Throat Flashcards
(188 cards)
1
Q
What is the anterior cylinder called
A
Larynx
2
Q
What is the posterior cylinder
A
Pharynx
3
Q
What does larynx continue into?
A
Larynx-trachea-airway
4
Q
What does pharynx continue into?
A
Pharynx- oesophagus
5
Q
Extension of larynx?
A
From C3 to C6
6
Q
What is larynx is made up of?
A
Muscles in between cartilages
7
Q
Cartilages of larynx
A
Total 6
3 paired
3 unpaired
8
Q
What is the Largest laryngeal cartilage?
A
Thyroid cartilage
9
Q
What are the three unpaired cartilages of the larynx?
A
ETC
Thyroid
Cricoid (ring like)
Epiglottis (leaf like, rises above the glottis)
10
Q
What are the three paired cartilages of larynx?
A
CAC
Arytenoid
Cuniform
Corniculate
11
Q
Which cartilage does not ossify with age?
A
Elastic cartilages:
Epiglottis will never ossify
Cuniform and corniculate aswell but they are rudimentary so not that important.
12
Q
What are the hyaline cartilage of larynx ?
A
CAT
Thyroid
arytenoid
Cricoid
13
Q
What are Vocal cords made up of?
A
Anterior 2/3rd membranous
Posterior 1/3rd cartilaginous
14
Q
Which cartilages make posterior one third of vocal cords?
A
Arytenoid Cartlidge
15
Q
What are pharyngeal arches made up of?
A
Mesoderm
(4 and 6.
5th obliterates)
16
Q
4th pharyngeal arch structures?
A
3 cartilages.
CuTE
Cuniform
Thyroid
Epiglottis
+
ALL pharyngeal muscles EXCEPT stylopharyngeous muscle
+
All extrinsic muscles of larynx
+
superior laryngeal nerve
17
Q
From which arch stylopharyngeus muscle is made of?
A
Third arch
18
Q
What are the two nerves that supply the larynx?
A
Superior laryngeal nerve (SLN)
Recurrent laryngeal nerve (RLN)
19
Q
6th pharyngeal arch structures?
A
CAC cartilages
Cricoid
Arytenoid
Coniculate
+
ALL intrinsic muscles of larynx EXCEPT cricothyroid muscle
+
Recurrent laryngeal nerve
20
Q
From which arch does cricothyroid muscle develop from?
A
4th pharyngeal arch
21
Q
What are the three pharyngeal constrictor muscles?
A
Superior, middle and inferior constrictor muscles

All supplied by vagus nerve
All Present Retropharyngeal
22
Q
All muscles of the pharynx are supplied by vagus nerve, except which muscle?
A
Stylopharyngeus
innervated by the glossopharyngeal nerve CN9
23
Q
What is Torus Tubarius?
A
It is an area of cartilage covered in mucosa raised above the auditory tube present in the nasopharynx
24
Q
What is pharyngeal plexus composed of?
A
CN8, CN9 and sympathetic fibres
25
Nerve supply of pharyngeal muscles
Vagus nerve- All muscles *except *
Stylopharyngeous- CN9
Tensor veli palatini- Mandibular div. Of CN5
26
Blood supply of pharynx
Common carotid artery — external carotid artery — **acsending pharyngeal artery**
Drained into pharyngeal venous plexus
27
lymphatic drainage of pharynx
Jugulodigastric nodes (tonsillar nodes)
28
What is the Adams apple?
It is laryngeal prominence present medially at the spine of the thyroid cartilage
29
Only complete ring of cartilage in the airway?
Cricoid cartilage
30
Innervation of larynx- Motor
The larynx is innervated by branches of the vagus nerve (CN X):
**Superior laryngeal n.**
• External branch - **innervates cricothyroid m**
**Recurrent laryngeal n.**
Motor - to all intrinsic muscles of larynx (except cricothyroid m.)
31
What are the intrinsic muscles of larynx
Adductors Abductors and tensors
**Vocalis m.** in vocal folds, produces minor adjustments in vocal ligament tension
**Arytenoid m.** (thyro, inter.) - **adduct** vocal folds (close glottis)
**Posterior cricoarytenoid m.** - **abduct** vocal folds (open glottis)
**only muscle that opens the airway!**
All innervated by **recurrent laryngeal n.** except cricothyroid
32
Lymphatics of larynx
Above vocal folds - **superior deep cervical lymph nodes**
Below vocal folds - **pretracheal or paratracheal lymph nodes**, then to **inferior deep cervical lymph nodes**
33
Blood supply of larynx
Arteries - branches of superior and inferior thyroid arteries
**Superior laryngeal a.** branch of superior thyroid a., pierces thyrohyoid membrane
**Inferior laryngeal a.** - branch of inferior thyroid a., runs with end of recurrent laryngeal n.
34
Stages of deglutition
• Stage 1 - voluntary, tongue pushes bolus against hard palate into oropharynx
• Stage 2 - involuntary
• Soft palate elevates to close passage into nasopharynx
• Epiglottis closes over larynx
• Stage 3 - pharyngeal constrictors sequentially contract pushing bolus into esophagus, esophagus transports bolus from pharynx to stomach
35
What is the primary function of larynx?
