Head & Neck, ENT Flashcards
What are the neck fascia?
A. Superficial cervical fascia
- lies between dermis and investing layer of deep cervical fascia
- contains the plastysma, and cutaneous vessels, nerves, lymphatics, fats
B. Deep cervical fascia
- *1) Investing layer of deep cervical fascia**
- contains SCM and trapezius
- arises from skull superiorly, attach to scapular spine, acromion, and clavicles inferiorly
- *2) Pretracheal fascia**
- anterior neck only
- extends inferiorly from hyoid bone into the thorax, merges with fibrous pericardium
- contains thyroid, trachea, esophagus
- *3) Prevertebral fascia**
- from base of skull to T3 vertebra
- contains vertebral column and associated muscles
- extends laterally as axillary sheath
4) Carotid sheath
How might deep fascia influence the spread of infection from the neck?
The neck fascia determines the direction in which a neck infection may spread:
- the investing layer of deep cervical fascia prevents the spread of abscesses
- if investing layer is breached, an infection between the investing and pre-tracheal layer can spread inferiorly to the thoracic cavity anterior to fibrous pericardium
- if abscess is located posterior to the pre-vertebral fascia, then it can extend laterally
What are the main neck muscles
i) innervation
ii) attachment
iii) function
- *1) Platysma**
i) innervated by CN VII (facial nerve)
ii) attach from mandible to pectoral muscle
iii) function: draws down corners of mouth - *2) Sternocleidomastoid (SCM)**
i) innervated by CN XI (accessory nerve)
ii) attach from mastoid to manubrium and clavicular head
iii) function: rotates head - *3) Trapezius**
i) innervated by CN XI (accessory nerve)
ii) Originates from occiput and spinous processes, cervical and thoracic vertebrae; inserts to scapular and clavicle
iii) function: elevates scapula
Where is the root of the neck?
- what is the boundaries
- what are the contents
Root of the neck refers to the junction between the thorax and neck, where structures pass from thorax to head:
- *Boundary:**
- anterior: manubrium
- posterior: body of T1
- lateral: 1st rib and costal cartilage
- *Contents:**
- Arteries: Brachiocephalic trunk (R), left CCA, left subclavian artery
- Veins: anterior jugular vein and IJV forms brachiocephalic vein, and EJV / subclavian vein
- Nerves: vagus nerve, RLN, phrenic nerve, sympathetic trunks, cervical sympathetic ganglia
What are the anatomical zones of the neck?
What is its clinical relevance?
Zone I
- from sternoclavicular notch to cricoid carilage
- vulnerable structures: cervcial pleura, lung apex, thyroid, trachea, esophagus, jugular vein, cervical vertebrae
Zone II
- from cricoid cartilage to angle of mandible
- vulnerable structures: larynx, pharynx, carotids, jugular vein, cervical vertebrae
Zone III
- from angle of mandible to base of skull
- vulnerable structures: oropharynx, oral cavity, nasal cavity
==================
It is used to describe penetrating trauma to neck:
-> Zone II is the most exposed zone, and is consequently the most likely to be injured; but best prognosis
-> Zone I and III has greatest morbidity and mortality, because:
i) may obstruct airway
ii) injured structures are difficult to visualise
iii) harder to control vascular damage by direct pressure in comparison to Zone II
Levels of neck LN
- *1a: Submental
1b: Submandibular** - *2: Upper jugular**
- from base of skull, to inferior border of the hyoid bone
- *3: Middle jugular**
- from inferior border of the hyoid bone, to inferior border of cricoid cartilage
- *4: Lower jugular**
- from inferior border of cricoid cartilage, to clavicles
- *5a: Posterior triangle
5b: Supraclavicular fossa** - *6: Anterior compartment**
- Pretracheal, paratracheal, precricoid (Delphian) and perithyroid nodes
7: Upper mediastinal
Drainage of neck lymph nodes
Level I
- Anterior nasal cavity
- Oral cavity
- FOM, tongue
Level II
- Nasal cavity, para-nasal sinus, nasopharynx
- Oral cavity, orophaynx
- Hypopharynx, supraglottic larynx
- Parotid and submanidbular glands
Level III
- oropharynx, hypopharynx, larynx
Level IV
- hypopharynx, larynx
- cervical esophagus
- thyroid
Level V
- oropharynx, nasopharynx
- posterior neck and scalp
Level VI
- thyroid
Anterior & posterior neck triangle borders
- *Anterior triangle:**
- Inferior aspect of mandible
- anterior border of SCM
- anterior midline
- *Posterior triangle:**
- Posterior border of SCM
