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Anatomy of larynx

Larynx
-Aka .voice box
-organ in the neck ,involved in breathing
-houses the vocal cord responsible
-located below level where tract(laryngopharynx) split into trachea and
oesophagus

Having 9 cartilage
3 paired
-arytenoid
-corniculate
-cuneiform

3 unpaired
-thyroid cartilage
-cricoid
-epiglottis

Muscle of larynx
Intrinsic muscle
-cricothyroid
-posterior crico
arytenoid
-lateral crico arytenoid
-transverse arytenoid
- oblique arytenoid
-thyroarytenoid

Extrinsic muscle
-thyrohyoid
-hyoglossus
-stylohyoid
-myloid
-geniohyoid
-digastric
-sternohyoid
-sternothyroid
-omohyoid

Innervation (by branches of vagus nerve one each side)


-recurrent laryngeal nerve
-superior laryngeal nerve ->external branches & internal branches
Disorder of larynx:
1.laryngitis-caused by smoking,frequent shouting
2.laryngomalacia-common in infant,soft immature cartilage collapse and
obstruct airway
3.Psebylarynx-atrophy tissue of larynx

Carcinoma of larynx
Male:female (10:1)
Age group:40-70 yrs
Etiology
-smoking and alcohol
-previous radiation of neck
-genetic
1.Supraglottic carcinoma
-common site:epiglottis,false cord,aryepiglottic folds
Spread through
a)local:tongue,pyriform fossa
b)nodes:upper middle cervical nodes
Symptoms:
-throat pain
-dysphagia
-weight loss
-respiratory obstruction
-halitosis

2.Glottic Carcinoma
-common in anterior middle 1/3 rd
on its free edge and upper surface
-spread through
a)local
-anterior commissure
-posterior to vocal process and
arythenoids
-upwards ventricle and false cords
-downwards subglottis
b)nodal involvment
symptoms:hoarsness of voice
and stridor

3.Subglottic carcinoma
-very rare
Spread through:
1.circumferential spread
-involve inner surface of subglottis wall
-involve to cricothyroid membrane and thyroid gland
2.pre and paratracheal
-lower deep cervical
-mediastinal lymph nodes
Symptoms:
-stridor and hoarsness of voice

Investigation
-chest x ray
-laryngogram
-CT scan
-laryngoscopy
Treatment:
-radiotherapy for early lesion
-surgery for late lesion

Pharynx

-a muscular tube,a patient of upper respiratory tract


-situates behind nose
3 parts:
-upper:nasopharynx (widest part,non collapsible)
-middle:oropharynx (narrow)
-lower:laryngophaynx (narrowest part,connected to GIT)
Length:12cm

Type
Situation
Nerve
supply
Lining
epithelium
Function

Nasopharynx
Behind nose
-pharyngeal
branches of
pterygopalatine
ganglion
Ciliated columnar

Oropharynx
Behind oral cavity
IX and X nerve

Laryngopharynx
Behind larynx
IX and X nerve

Stratified squamous
non keratinized

Respiration

Respiration and

Stratified
squamous non
keratinized
Food

food
Boundaries:
Superior:base of skull (post,patient of body of sphenoid+basilar patient of
occipital bone)
Interior:continuous with oesophagus at c6 level)
Lower border of cricoid cartilage
Posterior:pharynx glides freely on prevertebral fascia
Anterior:communicates with nasal cavity,oral cavity and larynx
On each side:
a)pharynx is attached to:
-medical pterygoid plate
-pterygomandibular raphe
-tongue
-thyroid and cricoid
b)communicate with middle ear cavity
-via auditory tube
c)pharynx related to
-styloid process and muscle

Oral Squamous cell carcinoma


1.Nasopharygeal carcinoma
-most common from pharynx
-common in asia Malaysia and china
-common in males
-arise from:
Nasal fossa
Posterior wall of oropharynx
Body of sphenoid
Basilar part of occipital bone
Soft palate
Sign and symptoms:
-cervical lymphadenopathy
-trismus
-otitis media
-pain
-nasal twang
Causes:
-infection of EB virus for type 2 and 3

-HPV for type one


Associated with
-petrosphenoidal syndrome
-retroparotid syndrome
Investigation:
-chest x ray,biopsy,MRI
Treatment
-surgery
-chemotherapy
Trotters triad
-conductive deafness
-homolateral immobility of soft palate
-pain in side of head

