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Tonsil, Oropharynx, And Carcinoma Larynx Anatomy Of Tonsil

Tonsil is subepithelial aggregation of lymphoid tissue which forms a part of Waldeyer’s ring. It is ovoid in shape and situated in the lateral wall of the oropharynx between the anterior and posterior pillars.

It has 2 surfaces (medial and lateral) and 2 poles (upper and lower).

Read And Learn More: Clinical Medicine And Surgery Notes

Tonsil Medial Surface

It is covered by non-keratinising stratified squamous epithelium which dips into the substance of the tonsil to form crypts which are 1215 in number. Crypta magna or intratonsillar cleft is the largest crypt situated in the upper part of the tonsil.

Tonsil Lateral Surface

Laterally it is covered by a well-defined capsule. Between the capsule and bed of the tonsil lies loose areolar tissue which forms the plane of dissection during tonsillectomy.

Bed of the tonsil (From medial to lateral)

  • Pharyngobasilar fascia
  • Superior constrictor muscle and styloglossus
  • Buccopharyngeal fascia
  • The glossopharyngeal nerve and stylohyoid ligament pass beneath the lower border of the superior constrictor
  • The peritonsillar vein running on the lateral surface of the capsule pierces the pharyngeal wall to join the pharyngeal plexus
  • The tonsillar artery, a branch of the facial artery, pierces the superior constrictor and supplies the tonsil
  • The posterior belly of the digastric, submandibular salivary gland, medial pterygoid muscle and mandible are the distant lateral relations.

Tonsil Upper Pole

Extends into the soft palate. Its medial surface is covered by a semilunar fold extending between anterior and posterior pillars. This fold encloses the supra tonsillar fossa.

Tonsil Lower Pole

A triangular fold extending from the anterior pillar to the anteroinferior part of the tonsil encloses the anterior tonsillar space. It is separated from the tongue by tonsillolingual sulcus.

Tonsil Arterial Blood Supply

  • Tonsillar branch of the facial artery
  • Ascending pharyngeal artery
  • Ascending palatine artery
  • Dorsal linguae, branches of the lingual artery
  • Descending palatine branch of the maxillary artery.

Tonsil Venous Drainage

The paratonsillar vein drains into the common facial which drains into the pharyngeal plexus.

Lymphatic Drainage

Upper deep cervical nodes, especially jugulodigastic nodes (tonsillar node).

Tonsil Nerve Supply

Lesser palatine branch of the sphenopalatine ganglion and glossopharyngeal nerve

Tonsillitis

Inflammation of the tonsil can present as acute or chronic.

Acute Tonsillitis

It is classified into 4 types based on the involvement of the following tissues:

  • Surface epithelium
  • Crypts
  • Lymphoid tissue.

Acute Tonsillitis Types

  1. Acute catarrhal tonsillitis: Seen in viral infection where tonsillitis is a part of generalized pharyngitis
  2. Acute follicular tonsillitis: Crypts are filled with purulent material.
  3. Acute parenchymatous tonsillitis: Tonsil substance is affected. It is enlarged and red.
  4. Acute membranous tonsillitis: Exudates from crypts coalesce to form a membrane over the surface.

Tonsil Etiology

  1. Age: Schoolgoing children and adults are commonly affected.
  2. Organisms: Hemolytic streptococci, staphylococci, pneumococci.

Tonsil Etiology Symptoms

  • Sore throat
  • Difficulty in swallowing
  • Fever with or without chills (38–40° C)
  • Ear ache
  • Constitutional symptoms such as headache, abdominal pain (mesenteric lymphadenitis), generalized body ache, and malaise.

Tonsil Etiology Signs

  • Fetid breath and coated tongue
  • Tonsils are covered with yellow spots on the surface (type 2), or a white membrane covering the tonsil which can be easily wiped away (type 4) or enlarged and congested (type 3).

Tonsil  Etiology Treatment

  • Bed rest
  • Increased fluid intake
  • Analgesics
  • Antibiotics: Penicillin or erythromycin.

