediatric population Fever, sore throat, malasia, dysphagia, neck swelling.. Etiology: Viruses: IMN, herpes Group A, B-hemolytic streptococci Diphteria

Acute tonsillitis
Diagnosis Physical examination is the most important Red swollen tonsils, follicular, membranous Cervical lymphadenopathy CBC ASOT Cultures

Acute tonsillitis
Treatment
Penicillin:
Penicillin G Procaine penicillin Benzathine penicillin

Single dose benzathine penicillin is the best choice < 30 kg child: 600.000 IU im >30 kg child: 1200.000 IU im

Acute tonsillitis
Oral antibiotics (10 days of tx) Penicillin V (oral suspension) Amoxicillin Erythromycin 2nd line..

Analgesia, fluids and bed rest are very important

Non-suppurative complications of acute tonsillitis

Scarlet fever
Scarlet fever is secondary to acute streptococcal tonsillitis or pharyngitis with production of endotoxins by the bacteria. Manifestations include an erythematous rash, severe lymphadenopathy with a sore throat, vomiting, headache, fever, erythematous tonsils and pharynx, tachycardia, and a yellow exudate over the tonsils, pharynx, and nasopharynx. A strawberry tongue with a rash and large glossal papillae is a good diagnostic sign

Poststreptococcal glomerulonephritis
The typical patient develops an acute nephritic syndrome 1 to 2 weeks after a streptococcal infection. The infection is secondary to the presence of a common antigen of the glomerulus with the streptococcus. Penicillin management may not decrease the attack rate, and there is no evidence that antibiotic therapy affects the natural history of glomerulonephritis. A tonsillectomy may be necessary to eliminate the source of infection.

Acute rheumatic fever

Mostly 5 15 years of age Occurs at the 3rd to 9th day of infection Johns criteria : major and minor Penicillin prophylaxis Tonsillectomy

 Poststreptococcal tonsillitis arthralgia ?????

Suppurative complications of acute tonsillitis

Peritonsillar abscess
The spread of infection is from the tonsil with pus formation between the tonsil bed and the tonsillar capsule Fever, severe throat pain, dysphagia, odynophagia, trismus, drooling It may lead to airway obstruction, aspiration or parapharyngeal and retropharyngeal abscess formation Treatment: incision and drainage, iv AB, tonsillectomy

Parapharyngeal space abscess

Parapharyngeal space: between the lateral pharyngeal wall and the mandible Contains dangerous structures like the carotid artery and the jugular veins. Tonsillitis, dental infections, sinusitis, lymphadenitis.can lead to parapharyngeal cellulitis or abscess Dx: clinical, USG, CT Tx: iv AB + incision and drainage (lateral cervical approach)

Retropharyngeal space

Retropharyngeal space infections

Mostly in children < 2 years Retropharyngeal space: between the pharynx and the prevertebral fascia, extending from the skull base into the mediastinum till tracheal bifurcation irritability, fever, dysphagia, muffled speech, noisy breathing, stiff neck, and cervical lymphadenopathy. Posterior pharyngeal wall bulging Cellulitis vs abscess Tx: transoral/ external incision

Retropharyngeal abscess

Chronic tonsillitis

Recurrent acute tonsillitis Chronic tonsillar and pharyngeal inflammation: pain, irritation, smagma, halitosis, tonsilolithiasis Hypertrophic tonsils

Indications for tonsillectomy

1.Infection
Recurrent, acute tonsillitis (more than six episodes per year or three episodes per year for 2 years) Chronic tonsillitis: halitosis, persistent sore throat, tender cervical adenitis Peritonsillar abscess

2. Obstruction
Excessive snoring and chronic mouth-breathing
Obstructive sleep apnea or sleep disturbances

3. Neoplasia
Asymmetric tonsillar hypartrophy

Adenoid diseases
Common in young children Adenoid hypertrophy caused by: infections, allergy, environmental.. Symptoms Otitis media and sinusitis Dx: palpation, X-ray, endoscopy Tx: Surgery

Indications for adenoidectomy

Recurrent purulent adenoiditits Adenoid hypertrophy associated with otitis media Adenoid hypertrophy associated with chronic sinusitis

Adenoid hypertrophy associated with excessive snoring and chronic mouth-breathing Sleep apnea or sleep disturbances Speech abnormalities
Neoplasia suspesion

Contraindications of adenotonsillectomy
Bleeding abnormalities Acute infections Cleft palate?? Age???