Post on 14-Apr-2018
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Pediatric pharyngeal diseases
Ehab ZAYYAN, MD, PhD
Hacettepe University- TurkeyConsultant and Head of ENT Department
European Gaza HospitalAssist. Professor, School of Medicine
Islamic University, Gaza
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Anatomy of the
pharynx
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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 musculu-membranous wall
that is deficient
anteriorly.
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Pharynx- posterior view
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The lateral andposterior walls of the
pharynx consist of 3pairs of muscles whichunite in the posteriormidline at the
pharyngeal raphe.1. Superior constrictor
muscle
2. Middle constrictor m
3. Inferior constrictormuscle.
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Nasopharynx
It lies behind thenasal cavities,
above the soft
palate.
The pharyngeal
tonsil (adenoid): a
collection of
lymphoid tissue inthe submucosa of
this region
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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
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Nasopharyngeal examination
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Oropharynx
From the soft palate tothe upper border of the
epiglottis
Roof: undersurface of the
soft palate Floor: root of the tongue
Anterior wall:
oropharyngeal isthmus
Posterior wall: C2, C3
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Oropharynx lateralwall
Palatoglossal fold
Palatopharyngeal
fold
Uvula Palatinal tonsils
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Palatine tonsils
Two masses of lymphoid tissuelocated in the tonsillar fossa.
The tonsil is covered bymucous membrane and itsmedial surface is free projectingin the cavity of the pharynx
Tonsillar crypts on thesurface.
Fibrous capsule covers thelateral surface of the tonsil. Itseparates it from the superiorconstrictor pharyngeal muscle.
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Waldeyeres ring of lymphoid tissue
At the junction of themouth andoropharynx and thenose with the
nasopharynx there isa collection oflymphoid tissue:
1. Palatine tonsils
2. Lingual tonsils3. Pharyngeal tonsils
4. Tubal tonsils
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Hypopharynx (laryngopharynx)
From the upper
border of the
epiglottis till the
lower border ofthe cricoid
cartilage.
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Lymph drainage of the pharynx
1. Nasopharynx retropharyngeal nodes2. Tonsils and oropharynx upper deep
cervical nodes, especially the
jugulodigastric node which is called the
tonsillar node.
3. Hypopharynx vessels thru thethyrohyoid membrane upper deep
cervical nodes
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Pharyngeal diseases
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Acute pharyngitis
Mostly a viral infection
Fever, sore throat,
odynophagia, malasia
Recovery within 57days
Tx: analgesics .
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Acute tonsillitis
Very common in pediatric population
Fever, sore throat, malasia, dysphagia,neck swelling..
Etiology:
Viruses: IMN, herpes
Group A, B-hemolytic streptococci
Diphteria
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Acute tonsillitis
Diagnosis
Physical examination is
the most important
Red swollen tonsils,
follicular,membranous
Cervical
lymphadenopathy
CBC
ASOT
Cultures
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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
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Acute tonsillitis
Oral antibiotics (10 days of tx)
Penicillin V (oral suspension)
Amoxicillin
Erythromycin
2ndline..
Analgesia, fluids and bed rest are veryimportant
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Non-suppurative
complications of acute
tonsillitis
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Scarlet fever
Scarlet fever is secondary to acutestreptococcal tonsillitis or pharyngitis withproduction of endotoxins by the bacteria.
Manifestations include an erythematousrash, severe lymphadenopathy with a sorethroat, vomiting, headache, fever,erythematous tonsils and pharynx,
tachycardia, and a yellow exudate over thetonsils, pharynx, and nasopharynx.
A strawberry tongue with a rash and largeglossal papillae is a good diagnostic sign
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Poststreptococcal glomerulonephritis
The typical patient develops an acute nephriticsyndrome 1 to 2 weeks after a streptococcalinfection.
The infection is secondary to the presence of acommon antigen of the glomerulus with thestreptococcus.
Penicillin management may not decrease the
attack rate, and there is no evidence thatantibiotic therapy affects the natural history ofglomerulonephritis.
A tonsillectomy may be necessary to eliminate
the source of infection.
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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
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Poststreptococcal tonsillitis
arthralgia
?????
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Suppurative complications ofacute tonsillitis
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Peritonsillar abscess
The spread of infection is from the tonsilwith pus formation between the tonsil bedand the tonsillar capsule
Fever, severe throat pain, dysphagia,odynophagia, trismus, drooling
It may lead to airway obstruction,
aspiration or parapharyngeal andretropharyngeal abscess formation
Treatment: incision and drainage, iv AB,tonsillectomy
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Parapharyngeal space abscess
Parapharyngeal space: between the lateralpharyngeal wall and the mandible
Contains dangerous structures like the carotidartery and the jugular veins.
Tonsillitis, dental infections, sinusitis,lymphadenitis.can lead to parapharyngealcellulitis or abscess
Dx: clinical, USG, CT
Tx: iv AB + incision and drainage (lateral cervicalapproach)
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R t h l
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Retropharyngeal space
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Retropharyngeal space infections
Mostly in children < 2 years Retropharyngeal space: between the pharynx
and the prevertebral fascia, extending from theskull base into the mediastinum till tracheal
bifurcation irritability, fever, dysphagia, muffled speech,
noisy breathing, stiff neck, and cervicallymphadenopathy.
Posterior pharyngeal wall bulging Cellulitis vs abscess
Tx: transoral/ external incision
R t h l b
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Retropharyngeal abscess
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Chronic tonsillitis
Recurrent acute tonsillitis
Chronic tonsillar and pharyngeal inflammation: pain,
irritation, smagma, halitosis, tonsilolithiasis
Hypertrophic tonsils
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Indications for tonsillectomy
1.Infection
Recurrent, acute tonsillitis
(more than six episodes
per year or three
episodes per year for 2years)
Chronic tonsillitis:
halitosis, persistent sore
throat, tender cervicaladenitis
Peritonsillar abscess
2. Obstruction
Excessive snoring and
chronic mouth-breathing
Obstructive sleep apnea
or sleep disturbances
3. Neoplasia Asymmetric tonsillar
hypartrophy
Adenoid diseases
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Adenoid diseases
Common in youngchildren
Adenoid hypertrophycaused by: infections,
allergy, environmental.. Symptoms
Otitis media andsinusitis
Dx: palpation, X-ray,endoscopy
Tx: Surgery
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Indications for adenoidectomy
Recurrent purulent adenoiditits Adenoid hypertrophy associated with otitis media
Adenoid hypertrophy associated with chronicsinusitis
Adenoid hypertrophy associated with excessivesnoring and chronic mouth-breathing
Sleep apnea or sleep disturbances
Speech abnormalities
Neoplasia suspesion
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Contraindications of
adenotonsillectomy
Bleeding abnormalities
Acute infections
Cleft palate??
Age???