Dr. Abdullah R. Alkhalil College Of Medicine University Of Duhok Chronic Pharyngitis Dr. Abdullah R. Alkhalil College Of Medicine University Of Duhok

Chronic Pharyngitis Common condition Male to Female Ratio is 1:1 “ Women seek medical attention more than Men” One of the most troublesome symptom due to difficulty in diagnosis and in treatment Wide variety of causes Idiopathic!!!

Chronic Pharyngitis Nonspecific chronic simple pharyngitis Specific syphilis TB

Chronic Pharyngitis Symptoms include Cervical pain Choking sensation Chronic cough Constant throat clearing Dysphagia “ Improved with eating!” Food sticking in throat

Chronic Pharyngitis Globus sensation Halitosis Hoarseness Unilateral otalgia Pharyngeal tightness Sore throat

Chronic Pharyngitis Etiology:

Chronic Pharyngitis BE AWARE OF THESE SYMPTOMS: Dysphagia Weight loss Hoarseness Haematemesis Haemoptysis Unilateral earache with normal eardrum Neck swelling Neurology

Chronic Pharyngitis SIGNS: Non specific Granular pharyngitis Halitosis Tonsillar enlargment tonsilolith

Chronic Pharyngitis

Chronic Pharyngitis Treatment: Difficult Treat underlying causes

Peritonsillar abscess (Quinsy) Etiology:  The infection spreads to the peritonsillar area (peritonsillitis). This region comprises loose connective tissue  susceptible to formation of abscess. Both aerobic and anaerobic bacteria can be causative. Commonly involved species include streptococci, staphylococci and hemophilus. Epidemiology: - occur as complication of acute tonsillitis. - more in adults (15-30) than in children.

Peritonsillar abscess (Quinsy) Clinical features Fever, dehydration. severe dysphagia Edema of soft palate Uvular deviation (downward and medially) Involvement of motor branch of CN V  increased salivation and trismus (Persistent contraction of the masseter muscles due to failure of central inhibition) Hot potato voice Unilateral referred otalgia

Peritonsillar abscess (Quinsy)

Peritonsillar abscess (Quinsy)

Peritonsillar abscess (Quinsy) Complications: Airway obstruction Bacteremia Aspiration pneumonia secondary to rupture of abscess

Peritonsillar abscess (Quinsy) Treatment: Preferably admitted to hospital and treated with analgesics and antibiotics. In a patient with an early peritonsillar abscess which is really a peritonsillar cellulitis incision and drainage are not recommended.

Peritonsillar abscess (Quinsy) Treatment: surgical incision and drainage of pus forming outside the capsule -- relieving the pain dramatically. Under general anesthesia – in children and anxious pts.

Peritonsillar abscess (Quinsy)

Retropharyngeal Abscess Retropharyngeal Space: Entire length of neck. Anterior border - pharynx and esophagus (buccopharyngeal fascia) Posterior border - alar layer of deep fascia Superior border - skull base Inferior border – superior mediastinum Combines with buccopharyngeal fascia at level of T1-T2 Midline raphe connects superior constrictor to the deep layer of deep cervical fascia. Contains retropharyngeal nodes.

Retropharyngeal Abscess

Retropharyngeal Abscess Most common symptoms Sore throat Odynophagia Neck swelling Neck Pain

Retropharyngeal Abscess Pediatric Fever Decreased oral intake Odynophagia Malaise Torticollis Neck pain Otalgia Trismus Neck swelling Vocal quality change Worsening of snoring, sleep apnea

Retropharyngeal Abscess Imaging: Lateral neck plain film Screening exam No benefit in pts with DNI based on strong clinical suspicion. Normal: 7mm at C-2 14mm at C-6 for kids 22mm at C-6 for adults Technique dependent Extension Inspiration Sensitivity 83%, compared to CT 100%

Retropharyngeal Abscess

Retropharyngeal Abscess

Retropharyngeal Abscess Treatment: Initial therapy Cover Gram positive cocci and anaerobes If pt is diabetic, should consider covering gram negatives empirically. Clindamycin, 2nd generation cephalosporin. gentamicin and flagyl - developing nations. IV abx alone (based on retro and parapharyngeal infections) Patient stability and nature of lesion. Cellulitis/phlegmon by CT. Abscesses in clinically stable patient. If no clinical improvement in 24 - 48 hours proceed to surgical intervention.

Retropharyngeal Abscess Treatment: External drainage Landmarks Tip of greater horn of hyoid Cricoid cartilage Styloid process SCM Transoral drainage Parapharyngeal, retropharyngeal abscesses Great vessels lateral to abscess Tonsillectomy for exposure Needle aspiration

Retropharyngeal Abscess Complications: Airway obstruction Trach 10 – 20% Ludwig’s angina - 75% Mediastinitis – 2.7% UGI bleeding Sepsis Pneumonia IJV thrombosis Skin defect Vocal cord palsy Pleural effusion Hemorrhage 20 - 80% mortality Multiple space involvement