1. DISEASES OF THE ORAL CAVITY
Prof. İlhan TOPALOĞLU
Otolaryngology Department
Yeditepe University
School of Medicine

2. ANATOMY OF THE ORAL CAVITY
anterior : vermillion border of the lips
posterior: oropharynx
oropharyngeal isthmus : (superior) junction of the hard and soft plates .
(lateral) anterior tonsillar pillars
(inferior) the line of the circumvallate papillae

3. ANATOMY OF THE ORAL CAVITY
1- Lips
2- Anterior portion of the tongue
3- Buccal mucosa
4- Upper and lower alveolar ridges
5- Retromolar trigone
6- Floor of the mouth
7- Hard palate

4. Exam: Lips

5. Exam: Lips-palpation Color, consistency
Area for blocked minor salivary glands
Lesions, ulcers

6. Pyogenic granuloma

7. Fibroma

8. Lip cancer

9. Lower lip carcinoma

10. CANCERS OF THE LIP 88-98% lower lip 2-7% upper lip
0,09-6,1% oral commisure
Male and older than 60 years old 
SCC 
Basal cell ca, melanoma, minör salivary gland tm.

11. Sensory innervation of the tongue
1 – chorda tympani and lingual nerve
2 – glossopharyngeal nerve
3 – vagal nerve

12. Motor innervation of the tongue
Extrinsic muscles of the tongue are innervated by cranial nerve XII
-Genioglossus
-Hyoglossus
-Styloglossus
-Palatoglossus
Intrinsic muscles of the tongue are also innervated by cranial nerve XII
-Superior longutudinal
-Inferior longutudinal
-Vertical
-Transverse

13. Exam: Tongue

14. Exam: Tongue
You may observe lingual varicosities

15. Exam: Tongue
You may observe geographic tongue (erythema migrans)

16. Exam: Tongue
You may observe drug reaction

17. Exam: Tongue
Observe signs of nutritional deficiencies

18. Hairy Leukoplakia

19. Hemangioma

20. Granular Cell Tumor

21. Exam: Tongue
You may observe cancer

22. CANCER OF THE ANTERIOR PORTION OF THE TONGUE

23. Tongue ca.

24. Tongue ca.

25. CANCERS OF TONGUE Lateral border Ocult met. 30%
No  supraomohyoid dissection
T1- T2 surgery or RT
T3- T4 surgery+RT
Stage, nodal metastases, lenfovasculer, perineural invasion and thickness of tumor are important prognostic factors.

26. Examination: Buccal Mucosa
Linea alba
Stenson’s duct

27. Examination: Buccal Mucosa
Lesions – white, red
Lichen Planus, Leukedema

28. CANCER OF THE BUCCAL MUCOSA
Advanced stage
Tm pterigoid muscles, maxilla, mandible, skin
clinic N(+)RND or MRND + cheek resection
There is no natural barrier
T1 surgery or RT
T2 surgery or RT
T3 and T4 surgery+ RT

29. Ameloblastoma

30. Gingival cyst

31. Malignant Melanoma

32. Mucoepidermoid tumor

33. CANCERS OF THE GINGIVA AND ALVEOLAR RIDGE
80 % lower gingiva and 1/3 posterior region.
Incidance of mandibular invasion rate is high
upper gingiva invasion of maksillary sinus
Pull out the tooth invasion of bone marrow
uncommon
Lower jaw ( posterior 1/3 dental arch)
Marginal mandibular resection
Stage 1-2 , surgery
Stage 3-4 ,surgery+ (+) neck MRND
(-) Neck Rtx

34. Exam: Retromolar trigone

35. Exam: Retromolar trigone
Edentulous

36. RETROMOLAR TRİGONE CA Uncommon Invasion of mandible
Late diagnose , advanced stage, cervical metastases are bad prognostic factors
T1 T2 surgery or RT
T3 T4 surgery + RT

37. Exam: Floor of mouth Visualize, palpate - bimanually Wharton’s duct
Must dry to observe
Does “lesion” wipe off?
Where are the two most
likely areas for oral cancer?
lateral border of the tongue
Floor of mouth

