SEMINAR 3:

SORE THROAT
• PRESENTED BY :
• Adlina Sabeni
• Afiqah Qhaierah
• Aisyamimi Afifah
• Anatasya Elsie Nara
• Ahza Syazani
ANATOMY OF ORAL CAVITY,
PHARYNX AND LARYNX
 ANATOMY OF ORAL CAVITY
Oral cavity
• Between oral fissures and oropharyngeal isthmus
• Divided into vestibule and mouth cavity proper

Vestibule
• space between the lips/cheeks externally, and the
gums/teeth internally

Mouth proper
• Roof - hard and soft palate
• Cheeks - Buccinator muscles (innervated by buccal branches of
CN VII)
• Floor
o Muscular diaphragm – comprised of the bilateral mylohyoid
muscles. It provides structural support to the floor of the
mouth and pulls the larynx forward during swallowing.
Innervation o Geniohyoid muscles – pull the larynx forward during
• Sensory: Trigeminal nerve (CN V) swallowing.
• Hard palate: Greater palatine & nasopalatine nerves (branches of
maxillary nerve (CN V2)
o Tongue – connected to the floor by the frenulum of the
• Soft palate: Lesser palatine nerve tongue, a fold of oral mucosa.
• Floor of oral cavity: Lingual nerve o Salivary glands and ducts.
• Tongue: Chorda tympani (Branch of facial nerve CN VII)
• Cheeks: Buccal nerve
 ANATOMY
OF PHARYNX
• Is a fibromuscular tube that connects oral
cavity and nasal cavity to the larynx
and esophagus
• It extends from the skull base above to the
cricoid cartilage (C6)
• Divided into 3 parts (superior to inferior)
o Nasopharynx
o Oropharynx
o Laryngopharynx
 Nasopharynx
• Extends from skull base to the soft palate
• Anterior - continuous with the nasal cavity
via posterior choanae
• Floor - communicates with oropharynx
• Posterior wall - pharyngeal tonsil or
adenoids (collection of lymphoid tissue)
• Laterall wall
o Eustachian tube (opening of the auditory)
o Fossa of Russenmuller (most common site
for nasopharyngeal carcinoma to start)
 Oropharynx
• Middle part of pharynx
• Located between the soft palate and the
superior border of epiglottis
• Anterior - pharyngeal aspect of the tongue
• 2 lateral walls - Palatine tonsils (between the
palatoglossal and palatopharyngeal arches of
the oral cavity)
• Posterior wall - extends from the body of the
second to the upper part of the third cervical
vertebrae (C2-C3)
• Voluntary and involuntary phases of swallowing
Laryngopharynx
• Most distal part
• Located between superior border
of epiglottis and inferior border of cricoid
cartilage
• Continuous inferiorly with esophagus
• Posterior to the larynx and communicates
with it via the laryngeal inlet, lateral to
which one can find the piriform fossae
• Posterior border - C4 – C6 verterbrae
• Posterior and lateral walls - middle and
inferior constrictor muscles
 ANATOMY OF LARYNX
Supraglottis – From the inferior surface of the
epiglottis to the vestibular folds (false vocal cords)
The larynx (voice box) is an organ
- Encompasses area include epiglottis, false vocal located in the anterior neck.
cords, aryepiglottic folds and arytenoids
• It is a component of the respiratory
tract
Has several important functions:
• Phonation
• The cough reflex
• Protection of the lower respiratory
tract.

Supraglottis
Glottis – Contains True vocal cords, anterior and
posterior commisure . The opening between the
vocal cords is known as rima glottidis, the size of
which is altered by the muscles of phonation
Glottis

Subglottis Subglottis – From inferior border of the glottis to

the inferior border of the cricoid cartilage
- Surgically important: narrowest, oedema,
obstruction and respiratory distress might
happen
 THE LARYNX
Arterial supply
• Superior laryngeal artery – a branch of the
superior thyroid artery (derived from the external
carotid)
• Inferior laryngeal artery – a branch of the inferior
thyroid artery (derived from the thyrocervical
trunk)
Venous drainage
• Superior and inferior laryngeal veins
Innervation
• Recurrent laryngeal nerve
o Infraglottis (sensory), internal muscles of
larynx except cricothyroid (motor)
• Superior laryngeal nerve
o Supraglottis (sensory – internal
branch), cricothyroid muscle (motor -
external branch)
Pharyngitis :
Acute and
Chronic
Inflammation of the mucous
membranes of the pharynx
 Acute Pharyngitis
Etiology:

• Viral causes are more common

• Group A beta hemolytic streptococci is important to treat because of its aetiology in
rheumatic fever and poststreptococcal glomerulonephritis
Clinical Features:
MILD MODERATE AND SEVERE

Symptoms: Symptoms:
❑ Discomfort in the throat ❑ Pain in throat
❑ Malaise ❑ Malaise
❑ Low grade fever ❑ High fever
❑ Dysphagia
Signs: ❑ Headache
▪ Pharynx: congested
▪ No lymphadenopathy Signs:
▪ Pharynx: erythema
▪ Posterior pharyngeal wall: Exudate and enlargement of
tonsils and lymphoid follicles
▪ Very severe case: oedema of soft palate & uvula with
enlargement of cervical nodes
McIsaac
Score:
Investigations:
• Culture of throat swab
• Helpful in diagnosis of bacterial pharyngitis
• 90% of Group A streptococci can be detected
• Failure to get any bacterial growth suggests a viral aetiology
Treatment of acute pharyngitis:
Symptomatic Antibiotic therapy for GABHS
treatment pharyngitis
1. Maintain adequate fluid intake • Antibiotics may be started if
2. Warm saline gargle • Documented group A streptococcal infection on
3. Simple analgesics/ antipyretics throat swab
4. Throat lozenges/ gargles • Clinically suspected for streptococcal sore
throat (toxic looking, if follow-up is not possible)
• Drug of choice for Group A Streptococcal pharyngitis
• Penicillin
• Oral: 250 mg t.i.d/q.i.d or 500mg b.i.d for 10
days
• Other alternatives
• Erythromycin
• Clindamycin

CPG Management of Sore Throat (April 2003)

 Chronic Pharyngitis
• Chronic inflammatory condition of the pharynx
• Characterized by hypertrophy of mucosa, seromucinous glands,
subepithelial lymphoid follicles and muscular coat of pharynx
• Chronic pharyngitis has two types:
• Chronic catarrhal pharyngitis
• Chronic hypertrophic (granular) pharyngitis
Persistent infection in the
neighbourhood
Environmental pollution
In chronic rhinitis and sinusitis → purulent discharge
constantly trickles down the pharynx → provide a Smoky/ dusty environment or irritant
constant source of infection → hypertrophy of the industrial fumes
lateral pharyngeal bands

Chronic irritants Faulty voice production/

Excessive smoking, chewing of tobacco and ETIOLOGY excessive use of voice
pan, heavy drinking

Mouth breathing
Breathing through the mouth → exposes the pharynx to unfiltered air → more
susceptible to infection
Causes
• Obstruction in the nose (nasal polyp, allergic/ vasomotor rhinitis, turbinal
hypertrophy, deviated septum/ tumours)
• Obstruction in the nasopharynx (adenoids and tumours)
 Signs
Chronic catarrhal pharyngitis
o Posterior pharyngeal wall: congested
with engorgement of vessels
Symptoms o Faucial pillar may be thickened
o Increase mucous secretion covering the
pharyngeal mucosa
• Discomfort/ pain in the throat
• Foreign body sensation in the
throat Chronic hypertrophic (granular) pharyngitis
• Tiredness of voice
o Pharyngeal wall: thick, oedematous with
• Cough congested mucosa and dilated vessels
o Posterior pharyngeal wall: studded with
reddish nodules (due to hypertrophy of subepithelial
lymphoid follicles)
o Lateral pharyngeal bands: hypertrophied
o Uvula: may be elongated and
oedematous
Treatment of chronic pharyngitis
• Sought and eradicate the aetiological factor
• Warm saline gargles
• Voice rest and speech therapy
• For those with faulty voice production
• Cautery of lymphoid granules
• Throat is sprayed with local anaesthetic
• Granules are touched with 10-25% silver nitrate
POSTNASAL DRIP
What is postnasal drip?
• It is when mucus from your
nose or sinuses drips down the
back of your throat

What causes postnasal drip?

