ENT2 Flashcards
What is found in the anterior triangle of the neck?
Larynx
Pharynx
Carotid vessels
Mass in the supraclavicular fossa is likely to be__
Chest disease rather than neck disease
eg breast tumour or lung tumour
Why is the fascia of the neck clinically relevant?
Superficial fascia: If broken in a stab wound then surgical investigation is necessary
?can you see muscle fibres
In quinsy, pus outside of tonsils can track downwards
If a mass in the neck moves when you swallow, what is it?
Means it is attached to trachea
Probably thyroid goitre
If a tongue deviates to left due to nerve injury, what nerve is injured? On which side?
Left hypoglossal nerve
What would cause nodes in the deep cervical chain to be inflamed?
Inflammation/infection of parotid, base of tongue, tonsil, skin of face and neck
What would cause submandibular nodes to be inflamed?
Dental infection, salivary disease, issues with skin of lip
Describe the pharyngeal phase of swallowing
Triggered at anterior facial arch • Elevation and retraction of the velum • Initiation of pharyngeal peristalsis • Elevation and closure of the larynx • Relaxation of the cricopharyngeal sphincter
What does the oral phase of swallowing rely on?
Intact labial seal, anterior to posterior tongue movement
Describe Zenker’s diverticulum
Pharyngeal out-pouching under the inferior pharyngeal constrictor muscle, between thyroid cartilages posteriorly, just above oesophagus
Describe the larynx
Protects the airway
Source of voice
Suspended, mobile structure
Made up of supraglottis, glottis and subglottis
Describe the subglottis
Narrowest part of the airway
At level of cricoid ring
Worried about subglottic stenosis after prolonged intubation
Describe the route of the recurrent laryngeal nerve
Left loops around liagmentum arteriosum: intrathoracic.
Right goes under subclavian artery.
How does aerodigestive tract cancer usually evolve?
95% SCC
Irritation-> dysplasia-> carcinoma in situ-> frank invasive carcinoma
Risk factors for aerodigestive tract carcinoma?
- Disease of men in urban areas
* Cigarette smoking, alcohol, HPV, beetle nut chewing
Describe 9 ways an aerodigestive tract cancer presents
- Chronic mouth ulcer or lump on tongue
- Tonsillar mass
- Persistent unilateral sore throat
- Difficulty swallowing (dysphagia)
- Odynophagia (pain on swallowing)
- Change in voice
- Stridor, breathing noise if impinges on airway
- Mass in the parotid
- Lump in the neck
What time frame would you get worried about a neck lump/mouth ulcer?
After 4-6 weeks, should be referred for a 2 week wait appt
What is done in a 2 week wait clinic for aerodigestive tract lumps/suspected cancers?
- Look at associated symptoms and risk factors
- ENT surgeon is the only person that can examine whole oropharynx
- Fine needle aspiration under USS used to diagnose lump, remove if lymphoma
- Rigid endoscopy (pandendoscopy) under GA and biopsy of primary site
- Stage (TMN), grade (histopathology aggression and differentiation)
Pros and cons of radiotherapy as treatment for aerodigestive cancer
Good due to: normal anatomy is preserved
Bad due to fibrosis, mouth dryness, soreness.
Normal tissue damage makes subsequent surgery more difficult.
Can’t re-irradiate the same tissues.
Treatment of aerodigestive tract cancer
- Early: Surgery or radiotherapy
- Late: Surgery and radiotherapy, chemoradiotherapy.
- Chemotherapy: cisplatin. Given at same time as radiotherapy for best outcome.
- Surgery: minimally invasive laser microsurgery or open. Damages normal anatomy. Only works of you can get around the cancer with a clear margin.
Describe the ladder of reconstruction (7 steps)
- Secondary healing (secondary intention, esp scalp and floor of mouth)
- Direct closure (crescent shape and suture)
- Skin graft (using planer, from thigh)
- Obturation and implants (eg for hard palate, must occlude hole)
- Local flaps
- Pedicled flaps (artery, vein and tissue supplied by them)
- Free flaps (esp bone from fibula)
Risk factors for oral cancer
- Smoking (x3 risk) , + alcohol (x6 risk), Beatle quid chewing, HPV 16 and 18
- Sun exposure (lower lip, cigarette rest), immunosuppression
Which is worse, a white patch or a red patch in the mouth?
Red is more invasive
How might oral cancer present? (6)
Ulcer, white patch, red patch (higher risk), lymphadenopathy, lump/mass, pathological fracture
What are the red flags for an oral ulcer? (3)
Raw edges, feels hard, present for over 3 weeks
Name 3 frenulums in the mouth
Superior labial
Inferior labial
Lingual
Name 4 structures of the soft palate
Glossopalatine arch
Pharyngopalatine arch
Palatine tonsil
Uvula
What is the opening at the back of the mouth-> oropharynx called?
Fauces
Where is the dorsal side of the tongue?
Dorsal is top of tongue, ventral is underneath
What makes up the gums?
Alveolar mucosa
Gingiva
Name the types of taste buds on the anterior tongue
Fungiform
Filliform
Foliate
Name the type of taste bud on the posterior tongue
Valate
Describe the sensory nerves of the tongue
Anterior 2/3 Trigeminal (lingual from mandibular) is for sensation of tongue. Facial nerve is taste sensation.
