Diseases
of the pharynx
Nasopharynx
Enlarged
adenoid
The most common cause of an enlarged adenoid (there is only one
nasopharyngeal adenoid, despite the common use of the term ‘adenoids’) is
physiological hypertrophy (Fig. 43.14). The size of the adenoid alone is not an
indication for removal. It is often associated with hypertrophy of the other
lymphoid tissues of Waldeyer’s ring. If excessive hypertrophy causes blockage
of the nasopharynx in association with tonsil hypertrophy, the upper airway
may become compromised during
Hypertrophy
of adenoid tissue most commonly occurs between the ages of 4 and 10 years, but
the adenoid tissue usually undergoes spontaneous atrophy during puberty,
although some remnants may persist into adult life. The relationship of adenoid
enlargement to recurrent secretory otitis media or recurrent acute otitis media
is not entirely clear. It has long been thought that eustachian tube dysfunction
results from either inflammatory oedema or interference with palatal elevation
which opens the
eustachian tube. However, the exact relationship has not been determined
and many children who have secretory otitis media do not always benefit from
adenoid removal.
Adenoidectomy
Adenoid tissue can be removed alone or in conjunction with a
tonsillectomy.
Indications
are:
• obstructive sleep apnoea
associated with postnasal obstruction;
• postnasal discharge;
• recurrent acute otitis media or prolonged serous otitis media usually
longer than 3 months’ duration;
• recurrent rhinosinusitis.
Operative technique. The adenoid tissue is removed with a guarded
curette (Fig. 43.15) pressed against the roof of the nasopharynx and then
carried downwards in a moderately firm sweeping movement bringing the excised
adenoid into the oropharynx (Fig. 43.16). The guard on the curette secures the
adenoid and prevents it from dropping inferiorly into the airway. A postnasal
swab is placed into the nasopharynx until all haemorrhage has ceased.
Tumours
of the nasopharynx
Benign. There are two main types of benign tumour of the nasopharynx:
the angiofibroma and the antrochoanal polyp.
Anglo
fibroma. This is often termed
‘nasopharyngeal angiofibroma’, but this is incorrect as the tumour arises
in the area
Macroscopically
there is a firm reddish-blue tumour covered with normal mucous membrane, but
ulceration may occur if the tumour hangs into the oropharynx or becomes exposed
anteriorly at the nostril. Microscopically it is composed of immature
fibroblasts and blood vessels, and it remains benign even in its advanced
stages. It should probably be regarded as a hamartoma. Clinically the tumour is
confined to male patients commonly between the ages of 8 and 20 years, i.e.
around puberty. It occasionally occurs in the
It rarely regresses and usually causes
progressive nasal obstruction, recurrent severe epistaxis, purulent rhinorrhoea
and occasionally loss of vision due to compression of the optic nerve. Although
the tumour is rare, these symptoms in a young boy should always arouse
suspicion.
Standard
clinical examination may easily reveal the tumour in the nasal cavity or
nasopharynx, but CT scanning best demonstrates the extent of the tumour and its
accompanying bony erosion. MRI scanning will further define the soft-tissue
extent and with these two modern investigations angiographic evaluation is
rarely indicated.
Biopsy should be avoided unless clinical and radiological examination is
not clear. There should be definite reasons for undertaking biopsy, and matched
blood must be in readiness and the surgeon prepared to deal with the haemorrhage.
Whilst
radiotherapy has occasionally been advocated, surgical resection is by the far
commonest management worldwide and requires an adequate exposure of the entire
region either through a midfacial degloving approach or a lateral rhinotomy (Figs 43.18 and
43.19). Both of these approaches allow ligation of the feeding
maxillary artery. A transpalatal approach may be used for the smaller tumours
but this does not give full control of any potential bleeding.
