HC pathologie Farynx en dysfagie-1.pptx

# Inflammations of the adenoids and pharynx This section details inflammations of the adenoids and pharynx, focusing on adenoiditis and adenoid hyperplasia, particularly in children, and covering their etiologies, clinical presentations, diagnostic methods, and treatment strategies. ## 1. Inflammations of the adenoids and pharynx ### 1.1 Adenoiditis and adenoid hyperplasia Adenoiditis and adenoid hyperplasia are common conditions, particularly in children, and are typically associated with the normal development of the immune system. Pharyngitis refers to the inflammation of the pharyngeal mucous membranes. Hyperplasia, or enlargement of the adenoids, often results from recurrent infections. #### 1.1.1 Causes The primary cause of adenoiditis and adenoid hyperplasia is usually viral. However, bacterial superinfections can also occur, presenting as a secondary infection. Several risk factors can predispose individuals to these conditions: * Age (more common in children) * Genetic predisposition * Atopy (allergic conditions) * Immunodeficiency * Cleft palate (schisis) * Seasonal factors (autumn/winter) * Attendance at daycare facilities * Exposure to tobacco smoke #### 1.1.2 Clinical presentation In young children, the symptoms of adenoiditis can be non-specific and may mimic those of an upper respiratory tract infection, including fever, abdominal pain, and diarrhea. Adenoid hyperplasia, characterized by enlarged adenoids, can lead to: * Nasal obstruction * Snoring * Mouth breathing * Hyponasal speech (speech with a reduced nasal resonance) If adenoid hyperplasia is long-standing, it can affect facial development due to insufficient tongue pressure. This can result in a narrow, high palate, protruding upper teeth, and an open mouth. #### 1.1.3 Diagnosis The diagnosis of adenoiditis and adenoid hyperplasia typically involves: * **Anamnesis:** Gathering a detailed medical history from the patient or caregiver. * **Nasofaryngoscopy:** A procedure to visualize the nasopharynx using a flexible endoscope. * **X-ray:** Imaging of the nasopharynx to assess the size of the adenoids. #### 1.1.4 Treatment Treatment strategies depend on the severity of symptoms and the presence of complications: * **Intervention of risk factors:** Addressing contributing factors such as environmental irritants or underlying conditions. * **Nasal rinsing:** Saline nasal rinses can help clear secretions and reduce inflammation. * **Antibiotics:** May be prescribed if a bacterial superinfection is suspected or confirmed. * **Adenotomy:** Surgical removal of the adenoids is indicated for recurrent cases or significant obstructive symptoms. > **Tip:** For children with significant nasal obstruction due to enlarged adenoids, early intervention with adenotomy can prevent long-term consequences on facial and dental development. ### 1.2 Pharyngitis While the document briefly mentions pharyngitis as an infection of the pharyngeal mucous membranes, the primary focus within the specified pages is on adenoiditis and hyperplasia. However, pharyngitis can be viral or bacterial and is often an associated symptom with adenoid issues. > **Tip:** Remember that pharyngitis is a general term for throat inflammation, and adenoiditis is a specific type of inflammation involving the adenoid tissue located in the nasopharynx. --- # Cleft palate and related conditions Cleft palate, also known as palatoschisis, refers to the incomplete fusion of the maxillary and frontonasal processes during embryonic development, resulting in a fissure in the palate. ### 19.1 Embryological origin and types Palatoschisis arises from the failure of the maxillary and frontonasal processes to fuse correctly during embryonic development. This can manifest in various forms: * **Cleft lip (cheiloschisis):** A fissure in the lip. * **Cleft palate (palatoschisis):** A fissure in the palate. * **Cleft lip and palate (cheilognatopalatoschisis):** Affecting both the lip and palate. These clefts can be unilateral or bilateral and complete or incomplete. ### 19.2 Causes and risk factors The etiology of cleft palate is multifactorial, involving genetic and environmental influences: * **Syndromic associations:** Cleft palate can be a component of various genetic syndromes, such as Stickler syndrome. * **Environmental risk factors:** * Maternal alcohol consumption. * Maternal nicotine exposure. * Maternal folate deficiency. ### 19.3 Incidence The incidence of cleft lip, jaw, and palate is approximately 1 in 1000 live births. Isolated cleft palate occurs with a frequency of about 1 in 2000 live births, and a submuceous cleft palate is seen in approximately 1 in 1200 live births. These figures can vary across different countries and populations. ### 19.4 Clinical presentation The clinical presentation of cleft palate depends on the extent and location of the fissure: * **Submucous cleft palate or uvula bifida (cleft uvula):** May be asymptomatic or present with mild symptoms. * **Cheilognatopalatoschisis:** Can have a significant impact on appearance, feeding, and speech production. * **Palatoschisis:** Can lead to impaired function of the Eustachian tube, increasing the risk of chronic otitis media. ### 19.5 Diagnosis Diagnosis of cleft palate is typically made through: * **Palpation and inspection:** A physical examination of the oral cavity. ### 