Core Curriculum Syllabus: Inflammatory Disorders of the Pharynx

Inflammatory disorders of the pharynx most commonly present as throat or neck pain. Dysphagia, 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 dysphagia.

I. 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
    • Dysphagia 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.

II. DIFFERENTIAL DIAGNOSIS OF THROAT PAIN

  • Trauma
    • Ingested foreign bodies may cause acute or chronic throat pain. Fish bones or chicken bones often lodge in the tonsil, the vallecula, pyriform sinuses, while such objects as coins are often wedged in the cricopharyngeal area. A careful history will elicit the probable type of foreign body, and the patient can often help localize the foreign body by indicating the site of the pain.
      • Diagnosis - Careful examination will usually reveal the foreign body if it is still present in the pharynx. Foreign bodies at the level of the cricopharyngeus or upper esophagus may be seen on soft tissue lateral x-ray of the neck. However, many objects are not radiopaque.
      • Treatment - Appropriate treatment involves either office removal, admission for endoscopy under general anesthesia, or reassurance. Patients who have swallowed a sharp object causing irritation may complain of a "foreign body sensation" for 3-5 days after the episode even if the foreign body has passed. If no object is seen on physical or radiologic exam, and the patient is able to swallow, he should be assured that the symptoms will probably subside. If symptoms persist beyond five days, or if there is drooling or inability to swallow liquids, endoscopy is indicated.
    • Chronic exposure to cigarette smoke, especially in conjunction with alcohol intake, can cause intermittent or persistent pharyngeal irritation.
    • Penetrating injuries of the pharynx and mouth may result from assault, or from falling with sharp objects in the mouth (especially pencil injuries in children). These can be complicated by vascular injuries or may lead to parapharyngeal or retropharyngeal abscess. Close observation, prophylactic antibiotics, and in some cases, arteriography, may be indicated.
    • Iatrogenic injury can result from nasogastric tubes or endotracheal intubation
    • Patients on anticoagulants may develop pharyngeal hematomas from seemingly insignificant trauma.
  • Infection: Most infectious conditions are characterized by acute onset of symptoms. The following list includes some of the more common conditions.
    • Viral or Bacterial Pharyngitis
      • Symptoms - This condition affects all ages, and is characterized by diffuse sore throat and other symptoms of upper respiratory infection.
      • Signs - Diffuse erythema and edema of the oral and nasopharyngeal mucosa. Cervical lymph nodes may be slightly enlarged. Viral infection cannot be reliably differentiated from bacterial infection on physical exam.
      • Treatment - In general, supportive care consists of good oral hygiene, hydration, saline gargles, rest, and analgesics such as aspirin or acetaminophen. If bacterial infection is present, antibiotics will hasten resolution and prevent rheumatic complications. Empiric prescription of antibiotics is controversial.
    • Infectious Mononucleosis (Epstein-Barr Virus)
      • Symptoms - Primarily affects young adults, who present with non-specific malaise, fatigue, and low-grade fever. They commonly complain of sore throat and tender cervical adenopathy.
      • Signs - Diffuse erythema of the oropharynx and tonsils often mimicking bacterial tonsillitis. The tonsils may appear almost necrotic. Diffuse cervical adenopathy is present bilaterally. CBC and mono spot are useful in diagnosis.
      • Treatment - Treatment of the sore throat in infectious mononucleosis generally consists of the supportive measures as outlined above for any viral pharyngitis. In severe cases adenotonsilles involvement can lead to upper airway obstruction, which may require treatment with steroids and antibiotics. Patients with infectious mononucleosis should also be followed by an internist or family physician to monitor for hepatitis and other complications of mono.
    • 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.
      • Symptoms - Rapid onset of throat pain with pain on swallowing associated with fever, often 102° - 103° F with malaise and fatigue being common.
      • Signs - Swollen erythematous mucosa of the oropharynx and hypopharynx, often with edema of the uvula and soft palate. The tonsils are red, enlarged and covered with an exudate or studded with white follicles. Tender, firm cervical adenopathy is often present.
      • Treatment - A 10-day course of penicillin is indicated. Erythromycin may be used in patients with a penicillin allergy. In resistant cases clindamycin may be helpful. Supportive measures such as hydration, humidification of inspired air and analgesics.
    • Peritonsillar Abscess (Quinsy) - This develops by a spread of bacterial tonsillitis to the peritonsillar space which lies between the tonsillar capsule and the superior constrictor muscle.
      • Symptoms - Progressively increasing pharyngeal pain, often unilateral with radiation to the ear on the affected side, and increasing dysphagia with eventual difficulty in handling secretions and opening the mouth (trismus).
      • Signs - Unilateral erythema and swelling of the anterior tonsillar pillar and soft palate with deviation of the uvula to the opposite side. Bilateral cervical adenopathy is common. Trismus is often severe and may preclude a complete examination unless a sphenopalatine block is employed.
      • Treatment -
        • Needle aspiration or incision and drainage of the peritonsillar space.
        • Antibiotic coverage (penicillin) parenterally followed by p.o. administration for at least ten days.
        • Rehydration, analgesics, and good oral hygiene are important adjunctive measures in patient care.
        • If the patient has a prior history of tonsillitis the abscess is likely to recur, and tonsillectomy is recommended. Whether this should be done acutely or after an interval of recovery is controversial.
    • Vincent's Angina - This condition, also termed ulcerative tonsillitis, pseudomembranous angina, and trench mouth, is characterized by acute inflammation and ulceration of the pharyngeal tonsils usually due to a fusiform bacillus.
      • Symptoms - Severe throat pain often radiating to the ears.
      • Signs - Tonsil is covered by a pseudomembrane (formed by the necrosis of the superficial layer of the mucous membrane and the tonsil). Removal of the pseudomembrane reveals ulceration.
      • Treatment - Oral or parenteral penicillin and vigorous oral hygiene
    • Lingual Tonsillitis
      • Symptoms - Pain in the upper throat. Voice is often garbled and odynophagia is a prominent symptom
      • Signs - Examination of the posterior tongue with a mirror reveals enlarged lingual tonsils usually with exudate
      • Treatment - 10-day course of penicillin and supportive therapy
    • Candidiasis - (Also known as thrush or moniliasis). A fungal infection most commonly seen in very young, elderly, or immunosuppressed patients. Long-term antibiotic therapy and radiation treatment also predispose patients to candidiasis.
      • Symptoms - Oral and pharyngeal pain
      • Signs - Diffuse pharyngeal erythema and edema with multiple white patches over the inflamed mucosa. Removal of the whitish material reveals superficially ulcerated mucosa. The diagnosis is made on a KOH prep which reveals budding yeast forms.
      • Treatment - Clotrimazole lozenges or Nystatin oral suspension.