38. Exam: Floor of mouth

39. Palpation of the floor of the mouth

40. Exam: Floor of mouth
Squamous Cell Carcinoma

41. Squamous Cell Carcinoma

42. FLOOR OF THE MOUTH CA. Incidance of mandibular invasion rate is high
Ocult met  10-30%
Primary resection of the floor of the mouth is peformed with ipsilateral or bilateral neck dissection (if the tumor is located at the midline)

43. Exam: Hard palate
Minor salivary glands

44. Median Palatal Cyst

45. CANCER OF THE HARD PALATE
uncommon
SCC and Adenoid cystic ca
Misdiagnosed as maxillary sinus tm
Incidance of neck metastases is low
Elective neck treatment is unnecessary
Prostodontist

46. ORAL PREMALİGNANCY
Leukoplakia
Erythroplakia
Mucosal atrophy

47. MALIGNANT LESIONS SQUAMOUS CELL CARCINOMA VERRUCOUS CARCINOMA
MINOR SALIVARY GLAND TUMOURS
SARCOMATOID CARCINOMAS
MALIGNANT MELANOMA

48. PATIENT EVALUATION Diagnosis Neoplasms of the oral cavity
Complete head and neck examination
Chest x-ray and liver function tests plus additional laboratory tests dictated by patient’s medical history
CT/MRI scan for extent of primary and possible cervical nodal evaluation
Dental evaluation
Radiotherapy evaluation
Staging endoscopy and biopsy

49. ETIOLOGY
Risk factors for oral cavity and oropharyngeal cancer include:
Cigarette
Alcohol
Exposure to the human papilloma virus (HPV) or Epstein-Barr virus (EBV)
ionizing radiation
Prolonged sun exposure, especially linked to cancer in the lip area and skin cancer.
Fair skin, also linked to lip cancer and skin cancer.
Age. People over the age of 45 years old are at increased risk for oral cancers (though it can develop in people of any age).
Poor nutrition.
Irritation from poorly fitting dentures in people who use alcohol and tobacco products.
Chewing betel nuts, a nut containing a mild stimulant popular in Asia.
Weakened immune system.
Vitamin A deficiency.
A rare condition called Plummer-Vinson Syndrome, which involves iron deficiency and causes difficulty swallowing.
Gender. Men are more likely to get lip cancer than women.
lichen planus
discoid lupus erythematosus
dystrophic epidermolysis bullosa

50. Symptoms Otalgia Odynofagia Bleeding Dysfagia Loss of teeth
Restriction of mouth movement
Trismus

51. EPIDEMIOLOGY 95 % SCC 95 % patiet  40 years old
Mean age 60 years old
After the treatment of oral cavity ca if the patient doesn’t give up smoking, second primary or recurrence rate is 40 %

52. CARCINOGENESIS tobacco ionizing radiation
dental travma and poor oral hygiene
alcohol
tertiary syphilis
human papilloma virus
candida albicans
some nutritional factors
oral submucous fibrosis
lichen planus
discoid lupus erythematosus
dystrophic epidermolysis bullosa
dyskeratosis congenita

53. TREATMENT
surgery RT
surgery + RT
KT + RT
Surgery + RT + adjuvant KT

54. The last cigarette

56. DISEASES OF OROPHARYNX
Prof. Dr. İlhan TOPALOĞLU
Otolaryngology Department
Yeditepe University
School of Medicine

57. ANATOMY OF THE OROPHARYNX
Anterior : oropharyngeal isthmus;
(superior) junction of the hard and soft plates .
(lateral) anterior tonsillar pillars
(inferior) the line of the circumvallate papillae
İnferior: the plane of the hyoid bone

58. OROPHARYNX SUBSIDES Soft palate and uvula Base of the tongue
Tonsillar region (tonsillar fossae and pillars)
Oropharyngeal walls (lateral and posterior)

59. Diseases of the Tonsils & Adenoid

60. Waldeyer's ring
Waldeyer's tonsillar ring (or pharyngeal lymphoid ring) is an anatomical term describing the lymphoid tissue ring located in the pharynx and to the back of the oral cavity.
It was named after the nineteenth century German anatomist Heinrich Wilhelm Gottfried von Waldeyer-Hartz.