Antrochoanal
polyp. This relatively uncommon lesion is not a tumour but a simple mucosal
polyp. It does not arise in the nasopharynx, but from the maxillary antrum, from
which it prolapses into the nasal cavity and thence expands backwards into the
nasopharynx and occasionally down into the oropharynx (Figs 43.20 and
43.21). It
also commonly occurs in young males, and therefore may mimic a tumour of the
nasal cavity or nasopharynx. It is distinguished clinically
Malignant.
Nasopharyngeal carcinoma is an interesting squamous cell carcinoma with a very
variable incidence. In most parts of the world the tumour is rare with an
incidence of less than one person in 100 000 per year. However, it is a common
tumour amongst southern Chinese, and this high-risk population has rates of
30—50 people per 100 000 per year. In the rest of China there are substantial
variations in the incidence but, in general, the incidence decreases from south
to north. Higher frequencies of nasopharyngeal carcinoma are also observed in
emigrant southern Chinese populations in south-east Asia and elsewhere around
the world, and it is also more common amongst Eskimo, the Kadazans in East
Malaysia and parts of northern Africa. It is now well accepted that mechanisms
leading to development of a cancer often involve a multi step process, and the
aetiology of nasopharyngeal carcinoma is most likely to be multifactorial with
no single cause adequately explaining the epidemiology of the disease. However,
it is also clear that three well-defined major aetiological factors are involved
in its development (Table 43.3). The exact mechanism as to how these factors act
is not yet fully understood. The majority of squamous carcinomas of the
nasopharynx is undifferentiated and the morphology of this tumour is
characteristic. Only a few are well-differentiated squamous carcinomas, and
these two lesions make up over 90 per cent of nasopharyngeal malignancy in
endemic areas. Other rare epithelial tumours are adenocarcinoma and adenoid
cystic carcinoma. B- and T-cell lymphomas also occur in this region and should
not be confused with the more common undifferentiated carcinoma.
Nasopharyngeal
carcinoma affects a younger age group of the population than almost any other
head and neck neoplasm. In endemic regions at least 60 per cent of patients are
under 50 years of age and this applies to both sexes.
Clinical
features. Symptoms are closely related to the position of the tumour in the
nasopharynx and the degree of distant spread which may be present. Early
symptoms are often minimal in nature and thus liable to be ignored by both
patient and doctor.
• Approximately half the patients
will present with a mass in the neck. This percentage is even higher in patients
under 21 years of age. It indicates that the tumour has already reached an
advanced stage. Fine needle aspirate or a biopsy of a neck node showing
undifferentiated carcinoma requires immediate thorough examination of the
nasopharynx.
• The nasopharynx may look normal or only minimally asymmetric
but contain submucosal nasopharyngeal carcinoma. Nasal complaints occur in
one-third of patients and aural symptoms of unilateral deafness, as a
consequence of
A biopsy of the nasopharynx is mandatory if there is suspicion of
nasopharyngeal malignancy.The traditional
method of indirect examination with a mirror, although adequate in some
patients, has been superseded by direct inspection carried out by a flexible or
rigid nasendoscope. If topical anaesthesia is used, a biopsy may be taken.
Serological investigation for Epstein—Barr virus-associated antigenic
markers, in combination with the clinical and histological examination, is
valuable for the early detection of disease. Highly sensitive assays for
antiviral antibodies, together with the newly discovered virus-associated
serological markers, are assisting not only in the early detection but in the
treatment and control of this disease. IgA antiviral capsid antigen (VCA)
antibody has recently been evaluated in mass surveys in southern China and has
been found to be an excellent screening method for the early detection of
nasopharyngeal carcinoma in high-risk groups.
Imaging.
Imaging is essential to determine the
extent of the disease and to enable correct staging. In areas where CT and MRI
are available plain film radiography of the nasopharynx and other ancillary
methods, such as xerography and tomography, have now been superseded. A chest
X-ray, however, should still be performed. CT has a major role in determining
the size and position of the tumour essential for radiotherapy planning and
assessing the response to treatment, diagnosing recurrence and detecting
complications.
Treatment.
