diseases of the oropharynx

DISEASES OF THE OROPHARYNX

CSA Espina, MD, DPBO

PHARYNX The pharynx is divided into:

OROpharynx NASOpharynx HYPO or LARYNGOpharynx

OROPHARYNXAnatomically, the oropharynx is located: Anatomically, the oropharynx is located: between the soft palate superiorly and the hyoid between the soft palate superiorly and the hyoid

bone inferiorlybone inferiorly continuous with the oral cavity anteriorlycontinuous with the oral cavity anteriorly communicates with the nasopharynx superiorly communicates with the nasopharynx superiorly Communicates with the supraglottic larynx and Communicates with the supraglottic larynx and

hypopharynx inferiorlyhypopharynx inferiorly

OROPHARYNX

OROPHARYNXThe oropharynx is divided into the following The oropharynx is divided into the following

sites:sites: Base of the tongueBase of the tongue Tonsillar region, which includes the fossa and Tonsillar region, which includes the fossa and

the anterior and posterior pillars. the anterior and posterior pillars. Soft palate, which includes the uvula. Soft palate, which includes the uvula. Posterior and lateral pharyngeal wallsPosterior and lateral pharyngeal walls

OROPHARYNX

Palatine Posterior and Lateral Pharyngeal Walls

LINGUAL THYROID

The diagnosis is usually made by the discovery of an The diagnosis is usually made by the discovery of an incidental mass on the back of the tongue in an incidental mass on the back of the tongue in an asymptomatic patient.asymptomatic patient.

ORAL CAVITY EXAMINATION SAGITTAL REFORMATTED CT SCAN

LINGUAL THYROID Relatively rare and is estimated to occur in 1 in Relatively rare and is estimated to occur in 1 in

3000 cases of thyroid disease. 3000 cases of thyroid disease. Most common location for functioning ectopic Most common location for functioning ectopic

thyroid tissue. thyroid tissue. Occurs much more commonly in women than in Occurs much more commonly in women than in

men. men.

LINGUAL THYROID May enlarge and cause dysphagia, dysphonia, May enlarge and cause dysphagia, dysphonia,

dyspnea, or a sensation of choking. dyspnea, or a sensation of choking. Lingual thyroid tissue is associated with an absence Lingual thyroid tissue is associated with an absence

of the normal cervical thyroid in 70% of cases. of the normal cervical thyroid in 70% of cases. Hypothyroidism is often present and may cause the Hypothyroidism is often present and may cause the

mass to enlarge and become symptomaticmass to enlarge and become symptomatic In women, symptomatic lingual thyroid glands In women, symptomatic lingual thyroid glands

develop during puberty or early adulthood in most develop during puberty or early adulthood in most cases. cases.

LINGUAL THYROID Should be suspected when a mass is detected in Should be suspected when a mass is detected in

the region of the foramen cecum of the tongue, and the region of the foramen cecum of the tongue, and it is definitively established by radioisotope it is definitively established by radioisotope scanning.scanning.

Treat with thyroid hormone therapy to suppress the Treat with thyroid hormone therapy to suppress the lingual thyroid and reduce its size. lingual thyroid and reduce its size.

LINGUAL THYROID Only rarely is surgical excision necessary. Only rarely is surgical excision necessary. Indications for surgery include:Indications for surgery include:

failure of suppressive therapy to reduce the sizefailure of suppressive therapy to reduce the size ulcerationulceration hemorrhagehemorrhage suspicion of malignancysuspicion of malignancy

HYPERTROPHIED TONSILS

Hypertrophy of the tonsils can result in snoring, mouth Hypertrophy of the tonsils can result in snoring, mouth breathing, disturbed sleep, and obstructive sleep apnea breathing, disturbed sleep, and obstructive sleep apnea during which the patient stops breathing and experiences a during which the patient stops breathing and experiences a drop in the oxygen content in the bloodstream. drop in the oxygen content in the bloodstream.

A tonsillectomy can be curative.A tonsillectomy can be curative.

Take note of the tonsillar crypts!

TONSILLOPHARYNGITIS

TONSILLOPHARYNGITIS Characterized by red, swollen tonsils that may or may not Characterized by red, swollen tonsils that may or may not

have exudates. have exudates. Other signs and symptoms of tonsillitis include a severe Other signs and symptoms of tonsillitis include a severe

sore throat, painful/difficult swallowing, headache, fever and sore throat, painful/difficult swallowing, headache, fever and chills, enlarged and tender lymph nodes, pain in the tonsil chills, enlarged and tender lymph nodes, pain in the tonsil area, and loss of voice.area, and loss of voice.

Viral tonsillitis may be caused by Epstein Barr virus or Viral tonsillitis may be caused by Epstein Barr virus or adenovirus.adenovirus.

