HNN Topic 19 - Mouth Flashcards
List the causes of mouth ulcers
- Traumatic ulcers
- Recurrent aphthous stomatitis
- Infection
- Viral - chickenpox, herpetic stomatis, HIV
- Bacterial - syphillis, tuberculosis
- Fungal
- Parasitic
- Drug induced - alendronate (bisphosphonate for osteoporosis), cytotoxic drugs (methotrexate, chemotherapy), NSAIDs, cocaine
- Malignancy
- Allergy
- Haematological e.g. anaemia
- GI e.g. coeliac, Crohn’s disease, ulcerative collitis
- Nutritional e.g. iron, folate, B12 deficiency
Describe the location of the deep cervical nodes
Vertical chain, close to internal jugular vein within carotid sheath
Where are the intrinsic muscles of the tongue and what is their function?
Within tongue, change tongue shape/size for speaking, chewing and eating
Describe the organisation of lymph nodes and vessels in the head/neck
- Superficial and deep vessels
- Superficial drain to superficial ring of lymph nodes at junction of head and neck
- Deep vessels arise from deep cervical nodes, converge to form the left and right jugular lymphatic trunks
- Superficial and deep cervical nodes
- Superficial in ring arrangement, drain into deep
- Deep in vertical column, drain to deep lymphatic vessels
Describe the pharyngeal phase of swallowing
- Bolus moved to pharynx, pressure receptors activated in the palate and anterior pharynx, signals to swallowing centre in brainstem
- Respiration inhibited, larynx raised, glottis closed, oesophageal sphincter opened
- Soft palate elevated to close nasopharynx and allow passage of food
- Vocal cords close to prevent aspiration
- Bolus moved towards oesophagus via peristalsis of pharyngeal constrictor muscles
What is the function of styloglossus muscle?
Retracts and elevates the tongue
Describe the complications of oral cancers and how these are overcome
- Dysphagia - risk of malnutrition, aspiration, pneumonia
- Speech
Managed by a speech and language therapist - exercises to improve speech and swallowing function
Describe the attachments of palatoglossus muscle
From palatine aponeurosis to attach broadly across tongue
Describe the innervation of the intrinsic muscles of the tongue
Hypoglossal nerve
List the intrinsic muscles of the tongue
- 4 paired muscles, named for direction of travel
- Superior longitudinal
- Inferior longitudinal
- Transverse
- Verticle
Describe the location and function of the submandibular nodes
3-6 nodes below the mandible in the submandibular triangle, collect lymph from cheeks, lateral nose, upper lip, lateral lower lip and gums/anterior tongue. Submental and facial nodes also drain into submandibular nodes.
Describe the location and function of occipital nodes
1-3 nodes on back of head, drain the occipital areas of the scalp
Describe the diagnosis of oral cancer
- Forceps biopsy of lesion - local anaesthesia
- Assess histology
- PET-CT of head and neck
- Shows size, presence/absence of neck nodes, distant metastases
Describe the treatment of mouth ulcers
- Cause-related treatment
- Usually heal without intervention
- Maintain good oral hygiene, use antiseptic mouthwash to prevent secondary infection
Describe the attachments of the genioglossus muscle
Mental symphysis of the mandible to the dorsum of the tongue
Describe the vasculature of the tongue
- Mostly lingual artery (branch of external carotid artery)
- Tonsillar artery (branch of facial artery) - collateral circulation
- Drainage - lingual vein, drains into internal jugular vein
Where do the deep cervical nodes drain to?
- Deep cervical vessels arise from the deep cervical nodes, converge to form the left and right jugular lymphatic trunks
- Left lymphatic trunk joins thoracic duct at root of neck
- Right lymphatic trunk empties into R lymphatic duct at root of neck
Describe the location and function of the superior cervical nodes
- Superficial anterior cervical lymph nodes and posterior lateral superficial nodes
- Anterior close to anterior jugular vein, drains superficial anterior neck
- Posterior close to external jugular vein, drain superficial neck
What is the function of the superficial cervical nodes?
