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Oral Cavity, Oropharynx, Larynx & Thyroid. Hardev Singh Mann [email protected] Objectives. Anatomy Common Conditions encountered Paediatrics Adult Oral cavity, nasopharynx, hypopharynx Major symptoms and examination. Anatomy. Anterior Triangle Posterior Triangle

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Oral cavity oropharynx larynx thyroid l.jpg

Oral Cavity, Oropharynx, Larynx & Thyroid

Hardev Singh Mann

[email protected]


Objectives l.jpg
Objectives

  • Anatomy

  • Common Conditions encountered

    • Paediatrics

    • Adult

    • Oral cavity, nasopharynx, hypopharynx

  • Major symptoms and examination


Anatomy l.jpg
Anatomy

  • Anterior Triangle

  • Posterior Triangle

  • Location of lumps


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Lymph Node Groups

  • To help identify primary pathology

  • A, submental nodes;

  • B, submandibular nodes; C, upper deep cervical nodes;

  • D, middle deep cervical nodes;

  • E, lower deep cervical nodes; F, posterior triangle nodes;

  • G, paralaryngeal nodes;

  • H, paratracheal nodes;

  • I, parotid nodes;

  • J, suboccipital nodes


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Lymph Node Levels 1

  • Head and Neck surgery

  • CT/US findings given in levels

  • I, submental and submandibular nodes; II, upper jugular group of nodes; III, middle jugular nodes; IV, lower jugular group of nodes; V, posterior triangle group of nodes; VI, anterior or central group of nodes.


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I submental and submandibular nodes and drains the lip, oral cavity and tongue

II upper jugular group of nodes and drains the oropharynx, larynx, hypopharynx and parotid

III middle jugular nodes and drains the larynx and pharynx

IV lower jugular group of nodes

V posterior triangle group of nodes and drains the other lymphatic regions in the neck

VI anterior or central group of nodes. This includes the paratracheal, perithyroidal and Delphian nodes.

Lymph Node Levels 2


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Paediatric Oral Cavity 1 cavity and tongue

  • Otitis Media, epistaxis, rhinitis, FB nose: not covered (common)

  • OSA: Tonsils and adenoid hypertrophy


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Paediatric Oral Cavity 2 cavity and tongue

  • Tonsillitis

    • Viral/bacterial

    • GABHS

  • Child ill

  • Abx, delayed px

  • Complications

    • Septicaemia etc


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Anatomy: Fascial Layers cavity and tongue

  • Superficial and deep

  • Important as infection spreads along these

  • Spaces (nb abscesses)

    • Retropharyngeal space

    • Parapharyngeal space


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Paediatric Oral Cavity 3 cavity and tongue

  • Quinsy (peritonsillar abscess)

  • Drainage and IV abx


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Paediatric Oral Cavity 4 cavity and tongue

  • Indications for tonsillectomy

    • Recurrent tonsillitis

    • 2 Quinsy

    • Obstructive tonsils (OSA)

    • Suspicion of CA (Lymphoma/SCC)

  • NB Unilateral tonsil swelling


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Paediatric Laryngology 5 cavity and tongue

  • Infectious Mononucleosis

  • Monospot test

  • Splenomegaly/ contact sports


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Paediatric Oral Cavity 6 cavity and tongue

  • Ranula

    • Cystic swelling of floor of mouth

    • Congenital/acquired

    • sublingual salivary gland obstruction (retention cyst)

  • Plunging Ranula

    • Extravasation beyond floor of mouth

    • No epithelial cell lining

    • Cf cystic hygroma


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Paediatric Laryngology 1 cavity and tongue

  • Stertor

    • Low pitch

    • Nasopharynx/mouth

    • Nasopharyngeal airway

  • Stridor

    • High pitch

    • Inspiratory: laryngeal

    • Expiratory: tracheal

  • Wheezing

    • Expiratory

    • Bronchial/alveolar


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Paediatric Laryngology 2 cavity and tongue

  • Epiglottitis

  • Child ill: drooling, dysphagia, inspiratory stridor

  • NOT attempt tongue depression

  • Supraglottitis


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Paediatric Laryngology 3 cavity and tongue

  • (Laryngomalacia)

    • Neonate, EUA if severe, glottic collapse on inspiration

  • (Tracheoesophgeal fistula)

  • (Laryngeal web)

  • (Choanal atresia)


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Paediatric Laryngology 4 cavity and tongue

  • Retained Foreign Body (NB also nose, vestibulitis)

  • Larynx

  • Trachea

    • (hyperinflation CXR)

  • Oesophagus:

    • Complication: retropharyngeal/ mediastinal abscess


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Paediatric Larngology 5 cavity and tongue

  • Branchial arch fistulae

  • 1st branchial (pharyngeal) arch rare

    • Pre-auricular sinus

  • 2nd arch 95%

  • 3rd & 4th pharyngeal arch fistulae rare


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Paediatric Laryngology 6 cavity and tongue

  • 2nd arch Branchial fistulae

    • Opening at junction of middle and lower 1/3 of SCM

    • End in tonsillar fossa (between ICA and ECA)


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Paediatric Laryngology 7 cavity and tongue

  • Thyroglossal Cyst

    • Incomplete decent of thyroid from foramen caecum

    • Junction anterior 2/3 and post 1/3 tongue

    • (lingual thyroid: nb scan!)


