Other Diseases of the Nasopharynx

Acute Nasopharyngitis

Definition and Aetiology

Acute nasopharyngitis, commonly known as the common cold, represents an acute self‑limiting infection of the nasopharynx. Viruses cause the majority of cases; however, bacteria can also be responsible. Among viruses, rhinovirus is the most frequent culprit, followed by parainfluenza virus and adenovirus. Bacterial pathogens include Streptococcus, Pneumococcus, and Haemophilus influenzae. The infection may remain confined to the nasopharynx alone, or alternatively, it may become part of a generalised upper respiratory tract infection. The infection spreads easily through droplets or through direct contact with infected secretions.

Clinical Features

The incubation period typically lasts 2 to 3 days. Initially, the patient experiences a burning sensation localised to the throat above the soft palate, followed shortly by dryness. Therefore, dryness and burning constitute the earliest symptoms. Subsequently, pain and discomfort develop at the back of the nose, and the patient notices some difficulty while swallowing. After a few days, rhinitis, repeated sneezing, malaise, and fever may appear. Children frequently develop ear pain due to associated otitis media. In severe infections, pyrexia rises further, and the cervical lymph nodes become enlarged. On examination, the nasopharyngeal mucosa appears congested and swollen, often covered with a whitish exudate. The entire illness usually lasts 7 to 10 days.

Differential Diagnosis

You must differentiate acute nasopharyngitis from allergic rhinitis and sinusitis. In allergic rhinitis, however, the patient does not complain of a sore throat. Instead, a history of seasonal variation or aggravation of symptoms after exposure to specific allergens points toward allergy.

Treatment

Mild cases resolve spontaneously without any active intervention. Nevertheless, you may prescribe simple analgesics for relief of pain and discomfort. Antibiotics are required only when you suspect a superadded bacterial infection, because most cases are viral in origin. Several studies have found steam inhalation effective, particularly in preventing further upper respiratory tract infections. Antihistamines, decongestants, and analgesics effectively relieve symptoms. Decongestant nasal drops reduce nasal stuffiness very effectively; however, we recommend them for short durations only (less than 7 days) to avoid rhinitis medicamentosa. Oral zinc has proven useful for recurrent cases, especially in children. In children with associated adenoiditis causing nasal obstruction, nasal decongestant drops provide additional benefit.

Chronic Nasopharyngitis

Aetiology

Chronic nasopharyngitis represents a persistent infection of the nasopharynx. Chronic infection of the adenoids (chronic adenoiditis), sinusitis, or long‑standing nasal infections usually cause this condition. Additionally, heavy smokers, chronic drinkers, and individuals exposed to dust and toxic fumes commonly develop chronic nasopharyngitis.

Clinical Features

Postnasal discharge and crusting constitute the most common complaints. This discharge constantly irritates the back of the throat; therefore, the patient feels a persistent desire to clear the throat by hawking or by inspiratory snorting (forcibly drawing nasal secretions back into the throat). On examination, the nasopharyngeal mucosa appears congested, and you will see mucopus or dry crusts. In children, the adenoids are often enlarged and infected, a condition we call chronic adenoiditis.

Treatment

You should attend to chronic infections of the nose, paranasal sinuses, and oropharynx as the first step. For chronic sinusitis, functional endoscopic sinus surgery (FESS) may become necessary. You must also advise the patient to correct excessive smoking and drinking habits. Preventive measures, such as avoiding dust and fumes, play a key role in management. Alkaline nasal douche effectively removes crusts and mucopus. Steam inhalations provide soothing relief. When conservative measures fail, especially in children with chronic adenoiditis, adenoidectomy may be required.

Thornwaldt’s Disease (Pharyngeal Bursitis)

Definition and Embryology

Thornwaldt’s disease is inflammation and abscess formation within the pharyngeal bursa. This bursa represents an embryonic remnant where the notochord attached to the endoderm of the primitive pharynx. Anatomically, the pharyngeal bursa lies in the midline of the posterior wall of the nasopharynx, embedded within the adenoid mass. The disease presents in two types: the cystic type and the crusting type. The cystic type usually remains asymptomatic because its drainage pathway remains closed; conversely, the crusting type drains openly into the nasopharynx.

Clinical Features

Many patients remain completely asymptomatic; therefore, the diagnosis often occurs incidentally during routine nasopharyngeal examination. However, when the cyst becomes infected, it gives rise to bursitis. The clinical features then include persistent postnasal discharge with crusting in the nasopharynx, nasal obstruction due to the swelling itself, and obstruction of the eustachian tube leading to serous otitis media. Additionally, patients may complain of a dull type of occipital headache, recurrent sore throat, and low‑grade fever. Other reported features include cervical myalgia, choanal discharge, and halitosis. On examination, you will find a cystic, fluctuant swelling on the posterior wall of the nasopharynx. The nasopharynx may also show crusts due to dried‑up discharge.

Treatment

You should administer antibiotics to treat the infection. Ultimately, marsupialisation of the cystic swelling with adequate removal of its lining membrane provides definitive treatment. This surgical approach effectively resolves the condition and prevents recurrence.

