GI – Oropharyngeal Pathology – Flashcards
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What makes up the palatopharyngeal arch?
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Palatopharyngeus muscle
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What makes the anterior tonsilar pillar?
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Palatoglossus muscle
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Where do the palantine tonsils sit?
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Tonsillar fossae - between the palatopharyngeal arch (palatopharyngeus muscle) and anterior tonsilar pillar (palatoglossus muscle)
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Which CNs control the soft palate?
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V3 (tensor and levator palatini), IX (sensation), X more muscle
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Where does the base of tongue start?
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Circumvallate papilla
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What is Waldeyer's Ring?
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Lymphoid tissue spanning from top of oropharynx to base of tongue. Adenoids (pharyngeal), tubal tonsils, palatine tonsils, lingual tonsils. Lymphatics drain to the same nodes. These nodes make up Waldeyer's Ring
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What controls the tongue muscles?
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CN XII
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Starting from the front and going to the back, what are the layers of the posterior pharyngeal wall?
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Mucosa, submucosa, pharyngeobasila fascia, superior and middle constrictors, buccopharyngeal fascia, prevertebral fascia
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What is referred otalgia?
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Jacobson's nerve (tympanic branch of CNIX) and Arnold's nerve (auricular branch of CN X) are responsible for ear pain that can be seen with tumors or infections of soft palate, base of tongue, or tonsil.
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What is Arnold's nerve cough reflex?
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Stimulation of external ear canal can stimulate auricular branch of CN X (Arnold's nerve) and cause cough reflex
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Describe the retropharyngeal space.
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This is between the buccopharyngeal fascia and the prevertebral layer of deep cervical fascia extending from skull base to mediastinum. It also contains lymph nodes.
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What is the extent of retropharyngeal space?
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Extends from skull base to mediastinum
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Describe the parapharygeal space.
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These are lateral to the oropharnyx. They extend from the skull base to the hyoid and lateral pharyngeal walls. The space is an inverted pyramid next to the carotid sheath and parotid gland.
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What are the 3 phases of swallowing?
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Oral, pharyngeal, and esophageal
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What happens in the oral phase of swallowing?
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Soft palate pulls forward, tongue base elevates, bolus is pushed into the pharynx and initiates the pharyngeal phase
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Which muscles and nerves are used for the oral phase of swallowing?
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Muscles of mastication (CN V, VII), tongue (CN XII), and pharyngeal muscles (CN IX, X).
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Why does soft palate pull forward in oral phase of swallowing?
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Prevents food from going into your sinuses
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What happens during the pharyngeal phase of swallowing?
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First, it's *involuntary*. Soft palate elevates. Epiglottis inverts over larynx, vocal cords close, larynx elvates, superior constrictors contract, cricopharyngeus (UES) opens
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Which nerves are involved in the pharyngeal phase of swallowing?
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CN IX, X, XII
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What happens during the esophageal phase of swallowing?
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UES relaxes to allow food in esophagus. Peristaltic contractions in esophagus are elicited in a wave in response to swallow. LES opens.
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Which nerves are involved in esophageal phase of swallowing?
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Sympathetic, parasympathetic, CNX
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What tools are most commonly used to diagnose dysphagia?
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Fluoroscopic swallow study, FEES (fiberoptic endoscopic evaluation of swallowing) - this is scope in nose and leave it there to watch
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What are causes of neurogenic oropharyngeal dysphagia?
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Stroke, vocal cord paralysis (stroke, cancer, iatrogenic), Parkinson's, ALS
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What does iatrogenic mean?
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Caused by health care provider
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Which kind of iatrogenic problems can cause oropharyngeal dysphagia?
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Thyroid, heart, lung, cervical spine surgery can all cause vocal cord paralysis
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What is tx for oropharyngeal dysphagia?
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Depends on the case, but sometimes permanent gastrostomy tubes are necessary.
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What are structural causes of oropharyngeal dysphagia?
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Head/neck cancer, cricopharyngeal and UES dysfunction (cricopharyngeal bar and Zenker's diverticulum)
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What is cricopharyngeal bar?
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When cricopharyngeus doesn't open (UES)
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Which patients are Zenker's diverticulum most common in?
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Elderly
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How do Zenker's diverticulum patients present?
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Dysphagia, regurgitation of *undigested* food, aspiration, and *halitosis*
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What causes Zenker's diverticulum?
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Stenosis of UES (cricopharyngeus) causes pressure and herniation of mucosa and submucosa.
