Kj Lee 10Th Ed - Chapter 21 - The Oral Cavity, Pharynx, And Esophagus

Front 1

What are the boundaries of the oral cavity?

Back 1

Vermilion border to jnct of hard & soft palate and circumvallate papillae (linea terminalis)

Front 2

What are the subunits of the oral cavity? Name all seven.

Back 2

Lip
Buccal mucosa
Upper and lower alveolar ridges
Retromolar trigones
Oral tongue (anterior to circumvallate papillae)
Hard palate
Floor of mouth

Front 3

What are the boundaries of the oropharynx?

Back 3

From jnct of hard & soft palate and circumvallate papillae to valleculae (plane of hyoid bone)

Front 4

What are the subunits of the oropharynx?

Back 4

Soft palate & uvula
Base of tongue
Pharyngoepiglottic and glossoepiglottic folds
Palatine arch (including tonsillar fossae with palatine tonsils and pillars)
Valleculae
Lateral & posterior oropharyngeal walls

Front 5

What are the boundaries of the hypopharynx?

Back 5

From level of hyoid bone (pharyngoepiglottic folds) to level of inferior border of cricoid cartilage

Front 6

What are the subunits of the hypopharynx?

Back 6

Pyriform sinus (laryngopharyngeal sulcus) - bordered by aryepiglottic folds medially and thyroid cartilage anteriorly with its apex at the level of the cricoid cartilage
Posterior and lateral pharyngeal walls (lateral merges with lateral wall of pyriform sinus)
Postcricoid region (inferior to arytenoids, extends to inferior margin of cricoid cartilage, and is contiguous with medial walls of pyriform sinuses)

Front 7

What are the boundaries of the esophagus?

Back 7

From cricoid cartilage to cardia of stomach

Front 8

What are the subunits of the esophagus?

Back 8

UES
Body (cervical-thoracic-intra-abdominal)
LES

Front 9

What are the distances from the incisors to
1) cricopharyngeal sphincter
2) stomach

Back 9

Incisors to cricopharyngeal spincter - 16cm (in adults)

Incisors to stomach - 38-40 cm (in adults)

Front 10

What's the name of the duct emerging from the sublingual gland?

Back 10

Rivinus's duct (empty near the junction of the tongue and the mouth's floor)

Front 11

How many deciduoud teeth and adult teeth are there?

Back 11

Deciduous teeth - 20

Adult teeth - 32

Front 12

What are the names of the four papillae of the tongue?

Back 12

Filiform (no taste fnct)
Fungiform (diffuse)
Foliate (lateral tongue)
Circumvallate (lie in a V-shape at jnct of ant-post tongue)

Front 13

Which pharynx are the lingual tonsils considered to be in?

What's the blood supply to the lingual tonsils?

Back 13

Oropharynx

Lingual artery & vein

Front 14

What are the extrinsic muscles of the tongue?

Which nerve innervates them?

Back 14

Genioglossus
Hyoglossus
Styloglossus
Palatoglossus

CN XII

Front 15

What are the intrinsic muscles of the tongue?

Which nerve innervates them?

Back 15

Superior longitudinal
Inferior longitudinal
Vertical
Transvese

CN XII

Front 16

What nerve innervates the anterior 2/3rd of tongue?

How about taste to anterior 2/3rd?

Back 16

Lingual nerve (V3) - touch, pain, temperatre

Taste is via lingual nerve to chorda tympani
- papillae --> afferent fibers --> lingual nerve --> chorda tympani --> geniculate ganglion --> intermediary nerve --> nucleus solitarius

Front 17

What nerve innervates the posterior 1/3rd of tongue?

Back 17

Sensory & taste = CN IX - touch and gag (visceral afferent)

Front 18

What's the vascular supply to the tongue?

Back 18

Lingual artery - 2nd branch of ext carotid

Lingual vein - travels with hypoglossal nerve (veins of Ranine) - drain into IJ

Front 19

What is the lymphatic drainage of the anterior & posterior tongue?

Back 19

Anterior tongue
- central drains to ipsilateral & contralateral nodes
- tip drains to submental nodes
- marginal/lateral drains to ipsilateral nodes

Posterior tongue
- drains to both ipsi and contralat deep cervical nodes (jugulodigastric nodes)

Front 20

What are the THREE foramina of the hard palate?