- Anterior border of trapezius
- Clavicle
Content in the posterior neck triangle
“SEreBII”:
1) Subclavian artery
2) External jugular vein
3) Brachial plexus (trunk)
4) CN XI
Borders of Sub-triangles in Anterior neck triangle
- *1) Submental**
- inferior border of mandible
- anterior belly of digastric
- hyoid
- *2) Submandibular**
- inferior aspect of mandible
- anterior & posterior belly of digastric
- *3) Carotid**
- posterior belly of digastric
- superior belly of omohyoid
- anterior border of SCM
- *4) Muscular**
- superior belly of omohyoid
- anterior border of SCM
Content in the carotid triangle
- *1) Carotid sheath**
i) common carotid artery (medially)
ii) IJV (laterally)
iii) vagus nerve CN X (posteriorly at the middle) - *2) Ansa cervicalis**
- lies within the anterior wall of the sheath over the jugular vein
3) Hypoglossal nerve CN XII
Define Neck dissection terminologies
- *1) Radical Neck Dissection:**
- ipsilateral level 1-5
- SCM
- spinal accessory nerve
- internal jugular vein
- *2) Modified radical neck dissection**
- ipsilateral level 1-5
- preserve 1+ of (SCM, spinal accessory nerve, IJV)
- *3) Functional neck dissection**
- ipsilateral level 1-5
- preserve all of SCM, spinal accessory nerve, IJV
- *4) Selective Neck Dissection**
- preservation of 1 or more of level 1-5 LN
- Supraomohyoid SND (Level 1-3)
- Lateral SND (Level 2-4)
- Postero-lateral SND (Level 2-5)
- *5) Extended Neck Dissection**
- Radical neck dissection
- and 1+ additional LN groups or nonlymphatic structures
- *6) Central compartment dissection**
- dissection of level 6 only (usu for thyroid)
Selective neck dissection in HnN cancers
Oral cavity cancer:
- Selective 1-3 (aka supraomohyoid SND)
+ level 4 in tongue cancer because of skip lesion
- *Orophaynx, hypopharynx, larynx:**
- Selective 2-4 (aka lateral SND)
- *H&N skin cancer:**
- Selective 2-5 (aka posterolateral SND)
Drainage of pharyngeal cancer to cervical LN
- *1) Nasopharynx (NPC):**
- Level 2-5
- *2) Oropharynx:**
- Level 1-3
- *3) Laryngo-pharynx:**
- Level 2-6
General Mx approach to HnN cancers
- *1) Resection**
- preserve important organ functions
- oncologically clear margins
2) Reconstruction
3) ± Neck dissection
4) Rehabilitation
Margins of resection for skin tumours on head
Squamous cell carcinoma: 1-2cm
Basal cell carcinoma: 3-5mm
Melanoma: 5-50mm
Dermatofibrosarcoma protuberans: 3-5cm
Common histology of H&N cancer
90% is Squamous Cell carcinoma
Common sites of HnN cancers
1) Nasopharynx: fossa of Rosenmuller
- *2) Oral**
- tongue (most common)
- buccal mucosa, lips, floor of mouth, hard palate
- *3) Oropharyx**
- Tonsil (most common)
- tongue base > soft palate
- *4) Hypopharynx**
- Piriform fossa (most common)
- post cricoid > posterior pharyngeal wall
- *5) Larynx**
- glottic > supraglottic > subglottic
Risk factors for Head and Neck cancer (SqCC)
- *Environement factor**
1) Smoking
2) Spirits, alcohol
3) Sharp teeth
4) Betel nut chewing (嚼檳榔 in TW)
5) Previous H&N RT
Patient factor
1) Male Sex (M:F = 4:1)
2) Dental Sepsis
3) Syphilis, HPV
4) GERD
5) Primary H&N tumour (synchronous tumours)
6) Family history
________
think about 6S of oral cancer:
- smoking, spirits, sex, syphilia HPV, sharp teeth, sepsis dental
Ix in head and neck tumours
- *1) Incisional biopsy**
- NOT excisional
- *2) USG, FNAC**
- mass or LN
3) Pan-endoscopy ± biopsy
to look for SYNCHRONOUS tumours
- flexible rhinoscopy
- flexible laryngoscopy
- OGD
- bronchoscopy
- *4) CT, MRI of H&N**
- T, N staging
- look for boney erosion in skull base, orbit
- *5) PET/CT, Bone scan**
- for distant & bone met
Staging of H&N tumours
TNM staging is same except nasal cavity & nasopharynx
T (2-4)
T1: <2cm
T2: 2-4cm
T3: >4cm
T4: adjacent structure
N (3-6) based on size
N1: <3cm
N2: 3-6cm
a: single; b= multiple; c = bilateral
N3: >6cm
M
M1: met
history taking of symptoms Head and Neck cancer (pre-op)
1) Primary Symptoms
2) Symptoms suggestive of synchronous tumours (ask ALL)
Nose
- epistaxis; blood mixed in sputum
- nasal obstruction
- post nasal drip
Ear
- hearing loss
- tinnitis
- otalgia
Mouth
- mass, ulcers, pain
- blood in saliva
- trismus
- loose teeth
Throat
- sore throat
- hoarseness
- dyspnoea
- dysphagia
- haemoptysis
- *3) Metastatic symptoms**
- local: visual, headache, neurological
- lymph: lymph nodes
- distant: lung as SOB, bone pain
Additional aspects affected by H&N cancers
(ask these in history!)