Tonsil  Etiology Complications

  • Chronic tonsillitis
  • Peritonsillar abscess
  • Parapharyngeal abscess
  • Cervical abscess
  • Acute otitis media
  • Rheumatic fever
  • Acute glomerulonephritis
  • Subacute bacterial endocarditis.

Tonsil Chronic Tonsillitis

  • Occurs due to incomplete resolution of acute infection.
  • Chronic sinusitis or chronic infection of teeth can be predisposing factors.

Chronic Tonsillitis Types

  1. Chronic follicular tonsillitis: In this condition, crypts are filled with yellow cheesy material.
  2. Chronic parenchymatous infections: Here tonsils are very much enlarged which
    interfere with speech, deglutition, and respiration. It can also cause obstructive sleep apnoea.
  3. Chronic fibroid tonsillitis: Here tonsils are small but infected.

Chronic Tonsillitis Clinical features

  • Recurrent/persistent sore throat
  • Chronic throat irritation/cough
  • Halitosis
  • Thick speech
  • Difficulty in swallowing
  • Difficulty in breathing (at night).

Chronic Tonsillitis Examination

  • Signs suggestive of 3 types of chronic tonsillitis as given below:
    • Congestion of anterior pillars
    • Enlarged and non-tender jugulodigastric lymph nodes.
    • Septic squeeze positive—release of pus/ cheesy material from tonsil on
      applying pressure on the anterior pillar, Erwin -Moore sign.

Chronic Tonsillitis Treatment

  1. Conservative
    • Improve general health
    • Good diet
    • Treat coexistent sinusitis or dental caries.
  2. Tonsillectomy

Complications of Chronic Tonsillitis

  1. Peritonsillar abscess
  2. Parapharyngeal abscess
  3. Intratonsillar abscess
  4. Tonsillolith
  5. Tonsillar cyst
  6. Focus of infection: Rheumatic fever, acute glomerulonephritis, eye/skin disorders.

Quinsy Peritonsillar Abscess

Collection of pus in peritonsillar space (between capsule of tonsil and superior constrictor muscle).

Quinsy Peritonsillar Abscess Etiology

  1. As a sequelae of acute tonsillitis.
  2. De novo.
  3. Causative organisms: Streptococcus pyogenes, Staphylococcus aureus, anaerobic organisms.

Quinsy Peritonsillar Abscess Mechanism

One of the crypts or crypto magna gets filled

Tonsil, Oropharynx And Carcinoma Larynx One of the crypts or crypta magna gets filled

Quinsy Peritonsillar Abscess Mechanism Clinical features General And Local

  • High-grade fever with chills and rigors
  • Severe unilateral throat pain
  • Malaise
  • Odynophagia leading to dehydration
  • Bodyache and headache
  • Hot potato speech
  • Nausea
  • Foul breath
  • Constipation
  • Poor or dental hygiene
  • Ipsilateral earache
  • Trismus

Quinsy Peritonsillar Abscess Mechanism Examination

  • Tonsils, pillars, soft palate: Congested on the involved side.
  • Uvula: Swollen and pushed to the opposite side.
  • The region of the soft palate and anterior pillar above the tonsil appears bulged.
  • Mucopus covering the tonsil.
  • Cervical lymph nodes are enlarged, and tender.
  • Torticollis: Head tilted to the involved side.

Quinsy Peritonsillar Abscess Mechanism Treatment

  1. Conservative
    • Hospitalization and 4 fluids
    • 4 antibiotics for aerobic and anaerobic organisms
    • Analgesics
    • Oral hygiene: Hydrogen peroxide and warm saline mouth gargles.
  2. Surgical
    1. Incision and drainage
      1. If no response to conservative management and frank pus is present, incision and drainage are done.
      2. Incision site: Point of maximum bulge above the upper pole of the tonsil, just lateral to the meeting point of lines drawn at the base of the uvula and along the anterior pillar.
      3. Once the incision is made, sinus forceps are inserted into the incision to open up the abscess.
    2. Interval tonsillectomy
    3. Interval tonsillectomy is done 4 to 6 weeks following quinsy.