—-End of the chapter—-

High-Yield Points (NEET PG & University Revision)

• Acute nasopharyngitis is mostly viral; antibiotics are not routine.
• Rhinovirus is the most common cause of the common cold.
• Early symptoms are burning and dryness behind the soft palate.
• Children commonly develop otitis media due to Eustachian tube blockage.
• Nasal decongestant drops should not be used for more than 7 days.
• Chronic nasopharyngitis is commonly secondary to chronic sinusitis or chronic adenoiditis,
• Postnasal drip and throat clearing (hawking) are classic chronic features.
• Thornwaldt’s disease is an infection of the pharyngeal bursa and is embryological in origin.
• Thornwaldt cyst is located in the midline posterior nasopharyngeal wall.
• Occipital headache + halitosis + postnasal discharge strongly suggests Thornwaldt’s disease.
• Definitive treatment of Thornwaldt cyst is marsupialisation.
• Adenoidectomy is indicated in chronic adenoiditis causing nasal obstruction or otitis media.

NEET PG Style MCQs (10)

1. The most common cause of acute nasopharyngitis is: A. Adenovirus B. Rhinovirus C. Influenza virus D. Epstein-Barr virus
2. Ear pain in children with acute nasopharyngitis is most commonly due to: A. Otitis externa B. Otitis media C. Mastoiditis D. Labyrinthitis
3. Nasal decongestant drops should ideally not be used for more than: A. 3 days B. 7 days C. 14 days D. 30 days
4. The most characteristic symptom of chronic nasopharyngitis is: A. Facial pain B. Postnasal drip with hawking C. Epistaxis D. Severe sore throat
5. Thornwaldt’s disease is due to infection of: A. Maxillary sinus B. Pharyngeal bursa C. Eustachian tube cartilage D. Rosenmuller fossa
6. Thornwaldt cyst is typically located on: A. Lateral nasopharyngeal wall B. Posterior wall midline C. Floor of nasopharynx D. Roof of nasal cavity
7. Best imaging modality for Thornwaldt cyst is: A. X-ray nasopharynx B. CT scan C. MRI D. Ultrasound
8. A common complication of acute nasopharyngitis in children is: A. Vocal cord palsy B. Otitis media C. Nasal polyp D. Deviated nasal septum
9. The cystic type of Thornwaldt disease is often asymptomatic because: A. It is malignant B. It has closed drainage C. It is painless D. It occurs in adults only
10. Definitive treatment for Thornwaldt cyst is: A. Antibiotics only B. Radiotherapy C. Marsupialisation D. Tonsillectomy

Answers: 1: B. 2: B. 3: B. 4: B. 5: B. 6: B. 7: C. 8: B. 9: B. 10: C.

Clinical Case Scenarios

1. Case 1. A 6-year-old child has had fever, sneezing, sore throat, and ear pain for 3 days. Otoscopy shows a congested tympanic membrane. Most likely diagnosis: Acute nasopharyngitis with acute otitis media. Best management: Analgesics + nasal decongestant short course + antibiotics if bacterial otitis media suspected.
2. Case 2. A 28-year-old man has nasal obstruction, sneezing, watery discharge, and itching of the eyes. He has no fever or sore throat. Symptoms worsen during the spring season. Most likely diagnosis: Allergic rhinitis, Best differentiating point from acute nasopharyngitis: Absence of sore throat and fever.
3. Case 3. A 14-year-old boy has chronic postnasal drip, halitosis, throat clearing, and recurrent ear blockage. Nasoendoscopy shows enlarged, infected adenoids. Most likely diagnosis: Chronic nasopharyngitis due to chronic adenoiditis. Best definitive treatment: Adenoidectomy.
4. Case 4. A 35-year-old patient complains of persistent foul-smelling postnasal discharge and dull occipital headache. Nasoendoscopy shows a midline cystic swelling on the posterior nasopharyngeal wall. Most likely diagnosis: Thornwaldt’s cyst, Best management: Marsupialisation.

Frequently Asked Questions in Viva

1. What is acute nasopharyngitis? Acute nasopharyngitis is a viral infection of the nasopharynx, causing sore throat, sneezing, rhinorrhea, and mild fever.
2. Why do children develop otitis media during the common cold? Because nasopharyngeal swelling blocks the Eustachian tube, leading to middle ear infection or effusion.
3. When should antibiotics be given in acute nasopharyngitis? Antibiotics are used only if bacterial infection is suspected, such as persistent fever, purulent discharge, or otitis media.
4. What is chronic nasopharyngitis most commonly caused by? It is commonly caused by chronic sinusitis or chronic adenoiditis.
5. What is Thornwaldt’s disease? Thornwaldt’s disease is an infection of a nasopharyngeal cyst arising from the pharyngeal bursa.
6. What is the best investigation for a Thornwaldt cyst? Diagnostic nasal endoscopy confirms it, and MRI is the best imaging method.
7. What is the definitive treatment of Thornwaldt cyst? Marsupialisation of the cyst with removal of its lining is the definitive treatment.

—-End—-

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

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