61. Waldeyer's ring
Pharyngeal tonsil (also known as 'adenoids' when infected)
Tubal tonsil (where Eustachian tube opens in the nasopharynx)
Palatine tonsils (commonly called "the tonsils" in the vernacular, less commonly termed "faucial tonsils")
Lingual tonsils

62. Anatomy Tonsils Adenoids
Between arcus palatoglossus (ant plica) and arcus palatofaryngeus (post plica)
Adenoids
The tonsil is nestled in a fossa formed by the muscular anterior and posterior tonsillar pillars (palatoglossus and palatopharyngeus) and lying superficial to the superior constrictor muscle; preservation of these muscular condensations and the overlying mucosa is critical to maintaining physiologic function of the palate postoperatively.
The tonsil is contiguous inferiorly with the lingual tonsil. The point of attachment (plica triangularis) must be transected during tonsillectomy. In pts with marked hypertrophy, this extension is freq quite large and can result in troublesome bleeding at the pt of transection at the base of the tongue.
The adenoid is positioned in the midline of the posterior wall of the NP immediately inferior to the rostrum of the sphenoid and extending laterally to but not onto the lateral wall of the NP. It makes up the most rostral portion of the pharyngeal lymphoid tissue termed Waldeyer’s ring. The space created lateral to the adenoid and posteromedial to the ET orifice is termed the FOSSA of Rosenmuller.
Gerlach’s tonsil is lymphoid tissue within lip of the fossa of Rosenmuller; goes into ET.
Inferiorly, the adenoid extends nearly to the superior margin of the superior constrictor…Passavant’s ridge.

63. Blood Supply Tonsils Adenoids
Ascending and descending palatine arteries
Tonsillar artery
1% aberrant ICA just deep to superior constrictor
Adenoids
Ascending pharyngeal, sphenopalatine arteries
Tonsillar branch of the facial artery is the main supply of the entire tonsil.
Facial artery:
Tonsillar art
Ascending palatine art
Lingual art
dorsal lingual branch
IMA
Desceding palatine
Greater palatine
Ascending pharyngeal (ECA)
Venous drainage of the tonsil is thru lingual and pharyngeal veins which empty into the IJ.
In most people the ICA lies 2cm posterolateral to the deep surface of the tonsil; however in 1% of the population, it is found just deep to the superior constrictor.
Adenoids: Ascending palatine, ascending phayrngeal, pharyngeal br of IMA, ascending cervical branch of thyrocervical trunk

64. Histology Tonsils Adenoids Specialized squamous Extrafollicular
Mantle zone
Germinal center
Adenoids
Ciliated pseudostratified columnar
Stratified squamous
Transitional
The luminal surface of the tonsil is covered by stratified squamous epithelium (E) which deeply invaginates the tonsil; the base of the tonsil is separated from underlying muscle by a dense collagenous hemi-capsule (Cap). The parenchyma contains numerous lymphoid follicles (F) dispersed just beneath the epithelium of the crypts.
The surface of the adenoids differs from the tonsils in that the adenoids have deep folds and few crypts , while the tonsils have from crypts and the surface of the adenoids is composed of ciliated pseudostratified columnar epithelium which functions in mucociliary clearance. With chronic infection, this layer is thinned, resulting in stasis of secretions and increased exposure of the tissue to antigenic stimuli. Deep to the surface epithelium lies a stratified squamous layer followed by a transitional layer. The SS layer thickens with chronic infection. The transitional layer is responsible for antigen processing.

