Oropharyngeal Disease

What Is Oropharynx?

The oropharynx is the part of the pharynx that is situated between the soft palate of the oral cavity and the epiglottis (the flap of cartilage in front of the larynx that blocks food from entering the larynx/voice box). The components of the oropharynx include;

• The back third of the tongue.

• The walls of the throat.

• The soft palate.

• The tonsils.

What Are the Clinical Features of Oropharyngeal Infection or Disease?

• Pain: Pain is the common symptom in the oropharyngeal area that may result from acute infections like tonsillitis, tonsillar abscess, trauma. Possibility due to carcinomas causing pain from the oropharyngeal diseases that may, in turn, be referred to the ear as well can be potentially life-threatening.

• Difficulty in Respiration: Trauma, tumors, and infections can lead to airway obstruction.

• Difficulty in Speech: Palatal paralysis can lead to improper closure of the nasopharyngeal isthmus in these patients with resulting hypernasality of voice. Enlarged adenoids or nasopharyngeal tumors can also result in a closed nasal voice.

• Ulceration of Pharyngeal Mucosa: Ulceration of the pharynx may be a manifestation of systemic diseases like leukemia, agranulocytosis, or aplastic anemia.

• Difficulty in Deglutition or Swallowing (Dysphagia): Difficulty swallowing may result from acute infections of the oral cavity. This can result from a variety of lesions in the oral cavity, pharynx, and esophagus, paralytic or neoplastic.

• Odynophagia: It is painful swallowing caused by inflammatory lesions in the oropharyngeal or supraglottis. Regurgitation occurs in paralytic lesions of the soft palate when the ingested material regurgitates into the nose. Paralysis of the pharynx may lead to dysphagia as well as to aspiration into the trachea.

• Cervical Lymphadenopathy: Enlargement of the cervical nodes is commonly due to infective or neoplastic lesions of the oral cavity, pharynx, larynx, and bronchi.

What Clinical Features Distinguish Oropharyngeal Cancers?

Any clinical features excluding the above-mentioned symptoms like sudden weight loss, unusual ear pain, non-healing ulcers of the oral cavity, continued trismus, white and red lesions of the oral cavity or the mucosa of the cheek, a thickened lining of the oral mucosa that does not heal within a few weeks all usually point to the probability of an oropharyngeal tumor.

Oropharyngeal or throat cancers also may show clinical symptoms of numbness in the tongue, near or around the lips, or in any area of the throat. Any clinical symptom that lasts longer than 14 days (2 weeks) needs thorough assessment as early diagnosis paves the way for intervention and prevention of the further spread of the oropharyngeal disease or tumor that can improve prognosis in these patients.

How Does a Dentist Examine the Oral Cavity and Pharynx for Oropharyngeal Diseases?

1. The clinical examination is done using a light source and a head mirror.

2. The lips are examined first to note any color changes, ulcerations, or tumors by the maxillofacial surgeon, physician, or dentist.

3. The patient is asked to open the mouth, and an inspection of the oral vestibule is done by the dental surgeon, usually with a tongue depressor that is used to lift the tip of the tongue and visualize or examine the orifices of the submandibular ducts and floor of the mouth.

4. Movements of the tongue are noted for paralysis or neoplastic infiltration.

5. Also, as oral hygiene assessment holds pivotal importance for oropharyngeal lesions, dental examination and sources of dental infection should be examined in detail by the dental surgeon. Faucial pillars and the condition of the tonsils are noted.

6. The color of the mucosa, ulcerations, and membrane formation are looked for in the oropharyngeal and buccal mucosa.

7. Surfaces of both the hard and soft palate are noted for any clefts, ulcers, or tumors.

8. Movements of the soft palate are observed by asking the patient to say the word multiple times like “ah.”

9. The posterior pharyngeal wall may be seen bulging in case of retropharyngeal abscess.

10. Mirror Examination - A view of the nasopharyngeal by a postnasal motor and that of the laryngopharynx by a laryngeal mirror is an important examination for diagnosing pharyngeal diseases.

11. Palpation - Finger palpation is necessary to examine the inside of the oral cavity and pharynx and should be routinely done. Bi-digital examination of the submandibular salivary gland and its duct should be done if necessary. Palpation of the tongue (kept inside the mouth) and that of the floor of the mouth is necessary for evaluating the extent of tumor infiltration. Palpation of the tonsils and base of the tongue is necessary to diagnose certain infiltrative growths which may not show on the surface. An elongated styloid process may be felt on palpation through the tonsillar fossa. Palpation of the neck for lymph nodes forms an essential part of the examination.

What Investigation Helps Confirm Oropharyngeal Diseases?

• Hematological Tests - Tests like hemoglobin estimation, total and differential counts are particularly required in ulceration of the oral cavity and oropharyngeal mucosa.

• Serological Tests - These are also preferably done to rule out syphilis infection or other STIs (sexually transmitted infections) like HPV (human papillomavirus) infections. Research indicates an evidential link between HPV and cancer of the oropharynx. Persistent HPV infection is a major risk factor that may be undetected. Its chronic origin increases the risk of oropharyngeal cancers.

• Radiological Investigations - A plain X-ray of the neck (lateral view) provides clues for evaluating pharyngeal diseases. An X-ray of the chest, lateral view of the other views may prove useful. CT (computed tomography) scan of the neck, however, is the radiological investigation of choice for space-occupying lesions of the head and neck.

What Are the Treatment Approaches for Oropharyngeal Diseases?

• The treatment plan for oropharyngeal diseases comprises primary prevention and control with antibiotics depending on the severity of infection (intravenous or oral). However, studies have shown long-term usage of antibiotics may also create oropharyngeal resistance of pathogenic bacterium causing disease.

• Transoral microsurgery (transoral robotic surgery or transoral laser surgery) is an advanced minimally invasive procedure to get rid of oropharyngeal cancers.

• Primary tumor surgery always remains the method of choice for surgical resection of a tumor; however, lymph node involvement in the later stages of cancer can be an indication for neck dissection that may be followed by chemotherapy or radiotherapy.

Conclusion:

Timely initial detection by the dentist or surgeon, especially if the patient reports persisting clinical symptoms, can be life-saving in the treatment of moderate oropharyngeal infections to fatal oropharyngeal cancers. Proper oral hygiene, regular dental check-ups, and timely diagnostic assessment play a crucial role as well in the prevention of diseases of this region.