Primary- protection of lower airways
Secondary- phonation
36
Process of phonation
Function of the true vocal cords or glottis in adduction position, (closed)
During the exhalation of air
37
What is puberphonia
Rx
Adult male, having high-pitched voice
Rx- speech therapy initially, (Hey man, have guts) **Gutzmann’s manoeuvre **
For 3 to 6 months
If no improvement
*Surgical management *- **type 3 thyroplasty** (surgical shortening and loosening of vocal cords)
38
What is Androphonia
Rx
Adult female with the low pitched voice.
Rx-
direct surgical manoeuvre- **type 4 thyroplasty** (surgical lengthening and tightening of vocal cords)
39
What are the two vocal disorders?
Androphonia
Puberphonia
40
Types of laryngoscopy
1. Indirect- using a straight mirror. Done in OPD.
2. Direct- using
CURVED BLADE **Macintosh** in ADULTS
STRAIGHT BLADE **miller** in infants(peads)
Pt. Is sedated, done in OT Only. Held in non dominant hand.
3. Flexible laryngoscope, wire thru the nose.
41
Indications for direct laryngoscopy
1 intubation
2 biopsy
42
Male, smoker, presents w hoarseness is voice
Dx
Keratosis larynx OR
Renkies edema
43
Normal lining of larynx
Pseudostratified ciliated, columnar epithelium
44
Normal lining of the vocal chords
Stratified squamous epithelium
45
What is ketosis larynx?
In smokers, the epithelium lining the vocal cords sheds at a faster rate. Therefore, there is hoarseness a voice, 
46
Ketosis larynx Rx
Decortication + quit smoking
47
Patient with complains of weak and breathy voice
Laryngoscopic examination shows **keyhole gap** incomplete closure of vocal cords even after complete adduction (elliptical gap)
Phonaesthenia
48
Phonaesthenia
Patho physio
Rx
Muscles of adduction- thyroarytenoid TA and interarytenoid IA weakness/ paralysis
Causing some gap
Both muscles- keyhole gap
TA only- elliptical gap
Rx- speech therapy
49
Chronic smoker
Hx of hoarseness
Laryngoscopy shows swelling of vocal cords
Dx
Rx
Reinke’s edema
Collection of fluid in the reinkes space of the VC.
(Space Bw the mucosa and vocal ligament)
RISK FACTOR - smoking
Rx. Of choice- decortication (same as keratosis larynx)
50
Laryngeal web
Rx
-Congenital anomaly
Extra tissue bw the VC
-Most common site is **glottis**
*child with hoarse cry*
RX.
- CO2 laser excision
51
Subglottic stenosis types
1 Congenital
Child, born with a smaller lumen
2 Acquired
Recurrent infections, causing inflammation, causing oedema, leading to stenosis
52
Subglottic stenosis grading
**Cotton myele grading**
Grade 1 and 2 (0-70)
conservative
Grade 3 and 4 (70-100)
surgical- LTR laryngotracheal reconstruction
53
Trumpet player presents to OPD with complain of neck swelling. on pressing swelling, hissing sound is noted.
X-ray soft tissue neck shows air filled swelling
CT same
Laryngocele
54
Hissing sound on pressing swelling
Bryce sign
55
Laryngocele
Dx
Rx
Abnormal dilation of saccule
In wind instrument players mostly or weight lifters
Do **X-ray soft tissue neck with VALSALVA MANOEUVRE**
Rx- surgical excision
56
Levels of neck
1. Submental + submandibular
2. Upper deep cervical
3. Middle deep cervical
4. Lower deep cervical
5. Supraclavicular
6. Prelaryngeal/pretracheal/delphian
7. Mediastinal
57
Lymphatic drainage of supraglottis
Level 2 and 3
Upper and middle deep cervical lymph nodes
58
Subglottis lymph drainage
Level 6 LN (pretracheal)
59
Glottis lymph nodes
No lymphatics
Best prognosis cause no mets
60
Intoxicated pt having meal, chokes, difficulty swallowing, respiratory distress, can’t speak anything
Rx
Rx- heimlichs manoeuvre
61
Paediatric larynx
Position- high, C2-C3
Shape- funnel shaped
Narrowest part- subglottis
Edema- high due to more loose areolar tissue
62
Adult larynx
Position- low C3-C6
Shape- cylinder shaped
Nastiest part- glottis
Edema- low
63
Only abductor muscle of larynx (opens)
Posterior cricoarytenoid muscle
64
Adductor muscles of larynx
4
Thyroarytenoid
Interarytenoid
Lateral cricoarytenoid
Cricothyroid
65
Tensor muscles of larynx
Main- cricothyroid
And vocalis
(Thyroarytenoid muscle also as vocalis is the internal part of it)
Responsible for quality of voice
66
Only unpaired muscle of larynx
Interarytenoid muscle
Also called transverse muscle
67
Innervation of larynx- sensory
Glottis- SLN and RLN
Supraglottis- internal branch of SLN (ILN)
Subglottis- RLN
68
Pt underwent thyroid surgery. after surgery, He has **poor quality of voice** and **recurrent aspiration.** What is the likely cause?