19.6 Treatment Treatment for cleft palate is managed by a multidisciplinary cleft team, which usually includes: * Plastic surgeon * Maxillofacial surgeon * Otorhinolaryngologist (ENT specialist) * Speech therapist * Psychologist The treatment approach is tailored to the individual patient and may involve surgical repair. --- # Tonsillar inflammations and hypertrophy This section details the various inflammatory conditions and enlarged states of the tonsils, encompassing their causes, clinical presentations, diagnostic approaches, and treatment modalities, including surgical intervention. ### 17.3.1 Acute tonsillitis Acute tonsillitis refers to the inflammation of the mucous membrane and parenchyma of the palatine tonsils. #### 17.3.1.1 Causes The primary causes are viral infections, such as those caused by rhinoviruses and coronaviruses. Bacterial superinfections, notably by group A beta-hemolytic streptococci, can also occur. #### 17.3.1.2 Clinical presentation In young children, symptoms are often non-specific and mimic those of an upper respiratory tract infection, including fever, abdominal pain, and diarrhea. A classic presentation in older individuals involves sore throat (which may radiate to the ear), pain when swallowing, fever, swollen and painful cervical lymph nodes, and visibly enlarged tonsils. #### 17.3.1.3 Diagnosis Diagnosis is typically made through clinical examination. A throat culture may be performed in cases of atypical presentation or in immunocompromised patients. #### 17.3.1.4 Treatment Management includes symptomatic relief such as pain management, rest, and adequate fluid intake. Antibiotics are prescribed if a group A streptococcal infection is confirmed or if the course is atypical. Tonsillectomy is considered for recurrent cases. ### 17.3.2 Tonsillar hypertrophy Tonsillar hypertrophy refers to the enlargement of the tonsils. This is particularly common in children, often between the ages of two and eight years, where the tonsils are a significant part of the Waldeyer's ring. #### 17.3.2.1 Causes Hypertrophy is frequently associated with repeated infections, leading to an increase in tonsil size. Other contributing factors can include genetic predisposition, atopy, immunodeficiency, cleft palate, and environmental exposures such as smoking and living in close proximity to others (e.g., in daycare settings). #### 17.3.2.2 Clinical presentation Enlarged tonsils can lead to obstructive symptoms, including: * Mouth breathing * Snoring and disturbed sleep * Obstructive sleep apnea syndrome * Dysphagia (difficulty swallowing), particularly with solid foods * Poor appetite and drooling * Insufficient nutritional intake A clinical sign often observed is "kissing tonsils," where the tonsils are so enlarged that they meet in the midline. Palpation can also reveal enlarged tonsils. #### 17.3.2.3 Diagnosis Diagnosis is primarily based on clinical examination, noting the presence of obstructive symptoms and signs like kissing tonsils. Palpation of the tonsils is also performed. #### 17.3.2.4 Treatment The primary treatment for significant tonsillar hypertrophy causing obstructive symptoms is tonsillectomy. This is often performed in conjunction with adenoidectomy (adenotonsillectomy) if the adenoids are also enlarged. The decision for surgery is based on a set of established indications. ### 17.3.3 Chronic tonsillitis Chronic tonsillitis is characterized by persistent or recurrent inflammation of the tonsils, typically seen in young adults. #### 17.3.3.1 Causes This condition arises from impaired drainage of the tonsillar crypts, leading to a buildup of debris and a sustained inflammatory state. #### 17.3.3.2 Clinical presentation Symptoms include chronic or recurrent sore throat, malaise, fatigue, and the presence of debris within the tonsillar crypts. Palpable, tender lymph nodes in the neck are also common. #### 17.3.3.3 Diagnosis Diagnosis is based on patient history (anamnesis) and physical examination, including palpation of the cervical lymph nodes. #### 17.3.3.4 Treatment Management involves general supportive measures, good oral hygiene, and pain relief. Tonsillectomy is indicated for persistent or bothersome symptoms. ### 17.3.4 Related conditions While not direct tonsillar inflammations, several related conditions can affect the pharynx and tonsillar area: #### 17.3.4.1 Adenoiditis and adenoid hypertrophy Inflammation (adenoiditis) and enlargement (adenoid hypertrophy) of the adenoid tissue, often occurring in children due to normal immune system development or recurrent infections. Symptoms include nasal obstruction, snoring, and open-mouth breathing, which can lead to developmental issues such as a narrow palate and malocclusion if prolonged. Diagnosis involves history, nasopharyngoscopy, and X-rays. Treatment may include intervention on risk factors, nasal irrigation, antibiotics for secondary infections, and adenoidectomy for recurrent issues. #### 17.3.4.2 Palatoschisis (cleft palate) A congenital condition involving incomplete fusion of the maxillary and frontonasal processes during embryonic development. It can manifest as isolated cleft palate, cleft lip and palate, or be part of a syndrome. Presentation varies from asymptomatic to severe impact on facial appearance, feeding, and speech. Diagnosis involves palpation and inspection. Treatment requires a