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Adult Salivary Gland Disorders 1 cavity and tongue

  • Salivary Gland swelling

  • Non Neoplastic

    • Infection

    • Stones

    • Autoimmune (eg sjogrens)

    • Radiotherapy (sicca)


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Adult Salivary Gland Disorders 2 cavity and tongue

  • Neoplastic

    • Parotid

      • Pleomorphic adenoma

      • VII palsy

      • US & FNAC (in clinic)

    • Submandibular

  • NB Surgery & Nerve damage


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Dysphagia 1 cavity and tongue

Swallowing phases

  • Oral

  • Pharyngeal

  • Oesophageal

  • ? True dysphagia ? Intermittent

  • Age

  • Smoking/alcohol

  • (occupation/medical hx)


  • Dysphagia causes 1 l.jpg

    Intrinsic cavity and tongue

    FB

    Stricture

    Benign (peptic)

    Malignant

    Oesophageal web

    Pharyngeal pouch

    Extrinsic

    Mediastinal mass/glands

    Goitre

    LA enlargement

    Dysphagia Causes 1


    Dysphagia causes 2 l.jpg

    Neurological cavity and tongue

    Pharyngeal disorders

    Bulbar palsy (eg MND)

    MG/MS/PD/

    Recurrent LN palsy

    Other (not oe causes)

    Tongue (eg Ca)

    Mouth (tonsillitis)

    Nasopharyngeal ca

    Oesophageal Motility Disorders

    Achalasia

    Scleroderma

    Diffuse Oe Spasm

    Presbyoesphagus

    DM

    Drug induced

    Dysphagia Causes 2


    Dysphagia 2 l.jpg
    Dysphagia 2 cavity and tongue

    • Globus Pharyngeus

      • Intermittent

      • Common

      • BUT RF previous

      • Diagnosis of exclusion

      • (Flexible Nasendoscopy. Ba swallow +/- EUA)


    Dysphagia 3 l.jpg
    Dysphagia 3 cavity and tongue

    • Laryngopharyngeal Reflux

    • Non specific dysphagia/sore throat

    • Flex Nasendoscopy changes

    • Gaviscon Advance

    • Review progress


    Dysphagia 4 l.jpg
    Dysphagia 4 cavity and tongue

    • Pharyngeal Pouch

    • Food sticks to throat

    • Regurgitation of undigested food

    • Halitosis, LRTI

    • (L neck lump)

    • Ba swallow

    • Endoscopic stapling


    Dysphagia 5 l.jpg
    Dysphagia 5 cavity and tongue

    • Neoplastic Causes

    • Oesophageal Ca

    • SCC

      • Larynx/subglottis/ supraglottis

    • Nasopharyngeal Ca

    • Lymphoma/ Leukemia

    • Mediastinal LN


    Dysphagia 6 l.jpg
    Dysphagia 6 cavity and tongue

    • Age/smoker/alcohol

    • True dysphagia

    • Hoarseness

    • Nb solids>liquids

    • Wt loss

    • OTALGIA

    • Lymphadenopathy


    Dysphagia ba swallow findings l.jpg
    Dysphagia Ba swallow findings cavity and tongue

    • (a) A large pharyngeal pouch with narrowing of the oesophageal lumen distal to the pouch;

    • (b)pharyngeal carcinoma;

    • (c)cricopharyngeal spasm;

    • (d) an anterior postcricoid web on the lateral view of the barium swallow in a patient with Plummer–Vincent syndrome;

    • (e) midoesophageal peptic stricture above a sliding hiatus hernia and evidence of reflux;

    • (f) lower third ulcerating oesophageal carcinoma producing irregular constrictions of the lumen;

    • (g)extrinsic compression of the oesophagus by mediastinal lymph nodes; (h)achalasia showing a dilated oesophagus with the smooth ‘bird beak’ tapering of the oesophagogastric junction;

    • (i)candida of the oesophagus showing the typical ‘shaggy’ mucosa with multiple irregular filling defects involving most of the oesophagus.