SLN injury
69
Injury to SLN
Aspiration and poor voice quality
❌ external laryngeal nerve— motor nerve supply to cricothyroid muscle — poor quality of voice as it is a tensor muscle
❌ internal laryngeal nerve — sensory nerve supply to supraglottis — ❌ cough reflex leading to aspiration
70
Vocal cord paralysis
More commonly **left sided palsy**
4:1 ratio
Because left RLN has a longer course (till middle of thorax a rough arch of aorta)
MCC of unilateral palsy-
1. Ideopathic
2. Carcinoma bronchus
MCC of bilateral palsy-
1. Iatrogenic trauma (thyroidectomy)
71
Which nerve injury more common during thyroid surgery
SLN injury
72
Pt. W c/o hoarseness of voice and it was found left atriomegaly is causing compression of left RLN. What is Dx?
**Ortner’s syndrome**
RLN palsy
73
Pt. After thyroid surgery, having respiratory distress and stridor.
What is Dx?
**Bilateral abductor palsy**
POSTERIOR CRICOARYTENOID MUSCLE PALSY
due to bilateral **RLN injury**
Vocal cords are closed causing distress and strider in pt.
74
B/L RLN injury
Rx
Emergency- tracheostomy
Definitive- type 2 thyroplasty
(Lateralisation of vocal cords)
75
Pt. With c/o Aphonia and aspiration pneumonia
Dx.
Bilateral vagal paralysis
**b/l RLN SLN injury** causing
Bilateral *ADDUCTOR* palsy
Vocal cords in the cadaveric / open/ intermediate position.
76
Bilateral ADDUCTOR palsy Rx
Definitive only
**Type 1 thyroplasty**
Medialisation of vocal cords
77
A neonate w c/o noisy breathing, **increasing** with crying or supine lying.
Picture shows **omega shape OR floppy epiglottis**
Dx
**Laryngomalacia**
Weakness of supraglottis
Most common congenital anomaly of larynx. And inspiratory stridor
Stridor decreases in prone position
78
Most common congenital anomaly of larynx
Laryngomalacia
79
Laryngomalacia Rx
Reassurance only.
Self resolving condition till 2years of age
If not improved after 2 years
SURGICAL:
**supraglottoplasty**
OR
**epiglottopexy**
80
Child (school going)
in emergency
sitting bent forward (tripod position) with severe rds
and cannot swallow.
Drooling of saliva
Dysphagia.
Odynophagia
Muffled **hot potato voice**
Fever high grade
Dx
Acute epiglottitis
Bacterial infection of epiglottis/ supraglottis
81
Acute epiglottitis investigation
First line- **X-ray soft tissue neck lateral view** will show characteristic **thumb sign**
82
Most common pathogen for Acute epiglottitis?
**Strep pneumoniae**
And in non-immunised children, HIB (heamophilus influenza B)
83
Acute epiglottitis Rx
First line management-
1. AIRWAY
Early elective intubation (high chance of stenosis) if not possible tracheostomy
2. Antibiotics
3. Steroids to reduce edema
4. **Nebulised epinephrine** as bronchodilator
84
6m- 3yr old child with low grade fever, with BARKING OR BRASSY cough
and BIPHASIC stridor
Dx
Croup/ Acute laryngo- tracheo- bronchitis
85
Croup/ Acute laryngo- tracheo- bronchitis most common site
Subglottis
86
Croup/ Acute laryngo- tracheo- bronchitis most common cause
Parainfluenza virus
87
Croup/ Acute laryngo- tracheo- bronchitis investigation
X-ray soft tissue neck anterior view
Will show narrowing to the subglottis called the **steeple sign**
88
Croup/ Acute laryngo- tracheo- bronchitis Rx
First line- Airway
-Steroids
-Bronchodilators
-Antipyretics
-Antibiotics (immunocompromised pt will have sec infection)
89
School aged child, 4-6yrs, with complains of hoarseness of voice and strider
Laryngoscopy shows multiple papilla (overgrowth)
Dx
Juvenile pappilomatosis of larynx
90
Juvenile pappilomatosis of larynx
- **Benign overgrowth** from the stratified squamous epithelium
- Common in children less than 18 years of age
- Associated with **HPV 6 and 11**
- Mother has genital warts during delivery
- Viral warts present on vocal cords seen w laryngoscopy.