Receive lymph from scalp, face and neck
Describe the voluntary phase of swallowing
- Mastication produces bolus of food
- Back of tongue elevated and soft palate pulled anteriorly - keeps food within oral cavity, allows airway to remain open
Describe the treatment of oral cancers
- Radiotherapy
- Surgery
- Chemotherapy
List the important deep cervical nodes
Jugulo-omohyoid, jugulodigastric, supraclavicular nodes
Describe the epidemiology of oral cancers
- Oral cancer - 6th most common malignancy worldwide, 3rd most common in developing countries
- Squamous cell carcinoma most common form
- Men > women
- Age of occurrence typically >40 years
- Usually identified in late stage, overall 5 year survival rate <60%
What is the function of the deep cervical nodes?
Receive all lymph from the head and neck - directly or indirectly
Describe the location and function of the facial nodes
Maxillary, infraorbital, buccinator and supramandibular nodes. Drain mucous membranes of nose and cheeks, eyelids and conjunctiva.
List the symptoms of oral cancer
- Red/white patches, lumps, ulcers
- Persistent pain in mouth
- Dysphagia
- Changes in voice/speech problems
- Swollen lymph nodes in neck
- Weight loss
- Bleeding/numbness in mouth
- Teeth becoming loose
- Difficulty moving jaw - trismus
Describe the lymphatic drainage of the tongue
- Anterior 2/3 - submental and submandibular nodes (drain to deep cervical nodes)
- Posterior 1/3 - deep cervical nodes
List the phases of swallowing
- Voluntary phase
- Pharyngeal phase
- Oesophageal phase
In what situation is it important that mouth ulcers are examined?
Mouth ulcers which don’t head in 2-3 weeks should be examined (by a dentist, oral specialist/surgeon or maxillofacial surgeon) to rule out oral cancer
What is the function of the genioglossus muscle?
- Inferior fibres - protrude tongue
- Middle fibres - depress tongue
- Superior fibres - draw tip of tongue back and down
Describe the attachments of styloglossus muscle
Styloid process (temporal bone) to side of tongue
Describe the location and function of the pre-auricular nodes
1-3 nodes anterior to auricle, drain superficial face and temporal region
What is the function of hyoglossus muscle?
Depresses and retract tongue
Describe the location and function of the postauricular nodes
2 nodes behind ear, drain posterior neck, upper ear and back of external acoustic meatus
Describe the attachments of hyoglossus muscle
Hyoid bone to side of tongue
List the causes of oral cancers
- Tobacco and alcohol use
- HPV infection
- Immunosuppression
- Diet low in fruit/vegetables
- Betel nut chewing - common in developing countries
Describe the sensory innervation of the tongue
- Anterior 2/3
- General sensation - lingual nerve (from mandibular)
- Taste - facial nerve (chorda tympani)
- Posterior 1/3
- General sensation + taste = glossopharyngeal nerve
Describe the location and function of the submental nodes
Superficial to mylohyoid muscle, drain centre of lower lip, floor of mouth and apex of tongue
List the superficial cervical lymph nodes
- Occipital
- Mastoid/post-auricular/retro-auricular
- Pre-auricular/parotid
- Submental
- Submandibular
- Facial (group)
- Superficial cervical
What is the clinical importance of the supraclavicular nodes?
- Virchow’s node - L supraclavicular node
- Enlarged - Troisier’s sign, indicates gastric cancer
Describe the innervation of the extrinsic muscles of the tongue
All innervated by the hypoglossal nerve, except palatoglossus which is innervated by the vagus nerve
List the extrinsic muscles of the tongue
- Genioglossus
- Hyoglossus
- Styloglossus
- Palatoglossus
What is the function of palatoglossus muscle?
Elevates posterior part of tongue
Describe the oesophageal phase of swallowing
- Upper 1/3 of oesophagus is voluntary skeletal muscle, lower 2/3 is involuntary smooth muscle
- Larynx lowers, returning to normal position
- Cricopharyngeal muscle contracts to prevent reflux and respiration begins again
- Bolus move down into oesophagus via peristalsis, coordinated by extrinsic nerves