Posterior 1/3: glossopharyngeal
Describe the salivary glands and where they empty
Parotid to 2nd molar level inner cheek
Submandibular gland, under floor, to papillae under tongue either side of lingual frenulum (stones are common, swells at dinner time)
Sublingual gland: empties under tongue in lots of little papillae
What should be screened for in someone with mouth ulcers
Iron and B12 deficiency
Describe oral lichen planus
White, lace-like pattern on the inner surfaces of the cheeks and tongue Can cause ulcers Autoimmune 1-5% are malignant, referred (non urgent)
Describe an mucucele
mucous retention cyst or mucous extravasation cyst. Usually lower lip, usually caused by trauma from biting lower lip.
What can happen with bisphosphonates and dental treatment?
When you remove a tooth you can cause necrosis of the jaw. = medication related osteonecrosis of the jaw (MRONJ).
What drugs can cause gingival hyperplasia? (3)
cyclosporine, nifedipine, phenytoin
When is pseudomembranous candidiasis seen?
If immunosuppressed, denture wearing, recent antibiotic use.
Describe the appearance of an oral SCC
raised rolled edge, granular surface, fixed to deep structures. Hardened (indurated), non-healing, bleeding. Classically on lower lips, especially on people that work outside.
What is the NICE RULE for referring an oral lesion?
RULE Red or white patch (erythroplacia/leucoplacia) Ulceration Lump, loose tooth or lymphadenopathy Extending for more than 3 weeks ->>Then refer under 2 week wait.
Explain how teeth are named
Teeth: 8 is wisdom tooth. Permanent teeth are numbers, baby teeth are letters.
Incisors (1&2), canine (3), premolar (4&5), molar (6, 7, 8)
Layers of a tooth
Enamel-> dentin-> pulp
Describe 4 ways of preventing tooth decay
- Reduce amount and frequency of sugary snacks and sugary drinks
- Brush teeth for 2 mins BD using fluoride toothpaste (don’t rinse out!)
- Floss and interdental brushes daily (in adults)
- Have regular dental checks
Describe peridontal disease
Ankylosis occurs: teeth become fixed to the bone, esp after trauma.
Peridontal ligament can be broken down by bacteria if plaque and poor oral hygiene. Gingivitis occurs, bleeding occurs on brushing-> clean more!
Gum disease, bone shrinks, teeth fall out!
How to avoid peridontal disease
Stop smoking
Healthy diet
Leave dentures out at night and clean them
Clean teeth BD and use interdentals.
When are antibiotics used in dentistry?
Antibiotics are used in: • Facial swelling • Spreading infection • Systemic infection • Bites to the face • Open fractures
Define laceration
burst of the skin over a bony structure after blunt force.
Define vermillion border
Between cheek and lip mucosa
What drug is used in uncooperative pts and children to suture their face?
Ketamine
Name the layer of the scalp
SCALP Skin C: subcutaneous tissue Apponeurosis L: gap Pericranium
Name 7 common causes of swelling in the anterior triangle of the neck
– Reactive lymphadenitis – Lymphoma – Metastasis – Branchial cyst – Thyroglossal cyst – Dermoid cyst – Goitre
3 common causes of swelling in the posterior triangle of the neck
Lymphadentitis
Lymphoma
Lipoma
Blood supply of thyroid gland
Superior thyroid a. (from internal carotid)
Inferior thyroid a. (from thyrocervical trunk from subclavian)
Where is the parathyroid?
Posterior aspect of thyroid gland
Which arteries are at risk when removing palatine tonsil?
Facial artery (+ tonsillar brach)
Ascending pharyngeal
Ascending palatine
Carotids aren’t far away
How is aspiration prevented?
Aspiration is prevented by good sensation
allowing the epiglottis to tilt, the larynx to
rise, and the false cords and cords to close
What is weakness at the back above
cricopharyngeus called?
Dehiscence of Killian
Proximal to upper oesophageal sphincter
Zenker’s diverticulum
Name the parts of the larynx, superior to inferior
Epiglottis Hyoid bone Thyroid cartilage Arytenoids & vocal ligaments Cricoid cartilage Trachea
Describe ventricle of larynx
Vestibular fold superiorly
Vocal fold inferiorly
Thyroarytenoid muscle as base
Describe voice production
The lungs power voice
Sound produced in the larynx by vocal fold
vibration
Modified in the mouth and nose (resonation chambers)
Pitch altered by vocal fold/cord tension
2 functions of eustachian tube
- ventilation of middle ear
Swallowing action pushes small volume of air into middle ear - mucociciliary function
Cilia clear mucus and debris
Where is the pars flaccida?
Superior part of ear drum
Describe the mechanism of hearing
Stapes compresses the fluid in the vestibule
The pressure wave travels up the scala vestibule and back down the scala tympani to the round window
What does a negative Rinne’s test mean?
Bone conduction is louder than air conduction
Conductive hearing loss
When can you get a false negative Rinne’s test?
In severe unilateral deafness when testing on side of deafness
Bone conduction heard on other side
If Weber is heard in the left ear more loudly, what is wrong?
Either conductive hearing loss in left ear or sensorineural hearing loss in right ear
What forms the external nose?
Upper and lower lateral cartilages
Fibrofatty tissue
Bony pyramid
Where does the posterior ethmoid and sphenoid sinuses drain?
Sphenoethmoid recess, superior meatus
Where does the middle and anterior ethmoid and frontal sinuses drain?
Middle meatues
Where does the nasolacrimal duct drain?
Inferior meatus
Function of turbinates
Increase resistance to airflow & regulate temperature and humidity of air before it reaches the lower respiratory tract
Venous drainage of nasal cavity
Facial and ophthalmic veins