- **Premalignant** condition
91
Juvenile pappilomatosis of larynx Rx
MLS surgery with CO2 laser excision
92
Pt w history of vocal abuse
Overgrowth in larynx
Hoarseness of voice
**Bilateral** Overgrowth in larynx **less than 3mm**
Vocal **nodules**
Teachers nodules/
**unilateral** Overgrowth in larynx **more than 3mm**
Vocal **polyp**
Teacher/ singer OR smoker OR with laryngopharyngeal reflux (gerd)
Overgrowth at the junction of ant 1/3rd and post 2/3rd
93
Vocal nodules Rx
Speech therapy
Voice rest
94
Vocal polyp Rx
MLS polyp removal
Speech therapy
Voice rest
95
What characteristics feature is present in vocal polyp and absent in nodules?
Diplophonia (2 voices at the same time)
96
Patient underwent a major surgery under general anaesthesia, and post surgery, complains of hoarseness of voice.
what is the likely diagnosis?
Intubation granuloma
Injury to the vocal cords while inserting the ET tube due to GA
97
Intubation granuloma RX
MLS excision
98
A 19-year-old female complains of loss of voice, (Aphonia)
Cough sound is normal
vocal cord movements are also normal. What is the best step in management?
**Functional/ Hysterical Aphonia**
Since everything is normal, pt is j being dramatic after a breakup or due to exams
Rx- sent for psychiatric consultation 👀
99
Tracheostomy indications
Prolonged mechanical ventilation (>3 weeks) due to high risk of laryngeal edema
CICO
cant intubate cant oxygenate
Due to cervical spine fracture
OR maxilla facial injury OR B/L abductor palsy
100
Best site for tracheostomy
Bw 2nd and 3rd tracheal ring
101
Types of tracheostomy tubes
-on the basis of material
Metallic (cause ischemic necrosis)
silicon( Skin friendly)
Plastic (for emergency)
-cuffed (if balloon is attached) used in ICU or comatose pts w diminished reflexes to prevent aspiration.
OR uncuffed
-fenestrated (can talk)
Unfenestrated (cannot speak, ER)
-Single or
double lumen (definitive)
Shilley
portex in ER
102
Complications of tracheostomy
1. Main- haemorrhage
2. Injury to lungs in children causing pneumothorax
3. Injury to RLN
4. Injury to thyroid gland
6. Tracheomalacia
7. Tube blockage
103
Tracheomalacia caused by using which type of tube
Rx
Cuffed tube
Rx- use a high volume but low pressure cuffed tube
OR
deflate cuff for 5 minutes after every hour
104
Tube blockage due to tracheostomy tube presentation
Rx
ICU pt in coma
Saturation started falling suddenly due to blockage of the tube by the secretions if they aren’t suctioned out properly.
Rx- immediately remove and replace tube.
Proper suctioning immediately
105
CA larynx
- can be of glottis, supraglottis or Subglottis
-Most common place is **glottis carcinoma**
- most common type is **squamous cell carcinoma**
-risk factors: **smoking, alcohol, HPV infection**
- more commonly seen in **males 40-60 years of age**
- **best prognosis** since no lymph drainage
106
Supraglottis cancer
- 2nd most common
- complaint of lump in throat
- Throat pain
- Hot potato voice
- Stridor
107
CA larynx treatment
High tracheostomy
(Bw 1st and 2nd rings)
(Usually avoid it due to subglottic stenosis risk )
108
TNM staging CA larynx
T1a only 1 vocal cord is involved
T1b both vocal cords are involved
Vocal cords are mobile in T1
T2 more than one structure involved
T3 fixed vocal cords/ immobile
T4 extra laryngeal extension
Rx-
For T1/T2 radiotherapy
For T3/T4 total laryngectomy followed by radiotherapy with or without radical neck dissection
109
What are the structures removed in radical neck dissection?