Primary treatment of nasopharyngeal
carcinoma is radiotherapy. The majority of the tumours belongs to the
radiosensitive undifferentiated squamous cell group. With the advent of CT,
precise radiotherapy treatment planning is now possible and brachytherapy (intracavitary
and interstitial radiotherapy) and chemotherapy are increasingly added in the
management plan. Elective external radiotherapy is given to the neck in all
cases, even when no neck nodes are apparent. For early disease, 3-year
disease-free survival rates of more than 75 per cent are now common. However,
late disease has figures of only 30—50 per cent for 3-year disease-free
survival. Although the benefit of modern radiotherapy is beyond doubt, the value
of additional chemotherapy remains debated, but it is likely that a
combination of chemotherapy and radiotherapy will produce better loco regional control of the tumour. Surgery is reserved for recurrent disease in neck nodes
and the occasional removal of recurrent skull base disease which has not
responded to additional radiotherapy or chemotherapy.
Oropharynx
Acute
tonsillitis
This common condition is characterised by a sore throat, fever, general
malaise, dysphagia, enlarged upper cervical nodes and sometimes referred otalgia.
Approximately half the cases are bacterial, the most common cause being a
Treatment.
Paracetamol or similar analgesia may be administered to relieve pain and
gargles of glycerol—thymol are soothing. The condition is frequently sensitive
to benzyl or phenyoxymethylpenicillin (penicillin V) and these are given until
antibiotic sensitivities are known. Ampicillin is avoided as it may exacerbate
the situation and precipitate a rash in patients with infectious mononucleosis.
Most cases resolve in a few days.
Quinsy
This is the formation of an abscess in the peritonsillar region causing
severe pain and trismus, and most usually associated with streptococcal
infection (see Fig. 43.23). Trismus caused by spasm induced in the pterygoid
muscles from the spreading infection may make examination difficult. This may be
overcome by the instillation of local anaesthesia into the posterior nasal
cavity (thereby anaesthetising the sphenopalatine ganglion) and directly into
the oropharynx. This simple manoeuvre aids subsequent examination which should
be carried out with good illumination and suction. A diffuse swelling of the
soft palate just superior to the involved tonsil is seen displacing the uvula
medially and, in more advanced cases, there may be an area of pus pointing
underneath the thin mucosa.
Treatment.
In the early stages where no distinct abscess is pointing, intravenous
broad-spectrum antibiotics are indicated and may produce resolution. However,
if there is frank abscess formation, incision and drainage of the pus can be
carried out under local anaesthesia (Fig. 43.24). A small scalpel is best
modified by winding a strip of adhesive tape around the blade so that only 1 cm
of the blade projects. In teenagers and young adults the patient sits upright
and an incision is made in the position shown in Fig.
43.24. This is
approximately mid-way between the base of the uvula and
Chronic
tonsillitis
Chronic tonsillitis usually results from repeat attacks of acute
tonsillitis in which the tonsils become progressively damaged and provide a
reservoir for infective organisms.
Tonsillectomy.
Indications for tonsillectomy may be divided into absolute or relative (Table
43.5).
When the size of the tonsils is contributing to airway obstruction or a
malignancy of the tonsils is suspected, the decision to perform tonsillectomy is
relatively straightforward. Complete tonsillectomy is preferable to wedge
biopsies when squamous cell carcinoma is suspected, and bilateral tonsillectomy
is performed in the case of suspected lymphoma as part of the staging process.
Considerable
interest now focuses on the area of sleep apnoea and related problems. Patients
should be admitted for
Recurrent
acute tonsillitis is the commonest relative indication for tonsillectomy in
children and adolescents, although it is important that these attacks are well
documented and do not simply constitute a minor sore throat usually of viral
origin and of short duration. Chronic tonsillitis more frequently affects young
adults in whom it is important to establish that chronic mouth breathing
secondary to nasal obstruction is not the main problem rather than the tonsils
themselves.
Ideally,
the procedure should be undertaken when the tonsils are not acutely infected,
and it is important to discuss factors which may increase the tendency to bleed.