Back 20

Incisural foramen - lies in midline of anterior palate, transmits incisural artery to anterior septum

Greater palatine foramen - conveys descending palatine branch of V2 to innervate palate as well as descending palatine artery (3rd division of maxillary artery); is 1cm medial to second molar --> supplies hard palate

Accessory palatine foramen - posterior to greater palatine foramen, coneys lesser descending palatine artery to soft palate --> supplies soft palate

Front 21

What is the arterial blood supply to the palate?

Back 21

Maxillary a --> descending palatine a --> greater palatine artery (hard palate) & lesser palatine artery (soft palate)

Front 22

What is the venous drainage of the palate?

Back 22

Hard palate --> pterygoid plexus --> IJ

Soft palate --> pharyngeal plexus --> IJ
Soft palate --> external palatine vein --> tonsillar fossa --> facial vein or pharyngeal vein

Front 23

How much saliva is produced a day in mL?

Back 23

1500 mL/d

Unstimulated, 2/3rd produced by submandibular glands
Stimulated, 2/3rd produced by parotid glands

Front 24

Which muscle contraction opens the eustachian tube?

Back 24

tensor veli palatini

Front 25

What is the motor innervation to the soft palate?

Back 25

CN V3 --> tensor veli palatine

CN X --> remainder of palatal muscles

Front 26

What is the arterial supply to the palatine tonsils?

Back 26

TOP (2)
Ascending Pharyngeal branch
Maxillary --> descending palatine a

BOTTOM (3)
Facial artery --> tonsillar branch
Facial artery --> ascending palatine
Lingual artery --> dorsal lingual

Front 27

What are Gerlach's tonsils?

Back 27

Lymphoid tissue within lip of fossa of Rosenmuller - involves eustachian tube

Front 28

What is Passavant's ridge?

Back 28

Visible constriction of superior end of superior constrictor, where fibers of the palatopharyngeal constrictor interdigitate.

It is seen during approximation of palate to posterior pharyngeal wall and during elevation of the pharynx during swallowing.

Front 29

Where does the superior constrictor originate from? Where does it insert?

Back 29

Medial pterygoid plate, mandible and base of tongue.

Inserts on median raphe

Front 30

Where does the middle constrictor originate from?

Back 30

Hyoid bone and stylohyoid ligament

Front 31

Where does the inferior constrictor originate from?

Back 31

Oblique line of thyroid cartilage

Front 32

What are the three pharygeal/laryngeal elevator muscles?

Back 32

Salpingopharyngeus
Stylopharyngeus
Stylohyoid

Front 33

Where is the Killian's triangle?

Back 33

The cricopharyngeus muscle is the most inferior portion of the inferior constrictor, and is separated from it by Killian's triangle (aka Killian's dehiscense)

Front 34

What is a Laimer-Haeckerman space/dehiscence?

Back 34

located between the posterior cricopharyngeus and the esophageal musculature

Front 35

Where is the Killian-Jamieson space?

Back 35

DO NOT confuse with Killian's dehiscence

Killian-Jamieson space/dehiscence is a lateral dehiscence between the oblique and transverse fibers of the CP muscles, where branches of the inferior thyroid artery pass

Front 36

What are the three phases of normal swallow?

Back 36

Oral phase
Pharyngeal phase (lasts <1 second)
Esophageal phase (conveys bolus to stomach in 3-6 s)

Front 37

When a bolus is formed during the oral phase of swallowing, what triggers the involuntary pharyngeal swallow?

Back 37

The oral phase is under voluntary control and ends when the bolus is pressed against the faucial arches to precipitate the involuntary pharyngeal phase.
Pressure-sensitive receptors on anterior tonsillar pillar (IX, X) trigger the involuntary pharyngeal swallow.

Front 38

Describe the anatomy of the esophagus?

Back 38

38-40cm in length in adult
No serosa
Outer longitudinal layer
Inner circular layer
Upper-mid portion is overlap of striated and smooth muscle

Front 39

What's the innervation to the esophagus?

Back 39

Myenteric plexus (plexus of Auerbach) within muscle layers (parasympathetic ganglion cells) innervated by CN X

Submucosal plexus (plexus of Meissner) - within submucosal layer

Vagus nerve rotates CLOCKWISE when viewed from above: left moves to anterior, right moves to posterior surface

Front 40

Describe the three types of esophageal peristalsis

Back 40

Primary peristalsis - physiologic propulsive wave of sequential constriction & shortening

Secondary peristalsis - nonphysiologic retrograde peristalsis

Tertiary - nonphysiologic segmental constriction without propulsion

Front 41

What is the esophageal structure that is absent in infants that predisposes them to reflux?