Level 1-5 lymph nodes
Submandibular gland
Tail of parotid gland
Sternocleidomastoid muscle
Omohyoid muscle
Accessory nerve
Internal jugular vein
110
Best vocal rehabilitation device after laryngectomy in CA larynx
1. TEP device
Tracheoesophageal puncture device
surgically placed between the trachea and oesophagus, so that the air from the trachea will go to the oesophagus, and is then converted to sound
**Blom singer prosthesis**
2. Electrolarynx
111
Pharynx extension
From skull base to C6
112
Pharynx parts
Fibromuscular tube forming
Nasopharynx
Oropharynx (epi)
Laryngopharynx (retro/ hypo)
113
Most common site for Laryngopharynx malignancy?
Pyriform fossa/ sinus
114
A middle-aged female with complains of pallor and fatigue with spoon shaped nails (koilonycia) Atrophic glossitis and post cricoid cancer.
what is appropriate diagnosis?
Plummer Vinson syndrome
More common in females
Classical triad:
1. Iron deficiency anemia
2. Atrophic glossaries
3. Post cricoid/ esophageal web (from which a cancer may arise)
Most common site: **post cricoid area**
115
A seven-year-old child with complains of bilateral conductive hearing loss, poor school performance and adenoid facies.
diagnosis?
Adenoid hypertrophy
116
Adenoid facies
Pinched nose, open mouth, crowded teeth, narrow palate, high palate arch
117
What are Adenoids?
Tonsils that are present in the junction of roof and posterior wall of nasopharynx
Are present at birth, grow till 6yrs then regress and are computer gone by the age of 20.
118
Most common cause for adenoid hypertrophy?
Recurrent upper airway infections
119
Why is there b/l CHL in adenoid hypertrophy
Due to blockage of ET by the enlarged adenoids the pt will have B/L glue ear as secretions will not drain
120
Adenoid hypertrophy Rx
Adenoidectomy
For CHL- myringotomy + grommet insertion
121
Most common site for nasopharyngeal carcinoma
Fossa behind the torus tubaris called the **fossa of rosenmuller**
122
What is anterior and posterior to the torus tubaris
Eustatian tube opening
Posterior is fossa of rosenmuller
123
14-year-old boy comes with **recurrent profuse, epistaxis** and **nasal mass.** What is the most common appropriate investigation to make diagnosis?
Juvenile nasopharyngeal angiofibroma
CECT- **hollman miller sign** ant bowing
Angiography
MRI to check for soft tissue extension intracranially in infratemporal fossa or orbit.
124
Nasopharyngeal carcinoma
Patho
Presentation
- most common malignant of nasopharynx
- arises from fossa of rosenmuller
- Moro coming in Chinese mongols
- commonly associated with **adenovirus**
- most common clinical presentation **painless cervical lymphadenopathy**
- most common CN involved is **5th CN**
**trotter’s triad**
NPC
N neuralgia due to 5th nerve involvement
P palatial palsy due to vague nerve injury
C conductive hearing loss (unilateral)
125
Nasopharyngeal carcinoma
Rx
Treatment of choice **chemo radiation**
126
Oropharynx anatomy
Roof- hard and soft palate
Floor- base of tongue
Laterally- palatiglossal and palatopharu heal arches are present
127
Palatine tonsils location
Bw the palatoglossal and palatopharyngeal arches
Also known as tonsillar fossa
128
What is the bed of the tonsils formed by?
Superior constrictor muscle
Contains the 9th cranial nerve and the styloid process
129
What is styalgia
Patho
Rx
When the styloid process is too long and irritates the cranial nerve 9, resulting in irritation of the nerve, causing pain throat and referred otalgia.
**eagle syndrome**
Rx- styloidectomy
130
What is the most common cause of whitish membrane on tonsils?
Acute membranous tonsillitis
131
Most common cause for acute membranous tonsillitis?
Group A beta haemolytic streptococci/
Streptococcus pyogenes
132
Patient with bronchial asthma currently taking inhalers develops whitish patches over oral cavity. patch bleeds on removal
Dx?
Rx?
Oral candidiasis
Candida albicans
Rx
DOC- fluconazole
133
Small child presenting with, **bilateral lymphadenopathy** with characteristic **bulls neck** and whitish membrane, extending up to the pallet from tonsils that bleeds on removal
Dx?
Diphtheria caused by corynebacterium dyphtheriae
134
Causes of whitish membrane over palate or in oral cavity
-Infective mononucleosis EBV
-Vincent angina due to borelia vincenti usually after dental carries or infection
-Leukaemia
-Agranulocytosis
135
Child presents w complains of fever neck swelling with dysphagia and trismus (locked jaw) examination findings show uvula pushed towards opposite side and abscess on ct
what is diagnosis?
Parapharyngeal abscess
136
Parapharyngeal abscess
Patho
Rx
More common in children
Neck swelling present and visible
(Diff factors from Quincy)
Rx
External incision and drainage
antibiotics
137
What is Quincy
Rx
Peritonsillar abscess
More common in adults
No neck swelling
Fever
Dysphagia
Hot potato voice
Most common cause is **strep pneumonia**
Rx
per oral incision and drainage
Antibiotics
138
Trismus in Quincy occurs due to spasm of which muscle?
