HNN Week 5 Flashcards
1
Q
What is a carcinoma?
A
A malignant cancer of epithelial tissue origin
2
Q
What is betel leaf?
A
Same as paan, a concoction common in India which is chewed and contains tobacco, areca nut, lime…
3
Q
What is the aetiology of oral cancer?
A
- 95% of all HNN cancers are squamous cell carcinomas (HNSCC)
- “field cancerisation” tends to occur -> exposure of epithelium and mucosa of the upper respiratory tract to carcinogens causes multiple tumours to develop independantly so there is 35% chance that an individual will develop and discover a second tumour within 2yrs of first
4
Q
Name some risk factors and promoters for HNSCC’s:
A
RF: alcohol, smoking (Betel leafs and cigarettes), FH, radiation
Promoters: irritation from ill-fitting dentures/jagged teeth
5
Q
What is the pathophysiology of oral cancer?
A
- multifactorial, activation of oncogenes and inactivation of TSG’s
- No specific mutations found but there is a sequence of genetic steps:
- > regions of chromosomes 3/9 are lost
- > inactivation of the CDK inhibitor gene p16
- > unregulated cell cycle and hyperplasia
- > mutation of p53 TSG which causes dysplasia
- EGFR over-expressed in many HNSCC’s
- popular cancer areas = ventral surface of tongue, floor of mouth, lower lip, soft palate and gums
6
Q
How would you investigate and diagnose oral cancer?
A
- take history
- EXAMINE: look for firm, raised, irregular plaques with roughened edges which can be mistaken for ulcers
- take a BIOPSY and carry out lab testing
7
Q
How would you treat oral cancer?
A
- prevention: avoid risk factors
- excision surgery + chemo/radiotherapy for metastasis
- medicines:
-> monoclonal antibodies or tyrosine kinase inhibitors are used and act as EGFR blockers to slow/stop cell growth
-> TKI’s include lapatinib/erlotinib
additional considerations:
-> tracheostomy at the level of 2nd tracheal ring
-> bad teeth removed prior to surgery to prevent infection
-> hemiglossectomy
Procedure:
- incision made under mandible on affected side
- mandible cut through to allow access to floor of mouth and mandible retracted
- tumour + margin of heathy tissue removed
- surgeon rewires mandible internally and a donor graph may be needed
8
Q
Why is dotted line between corner of eye and mandible relevant for lymphatic drainage?
A
Everything below the line = drained by submandibular nodes
Everything above the line = drained by pre-auricular nodes
9
Q
What are the main lymph nodes in the head?
A
- submental (under chin)
- pre auricular (parotid) and post-auricular (infront and behind of ear)
- occipital nodes
- submandibular nodes
- superficial and deep cervical nodes
- supraclavicular nodes
- jugulo-digastric node: large node where posterior belly of digastric muscle meets internal jugular vein
- jugulo-omohyoid node
- Virchow’s node = an enlarged supraclavicular node that is a sign of gastric malignancy
10
Q
What do the submental nodes drain?
A
- tip of tongue
- front of lower mouth
- lower lip
- chin
11
Q
What do the pre-auricular nodes drain?
A
- temporal region of head
12
Q
What do the occipital nodes drain?
A
- tissue at back of head
13
Q
What do the submandibular nodes drain?
A
- anterior 2/3 and lateral edges of tongue
- majority of mouth and lower face
- nasal cavity
- maxillary sinus
14
Q
What do the superficial cervical nodes drain?
A
- superficial neck
15
Q
What do the deep cervical nodes drain?
A
- posterior tongue, deep head, thyroid and larynx
16
Q
What do the supra-clavicular nodes drain?
A
- neck and some parts of mediastinum
17
Q
What is the lymphatic drainage of the tongue?
A
TIP = sub-mental nodes
LATERAL EDGES = submandibular nodes
MIDDLE = inferior deep cervical nodes
POSTERIOR = superior and deep cervical nodes
18
Q
What is the function of the tongue and its three main parts?
A
- mastication, taste, swallowing and oral cleansing
- root: posterior part that attaches between mandible and hyoid
- body: main middle part
- apex: anterior part that rests against incisors
19
Q
What is the median fibrous lingual septum?
A
- septum that divides the tongue into 2
20
Q
What is the terminal sulcus?
A
- characteristic V-shaped groove on posterior dorsum of tongue
- divides tongue into anterior and posterior portions
- points to the foramen caecum
21
Q
What is the foramen caecum?