Back 41

The angle of His - oblique angle of entry of the esophagus into the stomach.
Absent in infants (2/3rds of 4-month-old infants have reflux)

Front 42

Why does a hiatal hernia predispose to reflux?

Back 42

The diaphragmatic cruae surrounding hiatus create a sling which assists in LES function. This effect is lost with a hiatus hernia.

Front 43

What is dilaceration and what diseases is it associated with?

Back 43

Angular formation of the tooth root as a result of trauma.

Associated with Rickets and cretinism

Front 44

What's the difference between apical granuloma and radicular cyst?

Back 44

Apical granuloma <1.5cm, corticates margins

Radicular cyst >1.5cm (may be lateral to root), corticated margins

(abscess has less defined margins)

Front 45

What is the general term for any inflammatory disorder of the oral mucosa?

Back 45

stomatitis

Front 46

What causes acute necrotizing ulcerative gingivitis (ANUG)?

Back 46

synergistic mixed anaerobic infection including Borrelia vincetii (fusiform bacillus)

Front 47

What is the most common viral infection of the mouth?

Back 47

Herpes labialis

Front 48

Pt presents with this, as well as fever and coryza. What is the dx?

Back 48

Herpangina (group A coxsackievirus) - vesicular eruptions on the palate

Front 49

What is Noma?

Back 49

an acute necroting gingivitis that rapidly spreads into adjacent tissue.
It is most commonly seen in third world countries, with highest incidence in children.
Borrelia and other anaerobic fusiform bacilli are always present

Front 50

Mass of bacteria that form sulfur granules

Back 50

Actinomycosis

Front 51

What is Sutton's disease?

Back 51

recurrent aphthous ulcers (RAU) - forms multiple, large deep ulcers that can cause extensive scarring of the oral cavity

Front 52

What is the advanced case of lichen planus? Can it become cancerous?

Back 52

Erosive lichen planus - 10-15% chance of developing SCC

Front 53

What is Bechet's dz?

Back 53

Oral & GENITAL ulcers, conjunctivitis, iritis

Front 54

What is the disease? Spider-like blood vessels or angiomatous-appearing lesions on the oral mucosa, tongue and nasal mucosa, and is associated with recurrent epistaxis.

Back 54

Osler-Weber-Rendu dz - aka hereditary hemorrhagic telangiectasia

Front 55

What is menopausal gingivostomatitis?

Back 55

Aka senile atrophy - dry oral mucosa with a burning sensation, diffuse erythema, shiny mucosa, and occasionally fissuring in the melobuccal fold. Sx tx.

Front 56

What is oral mucosa melanosis?

Back 56

physiologic pigmentation, often seen as dark patches of the oral mucosa

Front 57

What is an amalgam tattoo?

Back 57

Inadvertent tattoo of gingiva from dental amalgam introduced through a mucosal laceration

Front 58

What did this patient likely ingest?

Back 58

Bismuth - black tongue

Front 59

What did this patient ingest?

Back 59

Lead - those are Burton's lines (blue-gray line that follows gingiva)

Front 60

A pt has pale round spots on erythematous base in the oral mucosa, as well as cough and conjunctivitis. What's the disease?

Back 60

Measles (robueola) - 3 C's = cough, coryza and conjunctivities, + Koplik spots.

Front 61

A kid has a "strawberry tongue" + sandpaper rash, what's the dz?

Back 61

Scarlet fever

Front 62

What percentage of isolated leukoplakia will demonstrate carcinoma or severe dysphasia on bx?

What percentage of pt's with erythroplakiq will demonstrate carcinoma or severe dysphasia on bx?

Back 62

Less than 10%

50%

Front 63

What is nodular erythroplakia?

Back 63

Mixed white and red plaques - greater malignant potential (similar to erythroplakia in risk of malignancy)

Front 64

What are these white pinpoint nodules seen on the lips?

Back 64

Fordyce granules - painless, pinpoint yellow nodules. Represent enlarged ectopic sebaceous glands and area a benign development anomaly.

