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Mindmap-Galerie Otolaryngology, Head and Neck Surgery--Pharyngology 002
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Otolaryngology, Head and Neck Surgery--Pharyngology 002
Otolaryngology-Head and Neck Surgery--summarizes knowledge points such as pharyngeal and maxillofacial abscesses, obstructive sleep apnea hypopnea syndrome, pharyngeal and maxillofacial tumors, etc.
Bearbeitet um 2024-03-25 23:18:13
Otolaryngology, Head and Neck Surgery--Pharyngology 002
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Otolaryngology, Head and Neck Surgery--Pharyngology 002
Chapter 4 Pharyngeal and maxillofacial abscesses
1. Peritonsillar abscess (peritonsillar abscess)
[Cause] Mostly secondary to acute tonsillitis (especially those with repeated acute attacks of chronic tonsillitis)
[Pathology] Mostly unilateral; divided into anterosuperior type (located between the upper pole of the tonsil and the palatoglossal arch, the most common) and posterosuperior type (located between the tonsil and the palatopharyngeal arch)
[Clinical manifestations] More common in young adults
symptom
3 to 4 days after the onset of acute tonsillitis, the fever continues/gets worse; the sore throat on one side is obvious, especially when swallowing, and may radiate; in severe cases, there may be slurred speech and difficulty opening the mouth (involvement of the medial pterygoid muscle)
examine
With an acute appearance, the head is tilted to the affected side. Patients often use their hands to support the affected neck to relieve pain.
In the early stage of peripheral inflammation, significant congestion of the palatoglossal arch on one side can be seen; in the anterosuperior type, the uvula on the affected side is red and swollen, deflected to the opposite side, the top of the palatoglossal arch is bulged, and the tonsils are covered and pushed inward and downward; in the posterosuperior type, It can be seen that the tonsils are pushed forward and downward; the lymph nodes in the ipsilateral mandibular angle are swollen
There may be pus when punctured at the protuberance.
complication
Parapharyngeal abscess, laryngitis/laryngeal edema, internal jugular vein thrombosis, purulent cervical lymphadenitis, sepsis
【Differential Diagnosis】
1. Parapharyngeal abscess: The swelling is located at the angle of the mandible on the side of the pharynx, accompanied by tenderness in the upper part of the neck; the tonsils and pharyngeal wall on the affected side are pushed to the midline; there are no lesions in the tonsils themselves
2. Pericoronitis of wisdom teeth: The crown is covered with swollen tissue and the gums are red and swollen, which can extend to the palatoglossal arch, but the tonsils and uvula are generally not affected.
3. Purulent submandibularitis: acute diffuse cellulitis in the floor of the mouth; painful lump in the floor of the mouth/under the jaw, raised tongue, pain when pressing/extending the tongue, limited mouth opening, but no trismus.
4. Malignant tonsil tumors: generally without fever, tonsils often enlarge rapidly and have ulcers.
【treat】
Before abscess formation
Treat as acute tonsillitis: adequate antibiotics, infusion; appropriate amount of glucocorticoids
After abscess formation
Puncture and pus aspiration: can determine whether an abscess has formed and the location of the abscess
Incision and drainage: In the anterosuperior type, the incision is made at the highest point of the abscess; in the posterosuperior type, the incision is made at the velopharyngeal arch.
Tonsillectomy: performed 2 weeks after inflammation subsides
2. Retropharyngeal abscess
3. Parapharyngeal abscess
[Pathology] Early manifestation is cellulitis, which later develops into abscess.
[Clinical manifestations]
symptom
Systemic symptoms: fever, chills, sweating, headache, loss of appetite
Local symptoms: severe parapharyngeal/neck side pain, difficulty swallowing, slurred speech, difficulty opening mouth (violating the medial pterygoid muscle)
examine
Acute appearance; neck movement is limited, swollen, hard to touch, and tender; there is a sense of fluctuation when an abscess is formed; the pharyngeal wall on the affected side is bulging and congested, and the tonsils are pushed toward the midline but there is no redness or swelling.
Pharyngeal CT, diagnostic puncture and pus aspiration
complication
Peripheral extension: retropharyngeal abscess, laryngeal edema, mediastinitis
Erosion of the internal carotid artery: fatal haemorrhage
Erosion of the internal jugular vein: thrombophlebitis
【treat】
Before abscess formation
Adequate systemic antibiotics; appropriate glucocorticoids
After abscess formation
Immediate incision and drainage of pus (external cervical approach); continue to prevent and treat infection after surgery
Chapter 5 Obstructive sleep apnea-hypopnea syndrome
【definition】
1. Sleep disordered breathing (SDB): It is a group of diseases related to sleep, mainly manifested by abnormal respiratory events; it is characterized by abnormalities in the rhythm and amplitude of breathing during sleep.
