Department of Otolaryngology Ruijin Hospital School of Medicine Jiao Tong University 蔡昌枰

1. Anatomy and Physiology of the pharynx Department of Otolaryngology Ruijin Hospital School of Medicine Jiao Tong University 蔡昌枰

2. Pharyngeal Anatomy • Part of the digestive tube and respiratory airway • Conical-shaped musculomembranous tube • Approximately 12 cm long • Common route for air and food under surface of the skull cricoid cartilage C6

3. Pharyngeal Anatomy • Subdivided into three regions: • Nasopharynx • Oropharynx • Laryngopharyx or hypopharynx

4. Nasopharynx • Superior-posterior wall: pharyngeal tonsil，咽扁桃体(adenoid，腺样体，增殖体，) • Lateral wall: torus tubalis， 圆枕 pharyngeal opening of pharyngotympanic tube，咽鼓管咽口 tubal tonsil，咽鼓管扁桃体 pharyngeal recess，咽隐窝 • Anterior wall: choanae Posterior view of the Nasopharynx

5. Lateral view of the nasopharynx

6. Oropharynx Anterior： faux，咽峡 Roof of the oral cavity: palatine, anterior 2/3:hard palatine, posterior 1/3:soft palatine. Palatoglossal arch Palatopharyngeal arch tonsilla lingualis， 舌扁桃体 Laterior： tonsilla palatina,腭扁桃体 lateral pharyngeal bands,咽侧索 Posterior： 淋巴滤泡lymph follicle Anterior view of the Oropharynx

7. Laryngopharynx 会厌谷，vallecula epiglottica 喉入口，laryngeal inlet 梨状窝，pyriform sinus 环后隙，postcricoid space Posterior view of the laryngopharynx

8. Laryngopharynx under fibrolaryngoscopy pyriform sinus vallecula epiglottica postcricoid space Viewed by laryngoscopy

9. Pharygeal Anatomy • Pharyngeal wall is composed of four layers 1) mucous membrane covered with psuedostratified ciliated epithelium superiorly and stratified squamous epithelium inferiorly 2) fibrous layer forming pharyngobasilar fascia 3) muscular layer (inner longitudinal and outer circular) 4) loose connective tissue – buccopharyngeal fascia

10. Pharyngeal Anatomy • Muscles of the pharynx • Three overlapping constrictors (superior, middle and inferior constrictors) • Stylopharyngeus • Salpingopharyngeus • Palatopharyngeus

11. Pharyngeal fascial space 咽后隙retropharyngeal space 婴幼儿较多淋巴结 咽旁隙parapharyngeal space 咽后隙两侧 前部-颈外动脉和静脉丛. 后部-颈内动脉，颈内静脉, 后组颅神经(IX,X,XI,XII) 交感干 颈深淋巴结上群. 咽后隙 茎突 styloid process 咽旁隙后部 咽旁隙前部 pharyngeal fascial space left side of oropharynx, cross section

12. Pharyngeal lymphatic tissue Inner ring Waldeyer ring: External ring 管扁桃体 Eustachian tonsil 内环： 咽侧索 lateral pharyngeal band淋巴滤泡 lymph follicle Adenoid Faucial tonsil Lingual tonsil

13. Pharnygeal tonsil (Adenoid) 腺样体 咽囊 腺样体残留、 增生、 肥大（纤维镜下鼻咽部像）

14. tonsilla palatina 扁桃体 扁桃 Crypts tonsillares 隐窝 支 扁桃体 组织 咽 泡 腭扁桃体冠状剖面图

15. Tonsillalingualis Tonsilla lingualis (hypertropic） epiglottis lymph follicles of postorior pharyngeal wall 纤维镜下舌扁桃体上面观

16. Pharyngeal Anatomy • Blood supply • Branches of the external carotid artery • Ascending pharyngeal • Dorsal branches from the lingual artery • Tonsillar branches of the facial artery • Palatine branches from the maxillary artery

17. Pharyngeal Anatomy • Innervation • Pharyngeal plexus of nerves • Run along the later aspect of the pharynx in the buccopharyngeal fascia • Formed by CN X and IX and sympathetic fibers from the stellate ganglion • Motor fibers from cranial root of CN XI – fibers carried by CN X • Exception - stylopharyngeus