May occur bilaterally in the buccal mucosa as well as the lips.

Front 65

What is the diagnosis?

Back 65

Odontogenic fibroma - circumscribed radiolucency with smooth borders, occuring around the crown of unerupted teeth in children, adolescents, and young adults. Radiographcally it resembles a dentigerous cyst. Tx is excision and nearly always curative.

Front 66

What is an ameloblastoma?

Back 66

it's a neoplasm of enamel origin that presents in the 3rd and 4th decade. The most common site is the mandible, especially the molar region.

Tumors are slow growing and painless, expanding surrounding bone. Tx is excision.

Front 67

What are cementomas?

Back 67

Broad class of lesions that form cementum (bone-like CT that covers tooth root).
Tumors usually arise at the tip of tooth roots in oung adults.
The radiographic appearance can vary from radiolucent to densely radiopaque, depending on the lesion.
Tx is enucleation.

Front 68

What is an odontoma?

Back 68

Tumor composed of ameloblasts (enamel) and odontoblasts (dentin). It appears as irregular radiopaque mass, often between tooth roots and is associated with unerupted teeth.
Tx is enucleation.

Front 69

What is an ameloblastic fibroma?

Back 69

A SLOW-growing, painless lesion seen in the molar area of the mandible in adolescents and children.
Contains both epithelial and mesenchymal tissue and is radiographically similar to an ameloblastoma.

Front 70

What is an ameloblastic sarcoma?

Back 70

Malignant, FAST-growing, painful, and aggressive varient of amelolastic fibroma. Occurs most commonly in young adults.
Tx is surgical excision. Recurrence is common.

Front 71

Diagnosis?

Back 71

Radicular cyst (called periapical cyst when it involves the tooth root)
- Commonly caused by dental infection and is usually assx. It presents as a radiolucent area on xray, and tx is extraction or root canal therapy

Front 72

What is the diagnosis?

Back 72

Dentigerous (follicular) cyst - is a development abnormality caused by a defect in enamel formation.
It is ALWAYS associated with an unerupted tooth crown, and most common in the mandibular third molar or maxillary cuspid.
Ameloblastoma formation occurs in the cyst wall.

Front 73

Diagnosis?

Back 73

Hairy tongue
- due to hyperplasia of filiform papillae
- may be black, blue, brown, or white depending on microflora and nicotine staining
- often associated with candida overgrowth

Front 74

Diagnosis?

Back 74

Epulis
- nonspecific term for tumor or tumor-like masses of the gingiva, often a pyogenic granuloma.
- common in pregnancy
- congenital epulis is rare and resembles a granular cell myoblastoma
- A giant cell epulis is more common and histologic examination demonstrates reticular and fibrous connective tissue with numerous giant cells. Radiographs show cuffing or sclerotic margins of bone.

Front 75

What is the tx of a ranula?

Back 75

Excision should include the entire sublingual gland in order to prevent recurrence

Front 76

What is the diagnosis?

Back 76

Quincke's disease
- swelling of the uvula often in association with acute bacterial tonsillitis.
- uvular swelling can also occur with trauma (heroin snorting, burn from hot food or beverages)

Front 77

ACE-I induced angioedema is most common in which race group?

Back 77

African descent (can occur at any time following initiation of therapy)

Front 78

What are the infectious etiologies of acute tonsillitis?

Back 78

Group A beta-hemolytic step
H. influ
Strep pneumo
Staph
TB

Front 79

In acute peritonsillar abscess, the pus is located between the tonsil and ________________________

Back 79

superior constrictor muscle

Front 80

List the complications of peritonsillar abscess

Back 80

1) Parapharyngeal abscess (d/t rupture through superior constrictor)
2) Venous thrombosis, phlebitis, bacteremia, and endocarditis
3) Arterial involvement to include thrombosis, hemorrhage, and pseudoaneurysm
4) Mediastinitis
5) Brain abscess
6) Airway obstruction
7) Aspiration pneumonia
8) Nephritis (d/t step antigen)
9) Peritonitis
10) Dehydration

Front 81

When was the first documented tonsillectomy procedure performed?

Back 81

By Cague of Rheims in 1757

Front 82

What are the criteria for tonsillectomy?