65. Common Diseases of the Tonsils and Adenoids
Acute adenoiditis/tonsillitis
Recurrent/chronic adenoiditis/tonsillitis
Obstructive hyperplasia
Malignancy

66. Acute Adenotonsillitis
Etiology
5-30% bacterial; of these 39% are beta-lactamase-producing (BLPO)
Streptococcus pyogenes (Group A beta-hemolytic streptococcus GABHS most important pathogen because of potential sequelae
1. MC bacteria:
Beta streptoccoci, staphylococci, streptoccocus pneumoniae, hemophilus
2. Prevalence of beta-lactamase producing organisms is rising:
from 2 % in 1980 to 44% in (FIND STUDY)
3. Prevalence of anaerobic org is also rising
Asymptomatic streptococcal pharyngitis responsible for at least 1/3 of ARF in 3rd world. Gold std is throat culture.
Blood agar plate with septra more sensitive than plain agar plate.
Culture both tonsils; if only one, may miss 25%.
Rapid streptococcal antigen test, 12 min.; highly specific but variable sensitivity; must confirm negative result with a throat cx.
Newer solid-phase enzyme immunoassay
Older latex agglutination test
Treat with 10 day course of PCN if high clinical suspicion (augmentin, clinda, pcn + rifampin for recurrence)
Post treatment culture: high risk RF, remain symptomatic, recurring symptoms; if asymptomatic but positive cx, treat if h/o RF or if FH of RF
Suspect infectious mononucleosis if sore throat and malaise persist despite abx treatment; order WBC and Paul-Bunnell. Characterized by white membrane covering one or both tonsils and hypersensitivity to ampicillin. Look for atypical mononuclear cells and positive Paul-Bunnell blood test.

67. Microbiology of Adenotonsillitis
Most common organisms cultured from patients with chronic tonsillar disease (recurrent/chronic infection, hyperplasia):
Streptococcus pyogenes (Group A beta-hemolytic streptococcus)
H.influenza
S. aureus
Streptococcus pneumoniae
Study by Brodsky et al (1988) taking cultures from core specimens (not surface).
Core species do not always correlate with surface bacteria. 90% correlation with H.influenza, 73% strept pyogenes

68. Acute Adenotonsillitis
Differential diagnosis
Infectious mononucleosis Malignancy: lymphoma, leukemia, carcinoma Diptheria Scarlet fever Agranulocytosis

69. Medical Management
PCN is first line, even if throat culture is negative for GABHS
Antibiotics aimed against BLPO and anaerobes
For acute UAO: IV abx, NP airway, steroids, and immediate tonsillectomy for poor response

70. Obstructive Hyperplasia
Adenotonsillar hypertrophy most common cause of SDB in children
Diagnosis
Indications for polysomnography
Interpretation of polysomnography
Perioperative considerations
Diagnosis of OSA is based on H & P (snoring, restless sleep, FTT, daytime symptoms… poor mentation, decreased attn span, poor scholastic performance, dysphagia, nocturnal enuresis, chronic mouth breathing; predisposing conditions craniofacial abnormalities, NM disorders, FTT, cor pulmonale, Downs syndrome) MC symptom in kids is snoring (adults is daytime somnolence).
Obtain sleep study when PE does not correlate with history ($1600), or when suspect central component.
Apnea (10s breathing pause)from complete obstruction is uncommon in children. Children tend to have a continuous partial obstructive hypoventilation that is characterized by decreased oxygen saturation, hypercapnia, labored paradoxical resp efforts, and snoring.
Controversy over how to interpret sleep study in kids… few normative data. Marcus et al.(1992) studied normal resp patterns in children during sleep.
Abnormal values: >1 obstructive apnea of any duration per hour
central apnea assoc with desat <90%
Pco2>53 or Pco2>45 for more than 60% test time
fall of o2 sat < 92%
No consensus on indications for surgery for those without severe obstruction/apnea.