2. Obstructive sleep apnea-hypopnea syndrome (OSAHS): refers to apnea and hypopnea caused by upper airway collapse and obstruction during sleep, often accompanied by snoring, sleep structure disorder, and frequent occurrence Decreased blood oxygen saturation, daytime drowsiness, inattention, etc., and can lead to multi-organ and multi-system damage such as hypertension, coronary heart disease, type 2 diabetes, etc.
[Cause] Abnormal anatomy of the upper airway leads to varying degrees of airway stenosis (especially oropharyngeal cavity stenosis), abnormal upper airway dilator muscle tone, and abnormal respiratory center regulatory function.
[Clinical manifestations] More common in middle-aged obese men
symptom
Snoring during sleep: progressively worse with age and weight; intermittent, accompanied by repeated apnea and daytime drowsiness
Others: headache after waking up in the morning, elevated blood pressure, dry throat; decreased memory, inability to concentrate; decreased sexual function, frequent nocturia; children may experience enuresis, decreased academic performance, thoracic deformity, and slow growth and development
Comorbidities: hypertension, ischemic heart disease/stroke, type 2 diabetes
physical signs
General signs: obesity, large neck circumference; stunted growth and deformities seen in children
Upper airway signs: oropharyngeal stenosis, tonsil hypertrophy, soft palate tissue hypertrophy, and uvula elongation; other factors that cause upper airway stenosis can also be seen, such as nasal septum deviation, nasal polyps, adenoid hypertrophy, and lingual tonsil hypertrophy.
examine
Polysomnography (PSG): gold standard for diagnosis; can monitor oral and nasal airflow, blood oxygen saturation, chest and abdominal respiratory movements, electroencephalogram, electrooculogram, body position, and electromyography
1. Apnea: cessation of oral and nasal airflow during sleep (reduced by ≥90% compared with baseline level), lasting ≥10 seconds; including central, obstructive, and mixed
2. Hypopnea: Oronasal airflow decreases by ≥30% compared to the baseline level during sleep, accompanied by a decrease in arterial oxygen saturation ≥0.04, lasting ≥10s; or oronasal airflow decreases by ≥50% compared with the baseline level, accompanied by a decrease in arterial oxygen saturation ≥ 0.03/micro-awakening, lasting ≥10s
3. Sleep apnea-hypopnea index (AHI): refers to the average number of apneas and hypopneas per hour of sleep.
4. Sleep-disordered breathing index (RDI): refers to the average number of apnea, hypopnea and respiratory effort-related micro-awakenings per hour of sleep.
【diagnosis】
【treat】
General treatment
Lose weight, stop drinking, establish side sleeping habits, and treat comorbidities
Medical treatment
Continuous positive airway pressure (CPAP), oral therapy
surgical treatment
One-stage surgery: such as nasal reconstruction, adenoid/tonsillectomy in children, uvulopalatopharyngoplasty
(UPPP) (most commonly used)
Second-stage surgery: such as mandibular advancement and tracheotomy
Chapter 6 Pharyngeal and Maxillofacial Tumors
1. Nasopharyngeal fibroangioma (angiofibroma of nasopharynx)
[Pathology] The most common benign tumor of the nasopharynx; composed of dense connective tissue, large amounts of elastic fibers and blood vessels
[Clinical manifestations] More common in young men aged 10 to 25 years old
symptom
Bleeding: Mostly the first complaint, manifesting as paroxysmal nasal/oral bleeding, which may be bright red blood; often accompanied by anemia. Nasal obstruction: accompanied by runny nose, obliterative nasal sound, and hyposmia.
Others: tinnitus, auricularia, hearing loss; exophthalmos, vision loss; cheek bulge; headache, cranial nerve palsy
examine
Anterior rhinoscopy: There are inflammatory changes in one/both sides of the nasal cavity; after retracting the inferior turbinate, a light red tumor in the back of the nasal cavity can be seen. Indirect nasopharyngoscopy: A red tumor in the nasopharynx, with a smooth surface and rich blood vessels.
Imaging: shows the location, size, shape, extent of involvement, degree of bone destruction, and surrounding anatomical relationships of the tumor; enhanced CT has diagnostic value
DSA: Understand tumor feeding arteries and perform embolization to reduce intraoperative bleeding
Biopsy is contraindicated before surgery
[Treatment] Mainly adopts surgical treatment; preoperative vascular embolization and intraoperative controlled hypotension can reduce bleeding.
