OtoRhinoLaryngology Portal

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The Oral Cavity & Oropharynx of An Adult

                          At rest                                At rest with the tongue depressed

             Upon phonating "AAA"                            Upon phonating "EEE"

 

The Anatomy of Floor of Mouth & The Tongue

[Arrow- Wharton's duct opening, 1- phrenulum,

V- lingual vein, dashed-circle- sublingual gland].

Arrow -Wharton's duct opening

Anterior/Base of Tongue Junction

Star denotes circumvallate papilla which runs over V-shaped outline with its apex

located at the obliterated foramen caecum.  It divides the base of tongue (posteriory) from its anterior part.

The Palate

SP- soft palate, HP- hard palate, arrow- surface marking of incisive foramen,

white dots- surface marking or greater and lesser palatine foramina. Note the corrugated surface of deeply adherent mucoperiosteum of hard palate

mucosa anteriorly.

Hard/Soft Palate Junction

HP- hard palate, SP- soft palate, A- alveolus,

yellow line- junction of hard/soft palate

 

A clearly demarcated junction in a patient who has trismus due to

bucco-alveolar sulcus abcess.  The hard palated appeared keratinized

and the tongue surface coated.  Small ulcer is seen (arrow)

Minor Salivary Glands over Palatal Mucosa

This figure shows the saliva secreted from minor salivary glands

of the palatal mucosa (yellow arrows).

[HP- hard palate, SP- soft palate, U- uvula, T- tonsil, blue line- junction of hard/soft palate]

Oral Thrush

Oropharyngeal thrush.

Diffuse oral thrush involving the palate and oropharynx.

Soft Palate Dysplasia

Figure shows mucosal appearance of soft palate in a histologically-confirmed dysplasia.  Intervening border beween nornal (anteriorly) and affected area (posteriorly) is clearly seen.

 

Soft Palate Mass/Tumour

Stensen's Duct Opening

The appearance of Stensen's duct opening on inner aspect of buccal mucosa (right side in this figure).

Oral Abscess- [Buccoalveolar Sulcus]

 

Figure shows anabcsess involving left upper buccoalveolar sulcus.

Erythroplakia- A Premalignant Mucosal Lesion

ML- upper molar tooth, T- tongue, star- erythroplakia lesion,

arrows- intervening leukoplakia border.

Tongue Tie (Ankyloglossia)- [Untreated]

Geographical Tongue

Hairy/Thickened Tongue  

This can occur secondary to poor oral hygiene, chronic heavy smoking,

and in betel quid consumption.  Fungal infection need to be considered.

Staining of filiform papillae after prolonged betel leaf chewing.  This leaf is usually taken together with aracea nut and mixed with mineral slaked lime (calcium hydroxide).  It also predisposes to submucous fibrosis

and dysplastic changes in the oral cavity.

Fibroma of Tongue Tip

Traumatic Tongue Ulcer

This elderly lady presented with left lateral border ulcer and granuloma formation.  Biopsy was negative for malignacy or dysplastic changes.  The culprit was the second molar tooth whic had caused recurrent traumatic abrasion most likely as a consequent of alveolar resorption which occurs with ageing process.

Mucositis

        

Inflammation of mucous membranes of oral cavity in a patient undegoing oncologic treatment of head and neck cancer is a common phenomena.  Oral disinfective rinse/gargle, pain relief, and attention to hydration and nutrition are essential during this acute phase which will slowly recover with time.

Ranula

Submandibular Duct Calculi with Floor of Mouth Cellulitis

The  majority of submandibular salivary gland calculi are radiopaque and visible on X-ray.  This patient has inflamed and swollen left floor of mouth with pus emanating from the Wharton's duct.  Intraocclusal view showed at least 2 radiopaque stones with the bigger one situated more anteriorly. 

Submandibular Triangle Anatomy During Supraomohyoid Neck Dissection

Pointer- lingual nerve, M- myelohyoid muscle, D- digastric muscle,

SM- submandibular gland being reflected downward, H- towards head, T- towards thorax, ML- medial, L- lateral, interrupted yellow line- lower border of mandible.

The Oropharynx & Base of Tongue

Tonsillar Cyst

Tonsillar Crypts

 

This image shows prominent tonsillar crypts of the left tonsil (arrows).