multidisciplinary team including plastic surgeons, maxillofacial surgeons, ENT specialists, speech therapists, and psychologists. #### 17.3.4.3 Cysts Various types of cysts can occur in the tonsillar region. Retention cysts may cause mild symptoms like difficulty swallowing or a globus sensation. Congenital neck cysts present as swellings in the neck. Diagnosis involves inspection, palpation, ultrasound-guided fine-needle aspiration, CT, and MRI. Treatment is typically surgical removal. #### 17.3.4.4 Chronic pharyngitis Chronic irritation of the pharyngeal mucosa, often caused by irritants like tobacco smoke, alcohol, or solvents. Symptoms include sore throat, pain on swallowing, and a persistent urge to clear the throat. Diagnosis is clinical. Treatment focuses on avoiding or managing the causative factors. #### 17.3.4.5 Papillomas Wart-like growths caused by HPV infection, usually asymptomatic but can cause a globus sensation. Diagnosis is clinical, and a biopsy may be performed. Treatment options include excision, often with a CO2 laser. #### 17.3.4.6 Benign (para)pharyngeal tumors Rare tumors such as fibromas and hemangiomas can occur. Larger tumors may cause snoring, obstructive sleep apnea, pain, and difficulty swallowing. Diagnosis involves clinical examination, biopsy, CT, and MRI. Surgical removal is the treatment of choice. #### 17.3.4.7 Angioedema Sudden swelling of the face, eyelids, lips, tongue, pharynx, and supraglottic larynx. Causes include medications, allergic reactions, and C1-esterase inhibitor deficiency. Presentation includes swelling and potential airway obstruction. Diagnosis relies on history and imaging. Treatment involves observation, potential intubation, and medication. #### 17.3.4.8 Oropharyngeal carcinoma (malignant tumors) Malignant tumors in the oropharynx, commonly affecting men, often located in the tonsil, tongue base, or soft palate. Risk factors include tobacco, alcohol, and HPV infection. Presentation is often late, with initial symptoms like globus sensation and pain on swallowing radiating to the ear. Diagnosis involves imaging and biopsy. Treatment options include surgery, chemotherapy, and radiotherapy. #### 17.3.4.9 Malignant lymphoma Malignant lymphoma can affect the Waldeyer's ring, often with a favorable prognosis. Symptoms include a globus sensation, difficulty swallowing, fatigue, fever, and night sweats. Diagnosis involves imaging and biopsy. Treatment typically includes chemotherapy and radiotherapy. #### 17.3.4.10 Hypopharyngeal carcinoma (malignant tumors) Malignant tumors in the hypopharynx, typically affecting men over 50 years old, often in the piriform sinus. Causes include alcohol and tobacco use. Symptoms include pain on swallowing radiating to the ear, increased mucus production, and hoarseness. Diagnosis involves flexible endoscopy with biopsy. Treatment can include surgery (tumor resection with reconstruction) and, for larger tumors, laryngectomy. > **Tip:** Understand that the TNM classification system is crucial for staging malignant tumors of the head and neck, including those in the oropharynx and hypopharynx, guiding treatment decisions and prognosis. #### 17.3.4.11 Globus sensation A subjective feeling of a lump or ball in the throat. Causes can include increased muscle tension, reflux, or anatomical abnormalities like outpouchings, diverticula, hypertrophy, or tumors. Clinical presentation involves the sensation itself, sometimes pain, weight loss, or voice changes. Diagnosis is made through clinical examination, palpation, endoscopy, and X-rays. Treatment depends on the identified cause. #### 17.3.4.12 Oropharyngeal swallowing disorders Difficulties with drinking, paradoxical cyanosis, and aspiration. Diagnosis involves videofluoroscopy to assess aspiration and coordination, as well as MRI and ultrasound. Treatment is symptomatic, potentially involving nasogastric tubes or percutaneous endoscopic gastrostomy (PEG) tubes. #### 17.3.4.13 Esophageal atresias and tracheoesophageal fistulas Congenital abnormalities of the esophagus characterized by incomplete development. Symptoms include excessive drooling, cyanosis, aspiration, and regurgitation after the first feeding. Diagnosis in newborns involves failure of a feeding tube to pass, X-rays, and potentially tracheoscopy or esophagoscopy. Treatment requires surgical repair. #### 17.3.4.14 Foreign bodies and perforations Foreign bodies in the airway or esophagus are common in children, while adults may ingest food boluses or bone fragments. Sharp objects can cause perforation. Symptoms vary from asymptomatic to severe, including shortness of breath, gag reflex, vomiting, regurgitation, and fever. Diagnosis involves history, clinical examination, and flexible endoscopy. Treatment depends on the location and nature of the object, ranging from removal to spontaneous evacuation. #### 17.3.4.15 Burns or corrosive injuries Ingestion of hot liquids or chemicals can cause inflammation, edema, and potential perforation of the esophagus. Symptoms range from asymptomatic to pain on swallowing, shortness of breath, fever, and shock. Diagnosis involves history, inspection, and esophagoscopy. Treatment involves stabilization, identifying the ingested substance, supportive care, antibiotics for severe lesions, and potentially esophageal resection. #### 17.3.4.16 Diverticula Outpouchings of