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Where do Zenker's diverticulum most commonly occur?
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Killian's triangle
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Which muscles make up UES?
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Cricopharyngeus muscles and inferior constrictors
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What are the borders of Killian's triangle?
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Bottom of inferior constrictor muscle and cricopharyngeus muscle
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Tx for Zenker's?
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Surgery
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What are common viral causes of pharyngitis?
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Entero/rhinovirus, adenovirus (may have conjunctivitis), EBV (mono)
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What is used for EBV mono diagnosis?
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Clinical picture (fatigue, abscesses), Monospot test (heterophile antibodies), EBV viral capsid antigen (IgM and IgG)
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What is tx for mono?
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Supportive
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(IgG/IgM) is more indicative of acute infection.
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IgM
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Tx for Strep throat?
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Penicillin or cephalosporins
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Sx of bacterial pharyngitis?
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Normal upper resp infection symptoms with *no cough or runny nose*.
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What patient types often suffer from candidiasis?
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Immunocompromised patients (infants, beetus, cancer, HIV)
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Where is the most common place for candidiasis infection?
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Esophagitis
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Sx of candidiasis?
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Sore throat, burning, odynophagia, dysphagia
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How is candidiasis diagnosed?
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White plaques with friability in endoscopic biopsy
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Tx for candidiasis?
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Oral nystatin swish spit/swallow. Oral fluconazole. IV ampho B
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When are people usually infected with HSV 1?
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2-4 y/o
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Which things can trigger herpetic stomatitis?
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Trauma, sun exposure, pregnancy, immunosuppression
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What is recurrent herpetic stomatitis?
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Herpetic lesions that come and go
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HSV esophagitis is caused by which herpes viruses?
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HSV-1 or 2
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How does HSV esophagitis look?
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Vesicles and small punched out ulcers
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How does a biopsy of HSV 1 or 2 look?
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Multinucleated squamous cells with eosinophilic Cowdry's type A viral inclusion bodies
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Tx for HSV infections?
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Acyclovir/valacyclovir reduces pain and morbidity
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CMV esophagitis occurs in what type of patients?
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Immunocompromised
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What type of ulcers does CMV cause?
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Serpiginous ulcers
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What type of cells does CMV affect?
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Endothelial cells
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How does CMV biopsy look?
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Endothelial cells with nuclear or cytoplasmic viral inclusion bodies
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What are aphthous ulcers?
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Canker sores - ulcers that show up on gingiva or lips
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What is cause of aphthous ulcers?
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We dunno - maybe autoimmune or viral
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How do aphthous ulcers look?
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Can be solitary or multiple, but usually solitary. Shallow ulcer with red rim
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What is leukoplakia?
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White patch or plaque that cannot be scraped off and cannot be characterized clinically or pathologically as any other disease. It is a precursor to cancer. Epithelium is replaced with stratisfied squamous epithelium.
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What is the most common risk factor of leukoplakia?
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Tobacco use
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What type of cancer do leukoplakias turn into?
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Squamous cell carcinoma
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How does leukoplakia look?
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It looks like a callous or a plaque
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Which has a poorer prognosis: leuko/erythroplakia?
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Erythroplakia
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What is the most common oropharyngeal cancer?
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SCC
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What are major risk factors to oropharyngeal carcinoma?
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EtOH, tobacco
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What dictates the prognosis of OP SCC?
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Primary location and initial staging
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How is recurrence rate of OP SCC?
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Very high
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Adults neck mass should be considered what?
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Malignancy - probably SCC, until proven otherwise
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Sore throat, ear pain, odynophagia, weight loss, neck mass is probably what?
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SCC
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How does SCC look on biopsy?
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Nests and islands of keratinocytes making keratin whorls
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What gene is associated with alcohol and tobacco use causing SCC?
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TP53 - it is a tumor suppressor gene. Induces cell apoptosis, cell cycle arrest, DNA repair
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Besides tobacco/EtOH, what is the most common cause of OP SCC?
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HPV 16, 18. Overexpression of p16 (cyclin-dependent kinase inhibitor)
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Which HPV cause warts?
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6 and 11
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Which HPV cause cervical and skin cancer?
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16 and 18
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What social history component is a risk factor for HPV cancer?
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Multiple sexual partners
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Is SCC prognosis better with or without HPV?
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With. These patients are younger with less field cancerization and the disease is radiosensitive.
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