OtoRhinoLaryngology Portal

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Median Pharyngeal Raphe

Acute Pharyngitis

An injected throat caused by infective inflammation involving pharyngeal mucous membranes and lymphoid follicles.  It is usually self-limiting and recovers naturally or with symptomatic treatment.

Infected Isolated Pharyngeal Lymphoids


Inflamed Scattered Lymphoid Follicles of Posterior Pharyngeal Wall

Inflamed scattered lymphoid follicles of posterior pharyngeal wall with normal coloured mucosa seen in between in a patient presented with generalized painless lymphadenopathy.  Excisional lymph node biopsy confirms lymphoma.

Scattered Lymphoid Hyperplasia on Posterior Pharyngeal Wall

Arrows point to the lymphoid follicles.


Nodular swellings of posterior pharyngeal wall due to scattered lymphoid hyperplasia.  The tonsils were enlarged bilaterally.

Pharyngeal Tonsils: A Close-Up View

Grade III tonsillar hypertrophy.  (T - tonsil, U - uvula)

   Grade II tonsillar hypertrophy with reticular surface appearance. 

(T - tonsil, U - uvula)

Tonsillar Crypts

This image shows prominent tonsillar crypts of the left tonsil (arrows).

Tonsillar Cleft

Wide and deep supratonsillar cleft.

Tonsillar Crypts and Cleft


Yellow arrows- cypts, blue arrow- cleft

Tonsillar Cleft and Retained Impissated Material

Tonsillar crypts and clefts predispose to several conditions like peritonsillar abscess, retained food residues, and tonsillolith formations.  Halitosis and

unusual tonsillar appearance are the usual presenting symptoms though it can be asymptomatic and found by chance on examination. Oropharyngeal endoscopic assessment, probing with blunt instrument, and digital palpation need to be done.  Figure shows cheesy-white materials in the supratonsillar cleft due to food residue/epithelial sloughs entrapment.  Beware of the underlying dysplasia/malignancy and if in doubt examination under anaesthesia

with/without excision biopsy (tonsillectomy)

will have to be performed.


Watch video of tonsil stone or keratosis tonsil @ Youtube

Watch video of entrapped impissated substance from tonsillar cleft @ YouTube

Tonsillar Crypts and Retained Impissated Material

Retained material/debris or phlegmon in tonsil crypts (arrows) with unilateral tonsillar enlargement.  Underlying tonsillolith (tonsil stone) need to be ruled out.

Keratosis Tonsils

White keratin on both tonsils surface especially worse at proximity of its crypts and clefts in an otherwise healthy patient.  No sorethroat, fever, or swallowing difficulty and no history to suggest recurrent tonsillitis.  (U - uvula, T - tonsil, X - incidental finding of small pedunculated papilloma) 



Throat Ulcers

Multiple throat ulcers involving the soft palate, uvula, and palatoglossal folds (arrows) which had caused severe sorethroat and painful swallowing.

Multiple large ulcers with thick fibrin causing severe sorethroat and painful swallowing.

Recovery phase of ulcers (same patient as above) showing fading fibrin, decreasing inflammatory borders, and shrinking ulcer size accompanied by clinical improvement of sorethroat/odynophagia.


An ulcer involving left palatoglossal fold with surrounding inflammation. 

Multiple oropharyngeal ulcers of various sizes (arrows) in a patient presented with sorethroat and odynophagia who was confirmed to have concurrent dengue fever.

Scattered Lymphoid Follicles Infection with Ulcerations

E - epiglottis, T - tonsil, PF - pyriform fossa.

Tonsillar Ulcer

This figure shows an ulcer over the inferior pole of right tonsil

after an alleged injury caused by chicken bone fragment.

Large ulcerative lesion involving right palatoglossal fold and tonsil.  (T - tonsil, U - uvula, PPW - posterior pharyngeal wall).

Tonsillar Cyst

Cyst of left tonsil.

Cyst of right tonsil (+). T - tonsil, PGF - palatoglossal fold, U - uvula.




An infected cyst with abscess formation (+).  PGF - palatoglossal fold, PPF - palatopharyngeal fold, U - uvula.