Blood transfusion is rarely required but it is normal practice to perform a
‘group and save’ in children under 15 kg in weight.
Dissection
tonsillectomy is carried out under general anaesthesia during which the patient
lies supine with the head extended and with the surgeon sitting at the end of
the operating table. The mucosa of the anterior faucial pillar is incised and
the tonsil capsule identified. Using blunt dissection the surgeon separates
the tonsil from its bed until only a small inferior pedicle is left (Fig.
43.25). Usually a snare is used to separate it from the lingual tonsil. Ribbon
Haemorrhage
is obviously the most common complication, occurring in the immediate
postoperative period (Table 43.6). Local pressure, hydrogen peroxide, gargles
and general supportive measures may help in mild cases, but it is generally
.wisest
to return to theatre for definitive treatment particularly in younger patients.
Blood loss is replaced with crystalloid whilst a cross-match is performed, and
frequent observations of blood pressure, pulse and respiratory rate are made.
Adequate analgesia is given without causing respiratory depression. With the
patient seated upright in bed the mouth is examined under reasonable
illumination to determine the site of bleeding and if possible to suction away
clots from the tonsillar fossa. A swab soaked in 1 in 1000 adrenaline may be
held against the bleeding area in a co-operative patient, but if this is not
possible and/or the bleeding persists theatre should be alerted. Under general
anaesthesia it may be possible to identify a bleeding spot, but often a more
generalised ooze is observed and suturing of the tonsil bed combined with the
Late
haemorrhage is generally secondary to infection and patients should be
immediately commenced on intravenous antibiotics with aerobic and anaerobic
cover. Significant or persistent bleeding may require a further general
anaesthetic and under sewing of the surgical bed, which by this time will often
be covered with slough and granulation tissue. Postoperative tonsillar
haemorrhage must still be regarded as a serious and life-threatening
complication and should not be underestimated, particularly in the younger
patient.
Parapharyngeal
and retropharyngeal abscess
Parapharyngeal abscess. The parapharyngeal abscess may be confused with
a peritonsillar abscess but the maximal swelling is behind the
posterior faucial pillar and there may be little oedema of the soft palate. The
patient is usually a young child and there may be a severe degree of general
malaise. With an obvious abscess pointing into the oropharynx, drainage may be
carried out with a blunt instrument or the gloved finger but general anaesthesia
is frequently required and the expertise of a senior anaesthetist, good
illumination and good suction are absolutely essential. A large parapharyngeal
abscess may compromise both the airway and swallowing. In the earlier cases
admission to hospital and the institution of fluid replacements coupled with
intravenous antibiotics may produce resolution. The advanced cases also require
intravenous antibiotics.
Acute
retropharyngeal abscess
This is the result of suppuration of the prevertebral lymph nodes and,
again, is most commonly seen in children with most of the cases occurring in
those under 1 year of age. It is
These
children should always be carefully examined, and an inspection of the posterior
wall of pharynx may show gross swelling and an abscess pointing beneath the
thinned mucosa. In countries where diphtheria still occurs, an acute
retropharyngeal
abscess may be confused with this but the presence of the greyish-green membrane
aids differentiation. Occasionally, a foreign body, most commonly a fish hone
which has perforated the posterior pharyngeal mucosa, will give rise to an
abscess in this situation in older children and young adults.
These
patients should be admitted to hospital and intravenous antibiotics instituted
immediately. Surgical drainage of the abscess may not be necessary but, if so,
requires experienced anaesthesia as on induction care must be taken to avoid
rupturing the abscess. The airway is protected by placing the child in a
head-down position whilst a pair of dressing forceps guided by the finger may be
thrust into an obvious abscess in the posterior wall with the contents being
evacuated. On other occasions an approach anterior and medial to the carotid
sheath via a cervical incision may he required.
