ORL

1. SORE THROAT

2. Introduction
Sore throat is one of the most common symptoms
encountered
Patients use the term to describe almost any feeling
in the throat, ranging from dryness to actual pain –
important to ascertain the precise nature of sore
throat & severity early in clinical history
Severity – dysphagia for solid?, liquids?, saliva?

3. Differential Diagnosis
of Sore Throat
1. Tonsillitis
2. Pharyngitis
3. Adenoiditis
4. Peritonsillar abscess
5. Infectious mononucleosis
6. Diphtheria
7. Lymphoma
8. Squamous cell carcinoma of tonsil
9. Trauma/Foreign body

4. Complication of sore throat
• Tonsilitis, peritonsillar abscess
• Sinusitis
• Mastoiditis
• Ear infection (otitis media)
• Laryngitis
• Rheumatic fever and glomerulonephritis
(GABHS)

5. Waldeyer’s Ring
Definition : A collection of lymphoid tissue in subepithelial layer of
the pharynx which is aggregated at places to form masses.

6. Content of Waldeyer’s Ring
1) Nasopharyngeal tonsil / adenoid
2) Palatine tonsils
3) Lingual tonsil
4) Tubal tonsils (in Fossa of
Rosemuller)
5) Lateral pharyngeal bands
6) Nodules (in posterior pharyngeal
wall)

7. Content of Waldeyer’s Ring
1. Adenoids
• A subepithelial collection of lymphoid tissue, lined in vertical ridge
separated by deep clefts. (no crypts, no capsule)
• Pseudostratified ciliated columnar, stratified squamous, transitional
epithelium
• Located at the junction of the roof & posterior wall of nasopharynx
overlying mucous membrane to be thrown into radiating folds
• Present at birth.
• Increases in size up to the age of 6 years - gradually atrophies, completely
disappears by age 20.
• Blood supply:
 Ascending palatine branch of facial
 Ascending pharyngeal branch of external carotid
 Pharyngeal branch of 3rd part of maxillary aa.
 Ascending cervical branch of inferior thyroid aa.
of thyrocervical trunk

8. Content of Waldeyer’s Ring
1. Adenoids
• Venous drainage : to pharyngeal plexus, which communicates
with the pterygoid plexus drains into the internal jugular &
facial veins
• Lympathic :
Efferent lympathic of adenoidretropharyngeal &
parapharyngeal LNs  upper jugular nodes
• Innervation : CN IX & CN X

9. Content of Waldeyer’s Ring
2. Palatine Tonsils
• Consist of 2 palatine tonsils (Right , Left)
• An ovoid mass of lymphoid tissue situated in the lateral wall
of oropharynx between the anterior & posterior pillars
• Non-keratinizing stratified squamous epithelium
MAIN

10. Content of Waldeyer’s Ring
2. Palatine Tonsils
• Venous drainage into paratonsillar veinjoins
common facial vein & pharyngeal venous plexus.
• Lymphatics: upper deep cervical nodes
• Innervation:
i) lesser palatine branches of sphenopalatine
ganglion (CN V)
ii)CN X –sensory nerve

11. Content of Waldeyer’s Ring
2. Palatine Tonsils
Applied Anatomy of Palatine Tonsils
 Actual size of the tonsil is bigger than
the one that appears from its surface
i) Extend upwards into the soft palate
ii) Extend downwards into the base
of the tongue
iii) Extend anteriorly into the palatoglossal arch
 2 surfaces – medial, lateral
 2 poles – upper, lower
Medial
surfaceLateral
surface

13. Bed of Tonsils
Formed by :
-Superior
contrictor
muscle
-Styloglossus
muscle

14. Content of Waldeyer’s Ring
Adenoid vs Palatine Tonsil
Adenoid Tonsil Palatine Tonsil
Not Encapsulated Encapsulated
One Two
Has furrows Has crypts
In naso pharynx In oropharynx
Psuedostratified
ciliated columnar,
stratified squamous,
transitional epithelium
Non-keratinizing
stratified squamous
epithelium