• Allergic rhinitis
• Sinusitis (Viral or bacterial
infections)
• Upper airway cough syndrome
• Changes in temperature and
humidity Symptoms of upper airway cough syndrome
• Dry cough that persist for 8 weeks or more
• Some medications (including birth • Postnasal drip
control pill and high • Abnormal, unpleasant sensations in throat
blood pressure medications) (something stuck, tickling or irritating throat)
To ease the symptoms Treatment (depends on its cause)
• Drink more fluids to thin out mucus • Allergic rhinitis
• Saline spray o Antihistamines
• Gargle with salty water 3-4 times
o Decongestant medicines
per day
o Nasal corticosteroid spray
• Use humidifier to add moisture to air
• Avoid substances causing o Saline nasal spray can also help
relieve symptoms
dehydration, such as alcohol and
caffeine (can worsen symptoms) • Sinusitis
• Avoid common irritants such as o Saline spray or saline washouts
cigarette smoke (irrigation)
o Viral infection -corticosteroid nasal
spray and decongestant nasal spray
o Bacterial infection - antibiotics
• Upper airway cough syndrome
o Antihistamines
(e.g., Chlorpheniramine)
o Decongestants
 Acute &
Chronic
Tonsillitis
Inflammation of the
tonsils
Acute Tonsillitis
Epidemiology Aetiology
• Mostly affects school-going • Haemolytic streptococcus – most
children, but also affects adults commonly infecting organism
• Rare in infants and persons who • Other cause: Staphylococci,
are above 50 years old pneumococci or H. influenzae
• These bacteria may primarily infect
the tonsil or may be secondary to
viral infection
• Viral infections: Rhinovirus,
Adenovirus, Influenza virus,
Epstein-Barr virus (EBV)
Tonsil consists of:
• Surface epithelium
• Crypts – tube like
invaginations from the
surface epithelium
• Lymphoid tissue
 Types
• Acute catarrhal or
superficial tonsillitis –
mostly seen in viral
infections
• Acute follicular
tonsillitis – infection
spreads into crypts,
filled with purulent
material at the openings Acute membranous tonsillitis Acute parenchymatous tonsillitis
of crypts (yellowish
spots)
• Acute parenchymatous
tonsillitis – tonsil
substance is affected,
tonsil is uniformly
enlarged & red
• Acute membranous
tonsillitis – exudate from
crypts coalesces to
form a membrane on the
surface of tonsil
Acute catarrhal tonsillitis Acute follicular tonsillitis
Clinical Features
Symptoms Signs