As H&N is the most exposed area of body, will affect morphology & physiology:
- *1) Morphology**
- affects external appearance & aesthetics
- psycho-social complications
- *2) Physiology** (as large number of vital organs in small area):
- vision
- airway
- taste
- swallowing
- speech
Major functions requiring rehabilitation after HnN cancer surgery
- *1) Vision**
- reduced visual acuity from CNII infiltration or RT
- dry eyes (post RT)
- epiphora: lacrimal drainage onbstruction from surgery
- diplopia from muscle impingement
- dystopia from orbital floor invasion
- *2) Airway obstruction**
- temporary oedema
- permanent stricture
- *3) Taste**
- temporary loss of taste (chemo)
- permanent after RT or surgery
- *4) Swallowing**
- immediately dysphagia after glossectomy or pharyngectomy
- delayed dysphagia post RT
- *5) Speech**
- Loss of phonation (post laryngectomy)
- Loss of articulation (glossectomy, nasal, paranasal sinus surgery)
Function preservation Mx for HnN tumours
- *1) Vision**
- eye shield during RT
- chloramphenicol ointment for dry eyes
- tarsorrhaphy
- *2) Airway**
- tracheostomy
3) Taste… :(
- *4) Swallowing**
- anastomosis
- speech therapist
- *5) Speech**
- voice prosthesis
- speech therapy
Oral cavities spaces
1) Oral cavity proper: space medial or posterior to teeth
2) Vestibule: space between teeth and cheek
- *3) Oropharynx:**
- behind the glossopalatine arch (anterior pillars)
Arterial supply of oral cavity
- *External carotid artery branches:**
- Lingual artery
- Facial artery
- Maxillary artery
Nerve supply of oral cavity
- Sensation: V2, V3
- Muscle of mastication: V3
- Tongue: XII (except Palatoglossus which is pharyngeal plexus)
- Taste: VII (chorda tympani)
PE in oral lesions
Get gloves, penlight, tongue depressor:
0) General Examination
- *1) Ask patient to “AHH” open mouth, stick out tongue**
- note hoarseness of voice
- note trismus, ankyloglossia
- *2) Inspection of oral cavity**
- palate (roof)
- buccal mucosa (sides)
- floor of mouth (below tongue)
- vestibule using 2-prong technique
- tonsils
- anterior & posterior fallucial pillars
- oropharynx
- “comment on alveolar & gum health”
- “to complete by looking @ tongue base using indirect mirror”
- *3) Inspection of tongue**
- lateral border
- frenulum & inferior aspect
- look for movement
- *4) Palpation**
- try scraping white lesions
- characterise the mass
- BIMANUAL PALPATION
- *5) Neck exam, Cranial Nerve exam**
- for LN, facial nerve involvement
White oral lesions DDx
1) Leukoplakia
2) Lichem planus
3) Candidiasis, secondary syphilis, EBV hairy leukoplakia
4) Linea Alba
5) Leukoedema
6) Papilloma
7) Verrucous carcinoma, Squamous cell carcinoma
8) Geographic tongue
9) Hairy tongue
Presenation of oral infective white lesions:
- *1) Oral candidiasis**
- white, easily scrapped off white plagues
- shows hyphae in Gram stain
- *2) 2° syphilis**
- Snail track
- *3) EBV**
- hairy leukoplakia
Why are some oral lesion white?
White colour due to scattering of the light through an altered epithelial surface
Leukoplakia
- White patch firmly attached to oral mucosa which cannot be rubbed off
- Precancerous; 5% undergo malignant change
Lichen Planus
- Common chronic inflammation of oral mucosa (usually buccal mucosa)
- T cell mediated auto-immune
- “Wickham’s striae” (white striae around the lesion)
- Skin manifestations: pruritic papules on flexor surface
- Low malignant potential
What is this? Contributing factors?
