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Examination Of Oral Cavity, Oropharynx, Larynx and Neck

(1 ) ORAL CAVITY:

Includes: Lips-buccal mucosa-Gums and teeth-Hard palate-Ant 2/3 tongue-Floor of mouth-retro molar trigone.

SYMPTOMATOLOGY:

  • Pain /referred pain
  • Salivation: Dryness/ excessive salivation
  • Disturbance of taste sensation
  • Difficulty in opening mouth
  • Bleeding from gums
  • Red painful gums
  • Sore tongue
  • Recurrent painful lip and oral ulcers
  • Small clusters of vesicles
  • Fissures over lips and angle of mouth
  • Ill-fitting dentures
  • Foul breath

EXAMINATION OF ORAL CAVITY:

LIPS:

  • Moisture /color /lumps /ulcers /cracking / scaliness
  • Swelling/ulcers/vesicles/crusts/scaly/redness/nodular lesion/Chancre
  • Hemorrhagic red multiple spots over lips and oral mucosa
  • Bluish pigmented spots over lips and oral mucosa.
  • Unilateral / bilateral cleft lips
  • Angioedema lips: Diffuse-nonpitting-tense swelling-non-itching

ORAL mucosa:
Alveolar mucosa /labial mucosa / buccal mucosa /mucosa over hard and soft palate

  • Change in color
  • Vesicles /bullae
  • White striae
  • Submucosal fibrosis (Blanched appearance with sub mucosal scars)
  • Leukoplakia –Persistent painless thickened white patches
  • Erythroplakia
  • Bluish pigmentation
  • Atrophic changes in mucosa
  • Reddish swollen Stensen’s ductal papilla
  • Aphthous ulcers
  • White patches and nodules
  • Koplik’s spots: small white speks with red back ground
  • Fordyce spots-small yellowish spots/granules
  • Petechiae-small red spots

Gums and teeth:
Teeth/gingiva/Gingival margins/ alveolar mucosa/intedental papillae/gingival sulcus

  • Toothache
  • Loose tooth
  • Impaction
  • Dental caries
  • Artificial dentures
  • Missing tooth
  • Redness of gingiva
  • Swollen interdental papillae
  • Gum bleeding
  • Gingival (Gum) hyperplasia-swollen heaped up masses (dilantin, pheno, pregnancy, leukemia)
  •  Bluish black lining of gums (lead line)
  • Swelling and ulceration of gingival (gum) margins and interdental papillae

Roof of the mouth: Hard palate

  • Cleft palate
  • High arch
  • Oronasal / oroantral fistula
  • Bulging
  • Bony growth
  • Torus palatinus: a mid line mass
  • Ulcers
  • Oral thrush (thick white plaques) –candidiasis
  • Deep purple color lesions –Kaposi’s Sarcoma

Tongue Anterior 2/3:tip / dorsum / lateral borders / under surface

  • Ulcers: Chronic non healing / pain full: yes /No
  • Persistent ulcers or nodule: white  / red
  • Indurations: yes  / no
  • Fissures / nodules
  • Hairy tongue
  • Geographic tongue: Scattered smooth red areas denuded of papillae.
  • Smooth tongue (Atrophic glossitis - Bald tongue) -absent papillae- Vitamin deficiency/anti cancer drugs
  • Hairy Leukoplakia: feathery, corrugated pattern-in HIV/AIDS
  • Macroglossia
  • Haemangioma / Lymphangioma
  • Edema / Abscess
  • Deviation on protrusion; Yes  / No

Floor of the mouth:

  • Short frenulum –Ankyloglossia
  • Aphthous ulcers: Painful, small oval or round ulcers-white or yellowish grey with reddened halo.
  • Ranula / Sublingual dermoid / Ludwig’s angina
  • Wharton’s duct:
  • Bimanual palpation

Retro molar trigone:

  • Impacted last molar 
  • Tumour lesion

(2). OROPHARYNX:
Includes: Tonsils and pillars-Soft palate-Base of tongue-posterior pharyngeal wall.

SYMPTOMATOLOGY:

  • Sore throat
  • Painful swallowing
  • Fever
  • Difficulty in swallowing
  • Neck stiffness
  • Change in voice: Hypernasality
  • Muffled or hot potato voice
  • Referred ear pain.
  • Snoring
  • Halitosis
  • Hard of hearing

  EXAMINATION OF OROPHARYNX:

1.Tonsils and pillars:

  • Hypertrophied -Obstructive
  • Small and embedded
  • Large normal tonsils
  • Crypts: White and yellow spots (follicular tonsillitis
  • Membranes
  • Ulceration over tonsils
  • Mass over tonsils
  • Pus on squeezing
  • Exudates over tonsils
  • Palpation: Hard /pulsation, tenderness in tonsillar area /elongated styloid process.
  • Pillars: Congestion
  • Congestion: Pillars  / posterior pharyngeal wall /tonsils