• Sore throat • Foetid breath and coasted tongue

• Difficulty in swallowing • Hyperaemia of pillars, soft palate and uvula
• Fever (38–40°C) ± chills and rigors • Tonsils – red, swollen with yellowish spots of
• Earache purulent material at the opening of crypts (acute
• Constitutional symptoms (headache, general follicular tonsillitis)
body aches, malaise, constipation) • Whitish membrane on the medial surface of
tonsil, easily wiped away with a swab (acute
membranous tonsillitis)
• Enlarged and congested tonsils, almost meet in
the midline along with some oedema of uvula &
soft palate (acute parenchymatous tonsillitis)
• Jugulodigastric lymph nodes are enlarged &
tender
Investigation
• Evaluation: History taking, physical examination, risk
stratification (Centor Score)
• Full blood count and basic metabolic panel to assess renal
function
• Throat culture and rapid antigen detection test: Group A beta-
haemolytic Streptococcus
• Pharyngeal swabs: Gonorrhoea, Chlamydia and HIV testing
• CT imaging of the neck: To exclude dangerous causes such as
abscess, epiglottitis and Lemierre disease
Centor Criteria
Criteria Interpretation
Management
• Put to bed and encouraged to take plenty of fluids
• Analgesics (paracetamol) – to relieve local pain and fever
• Antimicrobial therapy – Penicillin for Streptococcus,
Erythromycin if allergy to Penicillin
• Antibiotics should be continued for 7 – 10 days
Complication
• Chronic tonsillitis with recurrent acute attacks
• Peritonsillar abscess
• Parapharyngeal abscess
• Cervical abscess
• Acute otitis media
• Rheumatic fever
• Acute glomerulonephritis
• Subacute bacterial endocarditis
Chronic Tonsillitis
Aetiology
• Complication of acute tonsillitis
• Subclinical infections of tonsils without acute attack
• Mostly affects children and young adults, rarely occurs after 5
years
• Chronic infection in sinuses or teeth
Types
• Chronic follicular tonsillitis – tonsillar
crypts full of infected cheesy material
(yellowish spots)
• Chronic parenchymatous tonsillitis –
hyperplasia of lymphoid tissue,
enlarged tonsils interfere with speech,
deglutition and respiration, attacks of
sleep apnoea may occur
• Chronic fibroid tonsillitis – tonsils are
small but infected, with history of
repeated sore throats
Clinical Features
Symptoms Signs
• Recurrent attacks of sore throat or acute • Tonsils may show varying degree of
tonsillitis enlargement
• Chronic irritation in throat with cough • Yellowish beads of pus on medial surface of
• Bad taste in mouth and foul breath tonsil (chronic follicular type)
(halitosis) due to pus in crypts • Small tonsils, pressure on the anterior pillar
• Thick speech, difficulty in swallowing and expresses frank pus or cheesy material
choking spells at night (when tonsils are (chronic fibroid type)
large and obstructive) • Flushing of anterior pillars compared to the
rest of pharyngeal mucosa
• Jugulodigastric lymph nodes enlargement
Management Complications
• Conservative treatment – • Peritonsillar abscess
Diet, treatment of coexistent • Parapharyngeal abscess
infection of teeth, nose and
sinuses • Intratonsillar abscess
• Tonsillectomy – tonsils • Tonsilloliths
interfere with speech, • Tonsillar cyst
deglutition and respiration or • Rheumatic fever
cause recurrent attacks
• Acute glomerulonephritis
 Pharyngitis vs Tonsillitis
Pharyngitis Criteria Tonsillitis
Inflammation of throat Inflammation of the tonsils
Definition
mucosa
Dry, scratchy throat Enlarged tonsils
May have enlarged White patches on tonsils
Signs and symptoms
lymph nodes Sore throat
Sore throat
Analgesics Analgesics
Antibiotics Management Antibiotics
Warm saline gargles Tonsillectomy if indicated
Dehydration Sleep apnoea (if severely
Chronic throat pain swollen tonsils)
Complications
Ear infections Ear infections
Peritonsillar abscess
Tonsillectomy
Surgical removal of tonsils
Absolute Indications
Recurrent infections of throat
• ≥ 7 episodes in 1 year Tonsillitis which cause febrile seizures
• 5 episodes per year for 2 year
• 3 episodes per year for 3 year Hypertrophy of tonsils causing:
• ≥ 2 weeks of lost school or work in • Airway obstruction (sleep apnoea)
1 year • Difficulty in deglutition
• Interference with speech
Peritonsillar abscess
• Children: Done 4 – 6 weeks after Suspicion of malignancy – unilaterally
abscess has been treated
enlarged tonsils
• Adult: Second attack of peritonsillar
abscess
Relative Indications
• Diphteria carriers (do not respond to antibiotics)
• Streptococcal carriers (may be the source of infections to
others)
• Chronic tonsillitis with bad taste or halitosis, unresponsive to
medical treatment
• Recurrent streptococcal tonsillitis in patient with valvular heart
disease
Contraindications
• Haemoglobin level < 10 g%
• Presence of acute infection in upper respiratory tract, even acute
tonsillitis
• Children under 3 years of age
• Overt or submucous cleft palate
• Von Willebrand disease, bleeding disorders
• At the time of epidemic of polio
• Uncontrolled systemic disease
• Tonsillectomy is avoided during period of menses
Postoperative Care
• Immediate general care
• Diet
• Oral hygiene
• Analgesics
• Antibiotics
Complications