- *Oral candidiasis**
- Creamy-white
- elevated, removable plaques
Risk factors:
Local
- poor oral hygiene, xerostomia, dentures
Systemic
- immunocompromised: steroids, antibiotics, radiation, HIV, haematological malignancy, neutropenia
- *Linea Alba**
- Normal linear elevation of the buccal mucosa extending from the corner of the mouth to the 3rd molars at the occlusal line
- *Leukoedema**
- Normal anatomic variant of the oral mucosa
- Bilateral, involves most of the buccal mucosa (rarely the lips and tongues)
- If streched, will become red again
- Increased thickness of epithelium and intracellular edema of prickle cell
Exophytic white mass in oral cavity
- *1) Papilloma**
- Exophytic, painless
- fingerlike projections forming cauliflower pattern
- usually solitary
- *2) Verrucous Carcinoma**
- Exophytic
- Low-grade variant of SCC
- HPV related
- *3) Squamous cell carcinoma**
- Early SCC looks like leukoplakia
- 6 Ss
Red intra-oral lesions DDx
Red due to thin epithelium, inflammation, dilatation of blood vessels, increased number of blood vessels, extravasation of blood:
1) Trauma
2) Infection (Stomatitis, Glossitis)
3) Lupus erythomatosus, Reactive arthritis (Reiter’s syndrome)
4) Erythroplakia (pre-malignant)
5) Hereditary hemorrhagic telangiectasia
Erythroplakia
- Red, non-specific, well-demarcated patch that cannot be classified under any other disease
- 15 times increased risk of SCC
- 90% CIS or SCC at time of diagnosis
Pigmented intra-oral lesions
1) Malignant melanoma
2) Lentigo
3) Pigmented naevi
4) Black hairy tongue
5) Smoker’s melanosis
6) Amalgam tattoo (from adj dental fillings)
7) Peutz-Jeghers syndrome
8) Addison disease
Malignant melanoma characters
ABCDE
A - Asymmetrical Shape
B - Border is irregular
C - Color is variegated
D - Diameter >6mm
E - Evolution
Oral ulcerative lesions DDx
1) Traumatic ulcers (Sharp tooth, dentures etc)
- *2) Aphthous ulcer** (major, minor, herpetiform)
- SLE
- Reiters syndrome
- *3) SqCC**
- Everted, irregular edge with dirty floor
- Indurated base
- Painless at first, then painful with nerve infiltrated
4) Infective ulcers
Infective oral ulcer causes
- HSV
- Herpangina by Coxsackie virus
- TB
- Syphilis – 1°, 2°, 3°
Intra-oral mass DDx
Benign vs Malignant:
MALIGNANT:
★ 1) SqCC, verrucous carcinoma
★ 2) Minor salivary gland adenocarcinoma
3) lymphoma
4) melanoma
5) Kaposi sarcoma
BENIGN:
- *1) Fibroma**
- hard nodule
- *2) Ranula**
- At Floor of mouth
- soft pseudocyst filled with saliva
- Due to Blocked sublingual duct
- *3) Lipoma**
- Soft mass
- *4) Torus palatini**
- at the hard palate
- Boney hard
- normal anatomical variation
How to investigate oral mass
(aka what to Ix when suspicious of oral cancer)
(actually same as H&N with additional Ix*)
- *1) Incisional biopsy**
- for oral lesions that persist for >3 weeks
- *2) USG, FNAC**
- for enlarged LN
3) Pan-endoscopy ± biopsy
to look for SYNCHRONOUS tumours
- flexible rhinoscopy
- flexible laryngoscopy
- OGD
- bronchoscopy
4*) Orthopantomogram (look for bone erosion)
- *5) CT, MRI of H&N**
- T, N staging
- look for boney erosion in skull base, orbit
- *6) PET/CT, Bone scan**
- for distant & bone met
Risk factors for oral cancer
- *Environement factor**
1) Smoking
2) Spirits, alcohol
3) Sharp teeth
4) Betel nut chewing (嚼檳榔 in TW)
5) Previous H&N RT
Patient factor
1) Male Sex (M:F = 4:1)
2) Dental Sepsis
3) Syphilis, HPV
4) GERD
5) Primary H&N tumour (synchronous tumours)
6) Family history
________
think about 6S of oral cancer:
- smoking, spirits, sex, syphilia HPV, sharp teeth, sepsis dental
Pre-malignant intra-oral lesion
- erythroplakia
- leukoplakia
- erythroleukoplakia
- proliferative verrucous leukoplakia
Common sites of oral cavity cancer
- *1) Tongue** (most common)
- lateral margin, middle third
- *2) Lips**
- lower half
- *3) Floor of mouth**
- anteriorly below tongue
4) Buccal mucosa
5) Alveolus & gingiva
6) Hard palate
Where to take biopsy in a tongue ulcer?