Abscess Or Hot Tonsillectomy done in the presence of the abscess has The following disadvantages:

  1. Risk of rupture during anesthesia
  2. Increased bleeding.

Quinsy Peritonsillar Abscess Complications

  • Parapharyngeal abscess
  • Laryngeal oedema
  • Septicaemia
  • Pneumonitis/lung abscess
  • Endocarditis
  • Nephritis
  • Brain abscess
  • Jugular vein thrombosis

Retropharyngeal Abscess

Collection of pus in the retropharyngeal space.

Retropharyngeal Space

It communicates laterally with the nasopharyngeal space.

Site: It lies posterior to the pharynx between buccopharyngeal fascia and prevertebral fascia.

Extent: From the base of the skull to the bifurcation of the trachea. It is divided into two spaces of Gillette by fibrous raphe. Each space of Gillette has a retropharyngeal lymph node that disappears by 3–4 years of age.

Acute Retropharyngeal Abscess Aetiology

  • It is common in children less than 3 years. It occurs due to suppuration of retropharyngeal lymph node secondary to adenoids, sinusitis, or upper respiratory tract infections.
  • In adults, it is due to penetrating injuries to the posterior pharyngeal wall or cervical esophagus including foreign bodies.
  • Rarely pus from acute mastoiditis tracks along the undersurface of petrous bone, giving rise to a retropharyngeal abscess.

Acute Retropharyngeal Abscess Clinical features

  • Difficulty in swallowing and breathing
  • Stridor, croupy cough
  • Torticollis
  • Bulge in a posterior pharyngeal wall on one side of the midline.

Acute Retropharyngeal Abscess Investigation

X-ray neck soft tissue lateral view shows prevertebral widening, air-fluid level, and straightening of the cervical spine.

Acute Retropharyngeal Abscess Treatment

  1. Incision and drainage: It can be done without anesthesia.
    • Position: Supine with head low.
    • Mouth opened with gag.
    • A vertical incision was made on the most fluctuant area of the abscess, pus exudes out and is sucked with suction to prevent aspiration.
  2. Systemic antibiotics are given.
  3. Tracheostomy: It may be necessary in case of a large abscess when a patient presents with stridor.

Chronic Retropharyngeal Abscess Aetiology

  • Caries of the cervical spine.
  • Tuberculous infection of retropharyngeal lymph nodes secondary to tuberculosis (TB) of deep cervical lymph nodes.

Chronic Retropharyngeal Abscess Clinical features

  • Discomfort in throat
  • Difficulty in swallowing.
  • On examination: Fluctuant central/unilateral swelling.
    • Central → In case of caries spine.
    • Unilateral → Tuberculous lymphadenitis.
    • A neck examination may reveal enlarged cervical lymph nodes.

Chronic Retropharyngeal Abscess Investigations

X-ray neck lateral view to rule out caries spine.

Chronic Retropharyngeal Abscess Treatment

  • Incision and drainage: Vertical incision along the anterior border of sternocleidomastoid for low abscess, or posterior border of sternocleidomastoid for high abscess is made and pus is drained out.
  • Antitubercular therapy is given.

Parapharyngeal Abscess (Abscess Of Pharyngomaxillary/Lateral Pharyngeal Space)

Boundaries of parapharyngeal space

  • Medial: Buccopharyngeal fascia covering constrictor muscles.
  • Posterior: Prevertebral fascia and transverse process of cervical vertebrae.
  • Lateral: Medial pterygoid muscle, mandible, the deep surface of the parotid gland.
  • The styloid process divides parapharyngeal space into:
  • Anterior I prestyloid compartment, i.e. related to tonsillar fossa medially and medial pterygoid laterally.
  • Posterioripoststyloid compartment: Bounded medially by the posterior part of the lateral pharyngeal wall and laterally by the parotid gland.