71. Unilateral Tonsillar Enlargement
Apparent enlargement vs true enlargement
Non-neoplastic:
Acute infective
Chronic infective
Hypertrophy
Congenital
Neoplastic
Apparent: tonsil sits in more medial position, displacement medially by PTA or parapharyngeal space mass.
Chronic infections: tubercular tonsillitis, actinomycosis, and congenital syphilis
Congenital include teratoma, hemangioma, lymphangioma, and cystic hygroma.
Neoplastic:
Benign papillomas
Lymphoma (usually non-Hodgkins B-cell) and squamous cell

72. Peritonsillar Abscess
Displacement of tonsil and uvula medially, trismus, dysphagia, pain referred to the ear, malaise, fever, cervical adenopathy.
Initial mgmt is needle aspiration, IM penicillin, oral penicillin.
Quinsy tonsillectomy for uncooperative, toxic patient, bleeding.

73. ICA Aneurysm
This patient came to the ER for sore throat

74. Pleomorphic Adenoma
Consider masses in the parapharyngeal space for apparent UTE including tumors of the deep lobe of the parotid gland (ie pleomorphic adenoma), chemodectomas, neurofibromata, and enlargement of the parapharyngeal lymph nodes.

75. Toncil ca.

76. Papilloma

77. Other Tonsillar Pathology
Hyperkeratosis, mycosis leptothrica
Tonsilloliths
Yellow spicules due to hyperkearatineized areas of epithelium are sometimes extensive over the tonsil. It is important to probe the tonsil to be certain these areas are not exudate. No treatment is required unless assoc with tonsillitis.
Tonsilloliths are yellow gritty particles in crypts, more commonly seen in adults with a h/o recurrent tonsillitis.
Elongated styloid process causes pain exacerbated during maximal deglutition and deep breathing…. 2nd branchial arch derivitative, approx 2.5 cm long, located btw internal and ECA just lateral to tonsillar fossa.

78. Candidiasis
A fungal infection of the pharynx and one of the most common upper respiratory tract manifestation of AIDS. Also seen in neonates and may complicate treatment with broad spectrum antibiotics.
Characterized by extensive white areas (either continuous or punctate) covering the entire oropharynx and not limited to the tonsil.
Swab shows candida albicans.

79. Syphilis
Snail-track ulcers of secondary syphilis.

80. Retention Cysts
These are common on the tonsil and appear as sessile yellow swellings. If small, they can be ignored. Also seen after tonsillectomy in region of the fauces.

81. Supratonsillar Cleft
This recess near the superior pole of the tonsil tends if large to collect debris. A mass of yellow fetid tissue can be extruded from the tonsil with pressure, and discomfort, halitosis are symptoms. Tonsillectomy may be necessary.

82. Indications for Tonsillectomy
Paradise study
Frequency criteria: 7 episodes in 1 year or 5 episodes/year for 2 years or 3 episodes/year for 3 years
Clinical features (one or more): T 38.3, cervical LAD (>2cm) or tender LAD; tonsillar/pharyngeal exudate; positive culture for GABHS; antibiotic treatment
From the Children’s Hospital of Pittsburgh conducted parallel randomized and nonrandomized clinical trials to determine
1. efficacy of tonsillectomy in reducing the frequency and severity of episodes of pharyngitis,
2. the efficacy of adenoidectomy in reducing the freq/severity of OM, and
3. the effect of adenoidectomy of the course of nasal obstruction due to large adenoids
Findings:
1. Histories of recurrent throat infections that are undocumented do not validly predict recurrence; need documentation by physician before performing tonsillectomy
2. Using the selection criteria, the incidence of throat infection during the first 2 years of f/u was significantly lower in the surgical groups
3. Many pts in the nonsurgical group had fewer than 3 episodes of infx, and most cases were mild… therefore, treatment should be individualized, taking into consideration pt/parental preference, anxieties, tolerance of illness, tolerance of antimicrobial drugs, child’s school performance in relation to illness-related absence, accessability of health-care services, out-of-pocket costs, nature of available anesthetic and surgical services/facilities

83. Indications for Tonsillectomy
AAO-HNS:
3 or more episodes/year
Hypertrophy causing malocclusion, UAO
Halitosis, not responsive to medical therapy
UTE, suspicious for malignancy
Individual considerations
Contraindications:
Tonsillectomy
Acute infection
Anemia
Disorders of hemostasis