18. physiology of the pharynx 一.呼吸respiration 二.吞咽deglutition 三.共鸣及言语resonance and speech 四.防御与保护defenseandprotection（吞咽和呕吐） 五.调节中耳气压modulation of middle ear air pressure（吞咽→开放咽鼓管） 六.免疫immunity（咽淋巴内环以腭扁桃体最重要）

19. Acute pharyngitis Pharyngitis is defined as an infection or irritation of the pharynx

20. Etiology • Virus： coxsackie virus, adenovirus, parainfluenza virus • Bacteria： Group A streptococcus, pneumococcus, 流行性感冒杆菌 • Physical and chemical factors 粉尘, 刺激性气体

21. Symptoms • Sudden onset • Mild to moderate sore throat, • Slight difficulty in swallowing • Mild fever

22. Examination • Bacteria or viruses may directly invade the pharyngeal mucosa, causing a local inflammatory response: tonsillopharyngeal erythema and exudate • Particularly along the faucial pillars, lateral pharyngeal bands and discrete lymph follicles of postorior pharyngeal wall, • Sometimes it may be presented with white or yellow patches

23. Diagnosis • Sudden onset • Sore throat • Erythema

24. Treatments • Assess and secure the airway, if necessary. • Assess patient for signs of toxicity, epiglottitis, or oropharyngeal abscess. • Evaluate the hydration status, as severe pharyngitis limits oral intake. • Appropriate measures to rehydrate should be initiated, including intravenous hydration.

25. Treatments • Empiric antimicrobial therapy Penicillin Na: 8-9.6 million U IV Amoxicillin: 500 mg PO tid for 6 d Erythromycin: 500 mg PO qid for 10 d Azithromycin (Zithromax) : 500 mg PO qd for 4-5 d

26. Treatments • Antivirals • Traditional Chinese medicine：发热重，恶寒轻者则有银翘散内服，亦可用牛黄解毒丸。 • 局部用药：甲硝唑洁口液漱口，银黄含片、西瓜霜含片或含碘片含化，抗生素加激素雾化吸入。

27. Chronic pharyngitis A chronic inflammation of the pharyngeal mucous membrane and submucous lymphoid tissues.

28. Causes • 局部因素 （1）多为急性咽炎反复发作或延误治疗转为慢性； （2）患有各种鼻病，因鼻阻塞而长期张口呼吸及鼻腔分泌物下流，致长期刺激咽部，或慢性扁桃体炎，龋病等影响所致。 （3）长期烟酒过度，或粉尘、有害气体的刺激。 • 全身因素

29. Pathology • 慢性单纯性咽炎 • 慢性肥厚性咽炎 • 萎缩性或干燥性咽炎

30. Clinical Features • Discomfort, dryness and itching, swelling and soreness, • A sensation of obstruction and fullness in the throat, • Nausea and vomiting.

31. Examination • 慢性单纯性咽炎：粘膜弥漫性充血，小血管扩张，色暗红，附有少量粘稠分泌物。 • 慢性肥厚性咽炎：粘膜增厚，弥漫性充血，色暗红。咽后壁淋巴滤泡增生充血肿胀，呈点状分布或融合成块。两侧咽侧索亦充血肥厚。

32. 萎缩性或干燥性咽炎：粘膜干燥，萎缩变薄，色苍白发亮如蜡纸，并有脓痂附着。咽部感觉及反射减退，鼻咽部也有粘稠分泌物或脓痂附着，有时可在咽后壁见到颈椎椎体的轮廓。萎缩性或干燥性咽炎：粘膜干燥，萎缩变薄，色苍白发亮如蜡纸，并有脓痂附着。咽部感觉及反射减退，鼻咽部也有粘稠分泌物或脓痂附着，有时可在咽后壁见到颈椎椎体的轮廓。

33. Treatments • 消除各种致病因素，如治疗全身性疾病，治疗鼻窦炎。 • 注意营养，增强体质锻练。 • 避免刺激性食物及烟酒，发音不当应矫正。 • 在有粉尘或刺激性气体环境中工作者应戴口罩。 • 局部可用复方硼砂溶液、盐水、甲硝唑洁口液等漱口，3%碘甘油涂咽，或者含化碘喉片，薄荷喉片等。

34. The Type of Dryness of the Lung due to Yin-Deficiency • Nourishing yin, moistening dryness and purging pathogenic fire to relieve sore throat: 一清、慢咽舒宁、喉疾灵等

