Chronic Pharyngitis, Chronic Tonsillitis, Adenoids, and Tumors of the Pharynx

1. Chronic Pharyngitis

Definition & Pathophysiology

Etiology

• Infectious causes: Recurrent bacterial (Group A beta-hemolytic Streptococcus — GABHS, S. pneumoniae, H. influenzae) and viral (rhinovirus, adenovirus, EBV, CMV, coxsackievirus) infections
• Non-infectious causes:
  • Laryngopharyngeal reflux (LPR): Patients with gastroesophageal reflux disease can develop LPR, presenting with intermittent hoarseness, chronic cough, postnasal drip, a "globus" sensation, reactive airway disease, halitosis, and acid taste in the back of the throat. Laryngoscopy may reveal posterior laryngitis with swollen erythematous arytenoids, thickened vocal folds, interarytenoid edema, and mucosal thickening. In severe cases, cricopharyngeal spasm causes dysphagia and aspiration.
  • Tobacco smoke, alcohol, dry air, allergic rhinitis, chemical irritants
  • Immunodeficiency states

Clinical Features

• Persistent sore throat, pharyngeal dryness or irritation, throat-clearing, postnasal drip
• Dysphonia, halitosis, mild odynophagia

Treatment

• Infectious: Prolonged antibiotic courses for bacterial causes; antivirals (acyclovir, valacyclovir, famciclovir) for herpetic causes
• LPR: Dietary modification, behavioral change, elevation of head of bed, proton pump inhibitor (PPI) trial
• Eliminate irritants: Cessation of smoking, alcohol moderation, treatment of allergic rhinitis

2. Chronic Tonsillitis

Definition & Pathophysiology

Clinical Features

• Whitish or yellowish semisolid debris on or emanating from the tonsils
• Foul taste and odor → halitosis
• Chronic sore throat due to persistent low-grade infection
• Recurrent episodes of acute tonsillitis
• Possible history of peritonsillar abscess

Microbiology

• Anaerobic bacteria predominate in the deep crypts
• Actinomyces — a commensal of the oral cavity and oropharynx — is a key marker of chronic infection. Its presence indicates deep-seated disease resistant to antibiotics

Treatment

• Frequent gargling with hydrogen peroxide mouthwash
• Manual expression of debris from crypts
• Long-term antibiotics:
  • Amoxicillin 500 mg three times daily for 21 days
  • Clindamycin 300 mg orally three times daily for 21 days

1. Actinomyces is identified (antibiotics unlikely to be effective)
2. Recurrent acute tonsillitis: ≥6 episodes in 1 year, or 3–4 episodes per year for 2 consecutive years (Paradise/AAO-HNS criteria)
3. Peritonsillar abscess accompanies recurrent tonsillitis
4. Sleep-disordered breathing (snoring → obstructive sleep apnea)

• Adenotonsillectomy reduces frequency and duration of sore throat episodes in children in the first year post-surgery
• Benefit in adults is less clear — many improve spontaneously, and surgical risks (hemorrhage, severe post-op pain — more prevalent in adults) must be weighed against potential benefits

3. Adenoids (Adenoid Hypertrophy)

Anatomy & Embryology

• Adenoids (pharyngeal tonsils) develop at 16 weeks gestation as subepithelial infiltration of lymphocytes in the roof of the nasopharynx
• They are part of Waldeyer's ring (along with palatine tonsils at 8 weeks from 2nd pharyngeal pouch, and lingual tonsil at 6.5 weeks)
• They normally regress during adolescence; in adults, an NP mass should raise suspicion for malignancy rather than adenoid hypertrophy

Pathophysiology of Hypertrophy

• Adenoids sit adjacent to the paranasal sinuses and serve as a bacterial reservoir
• In children with chronic rhinosinusitis (CRS), up to 88–99% of the adenoid mucosal surface area is covered with dense biofilm, versus 0–6.5% in controls (Zuliani et al.)
• The bacteriology of hypertrophied adenoids mirrors the middle meatuses in children with recurrent sinusitis — adenoid core culture predicts middle meatal cultures
• The contribution to CRS is not purely mechanical (size-related) but also functional (biofilm reservoir)
• Inflammatory cells: CD8+ lymphocytes, neutrophils, macrophages, B lymphocytes, and plasma cells predominate in younger children; eosinophils more prominent in older children