Ulcer edge, because:
- can compare with normal tissue
- easier to suture for haemostasis
Management of CA tongue
- *1) Resection of the tumour** with adequate margins
- partial glossectomy if T1 (<2cm)
- hemiglossectomy if T2 (2-4cm)
- total glossectomy (might need concommitant laryngectomy due to aspiration risk)
- *2) Adequate neck dissection**
- Selective neck dissection of I-IV (classically is I-III i.e. supraomohyoid neck dissection but can skip metastasis to level IV)
- *3) Reconstruction**
- ALT flap
4) Adjuvant RT
DDx of ulcer on tonsils
Tonsillar ulcer can be due to:
- *1) Infective**
- acute tonsillitis
- diptheria
- infectious mononucleosis
- *2) Neoplasm**
- orophayngeal SCC
- lymphoma
- salivary gland tumour
- *3) Blood disease**
- agranulocytosis
- leukaemia
- *4) Others**
- apthous ulcer
- Bechets disease
- AIDS
Boundaries of oropharynx
Roof: oral surface of soft palate & uvula
Lateral: anterior & posterior pillars (glossopalatine arch & pharyngopalatine arch), palatine tonsils
Anterior: posterior third of tongue & vallecula
Posterior: level of hard palate to aryepiglottic fold
Common sites of oropharyngeal cancer
- Tonsils 50%
- Tongue base 25%
- Soft palate 10%
- Posterior wall 5%
Risk factors for oropharyngeal cancer
6Ss:
1) Smoking
2) Spirits, alcohol
3) Sharp teeth
4) Male Sex (M:F = 4:1)
5) Dental Sepsis
6) Syphilis, HPV
7) Betel Nut chewing (嚼檳榔 in TW)
Important Hx to ask in suspected oropharyngeal cancer
(+ what are the symptoms of oropharyngeal cancer)
- *1) Symptoms**
- local ulcer, pain
- sore throat, muffled hot potato speech
- trismus
- dysphagia, odynophagia
- constitutional symptoms
- cervical lymphadenopathy
- *2) Risk factors**
- 6Ss (Smoking, spirits, sharp teeth, male sex, dental sepsis, syphilis, HPV, betel nut)
- *3) Other primary cancer** (VERY IMPORTANT)
- 30% synchronous primary
- 1.5% yearly cummulative risk of metachronous tumour
Investigation in suspected oropharyngeal cancer
(actually same as H&N with additional Ix*)
1*) EUA (examation under anaes), biopsy, tonsillectomy
- *2) USG, FNAC**
- for enlarged LN
3) Pan-endoscopy ± biopsy
to look for SYNCHRONOUS tumours
- flexible rhinoscopy
- flexible laryngoscopy
- OGD
- bronchoscopy
- *4) CT, MRI of H&N**
- T, N staging
- look for boney erosion in skull base, orbit
- *5) CXR, PET/CT, Bone scan**
- for distant & bone met
Management of oropharyngeal cancer
1) Resection
- *2) Lymph node clearance**
- Level II-IV (lateral selective neck dissection)
3) Reconstruction
- Soft palate, tonsillar fossa: radial forearm free flap
- Extensive palatomaxillary defects: prosthesis or vascularized bone-containing free flaps
4) Chemo-RT
Sites of Hypopharyngeal carcinoma
(where are hypophayngeal carcinoma?)