Bacterial tonsillitis may be caused by Group A beta Bacterial tonsillitis may be caused by Group A beta hemolytic streptococcus.hemolytic streptococcus.

TONSILLOPHARYNGITIS In very rare cases, diseases like rheumatic fever or In very rare cases, diseases like rheumatic fever or

glomerulonephritis can occur. glomerulonephritis can occur. These complications are extremely rare in These complications are extremely rare in

developed nations but remain a significant problem developed nations but remain a significant problem in poorer nations.in poorer nations.

TONSILLOPHARYNGITIS Management consists of symptomatic treatment of Management consists of symptomatic treatment of

pain and fever.pain and fever. Penicillin and similar compounds are the most Penicillin and similar compounds are the most

useful and commonly prescribed antibiotics.useful and commonly prescribed antibiotics. Ibuprofen or other analgesics can decrease edema Ibuprofen or other analgesics can decrease edema

and inflammation which will ease the pain and allow and inflammation which will ease the pain and allow the patient to swallow liquids and hydrate sooner.the patient to swallow liquids and hydrate sooner.

TONSILLOPHARYNGITIS Warm saline gargle may help alleviate the patients Warm saline gargle may help alleviate the patients

symptoms also.symptoms also. Chronic cases may indicate tonsillectomy as a Chronic cases may indicate tonsillectomy as a

choice for treatment.choice for treatment.

INFECTIOUS MONONUCLEOSIS


AKA Kissing Disease, Pfeiffer's disease, Glandular AKA Kissing Disease, Pfeiffer's disease, Glandular Fever Fever

Seen most commonly in adolescents and young Seen most commonly in adolescents and young adults.adults.

Produces a very mild illness in small children, but is Produces a very mild illness in small children, but is typically asymptomatic. typically asymptomatic.


Caused by the Epstein-Barr virus (EBV), which Caused by the Epstein-Barr virus (EBV), which infects B-lymphocytes.infects B-lymphocytes.

Transmitted from asymptomatic individuals through Transmitted from asymptomatic individuals through saliva, or by sharing a drink, or sharing eating saliva, or by sharing a drink, or sharing eating utensils. It may also be transmitted through blood. utensils. It may also be transmitted through blood.


Symptoms usually appear 4-6 weeks after exposure Symptoms usually appear 4-6 weeks after exposure May resemble strep throat or other URTIs. May resemble strep throat or other URTIs. The typical symptoms and signs of mononucleosis are:The typical symptoms and signs of mononucleosis are:

FeverFever Tender and enlarged/swollen lymph nodesTender and enlarged/swollen lymph nodes Sore throatSore throat Fatigue and weaknessFatigue and weakness MyalgiasMyalgias Headache, loss of appetiteHeadache, loss of appetite


Other signs and symptoms:Other signs and symptoms: Splenomegaly or hepatomegaly Splenomegaly or hepatomegaly Abdominal painAbdominal pain Skin rashSkin rash Dizziness or disorientation Dizziness or disorientation


Many people exposed to EBV do not show symptoms of the Many people exposed to EBV do not show symptoms of the disease, but carry the virus. Children are typical carriers.disease, but carry the virus. Children are typical carriers.

About 6% of people who have had infectious About 6% of people who have had infectious mononucleosis will relapse.mononucleosis will relapse.

Paracetamol or nonsteroidal anti-inflammatory drugs Paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to reduce fever and pain.(NSAIDs) may be given to reduce fever and pain.

IV corticosteroids not recommended for routine use but IV corticosteroids not recommended for routine use but may be useful if there is a risk of airway obstruction.may be useful if there is a risk of airway obstruction.


AcyclovirAcyclovir may may reduce initial viral shedding. Valacyclovir has reduce initial viral shedding. Valacyclovir has recently been shown to lower or eliminate the presence of recently been shown to lower or eliminate the presence of the Epstein-Barr virus in subjects afflicted with acute the Epstein-Barr virus in subjects afflicted with acute mononucleosis, leading to a significant decrease in the mononucleosis, leading to a significant decrease in the severity of symptoms. severity of symptoms.

Antibiotics are not used as they are ineffective against viral Antibiotics are not used as they are ineffective against viral infections and their use can frequently precipitate a non-infections and their use can frequently precipitate a non-allergic rash. allergic rash.

Potential mortal complications include splenic rupture, Potential mortal complications include splenic rupture, bacterial superinfections, hepatic failure and the bacterial superinfections, hepatic failure and the development of viral myocarditis.development of viral myocarditis.