the esophagus or hypopharynx, such as Zenker's diverticulum. Symptoms can be absent or include obstruction, regurgitation, aspiration, and chronic mucus production. Diagnosis involves speech therapy assessment, palpation, and barium swallow studies. Treatment involves dietary adjustments and potentially laser or stapler interventions. #### 17.3.4.17 Gastroesophageal reflux disease (GERD) Inflammatory reactions in the esophagus and laryngopharynx due to the reflux of stomach contents. Symptoms include dysphagia, retrosternal pressure, globus sensation, and precancerous changes like Barrett's esophagus. In infants, it can cause laryngeal spasms, stridor, apnea, and dyspnea. Diagnosis involves esophagoscopy and biopsies. Treatment includes antireflux medication and lifestyle modifications. #### 17.3.4.18 Stenoses and rigidity Stenoses (narrowing) can result from scarring due to burns, foreign bodies, radiotherapy, or surgery. Rigidity of pharyngeal muscles and the epiglottis can also occur. Symptoms include food passage difficulties and aspiration. Diagnosis involves speech therapy assessment and barium swallow studies. Treatment includes endoscopic dilations and dietary advice. #### 17.3.4.19 Neurogenic and neuromuscular swallowing disorders Various conditions such as stroke (CVA), Parkinson's disease, amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS) can affect swallowing. Symptoms include food passage problems and aspiration. Diagnosis involves speech therapy assessment, FEES (Fiberoptic Endoscopic Evaluation of Swallowing), and videofluoroscopy. Treatment focuses on speech therapy interventions, including exercises and compensatory strategies, and potentially tube feeding. #### 17.3.4.20 Presbyphagia Age-related changes in the swallowing mechanism. This is not a disease but a natural consequence of aging, where muscles and nerves involved in swallowing function more slowly and with less power. Reduced muscle strength, delayed coordination, decreased sensation, and reduced salivary production contribute. Symptoms include prolonged swallowing, globus sensation, aspiration, and regurgitation. Diagnosis involves speech therapy assessment. Treatment includes speech therapy exercises and dietary modifications. #### 17.3.4.21 Benign tumors of the oral cavity Rare benign tumors like leiomyomas, granular cell tumors, and fibromas can occur in the mouth. Symptoms may include swelling, pain, and speech or swallowing difficulties. Diagnosis involves clinical examination, imaging, and biopsy. Treatment is primarily surgical. #### 17.3.4.22 Malignant tumors of the oral cavity Malignant tumors, most commonly squamous cell carcinoma, can occur in various locations within the mouth, with a predilection for the tongue and floor of the mouth. Symptoms include swelling, pain, and problems with speech and swallowing. Diagnosis involves clinical examination, imaging, and biopsy. Treatment typically involves surgery, sometimes with reconstruction, and may include speech therapy. --- # Dysphagia and esophageal disorders This section outlines various causes and presentations of dysphagia, broadly categorized into oropharyngeal and esophageal disorders, detailing their clinical features, diagnostic approaches, and treatment strategies. ### 4.1 Oropharyngeal swallowing disorders Oropharyngeal dysphagia refers to difficulties in initiating or executing the swallow from the mouth to the esophagus, often stemming from neurological conditions, structural abnormalities, or inflammation. #### 4.1.1 Neurogenic and neuromuscular swallowing disorders A significant portion of individuals experiencing dysphagia, particularly following a cerebrovascular accident (CVA), suffer from neurogenic swallowing difficulties, with roughly half of CVA patients developing dysphagia and a high risk of aspiration pneumonia. Parkinson's disease also impairs oropharyngeal and esophageal swallowing phases, partly due to muscle rigidity. Other conditions like Amyotrophic Lateral Sclerosis (ALS) and Multiple Sclerosis (MS) can also lead to these issues. * **Clinical presentation:** Difficulty passing food, aspiration, and regurgitation. * **Diagnosis:** Logopedisch slikonderzoek (speech therapy swallowing assessment), FEES (Fiberoptic Endoscopic Evaluation of Swallowing), and videofluoroscopy (swallowing videos). * **Treatment:** Speech therapy swallowing training, including strengthening swallowing muscles, swallowing maneuvers, and compensatory strategies. Feeding tube placement may be necessary. #### 4.1.2 Presbyphagia Presbyphagia is the age-related decline in the swallowing mechanism, not a disease itself, but a natural slowing and weakening of muscle and nerve function involved in swallowing. * **Changes:** Reduced muscle strength (tongue, lips, esophagus), delayed coordination, decreased oral/pharyngeal sensation, and reduced saliva production. * **Clinical presentation:** Prolonged food passage, globus sensation (feeling of a lump in the throat), aspiration, and regurgitation. * **Diagnosis:** Logopedisch slikonderzoek, FEES, and videofluoroscopy. * **Treatment:** Speech therapy swallowing training (muscle strengthening, maneuvers), dietary modifications, and potentially feeding tube placement. #### 4.1.3 Adenoiditis and adenoid hyperplasia These conditions involve inflammation and enlargement of adenoid tissue, typically affecting