Movement of soft palate:

  • Soft palate movement on- ah /yawn
  • Asymmetrical: Deviation – Right  /Left
  • Gag reflex: yes  / No
  • Soft palate: Bulging  / Redness   / tenderness
  • Bifid uvula
  • Nasal regurgitation

Posterior pharyngeal wall:

  • Reddened throat with exudates
  • Gray exudates (pseudomembrane) over Uvula  / Phx  / tongue
  • Granular pharyngitis
  • Purulent discharge

Base of tongue and Valleculae:
On IL mirror:

  • Normal /congested mucosa.
    •  
      • Mass- solid / cystic

Palpation of tongue base:

(3) LARYNX:

SYMPTOMATOLOGY:

Hoarseness:

  • Duration
  • Sudden/gradually worsening
  • Association with Dysphagia / Dyspnoea /Strider
  • Diurnal variation
  • Vocal abuse
  • Fatigability
  • Chronic rhino nasal allergy: Yes  / No
  • History of Asthma: yes / No
  • On topical steroids: Yes  / No
  • Smoking Duration:
  • History Hypothyroidism: yes  / No
  • Loudness
  • Pitch
  • Tone
  • Preceding /associated RTI

Quality of voice:

  • Hoarseness
  • Breathy
  • Husky voice
  • Week cry
  • Bitonal
  • Dysphonic /spasmodic
  • Whispered or feeble
  • Aphonia
  • Puberphonia
  • Strider
  • Aspiration: Episodes of cough on oral feeds
  • Easy fatigability of voice
  • Breathing difficulty: sudden /gradual
  • Stridor (Noisy breathing): acute /gradual
  • Cough and expectorant: Clear/blood stained/purulent/foul smelling fever/Dry cough
  • Irritant paroxysmal cough: yes /no
  • Dysphagia: sudden  / Gradual
  • FB history: Fish bone  / chicken or mutton bone / Coin /seeds
  • Throat pain: Duration –

                             Acute or chronic
                             Radiation of pain: yes  / no

  • Difficulty in swallowing: For solids   or liquids /Duration: acute or chronic
  • Fever: high /mild /decreased appetite
  • Weight loss
  • FB sensation in throat (hawking)
  • Snoring
  • Mass in the neck: yes /No

 

PERSONAL HISTORY:

  • Smoking
  • Alcohol
  • Spicy food
  • Tobacco chewing /Pan
  • Radiation exposure

Profession:

  • Teacher
  • Singer

EXAMINATION OF LARYNX:

  •  
    •  
      •  
        • External examination
        • Indirect laryngoscopy
        • Flexible or rigid fibre optic endosscopy
        • Assessment of voice
        • Assessment of cervical lymph nodes.
        • Asses of neck mass

INDIRECT LARYNGOSCOPY:
1.Oropharynx:

 
  • Base of tongue: Solid or cystic mass /Ulcer
  • Lingual tonsils
  • Valleculae
  • Median and lateral 
  • Glossoepiglottic folds

2.Larynx-Epiglottis:

  • Ary epiglottic folds
  • Arytenoids-corniculate-cunieform
  • Ventricular bands-ventricles
  • True vocal folds: Oedema
  • Position of vocal cord: Median /Para median /Moderated abduction/full abduction
  • Vocal cord movement: Normal
  • Nodules: single / multiple
  • Laryngeal: Polyp  / ulceration / submucosal hemorrhage
  • Anterior and posterior commissure
  • Sub glottis: stenosis/web
  • Tracheal rings

3.Laryngopharynx-

  • Pyriform fossae: mass lesion/pooling saliva /FB
  • Post cricoid region
  • Posterior wall of laryngopharynx

4.Assesment of voice:

5.Neurological assessment:

External examination of larynx:

        Skin:

 

  • Redness
  • Swelling  / tenderness
  • Widening of laryngeal frame work
  • Surgical emphysema /Soft tissue swelling
  • Movement of larynx: With deglutition / side to side
  • Laryngeal crepitus:  Present               absent
  • Carotid pulsation

EXAMINATION OF NECK:
Lymph nodes / Neck mass:
Memorial Sloan Kettering LN levels:
(1)-Upper Horizontal Chain Of Lymph Nodes:

  • Sub mental and submandibular-Level I
  • Submandibular
  • Parotid
  • Post auricular
  • Occipital
  • Facial

(2)-Lateral cervical nodes:
Deep group:

  • Internal jugular group
  •  
    • Upper
    • Middle
    • Lower
    Levels II, III &IV
  • Spinal accessory chain
  • Transverse cervical chain
Level V
  • Prelaryngeal
  • Pretracheal
  • Para tracheal
Level VI (juxtavisceral chain)
  • Mediastinal nodes: Level VII
  • Lymph nodes:

    • Lymph node enlargement: Acute /Chronic
    • Tender: Yes/No
    • Hard  / firm  / rubbery  /soft  / Discrete   / Matted /tenderness
    • Size
    • Shape
    • Mobility in both (side to side and up and down) direction:  yes  / No
    • Fixity to skin
    • Fixity to muscle / Bone

    Trachea and thyroid gland

    • Tracheal deviation: Mass effect-mediastinal mass, atelectasis or large pneumothorax
    • Thyroid gland: Moving with deglutition
    • Size
    • Shape
    • Consistency: Firm /hard /soft
    • Fixity: skin /muscle/bone
    • Nodules / tenderness /Bruit over the gland
    • Carotid artery pulsation: present  / absent. 

    INVESTIGATIONS:
    1.Flexible fibre optic endoscopy (rhinolaryngoscopy):

    2.Direct laryngoscopy:

    For glottic cancers:

    • Size
    • Site
    • Extent
    • Exophytic
    • Deep infiltration
    • VC mobility
    • Involvement of anterior commisure
    • Spread to vocal process
    • Supraglottic   / subglottic spread
    • Ventricle checked
    • Paraglottic space
    • Hypopharynx
    • Neck mass /lymph node

    Laryngoscopy for supraglottic cancers:

    • Size
    • Site
    • Extent
    • Extension to vallecula  /pre glottic space: Involved /No
    • Tongue base involvement: Involved /No
    • Extension to lateral pharyngeal wall: Involved /No
    • Medial wall of pyriform sinus: Involved /No
    • Vocal cord mobility: Yes /No
    • Paraglottic space: Involved /No
    • Hypopharynx: Involved /No
    • Neck mass: yes  /No

    Laryngoscopy for subglottic tumours:

    • Size
    • Site
    • Extent
    • Vocal cord mobility: Yes  / No
    • Paraglottic space; Involved / No
    • Oesophagus  / posterior tracheal wall: involved /No
    • Neck mass: present / No

    3.Videostroboscopy

  • Fundamental frequency
  • Bilateral symmetry
  • Periodicity of successive vibrations
  • Glottic closure
  • Amplitude of vibration
  • Mucosal wave
  • Non-vibration portion
  •  
     
    Otology Master Class
    From the Organizing desk

    Dear friends,

    MESIARC CME is here again. We have always strived to bring you the best in Otology, over the past 10 years, Our live surgery workshops, have focused on cutting edge surgery, detailed teaching, scientific deliberations of the highest order and top class video coverage from one of the most advanced otological theatre suites in the world this time, we are focusing on the enigma of budding otologists - cholesteatoma and Otosclerosis. Two very diverse conditions, but requiring surgical expertise of the highest order to deliver good results. The two-day surgical workshops will feature both myself and a luminary in Otology, Dr. Ashesh Bhumker from Thane, Mumbai and we would be demonstrating in detail the finer aspects of surgical techniques that can be adapted by a keen otologist to sustain good results over time.

    We have lined up an array of diverse cases- and the techniques that we intend to demonstrate include minimal access stapedotomy, Laser stapes surgery, stapes surgery with stapes head amputation for tendon preservation, bone obliteration technique for cholesteatoma, a variety of grafting techniques, intact canal wall tympanoplasty for limited cholesteatoma and a series of revision surgeries.

    Do send in your registrations early as we have to limit attendance to 70 seats. A smaller crowd is ideal for active discussions which is something so characteristic of MESIARC CME programs and we do not want to deviate from that agenda.


    Yours truly,

    Manoj MP  
    Organizing chairman

    Otology in Perspective Live Surgery 2015
    From the Organizing desk

    Mesiarc brings you a unique live surgical workshop- a demonstration of both endoscopic and microscopic otologic skills.

    Otologic surgery is special for its intricate anatomy, extreme precision and attention to detail. Traditionally done with the operating microscope, and now in some centers across the world with the endoscope, the repetoire of the art is widening.

    Confusion persists. Advocates of endoscopic work claim that the microscope is passe, and traditional surgeons laugh off the ability of the one handed

    The truth lies somewhere in between; there are specific conditions that require either of both of the techniques. Dogmatism, they say, is the end of science.

    Mesiarc brings you a unique live surgical workshop- a demonstration of both endoscopic and microscopic otologic skills.

    MESIARC has always stood for dissipation of knowledge and the live surgical workshops are not pubilicity events, nor are they grandiose. We have just one agenda- to educate.

    This workshop with a difference aims to demonstrate both endoscopic and microsopic skills in otologic surgery, while attempting to define which is more suitable for what. Do come and enjoy!


    Yours truly,

    Manoj MP  
    Organizing chairman

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