i.e. from the laryngopharynx (Level of hyoid to lower border of cricoid):
- 60% Piriform fossa
- 30% Postcricoid
- 10% Posterior pharyngeal wall
Hypopharyngeal carcinoma risk factors
- Smoking
- Alcohol
- Male predominance (exp in Postcricoid CA, more female than male)
- Irradiation for thyroid disease
- Plummer Vinson syndrome (aka Paterson-Kelly-Brown syndrome)
Clinical features of hypopharyngeal cancer
- Dysphagia
- Sore throat
- Hoarseness
- Otalgia
- LN 30% occult metastases
- Loss of laryngeal crepitus
Treatment of hypopharyngeal carcinoma
- *1) Surgical resection**
- Partial pharyngectomy
- Circumferential pharyngectomy + reconstruction
- Total pharyngo- laryngo- esophagectomy (PLO) with gastric pull up
- *2) Lymph node clearance**
- Level II-IV (lateral selective neck dissection)
- *3) Reconstruction**
- free flap (jejunal graft)
- regional flap (pectoralis major)
- (gastric pull-up for PLO)
4) RT
Larynx anatomy
1) Hyoid bone
- *2) Cartilages**
i) Cricoid cartilage
ii) Thyroid cartilage
iii) Epiglottis
iv) Arytenoids
v) Corniculate cartilage
vi) Cuneiform cartilage - *3) Ligaments**
- thyrohyoid ligament
- crico-thyroid ligament
- vestibular, vocal ligament
Nerves of the larynx (affected in surgery)
- *1) Recurrent Laryngeal Nerve**
- supplies all intrinsic muscles of larynx (except cricothyroid)
- *2) External** branch of Sup Laryngeal Nerve
- supplies cricothyroid muscle (tenses vocal cord)
- *3) Internal** branch of Sup Laryngeal Nerve
- sensation of vestibule
Causes of dysphonia
1) Organic
- *2) Functional**
- e.g. muscle tensional dysphonia
- *3) Psychiatric**
- Conversion disorder
Vocal cord nodules presentation and pathogenesis
aka Singer’s nodules
- *Presentation:**
- dysphonia, Breathy voice
- at junction of anterior and middle 1/3 of vocal folds
- always comes in pairs (bilateral & symmetrical), as chronic vocal trauma from vocalisation should symmetrically affect both sides of vocal folds
- *Pathogenesis:**
- Chronic vocal trauma (voice misuse) lead to local edema
- local edema causes fibrosis & nodules
Vocal cord nodules management
Speech therapy +/- excision
Vocal polyp (pathogenesis, presentation, management)
- *Pathogenesis**
- Acute vocal trauma creates haemorrhagic cyst
- becomes polyp
- *Presentation:**
- Dysphonia with breathy voice
- Unilateral protrusion
- *Management:**
- Excision
Vocal cord palsy causes
1) Idiopathic
2) Brainstem lesion
- *3) Recurrent laryngeal nerve palsy**
- CA thyroid, CA esophagus, CA lung
- Ortner syndrome in aortic stenosis
- *4) Aryteno-cricoid joint pathology:**
- intubation causing dislocation
- RA
- cancer infiltration
- *5) Iatrogenic**
- intubation
- H&N surgery
- thyroid, esophageal, cardiothoracic surgery
Management of vocal cord palsy in adults
- *1) Endoscopy**
- distinguish whether it is unilateral or bilateral
- if bilateral, whether in open or closed position
- *2) Assess airway adequacy and aspiration**
- bilateral open position -> aspiration risk
- bilateral close position -> airway obstruction
- *3) Rule out organic cause**
- CT/ MRI brain
- CT thorax
- *4a) For unilateral:**
- Vocal therapy
- Injection laryngoplasty (temporary)
- Medialization thyroplasty
- *4b) For bilateral**
- Tracheostomy for airway protection
History taking in Hoarseness
- *Onset, pattern**
- acute or chronic
- recurrent?
- acute vocal trauma e.g. screaming?
- *Occupation, vocal demand**
- singer? teacher?
- *Risk factors**
- smoking?
- GERD?
- hypothyroidism?
- neurological disorders?
- *Medical & Surgical Hx**
- CA mediastinum?
- H&N surgery?
- *Red flags for CA larynx**
- Bleeding
- Dyspnoea
- Dysphagia
- Constitutional symptoms
Ix in hoarseness
1) Cervical lymphadenopathy
2) Inspection of larynx
a) indirect laryngoscopy (DO NOT use direct layngoscopy which is for intubation)
b) Trans-nasal Flexible laryngoscopy
- less gag reflex
- inferior image quality
c) Trans-oral Rigid laryngoscopy with Stroboscopy
- Gag reflex
- better image quality
- Allows stroboscopy to detect subtle vocal cord lesions
Location of laryngeal tumour
1) Glottic 60%
2) Supraglottic 30%
3) Infraglottic 10%
CA laynx presentation
Depends on site:
- Glottic:*
- *1) Dysphonia, hoarseness of voice**
- progressive (>2 wks)
- non-resolving (>4 wks)
- Supraglottic:*
- *2) Sore throat
3) Odynophagia, dysphagia
4) Referred otalgia** - Subglottic*
- *5) Stridor, dyspnoea from airway obstruction**
- Others:*
- *6) Haemoptysis**
7) Cervical lymph node metastasis
8) Constitutional symptoms
CA larynx risk factors
1) Smoking
2) Alcohol
3) Radiation
4) Synchronous H&N cancer
5) Chronic laryngitis
6) GERD
7) Family history
HIV??