children and often linked to the normal development of the immune system. Repeated infections can lead to hyperplasia, causing obstructive symptoms. * **Causes:** Primarily viral, with potential for secondary bacterial superinfection. Risk factors include age, genetics, atopy, immunodeficiency, cleft palate, winter months, daycare attendance, and tobacco smoke exposure. * **Clinical presentation:** * Young children: Non-specific upper respiratory tract infection symptoms (fever, abdominal pain, diarrhea). * Hyperplasia: Nasal obstruction, snoring, mouth breathing, hyponasal speech. Chronic cases can result in insufficient tongue pressure, leading to palate deformities (narrow, high palate), protruding upper teeth, and an open mouth. * **Diagnosis:** History, nasopharyngoscopy, and X-ray scans. * **Treatment:** Interventions may include addressing risk factors, nasal irrigation, and possibly antibiotics if a bacterial superinfection is suspected. Adenotomy (surgical removal of adenoids) is considered for recurrent cases. #### 4.1.4 Palatoschisis (cleft lip or palate) This congenital defect results from incomplete fusion of the maxillary and frontonasal processes during embryonic development. It can manifest as a cleft lip, palate, or both (cheilognatopalatoschisis), occurring unilaterally or bilaterally, completely or incompletely. * **Causes:** Can be part of a syndrome (e.g., Stickler syndrome) or influenced by environmental risk factors (alcohol, nicotine, folic acid deficiency). * **Incidence:** Approximately 1 in 1000 for lip-jaw-palate clefts, 1 in 2000 for isolated palatal clefts, and 1 in 1200 for submucous cleft palate. Incidence varies geographically and ethnically. * **Clinical presentation:** * Submucous cleft palate/uvula bifida: May be asymptomatic or cause mild symptoms. * Cheilognatopalatoschisis: Significant impact on appearance, feeding difficulties, and speech production. * Palatoschisis: Impaired Eustachian tube function, leading to chronic otitis media. * **Diagnosis:** Palpation and inspection. * **Treatment:** Requires a multidisciplinary cleft team including plastic surgeons, maxillofacial surgeons, ENT specialists, speech therapists, and psychologists. #### 4.1.5 Pharyngitis and tonsillitis These are inflammatory conditions of the pharynx and palatine tonsils, commonly affecting children. * **Causes:** * Pharyngitis: Primarily viral (rhinovirus, coronavirus), occasionally with secondary bacterial infection. * Tonsillitis: Viral or bacterial (e.g., Group A Streptococcus). * **Clinical presentation:** * Young children: Non-specific symptoms similar to upper respiratory tract infections (fever, abdominal pain, diarrhea). * Classic presentation: Sore throat (radiating to the ear), odynophagia (painful swallowing), fever, swollen/tender cervical lymph nodes, and enlarged tonsils. * **Diagnosis:** Clinical examination. Throat swabs are used for atypical presentations or immunocompromised patients. * **Treatment:** Pain relief, rest, and adequate fluid intake. Antibiotics are prescribed for Group A Streptococcus infections or atypical cases. Tonsillectomy is considered for recurrent tonsillar hyperplasia. #### 4.1.6 Chronic tonsillitis Primarily seen in young adults, this condition arises from impaired drainage of tonsillar crypts. * **Clinical presentation:** Chronic or recurrent sore throat, malaise, fatigue, debris in tonsillar crypts, and painful cervical lymph nodes. * **Diagnosis:** History and palpation of cervical lymph nodes. * **Treatment:** General supportive measures, good oral hygiene, pain relievers, and tonsillectomy. #### 4.1.7 Chronic pharyngitis Characterized by chronic irritation of the pharyngeal mucosa. * **Causes:** Irritation from tobacco smoke, alcohol, and solvents. * **Clinical presentation:** Sore throat, odynophagia, and a sensation of needing to clear the throat (throat clearing) and coughing. * **Diagnosis:** Clinical examination. * **Treatment:** Avoiding or treating the causative factors. #### 4.1.8 Papillomas These are wart-like growths caused by HPV infection. * **Causes:** Viral transmission through direct contact. * **Clinical presentation:** Often asymptomatic, but may cause a globus sensation. * **Diagnosis:** Clinical appearance and biopsy. * **Treatment:** No specific causal treatment exists. Excision, often with a CO2 laser, may be performed. #### 4.1.9 Benign (para)pharyngeal tumors These include fibromas and hemangiomas. Salivary gland tumors, neurogenic tumors, and glomus tumors are rarer. * **Clinical presentation:** Often asymptomatic and discovered incidentally. Large tumors can cause snoring, obstructive sleep apnea, pain, swallowing difficulties, and neck swelling. * **Diagnosis:** Clinical examination, fine-needle aspiration or biopsy, CT, and MRI. * **Treatment:** Surgical removal. #### 4.1.10 Angio-oedema This condition involves sudden swelling of the face, eyelids, lips, tongue, pharynx, and supraglottic larynx. * **Causes:** Angioneurotic oedema, drug side effects, allergic reactions (e.g., to food), and C1-esterase inhibitor deficiency. * **Clinical presentation:** Swelling and potential airway obstruction. * **Diagnosis:** History and imaging. * **Treatment:** Hospital admission for observation, possible intubation if airway compromise occurs, and medication. #### 4.1.11 Oropharyngeal carcinoma (malignant tumors) More common