15. Content of Waldeyer’s Ring
3. Lingual Tonsils
• Located at the posterior 1/3 of the tongue, one on
each side
• Continuous with the lower end of the palatine tonsils

16. Content of Waldeyer’s Ring
4. Tubal Tonsils
• A collection of subepithelial lymphoid tissue situated
in the fossa of Rosenmuller (above & behind the
tubal elevation)
• Enlargement of this tonsil can cause Eustachian tube
occlusion

17. Role of Waldeyer’s Ring
in Body Defense Mechanism
 Function as an immunologic surveillance to
allow adaptation to environment esp. in
children.
 Produce lymphocytes and plasma cell
 Protect airway as guarding the entry of air and
food.

18. Tonsilitis
• Inflammation of the tonsils especially the
palatine tonsils
• Tonsillitis :
– Acute tonsillitis
– Chronic tonsillitis

19. TONSILS
• Lymphoidal tissue in the pharynx.
• 3 main tonsils:
• Palatine Tonsils
• Pharyngeal Tonsils
• Lingual Tonsils
• Palatine tonsil
• Situated at both side of oropharynx
• Lie between 2 pillars (palatoglossal
• and palatopharyngeal arch)
• 2 poles:
– Lower pole: attached to the tongue
– Upper pole: extends into soft palate

20. Acute Tonsillitis
Classification – based on structure that involve
A. Superficial Tonsillitis
- part of generalized pharyngitis
- mostly seen in viral infection
B. Follicular Tonsillitis
- infection spread into crypts and
it contain pus
- characteristic as yellowish spot

21. C. Parenchymatous Tonsillitis
- whole tonsil is involve
- generalized swollen and
hypereamia
D. Membranous Tonsillitis
- sequale of a follicular tonsilitis
- exudation from crypts coelesce
and form membrane on tonsil
surface

22. Etiology
• It often affects school age and adult group
• Rare in infant and adult > 50 yo
• Most common organism
- Haemolytic Streptococcus
- others: Staphylococci , Pneumococci, H.
Influenzae

23. Clinical Features
• Symptoms
– Sorethroat
– Dysphagia & odynophagia
– Fever (vary from 38-40oC)
– Earache (either referred pain from tonsils/due to otitis media
which may occur as a complication)
• Signs
– Fetid breath
– Coated tongue
– Hyperemia of pillars, soft palate & uvula
– Tonsils are red & swollen
– Cervical (jugulodigastric) lymph nodes are swollen & tender

24. Management
• Bed rest with soft diet and plenty of fluids intake
• Analgesic and antipyeretic
• Antimicrobial therapy (presence of tonsillar exudates,
presence of a fever, leukocytosis, contact with a person
who has a documented GABHS infection):
Penicillin/Erythromycin for 7-10 days
• Airway obstruction may require management by placing a
nasal airway device, using intravenous corticosteroids, and
administering humidified oxygen

25. Complication
• Chronic tonsillitis with recurrent acute attack
• Peritonsillar abscess (quinsy)
• Parapharyngeal abscess
• Acute otitis media
• Rheumatic fever (GABHS)
• Cervical abscess
• Acute glomerulonephritis
• Subacute bacterial endocarditis

26. Chronic Tonsilitis
• Usually following acute or subacute tonsillitis
• Mostly affect children and young adult. Rare after 50 yo
• Chronic infection of sinus or teeth as predisposing factor
• Types :
1. Chr. Follicular tonsillitis
– yellowish beads of pus on the medial surface tonsil
2. Chr. Parenchymatous tonsillitis
– hyperplasia of lymphoid tissue
– tonsil very enlarge and can interfere
– speech deglutition and respiration
3. Chr. Fibroid tonsillitis
– infected tonsils are small
– small tonsil but pressure on the anterior pillar expresses frank pus or
cheesy material
– with hx of repeated sore throat