Contents of posterior compartment:

  • Internal carotid artery
  • Internal jugular vein
  • IX, X, XI, XII cranial nerves
  • Sympathetic trunk
  • Upper deep cervical lymph nodes.

Parapharyngeal Abscess Aetiology

  1. Pharynx
    • Acute and chronic tonsillitis
    • Peritonsillar abscess
    • Adenoids
  2. Dental: Lower last molar tooth infection
  3. Ear: Bezold’s abscess, petrositis
  4. Other space infections: Parotid, retropharyngeal, submaxillary
  5. Penetrating injuries.

Parapharyngeal Abscess Clinical features

  1. Due to anterior compartment infection:
    • Tonsil appears prolapsed medially
    • Trismus
    • Swelling in the neck behind the angle of the jaw.
  2. Posterior compartment infection:
  3. The pharynx appears bulged behind posterior pillars.
    • IX, X, XI, XII, sympathetic trunk paralysis
    • Parotid swelling
    • Minimal tonsillar prolapse and trismus.

Parapharyngeal Abscess Common features

Fever, odynophagia, torticollis, toxic features

Parapharyngeal Abscess Complications

  1. Acute laryngeal edema: respiratory obstruction.
  2. Jugular vein thrombophlebitis: septicemia.
  3. Spread to retropharyngeal space.
  4. Spread to mediastinum along carotid space.
  5. Carotid artery erosion.

Parapharyngeal Abscess Treatment

  1. Drainage
    • Under general anesthesia.
    • Preoperative tracheostomy, if marked trismus is present.
    • Horizontal incision 2–3 cm below the angle of the mandible, at the level of the hyoid
      bone.
    • Drain is inserted.
  2. Systemic antibiotics are given.

Tonsillectomy

Tonsillectomy Indications

  1. Infection
    • Recurrent acute tonsillitis
    • Chronic tonsillitis
    • Peritonsillar abscess
    • Source of infection to heart, kidney, brain
  2. Obstruction
    • Obstructive sleep apnoea syndrome
  3. Approach
    • Removal of the styloid process
    • Glossopharyngeal neurectomy
  4. Miscellaneous
    • Unilateral enlargement, i.e. suspected neoplasia
    • Tonsillolith
    • Keratosis
  5. Techniques
    • Dissection and snare
    • Laser
    • Electrocautery
    • Coblation
    • Guillotine

Tonsillectomy Complications

  1. Intraoperative
    1. Primary haemorrhage
    2. Injury to surrounding structures
  2. Postoperative
  3. Early
    1. Reactionary haemorrhage
    2. Aspiration
    3. Pulmonary edema
  4. Late
    1. Secondary haemorrhage
    2. Remnants
    3. Scarring of palate

Carcinoma Larynx

  • Male: Female = 10 : 1
  • Age group: 40–70 years

Carcinoma Larynx Aetiology

Smoking, alcohol: A combination of smoking and alcohol increases risk 15 times.

  • Previous irradiation to the neck.
  • Genetic.
  • Occupational exposure to asbestos, mustard gas, chemical or petroleum products.

Carcinoma Larynx Classification (according to the site)

  • Supraglottic
  • Glottic
  • Subglottic

Each site is further classified by the TNM system.

Nodal Involvement

  • Nx Nodes cannot be assessed
  • N0 No clinically positive nodes
  • N1 Single homolateral 3 cm in diameter
  • N2a Single homolateral > 3 cm < 6 cm
  • N2b Multiple homolateral nodes < 6 cm
  • N2c Contralateral nodes
  • N3 Nodes > 6 cm.