Chronic
retropharyngeal abscess
This condition is now rare and most commonly the result of an extension
of tuberculosis of the cervical spine which has spread through the anterior
longitudinal ligament to reach the retropharyngeal space. In contrast to the
acute retropharyngeal abscess, this condition occurs almost solely in adults
and radiology usually shows evidence of bone destruction and loss of the normal
curvature of the cervical spine. The spine may be quite unstable and undue
manipulation may precipitate a neurological event. In addition to the retropharyngeal
swelling seen intraorally, there may be fullness behind the sternocleidomastoid
muscle on one side. A chronic retropharyngeal abscess must not he opened into
the mouth, as such a procedure may lead to secondary infection. Drainage of the
abscess may not be necessary if suitable treatment of the underlying
tuberculosis disease is instituted. If it is necessary then it should he carried
out through a cervical incision anterior to the sternocleidomastoid muscle with
an approach anterior and medial to the carotid sheath to the retropharyngeal
space. The cavity is opened and suctioned dry after taking biopsy material.
Occasionally surgery is required to decompress the spinal cord if there is a
progressive neurological deficit.
Glandular
fever (infectious mononucleosis)
This systemic condition is usually caused by Epstein—Barr virus but
similar features can be due to cytomegalovirus or toxoplasmosis.
Clinical
features. The tonsils are typically erythematous with a creamy-grey exudate, and
they appear almost confluent
and usually symmetrical in contradistinction to a quinsy. In addition to the
discomfort and dysphagia, the patient may drool saliva and have respiratory
difficulty, particularly on inspiration. They commonly have a high temperature
and gross general malaise with other notable cervical or generalised
lymphadenopathy. Occasionally an enlarged spleen or liver may be detected. These
features most commonly occur in teenagers and young adults, and diagnosis can be
confirmed by serological testing showing a positive Paul—Bunnell test, an
absolute and relative lymphocytosis, and the presence of atypical monocytes in
the peripheral blood.
Treatment.
Analgesia and
maintenance of fluid intake are important. A small number of patients requires
admission to hospital if the airway is compromised and a short course of
steroids may be helpful. If this is necessary it should only be carried out as
an in-patient where the airway can be constantly monitored. Antibiotics are of
little value and, indeed, ampicillin is contraindicated because of the frequent
appearance of a widespread skin rash.
Human immunodeficiency
virus
The
human immunodeficiency virus (HIV) is the causative agent of acquired
immunodeficiency syndrome (AIDS) which, although it was initially associated
with intravenous drug users and homosexual males, is now spreading in many parts
of the world to affect the heterosexual community. It can affect almost all of
the head and neck structures at any point during the disease. The initial
seroconversion may present with the symptoms of glandular fever which is
followed by an asymptomatic period of variable length. In the preAIDS period,
prior to the full-blown symptoms of the AIDS-related complex, many patients have
minor upper respiratory tract symptoms which are often overlooked such as otitis
externa, rhinosinusitis and a nonspecific pharyngitis. As the patient moves into
the full-blown AIDS-related complex a persistent generalised lymphadenopathy is
frequently found affecting the cervical nodes which is usually due to follicular
hyperplasia. However, patients may also develop tumours such as Kaposi’s
sarcoma, sometimes seen in the oral cavity, and high-grade malignant B-cell
lymphoma affecting the cervical lymph nodes and nasopharynx. In addition,
multiple ulcers may be found in the oral cavity or pharynx associated with
herpes infection. Severe candida may affect the oral cavity pharynx or even
larynx, and a hairy leucoplakia may affect the tongue (Fig.
43.27). There is
also an increased incidence of squamous cell carcinoma of the oral cavity.
The
globus syndrome
A
wide variety of patients has a predominant symptom of a feeling of a lump in the
throat (Latin: globus lump). The
The original name of globus hystericus is unhelpful and although these
patients may be anxious and at times introverted, they none the less require
full examination to exclude local disease. Radiological and endoscopic
investigation may be necessary to exclude an underlying cause.