3.Carcinoma of lip

-Incidence 10-12%
-common in elderly
-sunlight->actinic rays>cheilitis->erythema->cracks>carcinoma in situ
-predisposing
2.Carcinoma of tongue
features:smoking,alcohol,geneti
-2nd most common oral cancer
c factors
-premalignant lesion:leukoplakia,erythroplakia
-common side:lateral border of tongue Clinical features:
-elderly males
Risk factor
-non healing ulcer
-tobacco,alcohol,betel nut
-mobility:fixed to subcutaneous
-fungal/viral infection
structures of lip
Clinical presentation:
Treatment:
-non healing/bleeding ulcer
-surgery
-ankyloglossia:restricted mobility of tongue
-radiotherapy
-disarticulation:speech disruption
-dysphagia
Clinical examination:
Inspection and palpation:
-ulcer bleed with central slough
-test for mobility of tongue
1.forward protusion-genioglossus
2.backward movement-styloglossus
3.elevation-palatoglossus

4.depression-hyoglossus
Lymphatic spread:
-apical vessel
-lateral vessel
-central vessel
-basal vessel
Investigation:
1.biopsy
2.OPG
Treatment:
-glossectomy
Complication:
-recurrent aspiration pneumonia
-ulcer and hemorrhage

Several aggregations of lymphoid tissue

-in relation to oropharngeal isthmus


-most important aggregation is right and left palatine tonsil
Palatine tonsil
-occupy tonsillar fossa
-almond shape
-2 shape:medial and lateral
-2 poles:upper and lower
-medial surface:intratonsillar cleft
-lateral surface:cover by sheet of fascia

Dysphagia
1.congenital
-stenosis of esophagus
-tracheo esophagus fistula
-congenital web
2.Acquired
Causes within esophageal lumen (intraluminal)
-foreign body
Causes in esophageal wall (intramural)
-diverticulum
-achalasia cardia
-carcinoma
Causes outside esophageal (extramural)
-thyroid swelling
-mediastinal nodes
-mediastinal abscess
-aortic aneurysm
Painful disease of mouth and pharynx
-stomatitis
-tonsilitis
-pharyngitis
-retropharyngeal abscess

Neuromuscular disorder
-myasthenia gravis
Miscellaneous
-tetanus
-sjogren
-rabies

Zenkers diverticulum
-pouch/sac that is created by a herniation of a muscle wall
-pouches develop in pharynx,just above upper esophageal sphincter
When there is excessive pressure within the lower pharynx,the weakest
portion of pharyngeal wall balloons out,forming a diverticulum

Symptoms:
-dysphagia
-regurgitation of undigested food

-coughing after eating


-bad breath
-aspiration of food and liquid in airways
Diagnosis:barium swallow
-endoscopy
Treatment:
If small and asymptomatic:no treatment
If large and symptomatic:surgery to resect diverticulum
New line of oral anticoagulants:
1.dabigation-direct thrombin inhibitors
-alternative to warfarin
2.rivaroxaban-direct factor Xa inhibitor

Achalasia cardia

-primary esophageal motility disorder


-spasm of left esophageal sphincter

Etiology
-idiopathic
-absence or degeneration of auerbachs plexus
-chagas disease:organism destroy ganglion cells
Clinical features:
-woman:30-40 yrs
-dysphagia:solid(gravity),liquids(regurgitation)
-recurrent respiratory tract infection;due to spillage of liquids
-anemia:glossitis,stomatitis,pallor bald tongue
-retrosternal discomfort
Investigation:
-barium swallow

-plain x ray abdomen


Treatment:
-hellers cardiomyotomy
-forceful dilation with pneumatic balloon
Complication:carcinoma

GERD (reflux esophagitis)


-occasional episodes of gastro-esophageal reflux
-reflux is followed by esophageal peristalsis wave
-occurs when esophageal mucosa is exposed to gastroduodenal content for
prolonged period of time

Barretts esophagus
Def:when columnar mucosa extends at least 3cm into esophagus and shows
intestinal metaplasia
Pathogenesis
1.repeated reflux
2.shifting of esophago-gastric junction upwards
3.further increase reflux
4.intestinal metaplasia of lower and middle esophagus
Risk factors
-columnar lined esophagus >8cm
-smoking
-reflux due to previous gastric surgery
-high grade dysplasia
Treatment:
-laser photodynamic therapy
-argon beam plasma coagulation