Important investigations when suspecting CA larynx
(actually same as H&N with additional Ix*)
- *1*) Flexible indirect laryngoscopy; microlaryngoscopy + Biopsy**
- assess extent of tumour
- histological diagnosis
- *2) USG, FNAC**
- for enlarged LN
3) Pan-endoscopy ± biopsy
to look for SYNCHRONOUS tumours
- flexible rhinoscopy
- flexible laryngoscopy
- OGD
- bronchoscopy
- *4) CT, MRI of H&N**
- T, N staging
- look for boney erosion in skull base, orbit
- *5) CXR, PET/CT, Bone scan, blood ALP**
- for distant & bone met
____
All of the above are for TNM stageing:
T = Local tumour stage (Endoscopy, CT/MRI)
N = Regional lymph node (USG neck + FNA)
M = Distant metastasis (CXR, Blood test, PET)
Appearance of neoplasm around vocal cord (see in indirect laryngoscope)
Requires biopsy:
- Leukoplakia
- Erythroplakia
- Mass (CA larynx)
Treatment options for CA larynx
Early stage (T1-T2)
- *1) Radiotherapy**, or
- *2) Endolaryngeal laser surgery** (preserve voice)
- *3) Partial laryngectomy** (rarely)
- e.g. vertical hemilaryngectomy; supraglottic laryngectomy
Late stage:
- *1) Resection**
- total laryngectomy
- *2) Lymph node management**
- modified radical neck dissection (or II-IV if possible)
- *3) Reconstruction**
- terminal tracheostomy + voice prosthesis
4) Adjuvant radiotherapy and chemotherapy
What are the voice prosthesis post-laryngectomy? Pros & Cons?
1) Esophageal speech
+ no prosthesis, no cost
- difficult to learn, difficult to understand
- Fragmented speech, hard to speak after eating
2) Tracheo-esophageal speech (valve prosthesis e.g. Provox)
+ good tone & understanding
- costly, unclean
- complication e.g. swallowing
3) Pneumatic device
+ tone is acceptable, cheap
- conspicuous
4) Electrolarynx
+ one-off cost, easy to learn
- monotonal robotic voice
- need battery
Cx of laryngectomy
General: bleeding, SSI, etc
- *Specific**:
1) pharyngo-cutaneous fistula
2) tracheostomal stenosis (from radiation, infection)
3) Neo-pharyngeal stricture (thus dysphagia)
4) Hypothyroidism ± Hypoparathyroidism
Histology type of NPC
1) Non-differentiated carcinoma (95%)
2) Non-keratinising carcinoma
3) Keratising SqCC
NPC location (and metastases)
- *Site: Fossa of Rosenmuller** of nasopharynx
- clinically obscure area
- thus clinically silent until widespread metastases occur
- *Metastasis:**
1) Local spread to parapharyngeal space - > base of skull
- > cranium via foramina
2) Distal spread
- > usually by lymphatics to H&N lymph nodes
- > may be hemat spread to organs
NPC risk factors
- *1) Genetics**:
- Cantonese
- Combination of HLA-A2 & BW-46
- *2) Infection**:
- EBV +ve
- *3) Diet**:
- High nitrosamine e.g. Salted fish, preserved food
NPC clinical presentation
0) Constitutional symptoms
_Primary symptoms (ENT!)_ **1) Ear**: conductive hearing loss, recurrent OME, tinnitus
2) Nose: obstruction, epistaxis, postnasal drip
3) Throat: sorethroat
- *4) Headache and facial pains**
- trigeminal nerve compression (test for corneal reflex)
- usu temporal headache
- *5) CN palsy** (2-6, 9-12)
- sphenoid sinus above nasopharynx, above that is cavernous sinus
- optic chiasm is also close
LN met, distant met:
- *6) Neck LN**
- level 2-4 (more common contralat; can be bilat)
Why hearing loss in NPC?
Conductive hearing loss due to:
- Obstruction of the eustachian tube
Ix for NPC
- *1) EBV testing**
- EBV DNA titre
- EBV VCA-IgA has the highest sensitivity
- EBV EA-IgA has the highest specificity
2) Flexible nasal endoscopy + biopsy
3) US + FNAC of neck LN
4) CT, MRI H&N
5) CXR, PET for met
NPC treatment and complication
1) Radiotherapy (best for undifferentiated carcinoma, SCC least)
+) Adjuvant chemotherapy
-
if relapsed:*
2) Surgical management i.e. Nasopharyngectomy - maxillary swing classically
- now have endoscopic methods
Follow-up after NPC RT
Routine follow up with plasma EBV DNA
- High recurrence in first 2 year and after 10 years -> use plasma EBV DNA to determine relapse
- Monitor for RT complications e.g. sarcomas, xerostomia, hypopituitarism
What are the symptoms and signs of mandible fracture?