PERITONSILLAR ABSCESS

PERITONSILLAR ABSCESS Also known as Also known as QuinsyQuinsy Complication of tonsillitis and consists of a Complication of tonsillitis and consists of a

collection of pus around the tonsil.collection of pus around the tonsil. Arises as a complication of an untreated or partially Arises as a complication of an untreated or partially

treated episode of acute tonsillitis. treated episode of acute tonsillitis. Both aerobic and anaerobic bacteria can be Both aerobic and anaerobic bacteria can be

causative. causative.

PERITONSILLAR ABSCESS Progressively worsening unilateral sore throat, pain Progressively worsening unilateral sore throat, pain

during swallowing, and appetite loss usually are the during swallowing, and appetite loss usually are the earliest symptoms. earliest symptoms.

Persistent pain in the peritonsillar area, fever, Persistent pain in the peritonsillar area, fever, malaise, headache and change in voice (hot potato malaise, headache and change in voice (hot potato voice) and trismus may appear. voice) and trismus may appear.

PERITONSILLAR ABSCESS Neck pain associated with tender, swollen lymph Neck pain associated with tender, swollen lymph

nodes, referred ear pain and breath odour are also nodes, referred ear pain and breath odour are also common. common.

Physical signs include redness and edema in the Physical signs include redness and edema in the tonsillar area of the affected side and swelling of the tonsillar area of the affected side and swelling of the jugulodigastric lymph nodes. jugulodigastric lymph nodes.

The uvula may be displaced towards the unaffected The uvula may be displaced towards the unaffected side.side.

PERITONSILLAR ABSCESS Treatment is surgical Treatment is surgical incision and drainage incision and drainage of the of the

pus, thereby relieving the pain of the stretched pus, thereby relieving the pain of the stretched tissues. tissues.

Antibiotics are also given to treat the infection.Antibiotics are also given to treat the infection. Analgesics also afford some relief.Analgesics also afford some relief. Complications include parapharyngeal abscess, Complications include parapharyngeal abscess,

extension of abscess in other deep neck spaces extension of abscess in other deep neck spaces leading to airway compromise and septicaemia.leading to airway compromise and septicaemia.

OROPHARYNGEAL CANCER

OROPHARYNGEAL CANCER Involves patients in the 5Involves patients in the 5 thth to 7th decades of life to 7th decades of life Men are afflicted 3 to 5 times more often than Men are afflicted 3 to 5 times more often than

women. women. Tobacco and alcohol abuse represent the most Tobacco and alcohol abuse represent the most

significant risk factors.significant risk factors.


OTHER RISK FACTORS:OTHER RISK FACTORS: A diet poor in fruits and vegetables.A diet poor in fruits and vegetables. The consumption of The consumption of matématé, a stimulant beverage , a stimulant beverage

commonly consumed in South America. commonly consumed in South America. The chewing of The chewing of betel quidbetel quid, a stimulant preparation , a stimulant preparation

commonly used in parts of Asia.commonly used in parts of Asia. Infection with the Infection with the human papillomavirus (HPV), human papillomavirus (HPV),

especially HPV type-16 AND 18. especially HPV type-16 AND 18.


Histologically, almost all oropharyngeal Histologically, almost all oropharyngeal cancers are squamous cell carcinomas cancers are squamous cell carcinomas (SCCAs).(SCCAs).

Other cancers in this area include minor Other cancers in this area include minor salivary gland carcinomas, and lymphomas.salivary gland carcinomas, and lymphomas.

BASE OF TONGUE CANCER Insidious tumors; may grow in an infiltrative or Insidious tumors; may grow in an infiltrative or

exophytic pattern.exophytic pattern. Base of the tongue is devoid of pain fibers, these Base of the tongue is devoid of pain fibers, these

tumors are often asymptomatic until they have tumors are often asymptomatic until they have progressed significantly.progressed significantly.

Lymph node metastasis is common because of the Lymph node metastasis is common because of the rich lymphatic drainage of the base of the tongue rich lymphatic drainage of the base of the tongue levels II and III.levels II and III.

BASE OF TONGUE CANCER

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: Dysphagia/OdynophagiaDysphagia/Odynophagia Weight lossWeight loss Referred otalgia Referred otalgia Trismus Trismus Pain or numbnessPain or numbness Difficulty in articulation because of tongue fixationDifficulty in articulation because of tongue fixation AspirationAspiration Enlarged neck nodesEnlarged neck nodes

TONSILLAR CANCER Anterior tonsillar pillar and tonsil is the most Anterior tonsillar pillar and tonsil is the most

common location for a primary tumor of the common location for a primary tumor of the oropharynx.oropharynx.

These cancers can progress across a broad region These cancers can progress across a broad region including the lateral soft palate, retromolar trigone including the lateral soft palate, retromolar trigone and buccal mucosa, and tonsillar fossa.and buccal mucosa, and tonsillar fossa.