      (The following entities are commonly associated with respiratory obstruction in addition to sore throat:)

    • Epiglottitis - An acute inflammatory condition of the supraglottic larynx. This is most common in children aged three to five years but also occurs in adults. The usual organism is Hemophilus influenzae. This condition is an otolaryngologic emergency.
      • Symptoms - Rapid onset of sore throat and fever with increasing pain on swallowing. Dysphagia causes salivary pooling and progresses rapidly to difficulty in breathing and airway obstruction. Complete respiratory obstruction can occur within hours of the onset of symptoms.
      • Signs - The patient usually appears quite ill, often with fever of 102°-104° F and has a characteristic muffled voice. Examination with a tongue blade or indirect laryngoscopy may cause coughing or gagging which can precipitate sudden total airway obstruction, and should only be attempted by an experienced examiner with tracheotomy instruments immediately at hand. Examination reveals excessive secretions with erythema of the pharynx; the epiglottis is edematous and often "cherry" red.
      • Treatment - Prompt attention is mandatory, and management of the airway is of paramount importance when epiglottitis is diagnosed. The patient should be taken to the operating room for examination and an airway established either by endotracheal intubation or tracheotomy. Once the airway is secured, the larynx can be examined more carefully. Blood cultures are the most reliable means of obtaining a culture of the offending organism. The patient should be promptly started on appropriate antibiotics, (ceftriaxone, cefotaxime, or cefuroxime), humidified air and aggressive respiratory support as indicated.
    • Croup - Epiglottitis must be differentiated from croup (acute laryngotracheitis). This is a subglottic and tracheobronchial inflammatory process most commonly caused by parainfluenza, respiratory syncytial and other viruses, with circumferential subglottic erythema and edema.
      • Symptoms - Upper airway obstruction with a barking cough. The disease most commonly occurs in children between six months and two years of age. Viral croup is preceded by an upper respiratory infection with sore throat. "Nocturnal croup" or "spasmodic croup" is an idiopathic, recurrent upper airway obstruction which is usually benign and self-limited.
      • Signs - A characteristic croupy cough, stridor, hoarse voice and tracheobronchial secretions. The child is most often tachypneic and breathing is labored.
      • Treatment - Mild to moderate respiratory distress: humidified air and a mist tent, intravenous fluids, steroids, and epinephrine may be sufficient to reverse the acute inflammatory response. In patients with more significant respiratory distress, endotracheal intubation or even tracheotomy may be necessary. If bacterial infection supervenes, repeated bronchoscopy may be required to remove purulence and necrotic debris.
    • Deep neck infection - To understand deep neck infections, a brief review of the cervical fascia and fascial spaces of the neck will be useful.