Symptoms:
1) Gross disfigurement
2) Pain
3) Malocclusion
4) Drooling
Signs:
1) Trismus
2) Fragment mobility
3) Gingival laceration
4) Haematoma in floor of mouth
What are the complications of mandible fracture?
1) Malunion
2) Non-union
3) Osteomyelitis
4) TMJ ankylosis
Are mandibular fractures usually single or multiple?
They are usually multiple site
This is because the mandible forms an anatomic ring, thus >95% of mandible fractures have more than one fracture site
LeFort classification
For mid-face fracture:
Le Fort I
- transverse maxillary fracture, above dental apices
- also traverses the pterygoid plate
- thus palate necomes mobile, but nasal complex is stable
Le Fort II
- fracture through frontal process of maxilla
- through the orbital floor and pterygoid plate
- thus midface is mobile
Le Fort III
- fracture through the nasofrontal suture and fronto-zygomatic sutures
- thus complete craniofacial separation
What is a “tripod” fracture
i. e. zygomatico-maxillary complex fracture, involving 3 fractures:
1) Zygomatic arch fracture
2) Floor of orbit fracture (including maxillary sinus)
3) Lateral orbital rim and wall fracture
Deviated nasal septum (etiology & presentation & management)
- *Etiology:**
- Trauma at birth
- Trauma (e.g. fighting)
- Unequal growth of nasal septum
- *Presentation & PE:**
- Unilateral nasal obstruction
- nose speculum can see deviation, sometimes even septal spur (sharp bone growth from severe trauma, see pic)
- If severe, the deviation can be observed directly
- *Management:**
- Septoplasty/SMR (submucous resection of septum)
Septal hematoma (presentation & management)
- *Presentation:**
- bilateral nasal obstruction after nose trauma
- blood stain
- *Management:**
- Urgent drainage
Lobes of parotid gland
Superficial lobe & deep lobe, which is divided by:
- *Anatomically**
- Facial Nerve (anatomically)
- *Radiologically:**
- an imaginary line from mandible to mastoid
- the retromandibular vein might be used as surrogate of facial nerve (which cannot be visualised in MRI)
Location of submandibular gland
1) In Submandibular Triangle, i.e. superior to the digastrics
- *2) Gland wraps around the mylohyoid**
- superficial lobe (larger) palpable between body of mandible and mylohyoid
- smaller deep lobe
3) Superficially covered by platysma
Duct of submandibular gland
- *Wharton’s duct (5cm):**
- arises from medial surface of deep gland of submandibular gland
- lies between mylohyoid and hypoglossus
- opens into the oral cavity via Wharton’s duct on either side of the lingual frenulum.
Sublingual gland anatomy
- *Sublingual glands location:**
- at FOM, between Mandible & Genioglossus
- separated from base of tongue by submandibular duct and lingual nerve
- bilateral gland merge to form horseshow around lingual frenulum
Drainge: It drains directly into the buccal floor
- *Characteristics:**
- No capsule
- Basically a collection of many small glands, thus sialogram is impossible
Pleomorphic adenoma presentation, site, complication
- *Presentation:**
- Slow-growing, painless mass
- *Site:**
1) 80% of Parotid tumours: mostly in superficial lobe, most in tail of gland
2) 50% of submandibular tumours
3) 45% of Minor salivary gland: lateral palate, submucosal mass
4) 6% of sublingual tumors
- *Complication:**
- Malignant degeneration risk in long term (e.g. Carcinoma ex-pleomorphic adenoma)
Presentation of Carcinoma ex-pleomorphic adenoma
- *Presentation:**
1) Longstanding painless (usu parotid) mass i.e. pleomorphic adenoma, that undergoes sudden enlargement
2) Poorly circumscribed, Infiltrative
3) Hemorrhage and necrosis
Paranasal sinus structure
Air filled extension of nasal cavity in:
1) frontal
- *2) ethmoid**
- divided by middle turbinate into anterior & posterior
- *3) sphenoid**
- require Lateral X-ray for visualisation
4) maxilla
What is ear furunculosis
A localised abscess (boil) in the external auditory canal (EAC); a form of otitis externa
- very painful
Otosclerosis treatment
1) Conservative
2) Hearing aid
3) Stapedectomy
