Face and Neck

Question 1

Painful syndrome involving the mandibular joint

Answer 1

Temporomandibular Joint Dysfunction (TMJ)

Question 2

3 subtypes of Temporomandibular Joint Dysfunction (TMJ)

Answer 2

1. Myofascial pain and dysfunction
   - MC subtype
   - Affects masseter, temporal, pterygoids
2. Internal derangement
   - Dislocation of the articular disc in the glenoid fossa
3. Osteoarthritis
   - Degeneration of the articular cartilage

Question 3

epidemiology of TMJ

Answer 3

1. 31% adults, 11% children
2. 1.5x in females
3. 18 - 44 y/o
4. associated with mood disorders, other psychiatric comorbidities
5. increased prevalence with rheumatoid arthritis
6. bruxism

Question 4

cause of TMJ

Answer 4

1. Exact cause unknown
2. Can be associated with trauma
3. Orthodontic treatment
4. Arthritis
5. Excessive use of joint and muscles of mastication
   - Nail biting
   - Gum chewing
   - Teeth gritting
6. Psychogenic causes also linked to TMJ
   - often have depression, anxiety, stress
   - Psychogenic factors thought to exacerbate symptoms, rather than cause them

Question 5

clinical findings of TMJ

Answer 5

1. Joint pain
2. Joint noise
   - Clicks
   - Crepitus
3. Abnormal mandibular movement
4. Masticatory muscle tenderness
5. Patients may complain of pain using their jaw, their jaw locking, or their bite not feeling right
6. HA - frontal, temporal, occipital
7. Dizziness or vertigo that is associated with aural fullness or otalgia

Question 6

hx of TMJ

Answer 6

1. Facial pain -Pain with jaw function, limitation of movement, cracking or popping, jaw muscle fatigue after eating.
2. Ear sx - pain, aural fullness, tinnitus, vertigo, hearing loss.
3. Pain in the head, neck, shoulder, and upper back
   Headaches
4. Hx of previous TMJ surgery or trauma.
5. Hx of arthritis
6. “Habits” such as pencil biting, gum chewing, or clenching, gritting or grinding of teeth.
7. Bruxism, either night (sleep-related) or daytime (awake).
8. Evaluation for depression and anxiety as well as the presence of other chronic pain symptoms
9. Sleep quality

Question 7

PE of TMJ

Answer 7

1. Abnormal Jaw Movements
2. Palpation for tenderness or crepitus
3. Pain with dynamic loading - pt bite down on tongue blade
4. Evaluate for bruxism - look for wearing down of teeth
5. Evaluate postural asymmetry
   assess posture - does pt favor one side?
6. Neuromuscular exam
   - inspect and palpate the muscles of the neck and shoulders
   - assess cranial nerves - special consideration for CN V and VII

Question 8

tx for TMJ

Answer 8

1. Joint rest
   - To allow muscles of mastication to relax
   - Reduce mandibular condyle movement
2. Avoid chewing gum, biting nails, excessive talking
3. Eat a soft diet
4. Reduce stress
5. Physical therapy
   - Exercises include mouth opening and closing in a straight line
6. Intra-oral devices
   - Splints, night guards, bite guards
7. Botox injections
   - Muscle relaxation
   - Only temporary relief - 3-4 months

Diagnosis is usually clinical

Question 9

when to refer for TMJ

Answer 9

Symptoms do not improve after 6 months of joint rest
Progressive difficulty in opening the mouth
Inability to eat a normal diet
Recurrent dislocation of the temporomandibular joint

Question 10

MC head and neck cancer

Answer 10

SCC
paranasal sinuses, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx

Question 11

Tumors of what differ from the more common carcinomas of the head and neck

Answer 11

salivary glands

Question 12

Tumors of what differ from the more common carcinomas of the head and neck

Answer 12

salivary glands

Question 13

risk factors of head and neck cancer

Answer 13

1. Alcohol, Tobacco, Smokeless tobacco
2. Marijuana
3. Occupational exposures
   - Dry cleaning
   - Farming - pesticides
   - Construction - asbestos
4. Nickel refining
5. Exposure to textile fibers
6. Radiation therapy
7. Genetics
8. Poor oral hygiene

