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Sore Throat
Anatomy, phisiology,
examination and illnesses of
the throat
Head of otolaryngology department
Prof. Alexander I. Yashan
Sagital section
Anatomy of mesopharynx
(oropharyngoscopy)
Anatomy of epypharynx
(epypharyngoscopy)
Anatomy of hypopharynx
(hypopharyngoscopy-laryngoscopy)
EXAMINATION of the THROAT
(bacteriological)
EXAMINATION of the THROAT
(palpation)
PHISIOLOGY of the THROAT
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Breathing
Swallowing
Separating (channelization)
Speech (articulation)
SWALLOWING
• Normal mechanism - 3 stages
– 1st Stage - Oral (Voluntary) - tongue pushed against palate, forcing
food into pharynx, triggering reflex stages
– 2nd Stage - Pharyngeal involuntary lasts 1-2 seconds Food in
pharynx stimulates receptors with afferents in V and IX leading to
the medulla. Reflex efferent signals travel via V, IX, X, and XII to:
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Elevate soft palate to seal off nasopharynx
Move palatopharyngeal walls medially
Close glottis and depress epiglottis
Larynx moves superiorly, and anteriorly under base of tongue to shield
larynx and widen hypopharynx
• Relax cricopharyngeus
• Close superior constrictor as bolus passes into esophagus
– 3rd Stage - Esophageal (Involuntary)
• Liquids usually fall by gravity
• Peristaltic waves push solids. Innervated by vagi and myenteric
plexus.
Examination Scheme
External: Lips
Oral vestibule
Teeth and gums
Hard & soft palate
Palatal mobility
Put Tongue Depressor &
examine:
Tonsils
Ant. & post. Pillars
Tongue dorsal, ventral
surfaces,
Tongue Posterior 1/3
Floor of mouth
Post. Pharyngeal wall
Tongue mobility
& its mobility
Examination
Tongue Depressors
Taste Sensation &
Electrogustometry
INFLAMMATORY DISORDERS OF
THE PHARYNX
• Inflammatory disorders of the pharynx most
commonly present as throat or neck pain.
Disphagia, 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 disphagia.
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
– Disphagia 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.
Acute Viral or Bacterial Pharyngitis
• Pharyngitis is caused by a variety of microorganisms. Most
cases are viral and include the virus causing the common
cold, flu (influenza virus), adenovirus, mononucleosis, HIV
among various others. Bacterial causes include Group A
streptococcus which causes strep throat (15% of cases),
in addition to Corynebacterium, Arcanobacterium,
Neisseria gonorrhoeae,http://weed.ru/d/
Chlamydia pneumoniae and
others. In up to 30% of cases, no organism is identified.
• Most cases of pharyngitis occur during the colder months - during respiratory disease season. Spread among
household members is common. The medical importance
of recognizing strep throat as a cause of pharyngitis stems
from the need to prevent its complications which can
include acute rheumatic fever, kidney dysfunction and
severe disease such as bacteremia and rarely
streptococcal toxic shock syndrome.
Symptoms
• sore throat
• additional symptoms are dependent on the underlying
microorganisms
• step throat may be accompanied by fever, headache,
swollen lymph nodes in the neck
• viral pharyngitis may be associated with runny nose
(rhinorrhea) and postnasal discharge
• severe cases of pharyngitis may be accompanied by
difficulty swallowing and rarely difficulty breathing
• Signs and tests A physical exam with attention to the
pharynx to assess whether drainage/coating
(exudates) are present, as well as skin, eyes, neck
lymph nodes is frequently done.
Oropharyngoscopy
•Swollen,
erythematous
mucosa of the
oropharynx and
hypopharynx,
often with edema
of the uvula and
soft palate.
•Swollen cyanotic
lymphatic follicles
on the posterior
wall
•Mucous or
purulent
discharges on the
posterior wall
Complications
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complications of strep throat:
rheumatic fever,
glomerulonephritis (kidney inflammation),
chorea,
bacteremia (bloodstream infection) and rarely
streptococcal shock syndrome
• in some severe forms of pharyngitis (e.g.,
severe mononucleosis-pharyngitis)
• airway obstruction may occur
• peritonsillar abscess, retropharyngeal abscess
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.
General Symptoms
• Rapid onset of throat pain with pain on
swallowing associated with
• Fever, often 38°-39° C
• Malaise
• fatigue
• Chill
• Pain in extremities, muscles and joints
The Tonsils
Catharal and Follicular Tonsilitis
•The tonsils are
red, enlarged and
painfulness
with an exudate or
studded with white
follicles.
•Tender, firm
cervical
adenopathy is
often present.
Tonsillectomy
Tonsillectomy
Secondary
infection
Adenoidal facies
Adenotomy
• Adenoid grades
Tonsils
Effect of tongue depressor on size
Tonsillar hypertrophy
Large kissing tonsils
Asymmetrical tonsils
Acute tonsillitis
In mononucleosis the tonsils are hyperaemic and pus
accumulates in the tonsillar crypts. The debris in the
crypts coalesces to form a purulent membrane. The
clinical picture resembles of that in streptococcal
tonsillitis
Right peritonsillar abscess; the
peritonsillar space, the soft palate and
the uvula are swollen. The uvula is
displaced to the contralateral side
Peritonsillar Abscess Quinzy
Infectious
Mononucleosis
Keratosis
Concretions, exudate
Tonsil cysts
Tonsil Tumours
Papilloma
Carcinoma
Deep lobe of parotid
pushing tonsil medially
Hypertrophy of post pillar after tonsillectomy
Pharyngitis
Chronic Pharyngitis
Epiglottitis