A
- non functional remnant of the embryological thyroglossal duct from which the thyroid developed from
22
Q
Describe the locations of the 4 papillae groups on the tongue and what the function of papillae is:
A
- Vallate = anterior to the terminal sulcus
- Foliate = small folds of lingual mucosa found laterally
- Filiform papillae = found over most of dorsum and especially at tip of tongue with taste buds on surface
- Fungiform = sparse over dorsum and concentrated at tip
Function = to increase the surface area of the tongue to increase friction with food
23
Q
How do extrinsic muscles differ from intrinsic muscles of the tongue?
A
- they originate outside the tongue and function to alter the position (not shape) of the tongue
24
Q
Name the 4 extrinsic tongue muscles and their anatomical locations:
A
1) Palatoglossus: from the soft palate to the posterior lateral tongue on both sides
2) Genioglossus: from spine of mandible across entire dorsum of tongue and some fibres extend to the hyoid bone
3) Styloglossus: from styloid process to distal sides of tongue posteriorly
4) Hyoglossus: quadrilateral muscle running from hyoid bone to inferior lateral tongue
25
What is the function of palatoglossus muscle?
pulls soft palate down towards tongue
26
What is the function of genioglossus muscle?
protrudes tongue and retracts apex
| unilateral contraction will move tongue to the opposite side
27
What is the function of styloglossus muscle?
- retrudes tongue and curles the sides
| - works with genioglossus to make trough when swallowing
28
What is the function of hyoglossus muscle?
depresses and shortens tongue
29
How do intrinsic tongue muscles differ from the extrinsic and name the 4 intrinsic muscles:
- they originate and insert entirely inside the tongue and alter the SHAPE of the tongue (not position)
1) superior longitudinal
2) inferior longitudinal
3) transverse
4) vertical
30
Describe the position and function of the superior longitudinal muscle:
- elevates and shortens
- thin layer under mucous membrane of dorsum that runs from median fibrous lingual septum out to the margins of the sides of the tongue
31
Describe the position and function of the inferior longitudinal muscle:
- depresses and shortens
| - narrow band near ventral surface that runs from root to apex
32
Describe the position and function of the transverse muscle:
- narrows and elongates
| - deep to the superior longitudinal muscle
33
Describe the position and function of the vertical muscle:
- broadens and widens
| - fibres intersect with transverse muscle
34
Describe the arterial supply of the tongue:
- internal carotid artery -> lingual artery -> dorsal lingual arteries supply root -> deep lingual arteries supply body and apex and communicate
35
Describe the venous supply of the tongue:
- sublingual/dorsal/deep lingual veins -> lingual vein -> internal jugular vein
36
Describe the innervation of the tongue:
- hypoglossal (CN12) supplies all muscles except palatoglossus which is supplied by pharyngeal plexus from the vagus nerve
- chordae tympani nerve supplies taste to anterior 1/3 tongue
- lingual nerve (branch of CN5) supplies sensation to anterior 1/3 tongue
- lingual branch of glossopharyngeal nerve supplies taste and sensation to posterior 1/3 tongue
37
Describe the location and function of the larynx
- found at level of C3-6 vertebrae
- protects airway when swallowing
- contains vocal folds for voice production
- connects pharynx to trachea
- composed of 3 single and 3 paired (total of 9) cartilages
- lined by respiratory epithelium
38
Describe the three unpaired cartilages in the larynx:
1) thyroid - made from two sheets that pass anteriorly and join forming laryngeal prominence
- 2 superior horns on back that project to hyoid bone
- 2 inferior horns that are in contact with cricoid cartilage
2) epiglottis - leaf shaped elastic cartilage with stalk attached to thyroid cartilage
- closes off trachea when swallowing to prevent aspiration
3) cricoid - complete ring of hyaline cartilage which is narrow anteriorly and broader posteriorly
- lower border at C6
- provides attachments for 2 inferior horns of thyroid cartilage and also arytenoid cartilages
39
Describe the three paired cartilages in the larynx:
1) Arytenoid - pyramid shaped and sit on the cricoid cartilage
- base articulates with cricoid cartilage and apex articulates with corniculate cartilage
2) Corniculate - articulates with apices of arytenoid cartilages
3) Cuneform - found in aryepiglottic folds
- they strengthen the aryepiglottic folds
40
What is the boundary between the mouth and oropharynx?
What is this area often called?
- palatoglossal fold
| - often called isthmus of the fauces = the lumen of the mouth at the area where the mouth becomes oropharynx
41
What are the boundaries of the nasopharynx?
from end of nasal septum to tip of soft palate
42
What are the boundaries of the oropharynx?
from from tip of soft palate to tip of epiglottis
43
What is Waldeyer's ring?