The lymphatic drainage is primarily to level II nodes.The lymphatic drainage is primarily to level II nodes.

TONSILLAR CANCER

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS: DysphagiaDysphagia Weight lossWeight loss Referred otalgia Referred otalgia Trismus Trismus Enlarged neck nodesEnlarged neck nodes

SOFT PALATE CANCER Soft palate tumors are primarily found on the Soft palate tumors are primarily found on the

anterior surface. anterior surface. Lesions in this area may remain superficial and in Lesions in this area may remain superficial and in

early stages.early stages. The lymphatic drainage is primarily to level II nodes. The lymphatic drainage is primarily to level II nodes.

PHARYNGEAL WALL CANCER Typically diagnosed in an advanced stage because Typically diagnosed in an advanced stage because

of “silent” location.of “silent” location. Can spread superiorly to involve the nasopharynx, Can spread superiorly to involve the nasopharynx,

posteriorly to infiltrate the prevertebral fascia, and posteriorly to infiltrate the prevertebral fascia, and inferiorly to involve the pyriform sinuses and inferiorly to involve the pyriform sinuses and hypopharyngeal walls. hypopharyngeal walls.

Primary lymphatic drainage is to the Primary lymphatic drainage is to the retropharyngeal nodes and level II and III nodes. retropharyngeal nodes and level II and III nodes.

Bilateral cervical metastases are common.Bilateral cervical metastases are common.

A VERY IMPORTANT THEORYA VERY IMPORTANT THEORY

FIELD CANCERIZATIONFIELD CANCERIZATION

FIELD CANCERIZATION THEORY Originally described in 1953, proposes that tumors develop Originally described in 1953, proposes that tumors develop

in a multifocal fashion within a field of tissue chronically in a multifocal fashion within a field of tissue chronically exposed to carcinogens.exposed to carcinogens.

Entire epithelial surface of the upper aerodigestive tract Entire epithelial surface of the upper aerodigestive tract has has an increased risk for the development of (pre)malignant an increased risk for the development of (pre)malignant lesions because of multiple genetic abnormalities in the lesions because of multiple genetic abnormalities in the whole tissue region.whole tissue region.

Molecular studies detecting genetic alterations in Molecular studies detecting genetic alterations in histologically normal tissue from high-risk individuals have histologically normal tissue from high-risk individuals have provided strong support for this conceptprovided strong support for this concept

SECOND PRIMARY TUMORS Risk of developing a second primary tumor in Risk of developing a second primary tumor in

patients with tumors of the upper aerodigestive tract patients with tumors of the upper aerodigestive tract has been estimated to be has been estimated to be 3% to 7% per year3% to 7% per year. .

Because of this risk, surveillance of these patients Because of this risk, surveillance of these patients should be lifelong. should be lifelong.

Continued smoking and alcohol consumption after Continued smoking and alcohol consumption after treatment has been associated with the treatment has been associated with the development of second primary tumors of the development of second primary tumors of the aerodigestive tract.aerodigestive tract.

MANAGEMENT Surgery and/or radiation therapy have been the Surgery and/or radiation therapy have been the

standards of treatment of oropharyngeal cancersstandards of treatment of oropharyngeal cancers Frequently complicated by:Frequently complicated by:

Poor control of locoregional disease Poor control of locoregional disease Significant long-term functional deficitsSignificant long-term functional deficits Poor quality of lifePoor quality of life

MANAGEMENT Concurrent use of multi-agent chemotherapy and Concurrent use of multi-agent chemotherapy and

radiation has become the standard of care for the radiation has become the standard of care for the management of patients with late-stage disease.management of patients with late-stage disease.

Surgery is often reserved for salvage of those Surgery is often reserved for salvage of those patients who fail definitive nonoperative treatment.patients who fail definitive nonoperative treatment.

PROGNOSIS Rate of curability of cancers of the oropharynx Rate of curability of cancers of the oropharynx

varies depending on the stage and specific site. varies depending on the stage and specific site. The development of cervical node metastasis The development of cervical node metastasis

halves the five year survival rate.halves the five year survival rate.

TONSILLAR CARCINOMA

DISPLACED UVULA

TONSILLAR MASS

TONSILLAR LYMPHOMA

72/M with fungating hard and soft palate mass extending back towards the L tonsillar region and retromolar trigone.

He had a strong history of smoking and alcohol consumption.

Most of the hard and soft palate and uvula were excised, along with the L tonsil. Blackened areas represent areas cauterized to control bleeding.

(White object is gelfoam, placed to control bleeding.)

This is a picture of a palatal surgical obturator or prosthesis sutured in place to cover the raw area and allow the patient to speak and feed. The

patient also underwent a neck dissection.

Thank You

diseases of the oropharynx

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