Immediate Delayed

• Primary haemorrhage • Secondary haemorrhage

• Reactionary haemorrhage • Infection
• Injury to tonsillar pillars, uvula, soft • Lung complications
palate, tongue or superior • Scarring in soft palate and pillars
constrictor muscle • Tonsillar remnants
• Injury to teeth • Hypertrophy of lingual tonsil
• Aspiration of blood
• Facial oedema
 • Collection of pus in the
peritonsillar space
which lies between the capsule of
tonsil and the superior constrictor
Peritonsillar muscle
Abscess • Also known as quinsy
• Usually
follows acute tonsillitis though it
may rise de novo without previous
history of sore throat
Applied anatomy
Clinical features

• Severe pain in throat. Usually unilateral.

• Odynophagia.
• Muffled and thick speech, often called "hot potato voice".
• Foul breath due to sepsis in oral cavity and poor hygiene.
• Ipsilateral earache. Referred pain via CN IX supplies both tonsil and ear.
• Trismus. Spasm of pterygoid muscles which is in close proximity to the
superior constrictor muscle.
Physical examination

• Tonsil, pillars and soft palate are

congested and swollen.
• Uvula is swollen and pushed to
the opposite side.
• Cervical lymphadenopathy.
Jugulodigastric lymph nodes.
• Torticollis. Neck tilted to the side
of abscess.
Investigation
• Full blood count typically demonstrate
leucocytosis. Useful in monitoring
patient's response to treatment.
• Pre-operative assessments.
• Contrast-enhanced CT or MRI shows
the abscess and the extent of it.
• Needle aspiration provides material
for culture and sensitivity of bacteria.
Treatment

• Medical managements:
o Airway
o Fluid resuscitation
o Antibiotic therapy

• Surgical managements:
o Incision and drainage of abscess
o Interval tonsillectomy.
Complications

• Parapharyngeal abscess.
• Edema of larynx.
• Septicaemia.
• Pneumonitis or lung abscess.
• Jugular vein thrombosis.
• Spontaneous hemorrhage from carotid artery or jugular vein.
 • Commonly seen in children below 3
years. Result of suppuration of
retropharyngeal lymph nodes
secondary to infection in the adenoids,
nasopharynx, posterior nasal sinuses
Retropharyngeal or nasal cavity.
Abscess • In adults, it may result from
penetrating injury of posterior
pharyngeal wall or cervical esophagus.
• Rarely, may be from acute mastoiditis.
Applied anatomy
Clinical features
• Dysphagia and difficulty in
breathing.
• Stridor and croupy cough.
• Torticollis.
• Bulge in posterior pharyngeal
wall. Usually seen on one side of
the midline.
Investigation
• X-ray of neck. Lateral view.
• Contrast-enhanced CT shows
the extent of abscess and if
there is any other associated
abscess of the
parapharyngeal space.
 • Also known as abscess of
pharyngomaxillary or lateral
pharyngeal space abscess.
• More commonly seen in adults.
Parapharyngeal • Occur from:-
Abscess o Pharynx
o Teeth
o Ear
o Other spaces
o External trauma
Applied anatomy
Clinical features

• Depends on compartment involved. Fever, odynophagia, sore throat, torticollis are common.
• Anterior compartment produce a triad of symptoms:-
o Prolapse of tonsil and tonsillar fossa
o Trismus
o External swelling behind the jaw
• Posterior compartment produces:
o Bulge of pharynx behind posterior pillar
o Paralysis of CN IX, X, XI, XII and sympathetic chain
o Swelling of parotid region
Investigation
• Contrast-enhanced CT scan
neck will show the extent of
lesion.
• Magnetic resonance
arteriography if suspect
thrombosis of internal jugular
vein or aneurysm of internal
carotid artery.
Complications

• Acute edema of larynx with respiratory obstruction.