Back 82

Recurrent infections
- 3/yr for 3 yrs, 5/yr for 2 yrs, 7 or more in 1 yr, or >2wks of school/work missed in 1 yr
Hypertrophy causing upper airways obstruction
Hypertrophy causing deglutition problems
Peritonsillar abscess
Possibility of malignancy
Recurrent tonsillitis causing febrile seizsures
Diphtheria carrier

Front 83

What is the rate of hemorrhage post-tonsillectomy (based on this book...)?

What is the rate of mortality post-tonsillectomy?

Back 83

2-4%..

1:25,000 (hemorrhage, airway obstruction, and anesthesia)

Front 84

List some disorders of the tongue base

Back 84

1. Lingual tonsillar hypertrophy
2. Lingual tonsillitis
3. Lingual thyroid (failure of the descent)
4. Benign vallecular cysts
5. Neoplasms (SSC, lymphoma, minor salivary gland tumors & lingual thyroid)

Front 85

What are the sx of Eagle syndrome and what's it due to?

Back 85

Sore throat, dysphagia, tinnitus, facial and neck pain, and otalgia

D/t an elongated temporal styloid process (more than 30mm) is in conflict with the adjacent anatomical structures.

Front 86

List diseases of the hypopharynx

Back 86

1. Inflamation (associated with supraglottis)
2. Angioedema
3. Osteophyte
4. Aberrant carotid artery
5. Carotid aneurysm
6. Parapharyngeal space mass
7. Hypopharyngeal carcinoma

Front 87

What is Vincent's angina?

Back 87

Acute necrotizing ulcerative gingivitis

Front 88

If a patient has dysphagia secondary to tongue base weakness, what is the tx?

Back 88

Chin tuck to close vallecula, tongue base strengthening exercises, and liquid rinse during meals.

Front 89

What is the name of the mid-esophageal diverticulum?

Back 89

Traction diverticulum - usually midesophageal, typically on the left side, and often due to traction of adjacent inflammatory process (usually TB).

Front 90

List some conditions which predispose to sliding hiatal hernia

Back 90

Increased intra-abdominal pressure due to pregnancy, obesity, tight clothing, ascites and constipation
Age-incidence is 30% in the older population
Weakness of esophageal hiatus -results in incompletence of the LES
Kyphoscoliosis
Sandifer syndrome -abnormal contortions of the neck associated with unrecognized hiatus hernia in children
Saint's triad - GB dz, colonic diverticular dz, and hiatus hernia

Front 91

Does polymyositis affects the esophagus?

Back 91

Yes it can; it affects striated muscle, which is in the upper 1/3 of the esophagus

Front 92

What do esophageal webs look like and what are they associated with?

Back 92

They are asymmetric (as opposed to rings and strictures) and usually associated with Plummer-Vinson syndrome

Front 93

Where in the esophagus are Schatzki's rings typically found?

Back 93

Distal esophagus, usually at the EG junction
(esophageal webs, like those seen with Plummer-Vinson syndrome, are seen in the upper esophagus)

Front 94

How is a Schatzki's ring different from a peptic stricture?

Back 94

A Schatzki's ring involves ONLY mucosa

Peptic stricture due to reflex involves BOTH mucosa and muscle layers

Front 95

List the associated abnormalities in Plummer-Vinson syndrome

Back 95

Iron-deficiency anemia
Upper esophageal web or Dysphagia
Hypothyroidism
Glossitis
Cheilitis
Gastritis

Front 96

In decreasing order of frequency, list the areas of the esophagus that get cancer.

Back 96

Distal 1/3 (40-50%)
Middle 1/3 (30-40%)
Upper 1/3 (<30%)

Front 97

What are the two types of congenital diaphragmatic hernias?

Back 97

Anterior = retrosternal (Morgagni)

Posteior = pleuroperitoneal (Bochdalek's)

Front 98

What is Bayford syndrome?

Back 98

Aka dysphagia lusoria
- symptomatic compression of the esophagus by anomalous location of the right subclavian artery
- instead of arising from the innominate artery, the anomalous right subclavian originates from the descending aorta distal to the left subclavian and passes posterior to the esophagus to get to the arm.
- It is associated with a NONRECURRENT right recurrent laryngeal nerve and aneurysms of the aorta and the aberrant right subclavian artery.
- Dysphagia is intermittent but can lead to weight loss.
- Barium swallow will show posterior compression, CT is diagnostic.
- Tx: ligation and division with anastomosis of distal subclavian artery to carotid.