Pharyngeal
pouch
The pouch is a protrusion of mucosa through Killian’s dehiscence, a
weak area of the posterior pharyngeal wall between the oblique fibres of
thyropharyngeus and the transverse fibres of cricopharyngeus at the lower end of
the inferior constrictor muscle. These fibres, along with the circular fibres of
the upper oesophagus, form the physiological upper oesophageal sphincter
mechanism. Quite why the pouch forms is not yet clear even with modern video fluoroscopic
and manometric studies. Many patients with pharyngeal pouches
have been demonstrated to have normal relaxation of the upper oesophageal
sphincter mechanism in relation to swallowing, but others have been shown to
have incomplete pharyngeal relaxation, early cricopharyngeal contraction and
abnormalities of the pharyngeal contraction wave. As the pouch enlarges the
resistance of the vertebral column behind usually causes it to turn laterally to
the left (Fig. 43.28).
Clinical
features. Patients suffering from this condition are commonly more than 60 years
of age and it is twice as common in women as in men.
In
the initial phases when there is a small diverticulum the patients may present
with globus-type symptoms of a feeling of something in the throat or minor
difficulties and slight regurgitation on swallowing. A videofluoroscopic or
barium swallow study may show abnormalities of the upper
Radiological
examination. If a pharyngeal pouch is suspected, this is an extremely useful
examination. A thin emulsion of barium is given to the patient as a barium
swallow (Fig. 43.29) or, better still, as part of a videofluoroscopic swallowing
study. Care should be exercised in patients who cough on swallowing indicating
they may have aspiration. Just a few millilitres of barium is sufficient to
outline the pharynx pouch and upper oesophagus. The videofluoroscopic study
gives additional information about the pharyngeal contraction waves and the
performance of the upper oesophageal sphincter. Occasionally there is an
associated hiatus hernia at the lower end of the oesophagus and this should be
excluded. A chest X-ray is important to exclude aspiration pneumonitis.
Treatment.
Surgery is indicated when the pouch is associated with progressive symptoms,
and particularly when a prominent cricopharyngeal bar of muscle associated with
abnormality of the upper oesophageal sphincter mechanism causes considerable
dysphagia. In very elderly patients a decision to operate may be offset by the
general condition of the patient. Preoperative physiotherapy and attention to
the respiratory, cardiovascular and nutritional aspects of the
A
lower neck incision along the anterior border of the left sternocleidomastoid
muscle, or a transverse crease incision, is then used and the
sternocleidomastoid muscle and carotid sheath are retracted laterally and the
trachea and larynx medially. The middle thyroid vein is divided and, if
necessary, the inferior thyroid artery is found and ligated well laterally. The
retropharyngeal space is entered above the inferior corner of the thyroid
cartilage, thereby avoiding risk of damage to the recurrent laryngeal nerve. The
pouch is found medially behind the lower pharynx and is carefully isolated and
dissected back to its origin at Killian’s dehiscence. It may then be excised
and the pharynx closed in two layers or, if it is small, it may invaginated into
the pharyngeal lumen before closing the muscle layers. In all cases a myotomy
dividing the fibres of the cricopharygeus muscle and the upper oesophageal
circular muscle fibres must be performed. The wound is usually closed with
drainage and the patient fed through the nasogastric tube for 3—7 days.
Complications.
This classic operation has been associated with wound infection, mediastinitis,
pharyngeal fistula
Sideropenic
dysphagia
Prolonged iron deficiency anaemia may lead to dysphagia, particularly in
middle-aged females. In addition, they may have koilonychia, cheilosis and
angular stomatitis, together with lassitude and poor exercise tolerance. The
dysphagia is caused by a postcricoid web, and these patients have a higher
incidence of postcricoid malignancy. Prognosis of these postcricoid tumours is
very poor, requiring radical treatment with radiotherapy and major surgery, and
it is therefore important to prevent this problem by recognition and treatment
of the anaemia. The syndrome is associated with the names of Plummet and Vinson,
and Patterson and Brown Kelly.