• Lemierre's syndrome. Thrombophlebitis of internal jugular vein with
septicaemia.
• Spread of infection to retropharyngeal space or mediastinum.
• Pseudoaneurysm or rupture of carotid artery.
 LUDWIG’S
ANGINA
Infection of submandibular space
Applied Anatomy
• Submandibular space is divided into 2
compartments:
• Sublingual compartment (above the
mylohyoid)
• Submaxillary and submental
compartment (below the mylohyoid)
• These 2 compartments are continuous
around the posterior border of mylohyoid
muscle.
Aetiology
• Dental infections
• 80% of total cases
• Roots of premolars lie above the attachment of
mylohyoid and cause sublingual space infection
• Roots of molar teeth extend up to or below the
mylohyoid line and cause submaxillary space infection
• Bacteriology
• Mixed infections involving both aerobes and anaerobes
are common
• Common : Alpha-haemolytic Streptococci,
Staphylococci and bacteroides groups
• Rare : Haemophilus influenzae, Escherichia coli and
Pseudomonas
• Other cases : submandibular sialadenitis, injuries of oral
mucosa, fractures the mandible
Clinical Features
• Marked difficulty in swallowing (odynophagia) with varying
degree of trismus
• In infection localized to the sublingual space : structure in
the floor of mouth are swollen, tongue seems to be
pushed up and back
• When infection spreads to submaxillary space, submental
and submandibular regions become swollen and tender,
impart woody-hard feel
• Usually, there is cellulitis of tissues rather than frank
abscess
• Tongue is progressively pushed upwards and backwards -
threatening the airway
• Laryngeal oedema may appear
• In anaerobes infection, may have crepitus from gas
formation
Investigation
• Ludwig’s angina primarily is a clinical diagnosis
• CT Neck and Face
• Airway patency
• Extent of soft tissue swelling
• Underlying dental problems
• Local skin thickening
• Increase attenuation of soft tissue fat
• Muscle edema
• Focal fluid collection
• Loss of fat planes within submandibular spaces
Treatment
• Systemic antibiotic
• Incision and drainage of abscess
• Intraoral – if infection still localized to sublingual space
• External- if infection involves submaxillary space
• Tracheostomy, if airway is endangered
Complications
• Spread of infection to parapharyngeal and retropharyngeal spaces
and thence to mediastinum
• Airway obstruction due to laryngeal oedema, or swelling and
pushing back of the tongue
• Septicaemia
• Aspiration pneumonia
TUMOURS OF
OROPHARYNX
BENIGN TUMOURS MALIGNANT TUMOURS
• Far less common than malignant • Common sites :
tumours • Post 1/3 (base) of tongue
• Papilloma – arises from tonsil, • Tonsil and tonsillar fossa
soft palate, faucial pillars • Faucial palatine arch, i.e. soft
• Haemangioma – on palate, palate and post pillar
tonsils, post & lat pharyngeal • Post and lat pharyngeal wall
wall • Gross appearance types :
• Pleomorphic adenoma – • Superficially spreading – in palatine
submucosally on the hard/soft arch
palate • Exophytic – in palatine arch
• Mucous cyst – in vallecula • Ulcerative – base of tongue, tonsil
• Others : lipoma, fibroma, • Infiltrative – base of tongue, tonsil
neuroma
Malignant Tumours
Carcinoma of Post. One-Third or Base of Tongue

• Symptoms
• Sore throat, feeling lump in the throat, slight discomfort in swallowing
• Late symptoms - Referred pain in the ear, dysphagia, bleeding from mouth, change in quality of
speech (hot potato voice)
• Spread
• Local
• Lymphatic – 70% shows cervical metastases
• Distant metastases – bones, liver, lungs
• Treatment
• Radiosensitive tumours (anaplastic carcinoma, lymphoepitheloma, lymphoma) – radiotherapy
to the primary and neck nodes
• Advanced cancer, in patients with poor health – only palliation with radio or chemotherapy may
be required
Malignant Tumours (Cont).
Carcinoma of Tonsil and Tonsillar Fossa
• Squamous cell carcinoma – most common – present as ulcerated lesion w necrotic base
• Lymphomas may present as unilateral tonsillar enlargement with or without enlargement
• Symptoms
• Persistent sore throat, difficulty in swallowing, pain in the ear, lump in neck
• Later on – bleeding from mouth, fetor oris and trismus
• Spread
• Local
• Lymphatic – 50% have initial cervical node involvement
• Distant metastases – in late cases
• Treatment
• Radiotherapy
• Surgery
• Combination therapy
Malignant Tumours (Cont.)
Carcinoma of Faucial (Palatine) Carcinoma of Post and Lat
Arch Pharyngeal Wall
• Often squamous cell variety • Lesions remain asymptomatic for a
• Symptoms : long time
• Persistent sore throat, local pain or • May spread submucosally to the
earache adjoining areas (tonsils, soft palate,
• Growth may have been noticed by tongue, nasopharynx or hypopharynx)
patient while using mirror, or by physician • 60% patients may have lymph node
or dentist during examination
metastases
• Spread may occur locally to the
contiguous structures or lymph nodes • Treatment
• Irradiation or surgical excision of growth
• Treatment : irradiation or surgical with skin grafting
excision • When nodes are palpable, often
combined with block dissection
Obstructive Sleep
Apnoea (OSA)
A common sleep-related breathing
disorder
caused by repetitive upper airway
collapse resulting in partial/ complete
breathing cessation
 Age: 40 to 70 years old