2. Craniopharyngioma
[Characteristics] Abnormal development of the craniopharyngeal duct, hyperplasia of residual epithelium of Lattek's pouch; the tumor is located in the pedicle of the adenohypophysis; it grows slowly, and early symptoms are not obvious. Later, it may manifest as endocrine disorders, changes in vision and visual fields, and increased intracranial pressure ( Blocking the interventricular orifice)
3. Nasopharyngeal cancer (carcinoma of nasopharynx)
[Cause] Genetic factors, Epstein-Barr virus, environmental factors (such as the habit of eating pickled foods)
[Pathology] The most common head and neck tumor; the vast majority are poorly differentiated squamous cell carcinomas
[Clinical manifestations] Early symptoms are atypical
symptom
Nasal symptoms: Sniffles with blood may appear in the early stage; nasal obstruction may occur after the tumor increases (unilateral → bilateral). Ear symptoms: tinnitus, auricularia, hearing loss, tympanic effusion; easily misdiagnosed as secretory Otitis media
Cervical lymphadenopathy: more common, even accounting for 60% of the first symptoms; characterized by progressive enlargement of deep and upper cervical lymph nodes, which are hard, inactive, and non-tender
Cranial nerve symptoms: often invade V and VI first (related to the involvement of rupture holes), followed by II, III, and IV, resulting in headache, facial numbness, limited eyeball abduction, and ptosis; IX, X, and XI may also be involved. , XII (related to swollen affected lymph nodes), paralysis of the soft palate, choking, hoarseness, and deviation of the tongue.
Difficulty opening your mouth: seen in late stages
Distant metastasis: bone, lung, liver
examine
Nasopharynx: Indirect nasopharyngoscopy/nasopharyngolaryngoscopy/nasal endoscopy can show that tumors tend to occur on the anterior wall of the nasopharynx roof and pharyngeal recesses. They appear as small nodules/granuloma-like bulges with rough and uneven surfaces and are prone to bleeding. ; Early manifestations may be atypical, such as mucosal congestion, vasodilation, or fuller pharyngeal recesses on one side.
Neck: palpable lymph nodes, cranial nerve examination: involved
Epstein-Barr virus serological test: auxiliary diagnostic indicators
Videography
Nasopharyngeal puncture biopsy: confirmed diagnosis
【treat】
radiotherapy
The preferred treatment method; radiotherapy alone for T1 and T2 stages, and radiotherapy and chemotherapy for T3 and T4 stages
Operation
Indications: ① Residual primary tumor in the nasopharynx 3 months after radical radiotherapy and localized disease; ② Residual cervical lymph nodes/local recurrence after radical radiotherapy
Chemotherapy
Can enhance radiotherapy sensitivity
4. Malignant tumor of tonsil
【Pathology】tonsil cancer, sarcoma, etc.
【diagnosis】
symptom
Early stage: pharyngeal discomfort, foreign body sensation; sore throat on one side, obvious when swallowing
Late stage: worsening sore throat, difficulty swallowing, unclear speech, and difficulty breathing
examine
The tonsils on one side are obviously swollen, with surface ulceration/nodular bulges, which are hard to touch, easy to bleed, and adhere to surrounding tissues. The lymph nodes in the ipsilateral mandibular angle are swollen, hard, inactive, and non-tender.
Videography
[Treatment] Radiation therapy is suitable for malignant lymphomas, undifferentiated carcinomas, and squamous cell carcinomas with extensive lesions that are difficult to remove by surgery; those with lesions limited to the tonsils may undergo tonsillectomy; those with enlarged mandibular angle lymph nodes may undergo lymph node dissection.
5. Malignant tumors of hypopharynx
[Pathology] Pyriform fossa cancer (the most common), posterior cricoid area cancer (posterior cricoid cancer), and posterior hypopharyngeal wall cancer; 95% are squamous cell carcinomas, which are prone to submucosal metastasis and cervical lymph node metastasis
[Clinical manifestations]
symptom
Early stage: throat discomfort, swallowing infarction
Middle and late stages: pain in swallowing, ipsilateral reflex earache; progressive dysphagia, salivation, and blood in sputum; dyspnea and hoarseness may occur when the laryngeal cavity is involved.
examine
Indirect laryngoscopy, fiberoptic laryngoscopy; neck examination; imaging examination
[Treatment] Different surgical methods are adopted according to the extent of invasion, combined with comprehensive treatment such as radiotherapy and chemotherapy. 6. Parapharyngeal space tumors
[Pathology] 80% are benign tumors, 50% come from salivary glands (mixed tumors), 30% are neurogenic tumors (such as schwannoma, neurofibroma, paraganglioma); 20% are soft tissue malignant tumors
[Clinical manifestations] Most are asymptomatic in the early stage; pharyngeal symptoms are the most common, manifesting as foreign body sensation in the pharynx, swallowing discomfort, slurred speech and nasal congestion. Individual patients may have shortness of breath/dyspnea; there are also neck and jaw tumors and nerve involvement. Symptoms (ipsilateral vocal cord paralysis, choking, sore throat, facial numbness, tongue extension toward the affected side, tongue atrophy on the affected side, Horner syndrome)