Medial pterygoid muscle
139
Child brought to ER with respiratory distress, fever, muffled voice (hot potato) and dysphagia
x-ray shows collection on pus in retropharyngeal space
What is next management?
Acute retropharyngeal abscess
140
Sequence of throat?
1. Larynx
2.Laryngopharynx
3. Posterior wall of Laryngopharynx called buccopharyngeal fascia
4. Retropharyngeal space
5. Alar fascia
6. Danger space
7. Prevertebral fascia
8. Cervical vertebra
141
Retropharyngeal space
A space lying behind the pharynx between the buccopharyngeal fascia covering the pharyngeal constrictor muscles & the prevertebral fascia, extending from the base of the skull to the bifurcation of trachea. This space is divided into two lateral compartments called spaces of Gillette by a fibrous raphe.
142
Lymph nodes in the retro pharyngeal space
retropharyngeal lymph nodes which are again divided into 2 groups:
lateral- larger, more constant, present in **adults** & known as **node of Rouviere.**
medial-present in **children,** disappears at 3-4yrs of age & absent in adults.
143
Acute Retropharyngeal abscess symptoms
CLINICAL FEATURES:
• Age - <3 yrs. due to atrophy of RP lymph node in childhood.
• Sex - > in males.
• Difficulty in breathing & suckling.
• Croupy cough
• Stiffness of the neck (Torticollis)- keeping head extended
• Fever
ON EXAMINATION:
• Whole pharynx congested
• Bulging of the posterior pharyngeal wall on one side of the midline
• Oedema of the larynx
144
Acute Retropharyngeal abscess investigation
**X-Ray soft tissue neck, lateral view** shows widening of the prevertebral soft tissue, straightening of the cervical vertebral column & pushing the air column forward.
Sometimes air or fluid in prevertebral area.
**CT scan** of the neck showing bulging of the Retropharyngeal space.
145
Acute Retropharyngeal abscess treatment
1) Incision & drainage of the abscess **without anaesthesia perorally,**
patient lying supine with head low.
**Vertical incision** given in the most fluctuant area with the help of mouth-gag. As soon as the incision is given, patient is turned to one side & suction given to prevent aspiration.
146
Chronic Retropharyngeal abscess
**Tubercular in nature**
CAUSES:
1) Caries of cervical spine due to TB usually seen centrally behind the prevertebral fascia
2) TB infection of RP lymph nodes secondary to TB of deep cervical nodes usually seen on one side of the posterior pharyngeal wall behind the buccopharyngeal fascia
147
Chronic retropharyngeal abscess symptoms
1) Age – Adults & adolescents
2) Slow onset
3) Mild dysphagia
4) Sore throat & cough maybe present
5) Muffled voice
ON EXAMINATION:
1) Fluctuant swelling on one side in case of retropharyngeal lymph node infection & centrally in case of TB caries of cervical spine
2) Enlarged tubercular cervical lymph nodes
148
Chronic retropharyngeal abscess
Rx
1) Incision & drainage of the abscess with a vertical incision along the anterior border of sternocleidomastoid (if low abscess) & posterior border of the sternocleidomastoid (if high abscess).
2) Antitubercular therapy for 12 months.
3) Cervical collar for 12 months till spine gets stable.
149
Pre malignant lesions of Oral cavity
1- leukoplakia- **most common**
2- Erythroplakia- **highest chance of malignancy**
3- Oral submucous fibrosis
150
Most common oral cavity cancer?
Squamous cell carcinoma
151
Most common site for oral cavity cancer worldwide?
Lateral border of tongue
152
Most common side for oral cavity cancer in India?
Gingivobuccal sulcus
153
Investigation of choice for oral cavity cancer?
Biopsy
154
Oral cavity cancer
Rc
Oromandibular dissection
(Commando’s operation)
155
Child, with history of dental infection brought in ER with complains of respiratory distress
Mouth is completely obstructed by tongue pushed upwards
neck swelling
Dx
Ludwigs angina
156
What is Ludwig’s angina?
Infection of floor of mouth
**Submandibular space**
Pathogen: Streptococcus viridans + anaerobes
157
Ludwig’s angina
Rx
ER:
Airway- tracheotomy
External incision and drainage
Antibiotics.
158
Acute pharyngitis
Symptoms
Investigations
caused by both virus and bacteria.
Adino, rhino, influenza virus
Beta haemolytic strep
**Mild**
Discomfort in the throat.
Low grade fever.
Earache.