Tonsillar Crypts and Cleft

 

Yellow arrows- cypts, blue arrow- cleft

Tonsillar Cleft and Retained Impissated Material

Tonsillar crypts and clefts predispose to several conditions like peritonsillar abscess, retained food residues, and tonsillolith formations.  Halitosis and

unusual tonsillar appearance are the usual presenting symptoms though it can be asymptomatic and found by chance on examination. Oropharyngeal endoscopic assessment, probing with blunt instrument, and digital palpation need to be done.  Figure shows cheesy-white materials in the supratonsillar cleft due to food residue/epithelial sloughs entrapment.  Beware of the underlying dysplasia/malignancy and if in doubt examination under anaesthesia

with/without excision biopsy (tonsillectomy)

will have to be performed.

Foreign Body (Fish Bone) in Tonsillar Cleft

Acute Pharyngitis

Scattered Lymphoid Hyperplasia on Posterior Pharyngeal Wall

Aphthous Stomatitis

This figure shows a small shallow ulcer with overlying

fibrinous exudate involving right palatoglossal fold.

Multiple larger size ulcers.

Tonsillar Ulcer

This figure shows an ulcer over the inferior pole of right tonsil

after an alleged injury caused by chicken bone fragment.

Acute Exudative Tonsillitis

This image shows thick membranous exudate involving both tonsils in acute tonsillitis.  Severe odynophagia with poor oral intake warrants hospital admission with intravenous fluid and antibiotics therapy given.

Peritonsillar Abscess

Peritonsillar abscess is a collection of pus beyond the capsule of the tonsil.  Clinically, mucosal inflammation with swelling will be noted and the tonsils itself is pushed medially and the uvula can be seen off midline to the opposite site.  Figure shows left peritonsillar abscess and the red dot point to the drainage spot for diagnostic aspiration/drainage.

Parapharyngeal Mass [Pleomorphic Adenoma of Parotid]

Figure shows an extrinsic mass which had caused medial and downward bulge of the soft palate and pushing the right tonsil towards midline.  The adjacent figure shows the excised specimen- a firm multibosselated pleomorphic adenoma.

Haemangioma of Tonsillar Fossa

Unilateral Tonsillar Hypertrophy with Cervical Lymphadenopathy

Squamous Cell Carcinoma of Tonsil

                          

             Ulcero-fungating carcinoma involving right tonsil and its pillars. 

                     [Circle- carcinoma lesion, U- uvula, SP- soft palate]

Solid tumour presenting as an asymmetric left tonsillar enlargement.

Lingual Tonsillitis

Figure shows a resolving lingual tonsillitis (circles).

It presents with sorethroat and pain upon swallowing.

Venous Dilatation of Tongue Base

Base of Tongue Mass

                       Haemangioma                            Squamous cell carcinoma

                            

                              Midline mass with intact mucosal covering.

The Valleculae

V- vallecula, blue dots- median glossoepiglottic fold

Glossoepiglottic Folds

Yellow line- median glossoepiglottic fold, red arrows- lateral glossopeiglottic folds.

Vallecula Cyst

Epiglottis-Related Cyst

 

View on outpatient endoscopic assessment

of a cyst originating from its lingual surface.

 

Cyst arising along left pharyngoepiglottic fold.

Direct laryngoscopy view showing pedicle attachment

of an aryepiglottic cyst prior to its excision.

 

Video showing mucoid milky content of a cyst.

Uncapping of the cyst wall was then perfomed along its perimeter to allow

re-epitelization from the normal surrounding mucosa

while minimizing risk of recurrence.

Grading of Tonsillar Hypertrophy (after L. Brodsky)

 

 

Tonsillectomy: Intra-operative View

 

Boyle-Davis mouth gag

 

Before Surgery                                      After Surgery

                                                                        [By Using Cold Instruments]

Tonsillectomy by Using Coblator Device

Tonsillar Bed Post-Tonsillectomy

Sloughs formation in the tonsillar bed is a normal phenomena after tonsillectomy. 

As normal healing occurs, this will be replaced by normal epithelium

usually within 1-2 weeks.   

Healed Tonsillar Fossa Appearance Post-Tonsillectomy for OSA

This image shows the appearance of tonsillar fossa

after tonsillectomy performed for obstructive sleep apnoea (OSA).

Adenoidectomy Techniques

       

                       Adenoid curette                                        Microdebrider

Adenoidectomy: Intra-operative View

Before Surgery 

               After Surgery 

Torus Palatinus

Elongated Uvula

Elongated uvula can be associated with habitual snoring and OSA

as well as potential cause of unexplained throat irritation and coughs. 