27. Clinical Features
 Symptoms :
 Recurrent attack of sore throat or acute tonsillitis
 Chronic irritation in throat with cough
 Bad taste in mouth and halitosis (pus in crypts)
 Thick speech
 Difficulty in swallowing
 Choking spells in night (tonsils large and obstructive)
 Signs :
 Varying degree of tonsillar enlargement
 Yellowish beads of pus
 Small tonsil but may express frank pus or cheesy
material with pressure on anterior pillar
 Flushed anterior pillar
 Enlargement of jugulodigastric lymph nodes

28. Grading
• Grade 0: The tonsils are fully
inside the pillars.
• Grade 1: Tonsils found to be
enlarged and out of its pillars
• Grade 2: Tonsillar enlargement
extends just up to half the
distance of the uvula
• Grade 3: Tonsillar enlargement
up to the level of the uvula.
• Grade 4: Tonsillar enlargement
is so huge that they are virtually
in contact with each other i.e.
Kissing tonsil.

29. • Treatment:
– Conservative tx consists of attention to general health, diet, tx of
co-existent infection of teeth, nose and sinuses
– Tonsillectomy
is indicated tonsils interfere with speech, deglutition and respiration
or cause recurrent attacks.
• Complications:
– Peritonsillar abscess
– Parapharyngeal abscess
– Intratonsillar abscess
– Tonsilloliths (calculus of tonsils)
– Tonsillar cyst
– Focus of infection in rheumatic fever, acute glomerulonephritis, eye
and skin disorders

30. Pharyngitis
Acute Chronic
Viral
pharyngitis
Bacterial
pharyngitis
Fungal
pharyngitis
miscellaneous
Chronic
catarrhal
pharyngitis
Chronic
granular
pharyngitis

31. Acute Pharyngitis
Viral (most
common)
Bacterial Fungal Miscellaneous
 Rhinoviruses
 Influenza
 Parainfluenza
 Measles
 Chickenpox
 Coxsackie virus
 Herpes simplex
 Infectious
Mononucleosis
 Cytomegalovirus
 Streptococcus
(Group A, beta
hemolyticus)
 Diphtheria
 Gonococcus
 Candida
albicans
 Chlamydia
trachomatis
 Toxoplasmosis
(parasitic, rare)
Etiology :

32. • Discomfort in throat
• Malaise
• Low grade fever
• Pharynx is congested but no lymphadenopathy
Mild
• Pain in throat
• Dysphagia
• Headache
• Malaise
• High fever
• Pharynx shows erythema, exudate
• Enlargement of tonsils and lymphoid follicles on
posterior pharyngeal wall
Moderate
& Severe
• Oedema of soft palate and uvula
• Enlargement of cervical nodes
Very
severe
Clinical features :

33. Investigation :
Culture of throat swab
•Diagnosis of bacterial pharyngitis
•Can detect 90% of Group A Streptococci
**Failure to get any bacterial growth suggests a
viral aetiology

34. Treatment :
General measures
• Bed rest
• Plenty of fluids
• Warm saline gargles or pharyngeal irrigations
• Severe case – lignocaine viscous to relieve local
discomfort in throat and facilitate swallowing

35. Causes Drugs
Streptococcal pharyngitis (Group A, Beta
Haemolyticus)
Penicilin G, Erythromycin
Diphtheria Diphtheria antitoxin and
penicillin/erythromycin
Gonococcal pharyngitis Conventional dose of penicillin or
tetracycline
Candida infection Nystatin
Chlamydia trachomatis infection Erythromycin or Sulphonamides
Specific Treatment : Antibiotics

36. Chronic Pharyngitis
• Is a chronic inflammatory condition of the pharynx
• Pathologically:
Hypertrophy of mucosa, seromucinous glands,
subepithelial lymphoid follicles and muscular coat of
pharynx
Two types :
1. Chronic Catarral Pharyngitis
2. Chronic Granular Pharyngitis

37. AETIOLOGY
Persistent infection in
the neighbourhood
Mouth breathing
Chronic irritants
Environmental
pollution
Faulty voice
production
Ch. Rhinitis , Ch. Sinusitis,
Ch.Tonsillitis & Dental sepsis
 Obstruction in the nose,
nasopharynx
 Protruding teeth which
prevent apposition of lips
 Habitual, without any
organic cause
Excessive smoking, chewing
tobacco, heavy drinking, highly
spiced food
Smoky or dusty
environment or irritant
industrial fumes
Excessive use of voice or faulty
voice production where a
person resorts to constant
throat clearing