in men, these tumors typically arise in the tonsils, base of the tongue, or soft palate. * **Causes:** Tobacco use, alcohol consumption, and HPV infection. * **Clinical presentation:** Often diagnosed late, initially presenting with globus and swallowing difficulties, and odynophagia radiating to the ear. * **Diagnosis:** Imaging and biopsy. * **Treatment:** Surgery, chemotherapy, and radiotherapy. #### 4.1.12 Malignant lymphoma (malignant tumors) The Waldeyer's ring is a common site for lymphomas, which generally have a favorable prognosis. * **Clinical presentation:** Globus sensation, swallowing difficulties, and general lymphoma symptoms such as fatigue, fever, and night sweats. * **Diagnosis:** Imaging and biopsy. * **Treatment:** Chemotherapy and radiotherapy. #### 4.1.13 Globus This is the sensation of a lump in the throat without any underlying structural abnormality. * **Causes:** Increased muscle tension, reflux, and anatomical variations such as outpouchings, diverticula, hyperplasia, or tumors. * **Clinical presentation:** Sensation of a lump in the throat, pain, weight loss, food passage disorders, and voice changes. * **Diagnosis:** Clinical examination, palpation, endoscopic examination, and X-ray. * **Treatment:** Depends on the identified cause. #### 4.1.14 Hypopharyngeal carcinoma (malignant tumors) Typically affects men over 50, often originating in the pyriform sinus. * **Causes:** Alcohol and tobacco use. * **Clinical presentation:** Odynophagia radiating to the ear, increased mucus production in the throat, and hoarseness. * **Diagnosis:** Flexible endoscopic examination with biopsy. * **Treatment:** Surgery (tumor resection and defect repair). For large tumors, laryngectomy may be required. ### 4.2 Esophageal disorders Esophageal dysphagia arises from problems within the esophagus itself, affecting the transport of food from the pharynx to the stomach. #### 4.2.1 Oesophageal atresias and tracheo-oesophageal fistulas These are the most common congenital abnormalities of the esophagus, characterized by incomplete development. They are classified into various types based on the location of the abnormality. * **Clinical presentation:** Excessive drooling, cyanosis, aspiration, and regurgitation upon the first feeding. * **Diagnosis:** In newborns, difficulty passing a feeding tube. X-ray of the swallow may be performed. If uncertain, tracheoscopy or oesophagoscopy is indicated. * **Treatment:** Surgical repair. #### 4.2.2 Foreign bodies and perforations Foreign bodies are more common in children, with aspiration of sharp objects leading to perforation. Large objects can obstruct the airway. In adults, boluses of food and bone fragments are common, particularly in those with dentures. * **Clinical presentation:** Varies from asymptomatic to shortness of breath, gag reflex, vomiting, regurgitation, food passage disorder, fever, and severe dysphagia. * **Diagnosis:** History, clinical examination, flexible fiberendoscopic nasopharyngoscopy/oesophagoscopy, and potentially X-ray. * **Treatment:** Removal of foreign bodies in the proximal esophagus. Objects in the stomach are often evacuated spontaneously. #### 4.2.3 Burns or caustic ingestion These injuries can occur accidentally in children or intentionally in suicide attempts. Initial inflammation and edema are followed by potential perforation around 4-7 days later. Esophageal burns have significant morbidity. * **Causes:** Hot beverages or chemical substances. * **Clinical presentation:** Can be asymptomatic, or present with odynophagia, shortness of breath, fever, shock, and burns to the lips and oral mucosa. * **Diagnosis:** History, inspection, and oesophagoscopy (both rigid and flexible). * **Treatment:** Patient stabilization, identifying the ingested substance and consulting the poison control center, administering a feeding tube, antibiotics for third-degree burns, and possibly oesophageal resection. #### 4.2.4 Diverticula These are outpouchings of the esophagus or hypopharynx, classified as pulsion (e.g., Zenker's diverticulum) or traction diverticula. * **Clinical presentation:** Often asymptomatic. Large Zenker's diverticula can cause obstruction, regurgitation, aspiration, and chronic mucus production. * **Diagnosis:** Logopedisch slikonderzoek (speech therapy swallowing assessment) and palpation, videofluoroscopy with barium contrast. * **Treatment:** Dietary consistency adjustments. Laser and/or stapler techniques may be used. #### 4.2.5 Gastro-oesophageal reflux disease (GERD) GERD involves inflammatory reactions in the oesophageal and laryngopharyngeal mucosa due to the reflux of stomach contents. * **Clinical presentation:** Dysphagia, retrosternal pressure, globus sensation, and premalignant Barrett's esophagus. In infants, it can cause laryngeal spasms leading to shortness of breath, apnea, and stridor. * **Diagnosis:** Oesophagoscopy with biopsies. * **Treatment:** Antireflux medication and lifestyle modifications (avoiding alcohol, smoking, caffeine, and fatty foods). #### 4.2.6 Stenoses and rigidity Stenoses are strictures caused by scarring from chemical burns, foreign bodies, radiotherapy, or surgery for tumors. Rigidity can affect pharyngeal muscles and the epiglottis. * **Clinical presentation:** Food passage difficulties. Stasis and regurgitation can lead to aspiration. * **Diagnosis:** Logopedisch