The superficial portion of the gland lies on the mylohyoid muscle; the deep portion extends around the posterior edge of muscle into the floor of the mouth. Wharton’s duct leaves the deep part of the gland and runs forward to open into the anterior floor of the mouth, just lateral to the midline.
Swelling of the gland may be due to inflammation or tumour.
A tense, tender swelling usually results from a stone in the duct. This may be palpable bi-manually or evident on X-ray. There are several lymph nodes in the submandibular triangle and enlargement of these may mimic disease in the gland.
Treatment is with antibiotics and excision of the stone perorally. If this cannot be achieved , the whole gland may need to be removed by an external approach. Established infection may proceed to abscess formation.
Fine-needle aspiration of the mass should be performed. About 50% of tumours are benign, most commonly pleomorphic adenomas.
These should be excised with the entire gland, taking care to preserve the marginal mandibular branch of the facial nerve. Malignant tumours necessitate excision of the whole gland, with a radical neck dissection in certain cases.
Formed largely by the anterior two-thirds of the tongue and by reflection of mucosa from the sides of the tongue to the gum on the mandible. In the midline the lingual frenulum separates the orifices of the left and right submandibular ducts. Under the mucosa lie the sublingual salivary glands.
A cystic lesion arising from the sublingual gland. Usually presents in the floor of the mouth as a bluish, fluctuant swelling. Less commonly the “plunging ranula” can present as a lump in the neck.
For lesions confined to the floor of the mouth, marsupialization is usually adequate, although recurrence can occur. Plunging ranulae require formal excision via an external neck approach.
Squamous carcinoma (鱗狀細胞癌)
An ulcer in the floor of the mouth which may be painful with referred otalgia. Early spread to cervical nodes, which may be bilateral, is common.
Excision of the tumour with plastic surgical reconstruction and adjuvant radiotherapy.
A pharyngeal pouch develops from a herniation of pharyngeal mucosa through Killian’s dehiscence.
Dysphagia and regurgitation of food occur. Large pouches may cause aspiration pneumonia. Pooling of saliva in the hypopharynx may be noted on indirect laryngoscopy. Barium swallow confirms the diagnosis.
Following an endoscopy to exclude an associated carcinoma, the pouch may be excised via an external approach or the wall between the pouch and oesophagus divided endoscopically using a stapling gun.
Distension of the laryngeal saccule can produce an internal or external laryngocele.
Hoarseness or dysphagia may occur. External laryngoceles may produce a swelling in the neck accentuated by performing Valsalva’s manoeuvre. Laryngeal tomograms taken during this manoeuvre will demonstrate the laryngocele.
Following endoscopy to exclude an associated carcinoma, an internal laryngocele can be ‘uncapped’ whilst an external laryngocele is excised through the neck.
A tracheostomy is an artificial opening made into the trachea. It may be created after the larynx has been removed, when it is permanent, or when the larynx is still in place, when it is usually temporary.
Airway protection, e.g. after major head and neck surgery, neurological disease involving the larynx
Airway obstruction, e.g. epiglottitis, bilateral recurrent laryngeal nerve palsy, tumour
Respiratory insufficiency (when endotracheal intubation required for longer than 72h) e.g. severe chest wall injury, Guillain-Barre syndrome
Incision, horizontal, midway between the cricoid cartilage and suprasternal notch.
Vertical incision and separation of strap muscles.
Transfixion and separation of thyroid isthmus.
Creation of an opening into the trachea. In adults a window is cut out. A vertical slit incision is used in children. A trap-door flap should not be used.
Insertion of tracheostomy tube. A correctly sized cuffed synthetic tube is used for the first 24h. this can be replaced later on by an uncuffed tube.
Immediate. Pneumothorax, haemorrhage, surgical emphysema and tube displacement can all occur.
Early. Wound infection, dysphagia and tube obstruction are all common. Tracheal erosion with innominate artery rupture, perichondritis and apnoea in hypercapnoeic bronchitics are rare.