35. The Type of Stasis of Qi and Stagnation of Phlegm • Promoting circulation of qi, alleviating mental distress and reducing phlegm to resolve masses. • 对肥厚性咽炎可用10~30％硝酸银烧灼增生的淋巴滤泡。 • 对萎缩性咽炎可服维生素A、B2、C、E以促进粘膜上皮增生。

36. Acute Tonsillitis refers to inflammation of the pharyngeal tonsils. 常伴有一定程度的咽粘膜及咽淋巴组织的急性炎症。

37. Causes Group A beta-hemolytic Streptococcus pyogenes, 葡萄球菌，肺炎双球菌。腺病毒也可引起本病。 细菌和病毒混合感染也不少见。

38. Clinical Features • fever：起病急、恶寒、高热、可达39～40°Ｃ，尤其是幼儿可因高热而抽搐、呕吐或昏睡、食欲不振、便秘及全身酸困等。 • Lethargy and malaise are common

39. Sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing),

40. Acute catarrhal tonsillitis：redness, swelling, no exudates • Acute purulent tonsillitis：enlarged inflamed tonsils that may have exudates, can be removed without bleeding

41. Diagnosis 急性扁桃体炎一般都具有典型之临床表现，故不难诊断。 鉴别诊断：咽白喉、猩红热、樊尚咽峡炎、单核细胞增多症性咽峡炎、粒细胞缺乏症性咽峡炎、白血病性咽峡炎。

42. Treatments • Adequate rest for adults and children with tonsillitis accelerates recovery. • Hydration is important, and the oral route usually is adequate • Antibiotics First choice：Penicillin Clindamycin • 对症治疗：controlling pain and fever • 局部用药：清洁口腔 • 中医中药：疏风清热

43. Chronic Tonsillitis

44. Causes • 多由急性扁桃体炎反复发作或因隐窝引流不畅，而致扁桃体隐窝及其实质发生慢性炎症病变。 • 也可发生于某些急性传染病之后。

45. Clinical Features • 主要症状是反复发作急性扁桃体炎。 • chronic sore throat, halitosis, tonsillitis, and persistent tender cervical nodes. • 儿童过度肥大的扁桃体可引起呼吸、吞咽、语言障碍。 • Airway obstruction may manifest as mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea

46. Examinations • 扁桃体慢性充血，表面不平，可见瘢痕，与周围组织有牵连， • 有时可见隐窝口封闭，呈黄白色小点，其上盖有菲薄粘膜或粘连物， • 挤压隐窝开口处可有脓性分泌物或干酪样分泌物外溢， • Hyperaemia of palatoglossal arch and palatopharyngeal arch • 扁桃体大小不定。

47. 扁桃体的分度 临床上为记录方便，可将扁桃体的外形大小分为三度： Ⅰ度：扁桃体超出舌腭弓，但未遮盖咽腭弓； Ⅱ度：已遮盖咽腭弓； Ⅲ度：超出咽腭弓突向中线。 但扁桃体的大小不能作为炎症的指征，因为儿童有生理性肥大，成人多萎缩。

48. Diagnosis • 依据是：（1）有急性扁桃体炎反复发作史；（2）扁桃体及舌腭弓慢性充血；（3）扁桃体表面不平，有瘢痕或黄白点状物，挤压时有分泌物从隐窝口排出。

49. Treatments • Tonsillectomy (扁桃体切除术) • Indications （1）3 or more infections of tonsils and/or adenoids per year despite adequate medical therapy （2）History of peritonsillar abscess。 （3）扁桃体过度肥大，妨碍吞咽、呼吸，导致营养障碍者。 （4）be a suspect cause of rheumatic fever,nephritis, arthritis and rheumatic heart disease.

50. （5）因扁桃体，增殖体肥大，影响咽鼓管功能，造成慢性渗出性中耳炎，经保守治疗无效者。（5）因扁桃体，增殖体肥大，影响咽鼓管功能，造成慢性渗出性中耳炎，经保守治疗无效者。 （6）白喉带菌者，经保守治疗无效者。 （7）不明原因的长期低热，而扁桃体又有慢性炎症存在时。 （8）各种扁桃体良性肿瘤，对恶性肿瘤则应慎重选择病例。