slikonderzoek and videofluoroscopy with barium contrast. * **Treatment:** Endoscopic dilations, dietary advice, and swallowing exercises. #### 4.2.7 Benign tumors These include leiomyomas, granular cell tumors, and fibromas, which are rare. Malignant tumors, particularly squamous cell carcinoma, can occur in various locations, with a predilection for the tongue border and oral cavity. * **Clinical presentation:** Swelling, pain, and difficulties with speech and swallowing. * **Diagnosis:** Clinical examination, palpation, imaging, and biopsy. * **Treatment:** Primarily surgery. Bone resection may be necessary. Tongue reconstructions may involve tissue grafts. Speech therapy is also utilized. #### 4.2.8 Oropharyngeal swallowing disorders (general) These disorders manifest as difficulties in drinking, intermittent cyanosis, and aspiration. * **Diagnosis:** Videofluoroscopy to assess aspiration and impaired swallowing coordination, MRI, and ultrasound. * **Treatment:** Symptomatic management, including nasogastric tubes (PEG or PRG feeding tubes). --- # Tumors in the pharyngeal region This section details benign and malignant neoplasms affecting the pharynx, encompassing oropharyngeal and hypopharyngeal carcinomas, lymphomas, and benign growths. ### 5.1 Benign tumors of the pharyngeal region Benign tumors in the pharyngeal area are typically discovered incidentally due to their small size and lack of symptoms. Larger masses can lead to nasal obstruction, snoring, obstructive sleep apnea, pain, dysphagia, and visible swelling in the throat or neck. Diagnosis often involves clinical examination, palpation, imaging (CT, MRI), and biopsy or fine-needle aspiration. Surgical excision is the primary treatment. #### 5.1.1 Specific benign tumor types * **Fibromas and hemangiomas:** These are examples of benign growths that can occur in the pharyngeal region. * **Papillomas:** These are wart-like growths caused by Human Papillomavirus (HPV) infection, usually transmitted via direct contact. They are often asymptomatic but can sometimes cause a globus sensation. Treatment is not always necessary, but excision, often with a CO2 laser, may be performed. * **Salivary gland tumors, neurogenic tumors, and glomus tumors:** These are considered rare in the pharyngeal region. > **Tip:** While benign tumors may be asymptomatic, their growth can lead to significant obstructive symptoms if they become large enough. ### 5.2 Malignant tumors of the pharyngeal region Malignant tumors in the pharynx present a significant health concern, with varying prognoses and treatment modalities. #### 5.2.1 Oropharyngeal carcinoma Oropharyngeal carcinomas are more common in men and primarily affect the tonsil, tongue base, and soft palate. * **Causes:** Key risk factors include tobacco use, alcohol consumption, and HPV infection. * **Clinical Presentation:** Symptoms often manifest late, initially presenting as a globus sensation and dysphagia. Pain during swallowing that radiates to the ear is a characteristic symptom. * **Diagnosis:** Imaging studies and biopsy are crucial for diagnosis. * **Treatment:** A multidisciplinary approach involving surgery, chemotherapy, and radiotherapy is typically employed. #### 5.2.2 Hypopharyngeal carcinoma Hypopharyngeal carcinomas typically affect men over 50 years old and are most commonly found in the piriform sinus. * **Causes:** Alcohol and tobacco use are significant contributing factors. * **Clinical Presentation:** Symptoms include odynophagia (painful swallowing) with radiation to the ear, increased mucus production in the throat, and hoarseness. * **Diagnosis:** Flexible endoscopic examination with biopsy is the standard diagnostic method. * **Treatment:** Surgical resection of the tumor, with reconstruction of defects, is the primary treatment. For larger tumors, laryngectomy may be necessary. #### 5.2.3 Malignant lymphoma Malignant lymphomas can affect the Waldeyer's ring, a collection of lymphoid tissue in the pharynx. * **Prognosis:** Generally associated with a favorable survival rate. * **Clinical Presentation:** Symptoms may include a globus sensation, dysphagia, and general lymphoma-related symptoms such as fatigue, fever, and night sweats. * **Diagnosis:** Imaging studies and biopsy are essential. * **Treatment:** Chemotherapy and radiotherapy are the main treatment modalities. > **Tip:** Early detection of pharyngeal carcinomas is critical for improving treatment outcomes. Be aware of persistent symptoms like unexplained sore throat, difficulty swallowing, or ear pain. ### 5.3 Other pharyngeal region conditions with tumor-like implications While not strictly tumors, certain conditions can present with masses or swelling in the pharyngeal region, requiring differential diagnosis. #### 5.3.1 Cysts Cysts in the pharyngeal region can be retention cysts or congenital neck cysts. * **Clinical Presentation:** Retention cysts may be asymptomatic or cause mild swallowing or globus sensations, and respiratory issues if large. Congenital neck cysts present as swellings in the neck. * **Diagnosis:** Inspection, palpation, ultrasound-guided fine-needle aspiration, CT, and MRI are used. * **Treatment:** Surgical removal is the standard treatment. #### 5.3.2 Angioedema Angioedema involves sudden swelling of the face, eyelids, lips, tongue, pharynx, and supraglottic larynx. * **Causes:** It