Question 14

Viral etiology of head and neck cancer

Answer 14

EBV - Nasopharyngeal cancer
HPV - Oropharynx
HSV
Hep C
HIV

Question 15

what Dietary factors may contribute to head and neck cancer

Answer 15

Higher incidence with low consumption of fruits and vegetables

Question 16

specific risk factors of MC pt presentation of head and neck cancer

Answer 16

If tobacco related, usually > 60 y/o
HPV related, usually younger ~ 40-50 y/o
Males more frequently affected

Question 17

Unilateral serous otitis media / otalgia
Unilateral or bilateral nasal obstruction
Epistaxis
Advanced carcinoma may cause CN neuropathies
where is this cancer

Answer 17

nasopharynx

Question 18

Persistent hoarseness
where could the cancer be

Answer 18

larynx

Question 19

Non-healing ulcers
Changes in the fit of dentures
Painful lesions
where could the cancer be?

Answer 19

oral cavity

Question 20

Changes in tongue mobility
Alterations in speech
where is the cancer

Answer 20

tongue

Question 21

Sore throat
where could be the cancer

Answer 21

Oropharynx and hypopharynx

Question 22

work up for neck mass

Answer 22

1. H&P to delineate into 3 possible categories:
   - infectious
   - malignant
   - nonmalignant
2. This will direct further evaluation with lab tests, imaging, biopsies, and referrals

Question 23

what type of etiology is suspected based on a hx of the mass developing within a few days/weeks of an upper respiratory infection, dental infection, trauma, travel

Answer 23

infectious

Question 24

Stand alone features for neck mass not malignant

Answer 24

1. History
   - Lack of infectious etiology
   - Duration of greater than 2 weeks or unknown
2. PE
   - size > 1.5cm
   - Firm texture/fixed mobility
   - ulceration of overlying skin

Question 25

Rapid growing usually ___ cause, while firm, slowly enlarging masses are usually ___

Answer 25

infectious neoplastic

Question 26

supporting features of a neck mass not malignant

Answer 26

1. History - age > 40 - tobacco use/alcohol use - history of head/neck cancer - history of skin cancer of head/neck/face - immunocompromised status 2. PE - hoarseness/recent voice change - oral cavity/oropharyngeal ulcer - odynophagia/dysphagia - constant “sore throat” - hemoptysis - unexplained weight loss

Question 27

if Suspected malignancy, what is the next step/workup of the neck mass

Answer 27

Refer to ENT 1. Blood work - CBC - ESR - C-reactive protein - EBV - CMV - HIV 2. Imaging - **Contrast CT initial study of choice** - MRI - PET SCAN (positron emission tomography) - Ultrasound

Question 28

diagnostic studies of suspected malignant neck mass

Answer 28

1. **Fine Needle Aspiration (FNA): preferred option** 2. Core biopsy 3. Ultrasound or CT guided FNA 4. Incisional Biopsy

Question 29

congenital ddc of neck masses

Answer 29

branchial cleft cyst thyroglossal duct cyst vascular anomalies dermoid cyst teratoma

Question 30

inflammatory ddx neck masses

Answer 30

bacterial lymphadenopathy viral lymphadenopathy parasitic lymphadenopathy

Question 31

neoplastic ddx of neck masses

Answer 31

Thyroid masses Schwannoma Lipomas

Question 32

how do you stage head and neck masses in general

Answer 32

TNM Staging system (Tumor, Node, Metastasis) 1. Tumor - size and extent of main tumor 2. Nodes - number of nearby lymph nodes that have cancer 3. Metastasized - spread to other areas: from primary tumor to other sites/parts of the body

Question 33

tx for SCC on head and neck

Answer 33

1. Localized disease (early stage: I and II) - Surgery (removal of tumor/cancerous lesion) or Radiation Therapy 2. Locoregionally advanced disease (stage III/IV) - high risk of recurrence and metastasis - Combined modalities: Surgery, Radiation Therapy and or chemotherapy 3. Metastatic - Palliative chemotherapy, supportive care

Question 34

what viral infection can infect the oral mucosa and has been associated with squamous cell carcinoma of the oral cavity

Answer 34

HPV 16 IMPORTANCE OF VACCINATION! HPV associated cancers have increased dramatically and have substantially altered the epidemiology of oropharyngeal squamous cell carcinoma