84. Indications for Adenoidectomy
Paradise study (1984)
28-35% fewer acute episodes of OM with adenoidectomy in kids with previous tube placement
Adenoidectomy or T & A not indicated in children with recurrent OM who had not undergone previous tube placement
Gates et al (1994)
Recommend adenoidectomy with M & T as the initial surgical treatment for children with MEE > 90 days and CHL > 20 dB
Paradise:
Parallel randomized and nonrandomized clinical trials of
213 children who developed recurrence of OM after extrusion of t-tubes;
In both trials, over a period of 2 years, 28-35% fewer episodes than controls.
Gates: 578 children with chronic middle ear effusion. Adenoidectomy combined with myringotomy or with t tube placement proved to be more effective thatn myringotomy or tube placement alone in preventing recurrences of OM over a 2 year period
* differences were small (31 vs 36 weeks as mean cumulative times with effusion in 2 treatment groups over 2 yr f/u).
TT surgery alone is assoc with higher rate of repeat surgeries, increased rate of otorrhea, greater expense and human cost of illness than initial adenoidectomy and myringotomy

85. Indications for Adenoidectomy
Obstruction:
Chronic nasal obstruction or obligate mouth breathing
OSA with FTT, cor pulmonale
Dysphagia
Speech problems
Severe orofacial/dental abnormalities
Infection:
Recurrent/chronic adenoiditis (3 or more episodes/year)
Recurrent/chronic OME (+/- previous BMT)
Contraindications:
Adenoidectomy
Overt or submucous CP
Neurologic or neuromuscular abnormalities with impaired palatal function
Anemia
Disorders of hemostasis

86. PreOp Evaluation of Adenoid Disease
Triad of hyponasality, snoring, and mouth breathing
Rhinorrhea, nocturnal cough, post nasal drip
“Adenoid facies”
“Milkman” & “Micky Mouse”
Overbite, long face, crowded incisors

87. PreOp Evaluation of Adenoid Disease
Evaluate palate
Symptoms/FH of CP or VPI
Midline diastasis of muscles, bifid uvula
CNS or neuromuscular disease
Preexisting speech disorder?
Speech path consult for speech disorder.
Submucous cp 1 in 1200

88. PreOp Evaluation of Adenoid Disease
Lateral neck films are useful only when history and physical exam are not in agreement.
Accuracy of lateral neck films is dependent on proper positioning and patient cooperation.

89. PreOp Evaluation of Tonsillar Disease
History
Documentation of episodes by physician
Cor pulmonale
Poststreptococcal GN
Rheumatic fever

90. PreOp Evaluation of Tonsillar Disease
TONSIL SIZE
0 in fossa
+1 <25% occupation of oropharynx % %
+4 >75%
Avoid gagging the patient

91. PreOp Evaluation for Adenotonsillar Disease
Coagulation disorders
Historical screening
CBC, PT/PTT, BT, vWF activity
Hematology consult
von Willebrand’s disease
ITP
Sickle cell anemia
Von Willebrand’s disease is the most common inherited coagulopathy (AD with variable expression) (1% population) and is caused by a deficiency in Factor VIII:VW complex necessary in platelet activation. 3 types… type 1 is the most common (80-90%) with subnormal levels of qualitatively normal vWF and most will respond to desmopressin. Type 2 is a defect in the factor, type 3 is complete absence of the factor.
DX elevated PTT, BT, decreased vWF antigen, factor VIII procoagulant activity, ristocetin cofactor activity; measure response of levels to desmopressin (0.3microg/kg IV)
RX give IV over 30 min preop (peak levels min), 12 hr postop, then q am until eschar completely sloughed and fossae completely healed; also give aminocaproic acid or tranexamic acid preop and postop to decrease fibrinolysis (oral cavity high conc of fibrinolytic enzymes); not useful type 2/3
adverse effects… Na <132 or tachyphylaxis, d/c desmopressin, give cryoprepipitate or vWF-containing antihemophilic factor
ITP:

