Oral Cavity, Oropharynx, Larynx & Thyroid

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

2. Objectives • Anatomy • Common Conditions encountered • Paediatrics • Adult • Oral cavity, nasopharynx, hypopharynx • Major symptoms and examination

3. Anatomy • Anterior Triangle • Posterior Triangle • Location of lumps

4. 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

5. 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.

6. 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

7. Paediatric Oral Cavity 1 • Otitis Media, epistaxis, rhinitis, FB nose: not covered (common) • OSA: Tonsils and adenoid hypertrophy

8. Paediatric Oral Cavity 2 • Tonsillitis • Viral/bacterial • GABHS • Child ill • Abx, delayed px • Complications • Septicaemia etc

9. Anatomy: Fascial Layers • Superficial and deep • Important as infection spreads along these • Spaces (nb abscesses) • Retropharyngeal space • Parapharyngeal space

10. Paediatric Oral Cavity 3 • Quinsy (peritonsillar abscess) • Drainage and IV abx

11. Paediatric Oral Cavity 4 • Indications for tonsillectomy • Recurrent tonsillitis • 2 Quinsy • Obstructive tonsils (OSA) • Suspicion of CA (Lymphoma/SCC) • NB Unilateral tonsil swelling

12. Paediatric Laryngology 5 • Infectious Mononucleosis • Monospot test • Splenomegaly/ contact sports

13. 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

14. Paediatric Laryngology 1 • Stertor • Low pitch • Nasopharynx/mouth • Nasopharyngeal airway • Stridor • High pitch • Inspiratory: laryngeal • Expiratory: tracheal • Wheezing • Expiratory • Bronchial/alveolar

15. Paediatric Laryngology 2 • Epiglottitis • Child ill: drooling, dysphagia, inspiratory stridor • NOT attempt tongue depression • Supraglottitis

16. Paediatric Laryngology 3 • (Laryngomalacia) • Neonate, EUA if severe, glottic collapse on inspiration • (Tracheoesophgeal fistula) • (Laryngeal web) • (Choanal atresia)

17. Paediatric Laryngology 4 • Retained Foreign Body (NB also nose, vestibulitis) • Larynx • Trachea • (hyperinflation CXR) • Oesophagus: • Complication: retropharyngeal/ mediastinal abscess

18. Paediatric Larngology 5 • Branchial arch fistulae • 1st branchial (pharyngeal) arch rare • Pre-auricular sinus • 2nd arch 95% • 3rd & 4th pharyngeal arch fistulae rare

19. 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)

20. 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!)

21. Adult Salivary Gland Disorders 1 • Salivary Gland swelling • Non Neoplastic • Infection • Stones • Autoimmune (eg sjogrens) • Radiotherapy (sicca)

22. Adult Salivary Gland Disorders 2 • Neoplastic • Parotid • Pleomorphic adenoma • VII palsy • US & FNAC (in clinic) • Submandibular • NB Surgery & Nerve damage

23. Dysphagia 1 Swallowing phases • Oral • Pharyngeal • Oesophageal • ? True dysphagia ? Intermittent • Age • Smoking/alcohol • (occupation/medical hx)

24. Intrinsic FB Stricture Benign (peptic) Malignant Oesophageal web Pharyngeal pouch Extrinsic Mediastinal mass/glands Goitre LA enlargement Dysphagia Causes 1

25. 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

26. Dysphagia 2 • Globus Pharyngeus • Intermittent • Common • BUT RF previous • Diagnosis of exclusion • (Flexible Nasendoscopy. Ba swallow +/- EUA)

27. Dysphagia 3 • Laryngopharyngeal Reflux • Non specific dysphagia/sore throat • Flex Nasendoscopy changes • Gaviscon Advance • Review progress

28. Dysphagia 4 • Pharyngeal Pouch • Food sticks to throat • Regurgitation of undigested food • Halitosis, LRTI • (L neck lump) • Ba swallow • Endoscopic stapling

29. Dysphagia 5 • Neoplastic Causes • Oesophageal Ca • SCC • Larynx/subglottis/ supraglottis • Nasopharyngeal Ca • Lymphoma/ Leukemia • Mediastinal LN

30. Dysphagia 6 • Age/smoker/alcohol • True dysphagia • Hoarseness • Nb solids>liquids • Wt loss • OTALGIA • Lymphadenopathy

31. 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.

32. 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

33. Hoarseness • Causes • 1) Structural/ca • Reinkes oedema • VC nodules • Ca • 2) Neurological • Recurrent LN palsy • 3) (Inflammatory) • 4) Muscle tension imbalance • Diagnosis of exclusion

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

35. Key symptoms Persistent > 3/52 OTALGIA Age(>40) alcohol/smoking Wt loss Examination neck lump (thyroid/LN) (Cranial Nerve palsy) Hoarseness 3

36. Tongue 1

37. Tongue 2

38. Lip, Oral cavity & Tongue

39. Thyroid Cancer 1 • Women> Men • NB Hoarseness • Lymphadenopathy • US +/- FNAC • Benign Goitre may cause mass effect (airway/dysphagia)

40. Thyroid Cancer 2

41. Obstructive Sleep Apnoea (OSA) • Pickwickian syndrome • Daytime sleepiness • Epworth score • HGV/PSV • Oximetry/ sleep studies • CPAP

42. 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

43. 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

44. 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)

45. 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)