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Walker HK, hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.


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Definition

The pharynx is a room shared by the respiratory system and the cradle tract. It is separated into 3 areas: the nasopharynx, the oropharynx, and also the hypopharynx. The nasopharynx belongs entirely to the respiratory tract and also is situated behind the nose. Anteriorly the nasopharynx is defined by the posterior choanae the the nose, superiorly by the anterior and inferior wall surface of the sphenoid sinus, and posteriorly by the vertebral body of the cervical spine. The nasopharynx opens interiorly right into the oropharynx in between the distal sheet of the soft palate and the posterior pharyngeal wall. Lymphoid tissue known as the adenoids or the pharyngeal tonsils occupies the posterosuperior surface ar of the nasopharynx and is part of a larger collection of lymphoid tissue well-known as Waldeyer"s ring. The oropharynx opens up anteriorly into the oral cavity and interiorly right into the hypopharynx at the level that the basic of the tongue. The lateral walls are lived in by the faucial or palatine tonsils, i m sorry lie in between two crease of tissue, the anterior tonsillar column or palatoglossal fold, and also the posterior tower or palato-pharyngeal fold. The hypopharynx extends native the basic of the tongue to the apex of the pyriform sinuses. The pyriform sinuses room recesses formed in between the larynx and the thyroid cartilages the the larynx as they extend beyond the larynx. The pyriform sinuses offer to funnel food indigenous the hypopharynx right into the esophagus.


Technique

Examination the the nasopharynx is difficult and calls for special equipment. The simplest means is to use a tiny mirror (#0 or #1), a headlight, and also a tongue blade. The tongue is depression firmly with a tongue blade, and also the patience is instructed come breathe through his or her nose. The mirror is positioned in the neck so the a small part of the nasopharynx have the right to be seen. The winter is climate rotated tenderness to examine all parts of the nasopharynx. Treatment must it is in taken not to touch the posterior pharyngeal wall surface because this will reason the patience to gag. A small fiberoptic border is another method often used to research the nasopharynx. The limit is passed v the nose transform it has actually been anesthetized v a subject anesthetic right into the nasopharynx. And also all areas are examined. Also when the nasopharynx deserve to be seen through either method, the existence of mucus, i beg your pardon obscures the mucosal surface and the irregular surface of the adenoidal tissue, provides interpretation difficult.

The oropharynx is examined through a tongue blade and a great light. The tongue blade is placed in the center of the tongue at the junction that the anterior two-thirds and the posterior one-third that the tongue. The tongue is steady depressed, exposing the pharynx. The examiner have to note the visibility or absence of the palatine tonsils and their size. The tonsils have an irregular surface with deep crypts the are frequently filled with epithelial debris or lymphocytes, an especially when they are infected. The examiner should also note the symmetry of the palato-tonsil area. Bulging the one side v contralateral shifting of the uvula might be indicative the a peritonsillar abscess or parapharyngeal tumor. The posterior pharyngeal wall surface is the site of a collection of lymphoid organization that is spread out out over the surface. This lymphoid organization becomes much more hypertrophied during upper respiratory infections and has a "cobble-stoned" appearance.

The hypopharynx is examined v a mirror (#4 or #5) and also a headlight. The patient is positioned in a "sniffing" position, leaning forward slightly. The tongue is protruded and also held through the examiner"s fingers. A gauze sponge placed over the guideline of the tongue gives a far better grip as the tongue is tenderness pulled forward. The winter is carefully inserted right into the mouth and also placed come the left or ideal of the uvula under the soft palate. The palate is then lifted in a single movement, and the mirror is reflected right into the hypopharynx. The patience is instructed to say "eeee," which tenses the laryngeal musculature and causes the epiglottis to relocate anteriorly, exposing the endolarynx. Again, care should it is in taken no to touch the posterior wall surface of the pharynx because this will reason the patience to gag. If gagging is a problem, regional anesthetic injected on the posterior pharyngeal wall will alleviate it. The examiner must examine the entire hypopharynx including the epiglottis, the pyri-forni sinuses, and the larynx. Movement and symmetry that the vocal cords should be noted, and also any irregularity that the laryngeal mucosa. The true vocal cords are covered by squamous epithelium, instead of respiratory tract epithelium choose the rest of the larynx, and reflect light differently, offering the cords a white coloration. The trachea can sometimes it is in examined under to the carina, and also the clinician should be alert come any possible airway obstruction or lesion in the subglottic airway.


Basic Science

The role of the pharynx together a conduit for the digestive and respiratory street brings the into call with the exterior environment and also makes it susceptible to the miscellaneous allergens, microorganisms, and carcinogenic substances current there. Inflammation that the pharynx generally produces pain or sick throat with the sensory innervation detailed largely by the vagus nerve. Ache in the throat is regularly accompanied by otalgia, i m sorry is actually referred pain produced by concomitant vagal innervation of the exterior ear.

Many that the symptoms and also physical findings in the pharynx are created by the lymphoid tissue known as Waldeyer"s ring, i beg your pardon is typical in this area. In the nasopharynx, hypertrophy that the adenoidal organization can create nasal obstruction and interfere with the postnasal drainage that mucus produced in the nose and also sinuses. This may bring about infections in the middle ear and the sinuses. In the oropharynx, the lymphoid tissue well-known as the palatine tonsils has deep crypts in the surface that have the right to harbor bacteria and secretions that deserve to lead to tonsillitis. The size of the tonsils deserve to vary greatly. Size alone has no specific pathologic definition as it depends significantly on the age of the patient and also whether or not inflammation and infection space present. In general, the tonsils are quite prominent in children; tonsil enlargement continues until puberty, after i beg your pardon the tonsils have tendency to atrophy. Tonsillar hypertrophy after ~ this time is typical in persons v upper respiratory tract allergy or in those v recurrent tonsillitis. Lymphoid organization on the basic of the tongue or the lingual tonsils can likewise become infected or hypertrophied and also can develop pain or a feeling of a "lump in the throat" as the vallecula space is filled. The hypopharynx is typically void of lymphoid tissue.


Clinical Significance

Sore throat is just one of the most common complaints seen in physicians" offices. The differential diagnosis would encompass inflammation as result of allergy, infection because of viral or bacterial agents, physical irritation because of postnasal drainage or reflux esophagitis or neoplasm. Diagnosis relies on the integration that information acquired by history, physics examination, and also laboratory data, such as throat society or barium swallow.

Acute pharyngitis is typically viral in origin yet may be caused by team A beta streptococcus. This infections room usually add by fever and cervical lymphadenitis. Acute tonsillitis additionally may accompany pharyngitis and also is usually evident from the illustration of the tonsils, which room studded with purulent material in the crypts and may be extended with a mucopurulent exudate.

Malignant neoplasms can take place in any area that the pharynx; most are squamous cabinet carcinomas that take place as a an outcome of tobacco use. The nasopharynx is much less often associated than the other areas in most people, other than for the Chinese race. In this group nasopharyngeal carcinoma account for practically 20% of malignancies. The reason for this is no clear however is probably a mix of genetic and also environmental factors. In enhancement to the squamous cell carcinomas, the visibility of young salivary glands in the pharynx can lead come the breakthrough of outstanding gland neoplasms both benign and also malignant.


Paparella M, Shumrick D, eds. Otolaryngology: head and neck. Philadelphia: W.B. Saunders, 1980;3:2263–2371.

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Snow JB. Advent to otorhinolaryngolgy. Chicago: Year book Medical Publishers, 1979; 147–59.