can be hereditary (C1-esterase inhibitor deficiency), drug-induced, or an allergic reaction. * **Clinical Presentation:** Rapid swelling, potentially leading to airway obstruction. * **Diagnosis:** Primarily based on patient history and imaging. * **Treatment:** Hospital admission for observation, potential intubation, and medication are required. #### 5.3.3 Globus sensation The feeling of a lump in the throat can have various causes, including tumors. * **Causes:** Increased muscle tension, reflux, or anatomical abnormalities such as outpouchings, diverticula, hyperplasia, and tumors. * **Clinical Presentation:** Sensation of a lump, pain, weight loss, dysphagia, and voice changes. * **Diagnosis:** Clinical examination, palpation, endoscopic evaluation, and X-rays are used to rule out underlying pathology. * **Treatment:** Dependent on the identified cause. > **Example:** A patient presenting with a persistent globus sensation and dysphagia might undergo an endoscopy to rule out a pharyngeal tumor, in addition to investigations for reflux or muscle tension disorders. --- ## Common mistakes to avoid - Review all topics thoroughly before exams - Pay attention to formulas and key definitions - Practice with examples provided in each section - Don't memorize without understanding the underlying concepts

| Term | Definition | |------|------------| | Adenoiditis | Inflammation of the adenoid tissue, typically seen in children, often associated with the normal development of the immune system. | | Adenoid hyperplasia | Enlargement of the adenoid tissue, which can lead to nasal obstruction, snoring, and mouth breathing, often as a result of repeated infections. | | Pharyngitis | Infection of the mucous membranes of the pharynx, commonly caused by viruses but can also involve bacterial superinfections. | | Palatoschisis | A congenital condition characterized by an incomplete or absent fusion of the maxillary and frontonasal processes, resulting in a cleft lip or palate. | | Cheilognatopalatoschisis | A combined condition involving a cleft lip, jaw, and palate, presenting with significant impact on appearance, feeding, and speech production. | | Uvula bifida | A split uvula, which can be a sign of a submucous cleft palate and may present with mild or no symptoms. | | Chronic otitis media | Persistent inflammation of the middle ear, often a consequence of impaired Eustachian tube function, which can be linked to palatoschisis. | | Tonsillitis | Inflammation of the palatine tonsils, which can be acute or chronic, caused by viral or bacterial agents. | | Tonsillar hypertrophy | Enlargement of the tonsils, commonly observed in children aged 2-8 years, which can lead to obstructive symptoms like mouth breathing and snoring. | | Obstructive sleep apnea syndrome | A sleep disorder characterized by repeated episodes of upper airway obstruction during sleep, often associated with tonsillar hypertrophy. | | Globus pharyngeus | A sensation of a lump or foreign body in the throat, which can be caused by various factors including increased muscle tension, reflux, or anatomical abnormalities. | | Oropharyngeal carcinoma | A malignant tumor originating in the oropharynx, with common locations including the tonsil, base of the tongue, and soft palate, strongly linked to tobacco, alcohol, and HPV infection. | | Malignant lymphoma | A type of cancer affecting the lymphatic system, which can occur in the Waldeyer ring of lymphoid tissue in the pharynx and is generally associated with a favorable prognosis. | | Hypopharyngeal carcinoma | A malignant tumor located in the hypopharynx, typically affecting men over 50 and often associated with alcohol and tobacco use. | | Dysphagia | Difficulty in swallowing, which can manifest as food passage disorders, aspiration, regurgitation, and changes in voice. | | Esophageal atresia | A congenital defect where the esophagus fails to develop completely, resulting in an incomplete tube. | | Tracheo-esophageal fistula | An abnormal connection between the trachea and the esophagus, often occurring alongside esophageal atresia. | | Corpora aliena | Foreign bodies lodged within the digestive tract, most commonly aspirated by children and can cause obstruction or perforation. | | Esophageal burns | Damage to the esophageal lining caused by hot liquids or corrosive chemicals, leading to inflammation, edema, and potentially perforation. | | Diverticula | Outpouching or sacs that form in the wall of the esophagus or hypopharynx, which can be pulsion or traction type. | | Zenker diverticulum | A type of pulsion diverticulum located in the hypopharynx, above the cricopharyngeal muscle, which can cause obstruction and aspiration. | | Gastro-esophageal reflux disease (GERD) | A condition where stomach contents flow back into the esophagus and laryngopharynx, causing inflammation and symptoms like heartburn and dysphagia. | | Stenosis | Narrowing of a passageway, such as the esophagus, often due to scarring from burns, foreign bodies, radiation therapy, or surgery. | | Presbyphagia | Age-related changes in the swallowing mechanism that affect muscle strength, coordination, and sensation, leading to a slower and less efficient swallow. | | Benign tumors | Non-cancerous growths that can occur in the pharyngeal region, such as leiomyomas, granular cell tumors, and fibromas, which are typically rare. |