Male gender

Family history of OSA

Risk factor of Morbid obesity

OSA
Craniofacial features

• Increase soft palate and tongue thickness

• Reduced dimension of maxilla
• Reduce pharyngeal airway space
• Reduce skeletal sagittal dimensions
• Increase vertical skeletal dimesions
• A lowered position of hyoid
Pathophysiology of Obstructive Sleep Apnoea
Congestive
Hypoxia &
Apnoea during Pulmonary heart failure,
retention of
sleep constriction bradycardia and
carbon dioxide
cardiac hypoxia
History taking for OSA
Screening tools for OSA
• STOP-BANG* Questionnaire
• STOP - Snoring, Tiredness, Observed Apnoea and high blood pressure
• BANG – BMI, Age, Neck Circumference and Gender
• High risk of OSA: 3 or more criterias
• Epworth Sleepiness Scale (ESS) to assess daytime sleepiness
• Score range from 0– 24
• High risk: score 11 or more
Diagnosis
• Diagnosis of OSA can be confirmed by using
polysomnography (PSG)
• Monitors brain waves, blood oxygen level, heart
rate and breathing while sleeping
• In patient with suspected OSA, the PSG should be
performed within six month of initial consultation
• Severity of OSA in adults are shown below:

*AHI: Apnoea Hypopnoea Index

Treatment for OSA

Weight management and lifestyle modification

Positive airway pressure (PAP) therapy

• Golden standard treatment for OSA
• Positive airway pressure (PAP) therapy refers
to delivery of compressed air which splints
the collapsed upper airway
• Two types of PAP therapy
• Continuous PAP (CPAP)
• Bi-level PAP (BiPAP)

CPG Management of Obstructive Sleep Apnoea (2023)

Treatment for OSA continue…
Surgical treatment
• Patient who cannot tolerate/ accept PAP therapy
Indications • Patient with major structural upper airway obstruction

• Nasal surgery (septoplasty, turbinate reduction, polypectomy)

• Oropharyngeal surgery (Uvulopalatoplasty)
• Tongue surgery (conventional glossectomy, transoral robotic base
Types of surgery of tongue surgery)
• Maxillary expansion
• Maxillomandibular advancement
IMMUNOCOMPROMISED
STATE CAUSING SORE
THROAT
Immunocompromised States
• HIV/AIDS
• Organ transplant recipients
• Cancer patient undergoing chemotherapy
• Bone marrow transplant patients
• Long-term steroid use
• Chronic medical condition
 Traumatic
Causes of Sore
Throat
Direct trauma
• Injury due to external force (eg: striking the throat against a hard
surface)

Foreign body ingestion

• Fish bone ingestion, small object inhalation
• Common in paeds

Chemical injury
• Corrosive substances that irritate mucosal lining
• Rapid onset, severe pain especially during swallowing, presented
with coughing, drooling, inability to swallow, vomiting, vomit blood
and shortness of breath
References
• Dhingra, P.L. and Dhingra, S. (2018). Diseases of ear, nose and
throat and head and neck surgery. 7th ed.