An uninterrupted ring of tonsils that provide immune protection.
Includes pharyngeal tonsil, palatine tonsil, lingual tonsil and tubal tonsil.
44
What is the vallecula?
Recess between posterior tongue and epiglottis where swallowed objects may stick
45
What is the pyriform fossa?
A deep recess in the side of the pharynx where food notoriously sticks.
46
What is the pharyngeal recess?
A deep recess in the nasopharynx that is very deep laterally and if taking biopsy from here be careful not to puncture the internal carotid artery.
47
What bounds the inlet to the larynx?
Aryepiglottic fold = there is one on each side and passes from laryngeal prominence to the septum dividing the larynx and laryngopharynx
48
What are the laryngeal ventricles and where are they found?
Are found as out-pouchings between vestibular folds (superior) and vocal folds (inferior)
They have tubular extensions called saccules which contain many mucous glands to produce mucous and lubricate the vocal folds
49
What happens to the larynx in swallowing?
Each of the aryepiglottic folds contract (due to small muscle within them) and this causes the larynx to close like a sphincter mechanism and stops aspiration.
50
Describe the anatomy of the laryngeal folds:
- Avascular (white appearance) and are covered by stratified squamous non keratinised epithelium
- mucosa contains many GAG's which produce a watery like-structure and allow the folds to vibrate
1) Vocal folds = true folds = are abducted/tensed/relaxed to control pitch
2) Vestibular folds = false folds = lie SUPERIOR to the vocal folds and are fixed to provide protection to the larynx
51
What MDT members are important in care of oral cancer patient?
- dentist (promotes awareness that small asymptomatic lesions can be cancerous)
- speech therapists (supports entire family before and after and provides speech and swallowing exerises)
- surgeons
- medical oncologists (specialise in medical treatment of cancer
- clinical oncologists (specialise in radiotherapy treatment of cancer
- restorative dentistry consultants
- dietician
- psychologist
- social worker (helps apply for benefits)
52
What are common features of a MS patient that the neurophysiotherapist deals with?
- flexor and extensor spasticity
53
What is spasticity and how can it be treated?
- a velocity dependant increase in TONE due to an exaggerated stretch reflex
- it is a sign of an upper motor neuron lesion
Focal spasticity -> physiotherapy and tone management
Generalised spasticity -> may consider oral drug treatment:
- baclofen (a GABA receptor agonist)
- botulinism toxin injection
- lower limb block with anaesthetic
54
Name some common spasticity triggers:
- bowel and bladder dysfunction
- infection
- pain
- posture and poor positioning
55
Describe the roles of a NPT:
(neurophysiotherapist)
- obtain a comprehensive history
- monitor any symptom changes
- examine (skin, joints and positioning)
- liase with other medical professionals
- educate family and friends of the patient about the patient's condition and how best to manage
- implement and PHYSICAL and THERAPEUTIC plan
- try orthotics, functional electrical stimulation, standing, active and passive exercises
56
What are the issues a patient will face that has to adapt to living with a neurological condition like MS?
- loss of independence
- loss of job = financial difficulty
- bowel issues (embarrassment)
- isolation -> difficulty walking
- sleep disturbance
57
Describe the anatomical components of the visual pathway:
- retina
- optic nerve -> CN2, ~50mm long
- optic chiasm -> 50-60% fibres decussate
- optic tract
- lateral geniculate nucleus (LGN) -> relay centre in the thalamus where there are 6 layers of neurons that are grey matter, with white matter in-between = striped appearance
- optic radiation -> nerve fibres spread out like a fan to the visual cortex
- primary visual cortex
(as well as the LGN, fibres also extend to the superior colliculus and pre-tectum areas of the midbrain)
58
Describe the relationship between the visual field and how it projects into the retina
See HNN wk6 anatomy picture
- visual information projects onto either the temporal or nasal portions of the retina
- 50% of fibres from each of these regions decussate at the optic chiasm
59
What is the effect of a partial lesion of an optic nerve?
Ipsilateral scotoma
60
What is the effect of a complete lesion of an optic nerve?
Blindness in that eye
61
What is the effect of a lesion of the optic chiasm?
Bitemporal hemianopia (as fibres that are crossing from the nasal portions are damaged)
62
What is the effect of a lesion of the optic tract?
homonymous hemianopia
63
What is the effect of a lesion of Meyer's loop?