Aspirate from the lesion of the above patient showing formed pus. 

Tonsillar Polyp

Polyp arising from superior pole of right tonsil (arrow) in an asymptomatic patient.  (U - uvula)

Grading of Tonsillar Hypertrophy (after L. Brodsky)




Asymmetric Tonsillar Enlargement in Chronic Tonsillitis


Tonsillectomy: Intraoperative Endoscopic View

 T - tonsil, U - uvula

Uvula Oedema Post-Tonsillectomy

 Uvula (U) oedema which occurred in some patient after tonsillectomy.  Usually self-limiting and resolving naturally over few days. 

Tonsillar Bed Post-Tonsillectomy


 Thick and confluent fibrin exudates covering both tonsillar beds.

Thick fibrin covering the tonsil bed bilaterally. 

Confluent fibrin formed 5 days post-tonsillectomy.

Disappearing fibrin and speeding of re-epithelization

around 1 week post-tonsillectomy.


Fibrinous sloughs formation in the tonsillar bed is a normal phenomena after tonsillectomy. This will be replaced by normal epithelium usually within 1-2 weeks as healing occurs.


Watch video of pharyngitis post-tonsillectomy @ YouTube

Secondary Haemorrhage Post-Tonsillectomy

Blood clot attached to right tonsil bed in a patient who presented with haematemesis few hours earlier.  She had tonsillectomy done 9 days ago.  This is the typical features of secondary post-tonsillectomy haemorrhage.  Examination under general anaesthesia and haemostasis is indicated.  Warning: Do not remove the blood clot in the clinic!!!




 Bleeding with clot formation involving left tonsil bed in a patient who had tonsillectomy perfomed 10 days earlier.  This secondary haemorrhage is generally due to infection.  Examination under anaesthesia, removal of the blood clot and haemostasis was carried out.  Broad-spectrum intravenous antibiotic with anaerobe coverage was given and the patient showed dramatic response within 24 hours of treatment.  (T-tongue, U - uvula, PPW -posterior pharyngeal wall, X - blood clot within left tonsil bed, R - right, L - left)

The Normal Endoscopic View of Oropharynx Post-Tonsillectomy

 The throat views from different patients - above and below.



Posterior Pharyngeal Wall Lymphoid Hyperplasia Post-Tonsillectomy

 Secondary lymphoid hyperplasia after uvulo-palato-pharyngo-plasty (UPPP).

Secondary lymphoid hyperplasia (circles) after tonsillectomy. 

Note healed mucosa of tonsillar bed bilaterally (+).

Another image of the throat after tonsillectomy.  Secondary pharyngeal lymphoid hyperplasia is obvious seen.  (+) - site of tonsil pre-removal, U -uvula.

Acute Exudative Tonsillitis

This image shows thick membranous exudate involving both tonsils in acute tonsillitis.  Severe odynophagia with poor oral intake warrants hospital admission with intravenous fluid and antibiotics therapy given.

Confluent exudate covering the tonsillar surface in acute exudative tonsillitis.


Infectious mononucleosis need to be considered in such cases.  Prominent cervical lymphadenitis is usually present and variable degree of jaundice due to viral-induced hepatitis.

Acute Follicular Tonsillitis


Fibrin exudates at tonsillar crypt openings in a classic case of acute follicular tonsillitis.

T - tonsil, U - uvula.  Note the exudates along tonsillar crypts.

Oedematous uvula in acute tonsillitis.  Snoring, if already present can become worse during this time.

Inflamed posterior pharyngeal wall scattered lymphoids in acute tonsillo-pharyngitis.

Follicular Tonsillitis - Resolution Stage

Note whitish fibrin at tonsillar crypts bilaterally.

Acute Tonsillitis - Parenchymatous

Parenchymatous tonsillitis showing inflamed and swollen tonsils bilaterally (T) with minimal to absent surface exudates or follicles.  The uvula is oedematous and inflamed as well.