Distant Metastasis

  • Mx Not assessed
  • Mo No known distant metastasis
  • M1 Distant metastasis present
  • Stage 1 T1NoMo
  • Stage 2 T2NoMo
  • Stage 3 T3NoMo or T1/T2/T3 with N1 Mo
  • Stage 4 T4 or Any T with N2 Mo or Any T, Any N with M1

Carcinoma Supraglottis

  • Structures of supraglottis are epiglottis, aryepiglottic folds, arytenoids, ventricular bands, and saccule/ventricle.
  • Common locations are epiglottis, false cords, and aryepiglottic folds.

Carcinoma Supraglottis Spread

  1. Local: Vallecula, the base of the tongue, pyriform fossa; spread into pre-epiglottic space through carcinoma of laryngeal epiglottis or anterior part of false cords.
  2. Nodes: Early spread occurs here. The nodes involved are upper and middle deep cervical nodes; bilateral nodes in carcinoma epiglottis.

Carcinoma Supraglottis Symptoms

  • Throat pain, dysphagia, referred ear pain, neck mass, and hoarseness are the early features.
  • Weight loss, respiratory obstruction, and halitosis are late features.

Carcinoma Glottis

Most common site: Anterior and middle l/3rd on its free edge and upper surface.

Carcinoma Glottis Spread

  • Local spread is the chief method of spread.
  • Anteriorly to the anterior commissure and then to the opposite cord
  • Posteriorly to vocal process and arytenoids.
  • Upwards—ventricle and false cords
  • Downwards—Subglottis
  • Involvement of thyroarytenoid muscle causes fixation of cords
  • Nodal involvement is not common.

Carcinoma Glottis Symptoms

Hoarseness of voice and stridor due to laryngeal obstruction.

Carcinoma Subglottis

  • It is rare.

Carcinoma Subglottis Spread

  • Circumferential spread involving the inner surfaces of subglottic walls. Spread to glottis is late. Involvement of the cricothyroid membrane and thyroid gland can occur.
  • Pre and paratracheal, lower deep cervical, and mediastinal lymph nodes occur later.

Carcinoma Subglottis Symptoms

  • Stridor is common
  • Hoarseness of voice indicates late disease.

Carcinoma Subglottis Diagnosis

  1. History
  2. Indirect laryngoscopy is the chief investigation
    • Appearance of lesion
      • Exophytic, e.g. suprahyoid epiglottis
      • Ulcerative, e.g. infrahyoid epiglottis
      • Vocal cords → Raised nodule/ulcer/ thickening
      • Granulation tissue in anterior commissure →
      • Raised submucosal nodule in anterior ½ of subglottis
    • Mobility of vocal cord
      • Fixed due to involvement of thyroarytenoid muscle or due to involvement of
        recurrent laryngeal nerve or cricoarytenoid joint.
      • To adjoining structures
  3. Neck examination
    • Nodes
    • Extralaryngeal spread
      • Thyroid cartilage leading to perichondritis, tenderness of cartilage.
      • Preepiglottis space involvement in the form of the bulge in the thyrohyoid membrane.
  4. Involvement of thyroid gland and strap muscles.

Carcinoma Subglottis Investigations

  1. Chest X-ray: To rule out lung disease (TB), metastasis, second primary.
  2. Soft tissue lateral view of neck:
    • Extension to epiglottis, AE folds, and arytenoids.
    • Preepiglottic space
    • Cartilage invasion
  3. Contrast laryngograms
  4. CT scan
  5. Direct laryngoscopy to see the hidden areas like the anterior commissure, infrahyoid epiglottis, subglottis, and ventricles.
  6. Microlaryngoscopy
  7. Supravital staining with toluidine blue and biopsy.

Carcinoma Subglottis Treatment

Radiotherapy: Indicated in early lesions i.e. without impairment of VC mobility without cartilage invasion without node involvement. The cure rate in these cases is 90%. The chief advantage of radiotherapy is the preservation of voice.