    Dysphagia 7 l.jpg

    Key symptoms cavity and tongue

    Persistent true dysphagia

    Persistent sore throat

    OTALGIA

    Age (>40)

    Wt loss

    smoking/alcohol

    Examination

    Neck lump (LN/Thyroid)

    Laryngeal crepitus (FB)

    White patches (leukoplakia)

    Ulceration- NB bimanual examination

    CN palsy

    Dysphagia 7


    Hoarseness l.jpg
    Hoarseness cavity and tongue

    • Causes

      • 1) Structural/ca

        • Reinkes oedema

        • VC nodules

        • Ca

      • 2) Neurological

        • Recurrent LN palsy

      • 3) (Inflammatory)

      • 4) Muscle tension imbalance

        • Diagnosis of exclusion


    Hoarseness 2 l.jpg
    Hoarseness 2 cavity and tongue

    • Persistent hoarseness > 3 weeks urgent referral

    • Investigation: image Recurrent LN: Head to chest CT (aortic arch)

    • NB other neurology?


    Hoarseness 3 l.jpg

    Key symptoms cavity and tongue

    Persistent > 3/52

    OTALGIA

    Age(>40)

    alcohol/smoking

    Wt loss

    Examination

    neck lump (thyroid/LN)

    (Cranial Nerve palsy)

    Hoarseness 3


    Tongue 1 l.jpg
    Tongue 1 cavity and tongue


    Tongue 2 l.jpg
    Tongue 2 cavity and tongue


    Lip oral cavity tongue l.jpg
    Lip, Oral cavity & Tongue cavity and tongue


    Thyroid cancer 1 l.jpg
    Thyroid Cancer 1 cavity and tongue

    • Women> Men

    • NB Hoarseness

    • Lymphadenopathy

    • US +/- FNAC

    • Benign Goitre may cause mass effect (airway/dysphagia)


    Thyroid cancer 2 l.jpg
    Thyroid Cancer 2 cavity and tongue


    Obstructive sleep apnoea osa l.jpg
    Obstructive Sleep Apnoea (OSA) cavity and tongue

    • Pickwickian syndrome

    • Daytime sleepiness

    • Epworth score

    • HGV/PSV

    • Oximetry/ sleep studies

    • CPAP


    Facial nerve palsy l.jpg
    Facial Nerve Palsy cavity and tongue

    • Idiopathic (Bell’s Palsy) >90%

      • HSV/VZV?

      • Steroids/ Antiviral?

    • Trauma/Acoustic neuroma/parotid tumour/ mastoiditis /cholesteatoma etc

    • Frontalis NOT spared

    • Protect eye

    • Refer ENT

      • MRI

      • 1% need surgery


    Major symptoms signs l.jpg

    Hoarseness (duration) cavity and tongue

    Dysphagia

    Sore throat/ ulcer (duration)

    Otalgia

    Wt loss

    Smoking/alcohol

    Age

    Unilateral symptoms

    Visible lesion

    Leukoplakia

    Ulcer

    Palpation of mass (include bimanual)

    CN examination

    Palpation neck

    Nasendoscopy

    FNAC/Imaging (refer)

    2 week wait forms

    Major Symptoms & Signs


    Appendix 1 slides l.jpg
    Appendix 1- (Slides) cavity and tongue

    • Slide 7: a) Post nasal space viewed from nasendoscope

    • Slide 7: b) Post nasal pace with 90 degree endoscope through mouth

    • Slide 8: above viral tonsillitis; below bacterial tonsillitis

    • Slide 16 Laryngomalacia (above) Tracheo-oesophageal fistula (below)

    • Slide 21: below: pus from parotid duct (parotitis)

    • Slide 22: parotid swelling (due to pleomorphic adenomas) (above)

    • Slide 22: submandibular swelling (pleomorphic adenoma) (below)

    • Slide 29 (above) left vocal cord SCC; below: neck swelling due to lymph node metastases from ipsilateral laryngeal ca (piriformis fossa)

    • Slide 30: Barrett’s Oesophagus (above); Oesophageal Ca (below)


    Appendix 2 slides l.jpg
    Appendix 2- (Slides) cavity and tongue

    • Slide 33: Reinke’s Oedema (above); Vocal cord nodules (below)

    • Slide 34: left vocal cord (recurrent laryngeal nerve) palsy (above)

    • Slide 34 Muscular tension imbalance (psychogenic dysphonia) (below)

    • Slide 36 (clockwise) Geographic tongue, angular cheilitis (stomatitis), apthous ulcer, furred tongue

    • Slide 37 (clockwise) Lichen planus, candidiasis (thrush) tongue, dry tongue (xerostomia), hairy leukoplakia (HIV)

    • Slide 38 (clockwise) SCC lower lip, Leukoplakia floor of mouth, SCC floor of mouth, SCC lateral surface of tongue

    • Slide 39 Goitre

    • Slide 42 Right facial palsy (above), Vesicles in conchal bowl of left ear in Ramsey Hunt Syndrome (VZV with VIICN palsy)


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