No lymphadenopathy.
Congestion of pharyngeal mucosa.
**Severe**
Pain in the throat: severe.
Dysphagia.
Earache.
High grade fever.
Cervical lymphadenopathy.
Malaise, headache.
Investigations
Complete blood picture
Thoat swab culture
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Acute pharyngitis
Rx
bed rest
antipyretic
warm saline or antiseptic gargles
soft and liquid diet
Antibiotic is given if bacterial infection is suspected
Oral antibiotic against streptococci should be started immediately
160
Vincent’s angina
-Acute ulcerative lesion, involves 1 or both tonsils, may extend to soft, palate, pillars, and gums
- **Gram- fusiform Bacilli and Vincent spirochetes**
- Affects young adults and middle aged
- Poor oral hygiene, carious teeth, poor diet, overcrowding.
Symptoms
-Sudden onset with marked pain in throat
-Odynophagia
-Foul breath
- **Grey membrane** covering tonsils
-Lymphadenopathy
Investigations
**Swab test** and smear
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Vincent’s angina
Rx
systemic antibiotics ( penicillin )
metronidazole.
Local antiseptic gargles
analgesics
antipyretics
162
Thyroglossal duct cyst
• **Failure of complete obliteration of thyroglossal duct**
• Descent of thyroid gland - Foramen cecum
• Cystic midline swelling
• usually affecting **children**
• Rounded with a diameter of 2 - 4 cm
• presents as a draining sinus if it has burst due to infection or has been surgically drained.
• **Moves with tongue protrusion** Because of the attachment of thyroglossal d **foramen caecum** at the base of tongue
• Can occur anywhere in the course of thyroid duct
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Thyroglossl duct cyst Dx Rx
DIAGNOSIS
• Clinical - US/CT/MRI neck
TREATMENT
• Complete surgical excision - **Sistrunk's operation**
164
MC site for TDC
Subhyoid
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Sublingual DERMOID cyst
• It presents as a **midline submental swelling**
• **does not move on protrusion of the tongue** as it is not attached to foramen caecum.
• Sometimes it arises from the floor of mouth and needs differentiation from ranula.
166
Sublingual dermoid cyst Rx
Surgical excision
167
Thymic cyst
•Thymus develops from the **third pharyngeal pouch** then descends through the neck to the mediastinum
• caused by persistence of thymic remnants
•Swelling either cystic or solld
•It can occur in children or adults
presents as a **neck mass anterior and deep to middle third of sternocleidomastold muscle**
168
Thymic cyst Rx
• surgical excision.
• Sternotomy is required if it also extends into the mediastinum.
169
MC branchial cyst arises from which arch?
2nd branchial arch
- Ant neck to tonsillar fossa
- Common in second decade
- Round fluctuant non tender smooth mass
- Rx- surgical excision
170
Carotid body tumour
Dx
• **chemodectoma**
•Mostly presents after **40 years**
• Very slow-growing tumor
• **Painless swelling**
**pulsatile**and moves from side to side
• Bruit can be heard with a stethoscope
Dx
• Contrast-enhanced CT
**MRI with gadolinium - diagnostic**
• MRI angiography - **Lyre's sign**
• Serum catecholamines and urinary metanephrines and VMA
• **FNAC or biopsy should not be done**
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Lyres sign
Splaying of **External carotid artery** and **Internal carotid artery**
On MRI angiography
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Cystic hygroma
CYSTIC HYGROMA
""Lymphangioma" or "cavernous lymphangioma”
MC- posterior triangle of the neck
• Arises from obstruction or sequestration of jugular lymph sac
• **neonate, early infancy or childhood**
• MC seen in the supraclavicular region, axilla and groin
* May occur in the tongue and floor of mouth
• **Soft, cystic, multilocular, partially compressible and bilaterally transilluminant**
Presents as
• **Stridor, respiratory difficulty or feeding problems**
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Cystic hygroma Rx
• Surgical excision with preservation of neural and vascular structures
• Bipolar diathermy
• Aspiration or tracheostomy
174
Tubercular lymphadenopathy
• any age or sex
• single, multiple or matted LN
• Tubercular abscess may form
DIAGNOSIS
• FNAC or lymph node biopsy ( granulomatous lesion)
• Culture and sensitivity of AFB (acid fast bacillus)
• X-ray chest, skin test and work-up for other nodal group involvement
TREATMENT
• INITIAL 2 MONTHS COURSE OF FOUR DRUGS (RIFAMPICIN, ISONIARTD
PYRAZINAMIDE AND ETHAMBUTOL) FOLLOWED BY 4 MONTHS COURSE RIFAMPICIN AND ISONIAZID.
175
Cleft lip results from failure of fusion of two processes. What are the names of these process-es?