Carcinoma Subglottis Surgery

  1. Conservation laryngeal surgery is done to preserve the voice, prevent permanent tracheostomy, and at the same time allow adequate tumor resection. These are cordectomy via laryngofissure, vertical partial laryngectomy, and horizontal partial laryngectomy. Early lesions can be resected with a laser.
  2. Total laryngectomy: In this operation, the entire larynx with hyoid bone, pre-epiglottic space, strap muscles, and one/more tracheal rings are removed and a permanent tracheostomy is fashioned.
  3. Indications
    • Cord fixation
    • Bilateral cord lesions
    • Subglottic extension
    • Cartilage invasion
    • Failed cases after radiotherapy or conservation surgery
  4. Combined therapy
    • Surgery with pre-/post-operative radiotherapy.

Tracheostomy

“Making an opening in the anterior wall of the trachea and converting it into a stoma on the skin surface.”

Functions of Tracheostomy

  1. Respiration through an alternative pathway in case of obstruction above the stoma.
  2. Alveolar ventilation is improved due to a reduction in dead space by 30–50% (normal dead space 150 ml) and a reduction in the resistance to airflow.
  3. Protection of airway by way of cuffed tracheostomy tube, i.e. protection from aspiration of pharyngeal secretions in comatose patients and blood due to injuries in the pharynx, larynx, maxillofacial region.
  4. Tracheobronchial toilet
  5. Intermittent positive pressure respiration (IPPR) if required > 72 hours then a tracheostomy is preferred over endotracheal intubation.
  6. Administer anesthesia.

Tonsil, Oropharynx And Carcinoma Larynx Tracheostomy

Tracheostomy Indications

1. Respiratory obstruction

  • Infections —Ludwig’s angina, acute epiglottitis, peritonsillar, retro-/parapharyngeal abscess
  • Trauma to larynx, trachea, mandible fracture, maxillofacial injuries.
  • Tumour
  • Foreign body
  • Laryngeal edema due to allergy/ irritants/radiation
  • Bilateral abductor vocal cord palsy
  • Congenital anomalies like laryngeal web, cyst, tracheoesophageal fistula, bilateral choanal atresia.

Tonsil, Oropharynx And Carcinoma Larynx Metal Tracheostomy tude

2. Retained secretions (inability to cough)

  • Comatose patient
  • Respiratory muscle paralysis, e.g. polio, myasthenia gravis, Guillain-Barré syndrome
  • Painful cough trauma to the chest
  • Aspiration of pharyngeal secretion

3. Respiratory insufficiency: Due to chronic lung conditions like emphysema, chronic bronchitis, and bronchiectasis.

Indications Types

Emergency, elective, or permanent.

Indications Technique 

  • If possible patient is intubated prior to surgery (especially in children).

Tonsil, Oropharynx And Carcinoma Larynx Cuffed Tracheostomy

  • Position: Supine with neck extended under local or general anesthesia.

Indications Procedure

  • The incision can be vertical (in emergency cases) or transverse (in elective cases).
  • Veins on the surface are retracted/ligated, strap muscles are separated in the midline, and the thyroid gland is retracted upwards with a blunt hook.
  • Trachea exposed
  • 4% Xylocaine is infiltrated into the trachea.
  • A transverse incision was made between the 2nd and 3rd tracheal ring and extended upwards (U-shaped incision) and then the 2 ends joined with another transverse incision to remove that portion of trachea. The appropriate-size tracheostomy tube is placed and the cuff is inflated.
  • In children, a vertical or ‘H’ incision is made without removing cartilage.

Post-operative care

  1. Supervised for bleeding, breathing difficulty due to the displacement of the tube, and subcutaneous emphysema.
  2. Suctioning: Regularly, i.e. every ½ hour.
  3. Deflate the cuff every hour for 5 minutes.

Complications of Tracheostomy

  1. Early
    • Bleeding
    • Injury to esophagus
    • Injury to recurrent laryngeal nerve
    • Wrong placement of tracheostomy tube.
  2. Intermediate
    • Secondary infection of the wound
    • Blockage of the tube.
  3. Late
    • Tracheal stenosis
    • Scar and heloid

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