38. Symptoms :
• Discomfort or pain in the throat
- especially in the morning
• Foreign body sensation in throat
- has constant desire to swallow or clear his throat to get rid of ‘foreign
body’
• Tiredness of voice
- cannot speak for long, voice lose quality and may crack
• Cough
- tendency to cough as throat is irritable

39. Signs :
Chronic Catarrhal Pharyngitis Chronic Hypertrophic (Granular)
Pharyngitis
• Congestion of posterior
pharyngeal wall
• Engorgement of vessels
• Thickened faucial pillars
• Increased mucus secretion which
cover pharyngeal mucosa
• Pharyngeal wall appears thick
and oedematous with congested
mucosa and dilated vessels
• Post pharyngeal wall may be
studded with reddish nodules
• Lateral pharyngeal bands
became hypertrophied
• Uvula may be elongated and
appears oedematous

40. Chronic catarrhal pharyngitis Granular pharyngitis :
Reddish nodules on the posterior
pharyngeal wall

41. Treatment :
• Aetiological factor should be sought and eradicated
• Voice rest and speech therapy for patients with faulty
voice production
• Hawking, clearing the throat frequently should be
stopped
• Warm saline gargles (especially in the morning) – to
soothe and relieve discomfort

42. Adenoiditis

43. • Adenoid is a mass of lymphatic tissue situated
posterior to the nasal cavity, mainly in the roof
of nasopharynx.

44. Etiology
• Bacteria or viruses
– Streptococcus, adenovirus, influenza virus, EBV,
enterovirus, HSV
– Group A beta hemolytic Streptococcus pyogenes
(GABHS) is responsible for 30% childhood
adenoiditis and 10% of adult cases

45. Risk factors
• Children
• Family history of tonsillectomy
• Recurrent infection in the throat, neck or head
• Tonsillitis

46. Signs and Symptoms
• Nasal symptoms
– Nasal obstruction: snoring, sleep apnea, failure to
thrive in small child due to difficulty in feeding
– Nasal discharge: due to choanal obstruction,
normal nasal secretion unable to drain into
nasopharynx
– Sinustis: due to persistent nasal discharge
– Epistaxis: with nose blowing, in acutely inflamed
adenoids
– Voice change: lose nasal quality in voice due to
nasal obstruction

47. Signs and Symptoms
• Aural symptoms
– Tubal obstruction: adenoid mass blocks
eustachian tube, leads to retraction of tympanic
membrane and conductive hearing loss
– Recurrent otitis media: due to spread of infection
via eustachian tube
– Unresolved chronic suppurative otitis media due
to presence of infected adenoid
– Serous otitis media

48. Signs and Symptoms
• General symptoms
– Adenoid facies: characteristic facial appearance
due to chronic nasal obstruction and mouth
breathing
– Pulmonary hypertension
– Aprosexia

49. Features of Adenoid Facies
1) Underdeveloped thin/pinched nostrils
2) Short upper lip --> open mouth
3) Prominent upper teeth
4) Crowded teeth
5) Narrow upper alveolus
6) High-arched palate
7) Hypoplastic maxilla
8) Vacant & dull expression

50. Investigations
• Examination of postnasal space
– Rigid or flexible nasopharyngoscope
• Throat swab
• Soft tissue lateral radiograph
– Adenoid enlargement, size, extent of
nasopharyngeal space compromised.

51. Treatment
• Viral adenoiditis: analgesic, anti-pyretics
• Bacterial adenoiditis: antibiotics (penicillin)
• Marked symptoms (snoring, mouth breathing,
sleep apnea, speech abnormalities, recurrent
rhinosinusitis, chronic secretory otitis media,
recurrent ear discharge in chronic suppurative
otitis media): do adenoidectomy

52. Complications
• Otitis media
• Sinusitis
• Chest infection
• Cor-pulmonale
• Obstructive sleep apnea