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Oral Cavity, Oropharynx, Larynx & Thyroid. Hardev Singh Mann hardevsingh5@yahoo.com. 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

Oral Cavity, Oropharynx, Larynx & Thyroid

Hardev Singh Mann

hardevsingh5@yahoo.com

objectives
Objectives
  • Anatomy
  • Common Conditions encountered
    • Paediatrics
    • Adult
    • Oral cavity, nasopharynx, hypopharynx
  • Major symptoms and examination
anatomy
Anatomy
  • Anterior Triangle
  • Posterior Triangle
  • Location of lumps
lymph node groups
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
lymph node levels 1
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.
lymph node levels 2
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
paediatric oral cavity 1
Paediatric Oral Cavity 1
  • Otitis Media, epistaxis, rhinitis, FB nose: not covered (common)
  • OSA: Tonsils and adenoid hypertrophy
paediatric oral cavity 2
Paediatric Oral Cavity 2
  • Tonsillitis
    • Viral/bacterial
    • GABHS
  • Child ill
  • Abx, delayed px
  • Complications
    • Septicaemia etc
anatomy fascial layers
Anatomy: Fascial Layers
  • Superficial and deep
  • Important as infection spreads along these
  • Spaces (nb abscesses)
    • Retropharyngeal space
    • Parapharyngeal space
paediatric oral cavity 3
Paediatric Oral Cavity 3
  • Quinsy (peritonsillar abscess)
  • Drainage and IV abx
paediatric oral cavity 4
Paediatric Oral Cavity 4
  • Indications for tonsillectomy
    • Recurrent tonsillitis
    • 2 Quinsy
    • Obstructive tonsils (OSA)
    • Suspicion of CA (Lymphoma/SCC)
  • NB Unilateral tonsil swelling
paediatric laryngology 5
Paediatric Laryngology 5
  • Infectious Mononucleosis
  • Monospot test
  • Splenomegaly/ contact sports
paediatric oral cavity 6
Paediatric Oral Cavity 6
  • 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
paediatric laryngology 1
Paediatric Laryngology 1
  • Stertor
    • Low pitch
    • Nasopharynx/mouth
    • Nasopharyngeal airway
  • Stridor
    • High pitch
    • Inspiratory: laryngeal
    • Expiratory: tracheal
  • Wheezing
    • Expiratory
    • Bronchial/alveolar
paediatric laryngology 2
Paediatric Laryngology 2
  • Epiglottitis
  • Child ill: drooling, dysphagia, inspiratory stridor
  • NOT attempt tongue depression
  • Supraglottitis
paediatric laryngology 3
Paediatric Laryngology 3
  • (Laryngomalacia)
    • Neonate, EUA if severe, glottic collapse on inspiration
  • (Tracheoesophgeal fistula)
  • (Laryngeal web)
  • (Choanal atresia)
paediatric laryngology 4
Paediatric Laryngology 4
  • Retained Foreign Body (NB also nose, vestibulitis)
  • Larynx
  • Trachea
    • (hyperinflation CXR)
  • Oesophagus:
    • Complication: retropharyngeal/ mediastinal abscess
paediatric larngology 5
Paediatric Larngology 5
  • Branchial arch fistulae
  • 1st branchial (pharyngeal) arch rare
    • Pre-auricular sinus
  • 2nd arch 95%
  • 3rd & 4th pharyngeal arch fistulae rare
paediatric laryngology 6
Paediatric Laryngology 6
  • 2nd arch Branchial fistulae
    • Opening at junction of middle and lower 1/3 of SCM
    • End in tonsillar fossa (between ICA and ECA)
paediatric laryngology 7
Paediatric Laryngology 7
  • Thyroglossal Cyst
    • Incomplete decent of thyroid from foramen caecum
    • Junction anterior 2/3 and post 1/3 tongue
    • (lingual thyroid: nb scan!)
adult salivary gland disorders 1
Adult Salivary Gland Disorders 1
  • Salivary Gland swelling
  • Non Neoplastic
    • Infection
    • Stones
    • Autoimmune (eg sjogrens)
    • Radiotherapy (sicca)
adult salivary gland disorders 2
Adult Salivary Gland Disorders 2
  • Neoplastic
    • Parotid
      • Pleomorphic adenoma
      • VII palsy
      • US & FNAC (in clinic)
    • Submandibular
  • NB Surgery & Nerve damage
dysphagia 1
Dysphagia 1

Swallowing phases

    • Oral
    • Pharyngeal
    • Oesophageal
  • ? True dysphagia ? Intermittent
  • Age
  • Smoking/alcohol
  • (occupation/medical hx)
dysphagia causes 1
Intrinsic

FB

Stricture

Benign (peptic)

Malignant

Oesophageal web

Pharyngeal pouch

Extrinsic

Mediastinal mass/glands

Goitre

LA enlargement

Dysphagia Causes 1
dysphagia causes 2
Neurological

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
Dysphagia 2
  • Globus Pharyngeus
    • Intermittent
    • Common
    • BUT RF previous
    • Diagnosis of exclusion
    • (Flexible Nasendoscopy. Ba swallow +/- EUA)
dysphagia 3
Dysphagia 3
  • Laryngopharyngeal Reflux
  • Non specific dysphagia/sore throat
  • Flex Nasendoscopy changes
  • Gaviscon Advance
  • Review progress
dysphagia 4
Dysphagia 4
  • Pharyngeal Pouch
  • Food sticks to throat
  • Regurgitation of undigested food
  • Halitosis, LRTI
  • (L neck lump)
  • Ba swallow
  • Endoscopic stapling
dysphagia 5
Dysphagia 5
  • Neoplastic Causes
  • Oesophageal Ca
  • SCC
    • Larynx/subglottis/ supraglottis
  • Nasopharyngeal Ca
  • Lymphoma/ Leukemia
  • Mediastinal LN
dysphagia 6
Dysphagia 6
  • Age/smoker/alcohol
  • True dysphagia
  • Hoarseness
  • Nb solids>liquids
  • Wt loss
  • OTALGIA
  • Lymphadenopathy
dysphagia ba swallow findings
Dysphagia Ba swallow findings
  • (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
Key symptoms

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
Hoarseness
  • 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
Hoarseness 2
  • Persistent hoarseness > 3 weeks urgent referral
  • Investigation: image Recurrent LN: Head to chest CT (aortic arch)
  • NB other neurology?
hoarseness 3
Key symptoms

Persistent > 3/52

OTALGIA

Age(>40)

alcohol/smoking

Wt loss

Examination

neck lump (thyroid/LN)

(Cranial Nerve palsy)

Hoarseness 3
thyroid cancer 1
Thyroid Cancer 1
  • Women> Men
  • NB Hoarseness
  • Lymphadenopathy
  • US +/- FNAC
  • Benign Goitre may cause mass effect (airway/dysphagia)
obstructive sleep apnoea osa
Obstructive Sleep Apnoea (OSA)
  • Pickwickian syndrome
  • Daytime sleepiness
  • Epworth score
  • HGV/PSV
  • Oximetry/ sleep studies
  • CPAP
facial nerve palsy
Facial Nerve Palsy
  • 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
Hoarseness (duration)

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
Appendix 1- (Slides)
  • 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
Appendix 2- (Slides)
  • 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)