Maxillary process and median nasal process
176
Cleft lip due to?
Failure of fusion of palatine processes
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Aphthous ulcer
- **superficial small recurrent ulcers form on the mucosa of the oral cavity.**
Inner surface of the lips, buccal mucosa, floor of the mouth and soft palate are mostly involved.
- viral, psychogenic, vitamin deficiency, hormonal and autoimmune disorders.
- period of stress causes exacerbation.
- Size- pinhead to 2 to 3 cms.
- **sloughing base w hyperemia**
Rx- oral hygiene
Topical steroid
Local anaesthetic
Vits supplements
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Contributing Factors in Chronic Pharyngitis
• Heavy smoker.
• Excessive alcohol use.
• Postnasal dripping.
• Mouth breathing.
• Gums and teeth infections.
• Dry and dusty atmosphere.
• Industrial pollution. Allergy.
• Gastrooesophageal Reflux Disorder (GERD).
• Lowered resistance.
179
other name for gram + ve corynebacterium diphtheriae?
Klebs Loeffler's bacilli.
180
A 4-year-old girl came in ER and clinically suspected to be suffering from pharyngeal diphtheria. What complications can occur if diphtheria antitoxin is not given immediately?
myocarditis and muscle paralysis.
Due to releases of exotoxins
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Paul Bunnell test and Monospot test
These are serological tests for detection of antibodies against the virus. These tests are usually positive in the first week of the disease, although around 10% of the patients never develop a positive test.
182
Acute Tonsillitis types
1. Acute catarrhal or superficial tonsillitis: The infection is superficial involving only the covering mucous membrane and the infection is part of generalized pharyngitis
2. Acute follicular tonsillitis: The infection spreads into the tonsils, which are filled with infected fibrin and pus
This leads to the **characteristic spotted appearance** as opening of the crypts are filled with pus.
3. Acute parenchymatous tonsillitis: The infection spreads to the underlying lymphoid tissues and causes increase of the lymphoid follicles. The tonsils are enlarged uniformly.
4. Acute membranous tonsillitis: This is a more severe and advanced stage where the exudation from the crypts coalesces giving the appearance of a whitish yellow false membrane on the tonsil
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Acute tonsillitis Dx
Rx
clinical features :
•Sore throat.
• Difficulty or pain on swallowing.
•Fever.
• Bodyache, malaise, headache. Referred earache.
• Congested and enlarged tonsils and pillars.
• Pus in the crypts or over the tonsils.
• Palpable and tender jugulodigastric lymph nodes.
Rx
broad spectrum antibiotics immediately. antibiotics like **penicillin or erythromycin are the drug of choice** Analgesic
antipyretic like **paracetamol**
bed rest,
soft diet,
proper fluid intake
Antiseptic gargle
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Tonsillectomy indications
1. Recurrent tonsillitis: Tonsulectomy is indicated when there are **seven attacks in one year or five attacks in a year, for two consecutive years or three attacks in a year for three consecutive years.**
2. Chronic tonsillitis
3. Enlarged tonsils interfering with swallowing, respiration or speech.
4. Quinsy after 4-6 weeks
5. For biopsy
6. After pharyngeal diphtheria,
7. rheumatic fever, glomerulonephritis or endocarditis.
8. Tonsillar stones
185
Tonsillectomy procedure
under **general anesthesia** with nasal or oral endotracheal intubation.
supine with head extended by placing sand bag under the shoulder known as **Rose's position**
mouth is opened by a **Boyle Davis mouth gag** which is suspended by **Draffin's suspension rods.**
methods of tonsillectomy are by **dissection method and diathermy method'.**
The tonsil is grasped with tonsil holding forceps and pulled medially. An incision is made in the mucous membrane of the tonsil along the anterior pillar by a knife, scissors or diathermy.
Tonsil is separated from its bed by tonsillar dissector or by diathermy till the lower pole or the pedicle is reached
Pedicle can be cut by tonsillar snare, diathermy or scissors after applying
**Negus forceps** on its pedicle Tonsillar bed is checked for any bleeding and procedure is repeated on the other side.
Hemostasis in the tonsillar bed is achieved either by coagulation diathermy or tying with silk suture.
There are also other methods for removal of tonsils like, **harmonic scalpel, diode or CO, LASER, radiofrequency ablation, microdebrider and coblation tonsillectomy**
186
A 9-year-old girl suffered from tonsillitis and as a complication she developed swelling and pain in multiple joints. What is the most likely microorganism responsible for this condition?
beta hemolytic streptococcus.
187
Nerve present deep to tonsillar bed?
Glossopharyngea nerve
188
What is the typical location of the adenoids in normal people?
roof and posterior wall of the nasopharynx