Incidental finding in aymptomatic individual is common.

Cleft Palate

Cleft palate causes difficulty in feeding, nasal regurgitations, and hyponasality.  It predisposes to eustachian tube dysfunction with formation of "glue" ear for which

insertion of a ventilation tube being commonly indicated.

The nasopharyx in a patient with cleft soft palate.

Pedunculated Papilloma of The Uvula

Papilloma of Soft Palate

The Midline Raphe

Midline mucosal fold which corresponds to the underlying midline raphe

where the constrictor muscles from either sides meet.

The Pharyngeal Constrictors

Figure shows the occasionally seen demarcation between superior

and middle pharyngeal constrictor muscle groups (white dots).

The Pyriform Fossae Views as Seen by Using a Flexible Endoscope

      During spontaneous breathing                           Upon phonation

Upon forceful nose blowing with the mouth closed

The Pyriform Fossae Views as Seen by Using 70 Degree Rigid Endoscope

The Pyriform Fossa: Visible Neurovascular Bundles Traversing Thyrohyoid Membrane

Sinus Opening in Branchial Arch Anomaly

Figure shows an internal sinus opening (arrow) in branchial arch anomaly.

Anomaly of TheSuperior Cornu of Thyroid Cartilage

These figures show anteromedial projection of right superior thyroid cartilage cornua (circle).  It can be associated with foreign body sensation or globus. 

This finding is mostly incidental and it rarely cause significant symptom. 

Similar lesion may also be seen following laryngeal trauma.

The Post-cricoid

The post-cricoid region is one of the subsite of hypopharynx.  It not visualized upon indirect or rigid laryngoscopy examination as it is kept close by tonic contraction by the upper oesophageal sphincture which only opens upon second stage of swallowing. 

The hypopharynx leading to upper       Occasionally brisk opening seen opon

         oesopageal sphincter.                      laryngeal examinarion (arrow).         

 

         Spontaneous upper oesophageal                  Upper osophageal opening

           sphincter opening- a rare view.                  upon rigid oesophagoscopy.     

Pooling of Saliva in Hypopharynx

Figure shows cumulation of saliva in the hypopharynx caused by pseudobulbar palsy.  Dysphagia, dysphonia, and aspiration are the main issues that need wholesome management.

Nasogastric Tube In-Situ: Hypopharyngeal View

Cervical Osteophytes

Retropharyngeal Mass

Facial Nerve Paralysis/Paresis- House-Brackmann Scale

Grade I   

Normal symmetrical function in all areas

Grade II  

Slight weakness noticeable only on close inspection
Complete eye closure with minimal effort
Slight asymmetry of smile with maximal effort
Synkinesis barely noticeable, contracture, or spasm absent

Grade III 

Obvious weakness, but not disfiguring

May not be able to lift eyebrow

Complete eye closure and strong but asymmetrical mouth movement with maximal effort

Obvious, but not disfiguring synkinesis, mass movement or spasm

Grade IV 

Obvious, but not disfiguring synkinesis, mass movement or spasm

Grade V 

Obvious disfiguring weakness
Inability to lift brow
Incomplete eye closure and asymmetry of mouth with maximal effort
Severe synkinesis, mass movement, spasm

Grade VI 

No movement, loss of tone, no synkinesis, contracture, or spasm

House, J.W. and Brackmann, D.E. (1985) Facial nerve grading       system. Otolaryngol. Head Neck Surg., 93, 142-147

 

 

Facial Nerve Palsy (right)-Grade VI House-Brackmann Scale

 

At rest 

On maximal eye closure

Bell's Sign in Lower Motor Neurone Facial Nerve Palsy

 

The eyeball on the affected side turn up when the patient 

attempts to close the eyelid (right side in this figure).

Intraoperative Facial Nerve Monitoring

The Facial Nerve: Intraoperative View

 

 T- Parotid tumour, P- pinna lobule, S- sternomastoid muscle.

Arrow- tragal pointer.

Facial nerve stimulator tip is pointing to the main trunk of right facial nerve as it exits the stylomastoid foramen

 

.

The main branches of left facial nerve. 

White arrow- main trunk, Blue arrow- upper trunk, Green arrow- lower trunk,

T- parotid tumour

 

Figure shows facial nerve course in relation to posterior belly of digastric.