Cervical fascia and fascial spaces of the neck

  • Anatomy
    • Fascial Layers
      • Superficial cervical fascia beneath the skin and superficial to the platysma muscle of the neck.
      • Deep cervical fascia has three subdivisions:
        • Anterior layer (superficial) - surrounds the sternocleidomastoid, trapezius muscles and strap muscles.
        • Pretracheal (visceral) - envelopes the trachea, larynx and hypopharynx.
        • Prevertebral fascia - runs posterior to the esophagus and great vessels, and ensheathes the prevertebral musculature.
    • Fascial spaces -
      • The visceral space - contains the lower pharynx, larynx, trachea and cervical esophagus, thyroid gland and great vessels
      • The prevertebral or retropharyngeal space - between the prevertebral musculature and prevertebral fascia. It is continuous with the mediastinum
      • Carotid sheath
      • Submental space
      • Submaxillary space
      • Sublingual space.
  • Neck spaces are interconnected with each other and also communicate with the mediastinum so that infections can spread easily to a variety of areas. Common clinical conditions which can occur in these spaces are retropharyngeal abscess, parapharyngeal abscess, as well as infection of sublingual and submental space including Ludwig's angina.
    • Parapharyngeal space infections
      • Etiology: suppuration of deep cervical lymph nodes, direct contamination by needle sticks or as the result of vascular inflammation such as phlebitis or thrombosis of the deep neck veins. Infections extending into the deep neck structures frequently begin with a bacterial pharyngitis, acute tonsillitis, or dental abscess. It may also follow surgical manipulation of the tonsils or dental extraction.
      • Symptoms - Sore throat, neck pain, dysphagia and swelling.
      • Signs - Patient is frequently toxic with a high fever. Trismus due to splinting of the pterygoid muscles is a prominent symptom. Displacement of the lateral pharyngeal wall without swelling or enlargement of the tonsil is characteristic. Tender swelling of the neck.
      • Treatment - Blood cultures and intravenous antibiotics. If the patient does not respond to this therapy, then incision and drainage through the neck is indicated.
    • Retropharyngeal abscess can occur at any age but most commonly is seen in young children.
      • Etiology - suppuration of the retropharyngeal lymph nodes, injuries to the posterior pharyngeal wall
      • Symptoms - Severe sore throat, difficulty swallowing, possible airway obstruction.
      • Signs - Erythema and edema of the oropharynx, bulging of the posterior pharyngeal wall. A lateral soft tissue xray of the neck demonstrates widening of retropharyngeal space.
      • Treatment - Incision and drainage under general endotracheal anesthesia followed by vigorous oral hygiene and appropriate antibiotic coverage
    • Ludwig's Angina - An unusual inflammatory condition of the floor of the mouth, with pronounced edema and often abscess formation in the sublingual space. It can lead to fatal airway obstruction.
      • Etiology - usually trauma to the floor of the mouth, severe dental caries, tonsillitis, peritonsillitis, or recent dental extraction
      • Symptoms - Pain in the floor of mouth and submental area
      • Signs - Severe swelling and induration of the floor of the mouth, gums and tongue with displacement of the tongue posteriorly and superiorly, oropharyngeal airway obstruction, and drooling
      • Treatment - Intravenous antibiotic (penicillin) following blood cultures, close observation and often tracheostomy. If cellulitis progresses to abscess formation then incision and drainage is indicated.
  • Neoplasia - Cancer of the upper aerodigestive tract frequently will present as a chronic sore throat. The possibility of cancer must be considered in any patient over the age of 30 who has persistent sore throat, especially with a strong smoking or drinking history. Careful evaluation and attention to other factors and findings as mentioned above may reveal a benign etiology for the persistent throat pain. However, when no other simple explanation can be made, it is important for the physician to rule out the presence of carcinoma. The systematic evaluation for malignancy is covered in a separate section (see chapter on Head and Neck Tumors).

III. TONSILLECTOMY AND ADENOIDECTOMY - These two procedures are among the most commonly performed operations accounting for nearly 1/2 of all childhood surgical procedures. Although the literature concerning these procedures is vast, most published papers are based on opinion rather than scientific fact. This is due to the difficulties inherent in maintaining a large controlled series. Patients randomized for non-operative management frequently drop out to seek surgery elsewhere. However, most otolaryngologists agree on general guidelines for tonsil and adenoid surgery as presented below.

  • Tonsillectomy
    • Indications
      • Strong
        • Cor pulmonale secondary to hypertrophied tonsils
        • Upper airway obstruction
        • Obstructive sleep apnea
        • Complications of streptococcal infection, such as rheumatic fever or nephritis
        • Dysphagia secondary to hypertrophied tonsils
        • Peritonsillar abscess
        • Unilateral tonsillar hypertrophy
      • Relative
        • Recurrent tonsillitis, 5-6 episodes/year or 3-4 episodes in successive years
        • Chronic tonsillitis with halitosis or sore throat
        • Tonsillary hypertrophy with speech distortion or snoring
    • Contraindications - abnormal clotting
    • Complications
      • Hemorrhage -
        • Early - within 24 hours
        • Late - 7-10 days
      • Dehydration secondary to odynophagia and trismus - low-grade fever
      • Infection of tonsillar bed - high fever
  • Adenoidectomy
    • Indications
      • Urgent - severe nasal obstruction
      • Relative
        • Persistent nasal obstruction
        • Chronic or recurrent otitis media
        • Chronic or recurrent adenoiditis
        • Chronic or recurrent sinusitis
    • Contraindications
      • Clotting disorder
      • Submucosal cleft palate (bifid uvula, is "red flag")
      • Short soft palate
    • Complications
      • Bleeding - rarely serious
      • Infection
      • Velopharyngeal insufficiency with speech defect and or nasal regurgitation
      • Scarring of eustachian tube orifice

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Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery
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Last modified: Jan. 23, 2006