92. Principles of Surgical Management
Numerous techniques:
Guillotine
Tonsillotome
Beck’s snare
Dissection with snare (Scissor dissection, Fisher’s knife dissection, Finger dissection
Electrodissection
Laser dissection (CO2, KTP)
… Surgeon’s preference

93. Post Operative Managment
Criteria for Overnight Observation
Poor oral intake, vomiting, hemorrhage
Age < 3
Home > 45 minutes away
Poor socioeconomic condition
Comorbid medical problems
Surgery for OSA or PTA
Abnormal coagulation values (+/- identified disorder) in patient or family member
MC reasons for inpt stays… emesis, dehydration, hemorrhage, obstruction, pulm edema
< 3years: 7% airway complications (2.3 times other kids), 4% dehydration, 1.5 % hemorrhage; less likely to cooperate with oral intake and more likely to have surgery for airway obstruction
Conditions associated with a complicated postop course (resp compromise):
CP, seizures, age <3, congenital heart disease, prematurity, chromosomal abnormalities, loud snoring with apnea, difficulty breathing during sleep
Excessive adenotonsillar tissue obstructs airway and increases resistance to inspiration/expiration… maintains PEEP with increased intrathoracic venous and hydrostatic pressure. Sudden relief of excess PEEP by intubation or T & A results in transudation of fluid into interstitial and alveolar spaces….pulm edema. Treatment… intubation and reestablishment of PEEP.

94. Complications #1 Postoperative bleeding Other:
Sore throat, otalgia, uvular swelling
Respiratory compromise
Dehydration
Burns and iatrogenic trauma
Mortality 1 in 16,000 to 35,000 (anesthetic and hemorrhage); Hemorrhage %; 76% occur within first 6 hrs; 0.04% require transfusion; 0.002% mortality (mc for primary); Etiology: retained adenoid tissue, damage to post pharyngeal wall muscle; Increased incidence winter, age > 20
Anesthetic: kinking, extubation, fire, laryngospasm
Resp compromise: sudden loss of PEEP… pulmonary edema; avoid sedating analgesics
Assess for loose teeth… post op CXR to r/o aspiration if loss of tooth
Draping to avoid burns… avoid towel clips (penetration); avoid tape (accidental extubation when take drapes off)
Sore throat: increased with increased age, electrocautery, KTP/ less with CO2 lasere and periop/postop antibiotics (4.4 to 3.3 days)
Otalgia: referred from IX, r/o otitis, ET tube injury or edema
Fever: normal in 1st 36 hr… watch for dehydration
Dehydration: n/v 2nd to anesth, swallowed blood; decreased po intake with pain, esp younger kids less cooperative and smaller volume reserve; single intraoperative steroid earlier return to nl diet

95. Rare Complications Velopharyngeal Insufficiency
Nasopharyngeal stenosis
Atlantoaxial subluxation/ Grisel’s syndrome
Regrowth
Eustachian tube injury
Depression
Laceration of ICA/ pseudoaneursym of ICA
VPI: usu transient; sig in 1 in ; only 1/3 identified preop as increased risk; > 2mo speech therapy; > 6-12mo pharyngeal flap
NP stenosis: circumferential contracture of pharynx Waldeyer’s ring, T AND A; syphilis; increased risk with excessive mucosal excision; difficult to rx
AA subluxation.. Grisel’s syndrome vertebral body decalcification and laxity of anterior transverse ligament secondary to infection in the nasopharynx… may cause spontaneous subluxation 1 week postoperatively…pain and torticollis (traumatic adenoidectomy or injection of local anesthestic into prevertebral space)
15-28% tonsil tags; 6% recurrent pharyngitis
adenoids may grow from adjacent lymphoid tissue… incomplete removal?
Laceration of ICA usu occurs medially and near the skull base.
Pseudoanerusym of ICA requires embolization and proximal ligation.

96. Toncil ca.

97. TONCIL CA 75-80% of oropharyngeal cancer
İncidance of lymphatic metastases rate is high 75% (mostly jugulodigastric met.)
T1 – T2  RT
N2 – N3  surgery + RT
T3 – T4  surgery + RT