The superficial lobe still attached and retracted inferiorly. [SP- sternomastoid muscle, M- masseter muscle, SP- superficial lobe of parotid gland, L- lobule of left ear, yellow arrow- posterior belly of digastric tendon, green arrow- intraparotid veins, black arrow- main trunk of facial nerve before its branches]

The full extracranial branches of right facial nerve after total conservative parotidectomy. 

Yellow rubber retracting the main trunk of facial nere. 

Angle of mandible (M) and preserved intraparotid vein were seen clearly. 

 

An intraparotid lymph node [circle] occasionally seen and need to be sent for histopathological diagnosis. 

N- neck, H- head, sm- sternomastoid muscle,

green arrow- tragal pointer,blue arrows- main brainches of facial nerve.

Neck Lump

The probable aetiologies of a neck lump in this area includes lymph nodes enlargement, branchial cyst, and parotid mass.  CT-scan and FNAC are usually carried out prior to its surgical intervention.

Swelling caused by benign parotid tumour.

Thyroid Isthmus Mass

Thyroid isthmus mass(circle). Yellow dots- sternal ends of clavicles.

Thyroid Movements Upon Swallowing

 

  Thyroid swelling characteristically

moves up upon swallowing.

Grave's Opthalmopathy

Significant proptosis and conjunctival chemosis

The Recurent Laryngeal Nerve after Thyroidectomy

Endotracheal Tube for the Purpose of Intraoperative Laryngeal Nerve Monitoring during Thyroidectomy

The Recurent Laryngeal Nerve Anatomical Relations During Total Laryngectomy

                   

  H- head, T- thorax, S- sternomastoid, CA- common carotid artery, T- trachea, E-           oesophagus, TH- thyroid gland, arrow- recurrent laryngeal nerve.

Views during Müller Manouevre for OSA Evaluation

 

SP- soft palate, PW- posterior pharyngeal wall,

T- tonsils, BOT- base of tongue, L- Larynx

 

Suggested reading:

Johns MW. A new method for masuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.

Surgery for OSA: Modified CAPSO

Palatal & oropharynx view before surgery.

   Quadrangular mid-soft palate partial               Palatal & oropharynx view 

    mucosal and soft tissue excision.                  at completion of surgery.

Healed post-operative view of palate showing scar line

and widened nasopharyngeal opening.

SP- soft palate, PW- posterior pharyngeal wall, stars- scar line.

 

Suggested reading:

Pang KP, Terris DJ. Modified cautery-assisted palatal stiffening operation: new method for treating snoring and mild obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007 May;136(5):823-6.

Kaluskar Foreign Body Removal Forceps

 

The widely used forceps for the purpose of foreign body removal in the oropharynx, especially at the tongue base and vallecula areas. Suited for linear or slim foreign objects.  Slender tip, serrated, with sideway movements.  Blackened/ebonized to reduce reflections from lights use and differentiate better with the surrounding mucosa and foreign material.  Alternatively, other angled instruments

like Negus tonsil artery forceps can be use.

 

Submucosal Fish Bone Impaction Into Lingual Tonsil

Cricoid Cartilage Calcifications

 

Cricoid and thyroid cartilages undergo calcification as the age increases.  It significance occurs in traumatic injury to the larynx and in cases of foreign body impaction in the upper oesophagust.  The former can result in fractures and in the latter it may be mistaken with a radiopaque foreign body.  This soft tissue X-ray of the neck show calcifications primarily involving the cricoid cartilage.

Foreign Body in The Upper Oesophagus

Figure shows a radiopaque foreign body in the post-cricoid/upper oesophageal segment.  [Red arrow- vertebral body, Green arrow- vertebral body + prevertebral soft tissue swelling, circle- impacted foreign body, inset image- the recovered foreign body]

Laryngeal Oedema in Upper Oesophageal Foreign Body Impaction

Intraluminal View of Oesophagus in Foreign Body Impaction:Meat Bolus

  Impacted meat bolus with surrounding             Submucosal haematoma.

     oedema and muscular spasm. 

 

Intraluminal View of Oesophagus in Foreign Body Impaction:Coin

Barium Swallow- The Pharyngeal and Upper Oesophageal Phases

These images show the normal barium swallow appearance 

during pharyngeal and upper oesophageal phases of swallowing

in a patient presented with dysphagia.

Barium Swallow: Extrinsic Compression by Cervical Osteophytes

3D Reconstructed CT-scan of The Skull

3D Reconstructed CT-scan of Cervical Spine

Head & Neck Arterial Supply on MRA