Homonymous upper quadrantanopia
64
What is the effect of a lesion of the optic radiation?
Homonymous hemianopia
65
What is the effect of a lesion of the visual cortex?
Homonymous hemianopia
66
What is the effect of a lesion of the bilateral macular cortex?
Bilateral central scotoma
67
What does hemianopia mean?
blindness over half the field of vision
68
What does scotoma mean?
area of partial alteration in the visual field
69
What can cause an optic nerve lesion?
- acute optic neuritis due to MS
- trauma
- optic atrophy
70
What can cause a lesion in the optic chiasm?
- tumours (pituitary)
| - aneurysm of the anterior communicating artery in the circle of Willis
71
What can cause a lesion in the optic tract?
- tumours
trauma
aneurysm of posterior cerebral artery
72
What other areas can fibres project to except the LGN and what are the functions of these areas?
1) superior colliculus (area of the midbrain) that controls rapid directional movements of the eye
2) pretectal area (also in midbrain) that controls reflex eye movements including pupillary light reflex
73
What is the anatomy and pathophysiology involved in sympathetic pupil control?
- signals from sympathetic trunk sent up to superior cervical ganglion
- innervate dilator pupillae muscle causing pupil dilation
74
What is the anatomy and pathophysiology involved in parasympathetic pupil control?
- one afferent tract (via optic nerve CN2 fibres travel to pretectal nucleus area of midbrain)
- efferent occulomotor fibres then travel from pretectal nucleus to the Edinger Westphal nuclei and synapse with parasympathetic fibres in the ciliary ganglion
- postganglionic fibres then leave ciliary ganglion and innervate the ciliary sphincter muscle causing constriction
- two efferent fibres (one ipsilateral and one contralateral) so that light stimulation of one eye causes constriction of both pupils
75
What is the pupillary light reflex and its purpose?
- pupil constricts in response to light
- balance between para/sympathetic systems
- allows us to see in dim light and to protect the retina from bright light
76
Describe how the pupillary light reflex works:
1. light shone directly onto retina of one eye
2. action potentials from right eye reach both left and right pretectal nuclei
3. Pretectal nuclei stimulate both sides of Edinger-Westphal nucleus
4. EW nucleus generates AP through the L and R occulomotor nerves causing both pupils to constrict
5. Occulomotor nerves go on to innervate ciliary sphincter muscles
- constriction of ipsilateral pupil = direct pupillary light reflex
- constriction of contralateral pupil = consensual/indirect pupillary light reflex
77
What can the swinging light test identify?
- assymetry of the afferent input in the pupillary light reflex and may show a RAPD (relative afferent pupil defect)
- there will be an afferent lesion in the optic nerve on the side of the dilating pupil that does not constrict when light is shone on it
78
What is the accommodation reflex and how does it work?
When the pupils constrict and the eyes converge when looking from a distant object to a close one.
- stimulus for the reflex is an out of focus image
1) pupils constrict by constrictor pupillae muscles
2) ciliary muscles cause lens to accomodate and become more convex
3) there is contraction of both medial rectus muscles and convergence of eyes in towards the nose
79
Which reflex can be used to test brainstem integrity and why?
- pupillary light reflex (as it involved brainstem only)
| - accommodation reflex cannot be used as it also involves the cortex
80
What are the 4 steps used to examine the pupils?
1) inspect them for asymmetry or irregularity (small size difference of 1-2mm normal)
2) check direct and consensual reactions to light
3) try swinging light test
4) try accommodation-convergence reflex
```
PERL = pupils equally react to light
PERLA = "" and accommodation
```
81
What is hippus?
- when light is shone onto the pupil and it contracts and relaxes a little and can oscillate = this is a physiologically normal response of a healthy eye
82
What do you look for when using an ophthalmoscope?
- examine fundus of the eye
- optic disc is the bright area
- fovea of macula is the small dark area
- arteries are LIGHTER than veins
83
How big is the macula?
1.5mm diameter
84
What are the layers of the retina from light hitting first to last?
- ganglion cells
- bipolar cells
- photoreceptive cells
- retinal pigment epithelial cells
- choroid
85
Describe how visual acuity is measured and what the measurements mean:
- recorded as the distance the chart is read : the distance at which it should be normally read
- NORMAL = 6/6 (the person is reading something from 6m away which should normally be read at 6m away)
- 6/12 = the patient is reading from 6m away something that should normally be able to read from 12m away
86
What is Virchow's node?
An enlarged supraclavicular lymph node that drains stomach and can be a sign of gastric malignancy