Inflamed and enlarged tonsils with minimal exudates at supratonsillar cleft bilaterally

Acute Tonsillopharyngitis

Acute infective inflammation involving the tonsils (T) and posterior pharyngeal wall scattered lymphoid follicles (+).  Noted whitish-grey exudates coating the surface of these lymphoid structures.  View taken at velopharyngeal level by using distal chip fiberoptic scope.

Greyish-white fibrin exudate covering surfaces of infected tonsils (T), scattered pharyngeal lymphoids (arrows), and the lowermost nasopharyngeal lymphoid (X). [U - uvula]

Infectious Mononucleosis



Grade IV tonsillar hypertrophy with thick adherent exudate in infectious mononucleosis confirmed by monospot test. 


A unilateral infective inflammation beyond tonsillar capsule which presents with sorethroat, odynophagia (painful swallowing) and fever.  Clinically there is fullness or swelling around palatoglossal fold (elipse) and distal ipsilateral soft palate with no obvious exudate seen on tonsillar surface or from its crypts.  The uvula remains central but can be odematous.  This lesion may lead to peritonsillar abscess if not treated appropriately.  Diagnostic aspiration is negative for pus.  CT-scan seldom required unless pain worsens with severe odynophagia (even to swallowing own saliva), presence of trismus with limited mouth opening, or unsettled fever.  These symptoms are highly suggestive of peritonsillar abcess formation which will needs a proper incision and drainage procedure to be done.

 Indurated soft palate crossing midline in established of left-sided peritonsillitis (red outline).  The uvula is inflamed and swollen (+).  (white line - midline)

Peritonsillar Abscess

Peritonsillar abscess is a collection of pus beyond the capsule of the tonsil.  Clinically, mucosal inflammation with swelling will be noted and the tonsils itself is pushed medially and the uvula can be seen off midline to the opposite site.  Figure shows left peritonsillar abscess and the red dot point to the drainage spot for diagnostic aspiration/drainage.


See video of peritonsillar abscess @ YouTube


 Abraham's tonsillar knife commonly used for incision and drainage of peritonsillar abscess.


Multiloculated abscess involving left peritonsillar space (1,2,3,4).  U - Uvula, T - left tonsil.  Incision and drainage was performed under general anaesthesia.

Peritonsillar Abscess with Ipsilateral Cervical Lymphadenitis

 Dotted line - midline, PT - indurated and grossly swollen right peritonsillar area with an abscess within, U - an oedematous uvula which was pushed off midline.



X - swelling due to underlying reactive lymphadenitis. 

Tonsil Abscess

Left tonsil enlarged due to abscess formation within infected tonsil.

Abscess exuding upon aspiration site.


Intra-Tonsil Abscess Found During Tonsillectomy


 Panaromic view of oropharynx during tonsillectomy.


Abscess (A) in right tonsil tissue.


 Abscess (A) in left tonsil tissue.

Spontaneous Tonsil Bleeds

Fresh blood from bleeding right tonsil surface of unknown cause.  An antibiotic course, throat gargle and tranexamic acid was prescribed and the bleeding stopped several hours later.  Haematologic indices were within normal range.  (RT - right tonsil, LT - left tonsil, U - uvula)

Oropharyngeal Candidiasis

White lesions ('curdled-milk' appearance) of thrush with the background of indurated mucosa in a patient with oropharyngeal candidiasis.   



Oral and  Pharyngeal Candidiasis

Unilateral Tonsillar Hypertrophy with Cervical Lymphadenopathy

Tonsillar Malignancy

   Ulcero-fungating squamous cell carcinoma involving right tonsil and its pillars. 

                     [Circle- carcinoma lesion, U- uvula, SP- soft palate]

Left tonsil tumour covered by thick greyish mucosa seen medially and bulging palatoglossal fold.  [SP - soft palate, U - uvula, T - tonsil, PPW - posterior pharyngeal wall, R - right, L - left]

Solid tumour presenting as an asymmetric left tonsillar enlargement.

Suspected lymphoma of right tonsil.

An incidental finding of left tonsillar enlargement in a patient presented with otalgia

An obvious mass (X) originating from the left tonsil.