Clinical Effects of Adenoid Hypertrophy

• Nasal obstruction → mouth breathing, hyponasal speech
• Chronic rhinosinusitis and recurrent otitis media (Eustachian tube dysfunction)
• Sleep-disordered breathing: snoring, obstructive sleep apnea
• Postnasal drip, chronic cough

Treatment

• Adenoidectomy: Effective in resolving CRS symptoms in antibiotic-resistant cases by removing the biofilm reservoir
• Combined adenotonsillectomy for obstructive sleep apnea and recurrent tonsillitis
• Indications include: adenoid-related CRS, recurrent otitis media, significant nasal obstruction, sleep apnea

4. Tumors of the Pharynx

4A. Benign Tumors of the Nasopharynx

Juvenile Nasopharyngeal Angiofibroma (JNA)

• Most common benign tumor of the nasopharynx in adolescent males
• Locally aggressive, highly vascular, but histologically benign
• Can extend into: paranasal sinuses, infratemporal fossa, skull base, and intracranially
• Presentation: Adolescent male with epistaxis and nasal obstruction
• Diagnosis: CT/MRI before biopsy (risk of hemorrhage); biopsy only in operating suite
• Treatment: Surgery (endoscopic or open); recurrence rates up to 33%

Thornwaldt Cyst

• Second most common epithelial growth in nasopharynx (after adenoid hypertrophy)
• Arises from remnant of Rathke pouch (embryologic nasal-pharyngeal cleavage)
• Usually asymptomatic; may cause postnasal drip
• Management: Observation if asymptomatic; surgical removal under general anesthesia if symptomatic (root may adhere to prevertebral fascia)

Squamous Papilloma / Inverting Papilloma

• Benign epithelial tumor; epithelial changes may be inverting at the basal membrane (Schneiderian/inverting papilloma)
• Requires complete excision with margin of normal tissue; powered instrumentation helpful

Craniopharyngioma

• Histologically benign, arises from Rathke pouch
• Presents with endocrine and pituitary-like symptoms

4B. Malignant Tumors of the Pharynx

Nasopharyngeal Carcinoma (NPC)

• Strong correlation with Epstein-Barr virus (EBV) infection — the most important etiologic factor
• Ethnic predilection: Southern Chinese (Guangdong, Hong Kong, Singapore), Alaskan and Californian populations
• Also associated with dietary habits (salted fish, nitrosamines) and environmental exposures
• Found with nodal metastasis in >50% of cases at diagnosis due to the diagnostic inaccessibility of the nasopharynx — tumors reach significant size before symptoms arise

• Confined nasopharyngeal space
• Diagnosis inaccessibility
• Presenting signs: ear fullness/deafness (Eustachian tube obstruction), nasal obstruction, epistaxis, neck mass (nodal metastasis), cranial nerve palsies

• Imaging first: CT and MRI (CT for bony detail, MRI for soft tissue extent and intracranial extension)
• Transnasal biopsy in clinic (endemic areas) or in OR if JNA suspected
• Serologic screening: EBV serology and plasma EBV DNA are useful screening tools

Squamous Cell Carcinoma (SCC) — Oropharynx & Hypopharynx

• Tobacco (dose-proportional risk)
• Alcohol (synergistic with tobacco — substantially increases risk)
• High-risk HPV (especially HPV-16) — increasingly the dominant cause of oropharyngeal SCC
• Nutritional deficiency, prior irradiation

• Begins as in-situ lesions → pearly gray wrinkled mucosal plaques → ulcerated fungating masses
• Histologically: variable anaplasia, tumor giant cells, bizarre mitotic figures
• Adjacent mucosa often shows squamous hyperplasia with dysplasia/carcinoma in situ

• Can detect >95% of mucosal neoplasms in the pharynx below the pharyngoepiglottic fold
• Characterized by: intraluminal mass, mucosal irregularity, loss of distensibility
• Synchronous esophageal cancers are increased → esophagus must be evaluated at diagnosis

• Overall 5-year survival ~20% for pharyngeal SCC
• Slightly better than esophageal carcinoma
• Most patients present with advanced disease

• Early disease: organ-preserving (laser surgery, microsurgery, radiation)
• Advanced/recurrent: combined chemoradiation with or without surgical resection
• Neck dissection for regional nodal disease

Summary Comparison Table