Late. Tracheal stenosis may result from prolonged or overinflation of the cuffed tube. Decannulation may be difficult in children. Surgical closure of a persistent tracheocutaneous fistula is rarely required after decannulation.
Stomal stenosis (造瘻口狹窄) Aetiology:Following laryngectomy the lower end of the trachea is brought out through the neck skin. Local wound infection, radiotherapy and keloid formation all predispose to the later development of a stomal stenosis. The other cause of stomal stenosis is recurrence of tumour.
Management of benign stomal stenosis is either by the permanent wearing of a stoma button or laryngectomy tube or by surgical revision of the stoma.
Most common midline neck cyst usually presenting in childhood.
Painless, unless infected, and moves on protrusion of tongue. Sinus formation may follow previous infection or incomplete excision.
If a thyroid scan shows functioning tissue elsewhere, then excise with central portion of hyoid bone and tract up to foramen caecum (Sistrunk’s operation).
Branchial cyst and fistula (鰓裂囊腫及瘻管)
Represent branchial apparatus remnants. The fistula results from persistence of the second pouch and cervical sinus.
Cysts usually lie deep to the anterior border of sternomastoid, presenting with a painless neck swelling or mimicking a parapharyngeal abscess if infection occurs. A complete branchial fistula has its internal opening in the region of the tonsil and an external opening anterior to sternomastoid. Diagnosis can be confirmed by needle aspiration of cyst contents.
Excision, with any fistulous tract.
Cystic hygroma (水囊狀淋巴管瘤)
A variety of lymphangioma.
A soft transilluminable mass usually presenting in the parotid region in the first year of life.
Excision, which may have to be incomplete because of the diffuse infiltration of soft tissues by the tumour.
Fish bones may lodge in the tonsil or tongue base.
The patient complains of pain on swallowing and points to the suprahyoid region. The bone may only be obvious on palpation: X-rays are unhelpful.
Removal under direct vision.
A bone or food bolus usually gets lodged at one of four sites:
One piriform fossa
The postcricoid region (15cm from the upper incisor)
The level of the aortic arch (at 25cm)
At the oesophago-gastric junction (40cm)
Dysphagia may be total, the patient spitting out saliva and pointing to the suprasternal or retrosternal region. A soft tissue lateral X-ray of the neck may delineate a bone.
Endoscopic removal should be undertaken as soon as possible, to avoid airway oedema, soft tissue infection or oesophageal perforation.
Often a peanut in a young child.
After an initial coughing fit there is often a latent period before respiratory distress becomes obvious. The chest X-ray may show collapse of the lung distally, if the obstruction is complete, or emphysema of the involved side if the obstruction acts as a one-way valve.
Localized infection with human papillomavirus (HPV).
In the child (juvenile form): multiple lesions that may spread to the trachea and bronchi. Cases may regress at puberty.
In the adult: less common and usually a single lesion.
Both forms present with hoarseness or airway obstruction.
Endoscopic removal using either suction diathermy or a CO2 laser. Surgical seeding of lesions within the larynx or trachea is common, and removal may be necessary for frequent recurrence.
Associated with cigarette smoking and high alcohol intake, although the latter is more important in causing piriform fossa carcinoma.
Usually presents as persistent hoarseness. Dysphagia, chronic cough, stridor and referred otalgia may also occur. Occasionally a supraglottic tumour may present with metastatic neck nodes. The tumour may be evident on indirect laryngoscopy but endoscopic assessment and biopsy are mandatory before deciding on the appropriate treatment. A second primary (1%) in the upper aerodigestive tract should be searched for at this time.
Fine-needle aspiration cytology of any suspicious neck mass should also be undertaken. A CT scan will show any spread outside the larynx, or involvement of laryngeal cartilages.
Small (T1 and T2) carcinomas are best treated with primary radiotherapy, laryngectomy being reserved for post-radiation recurrences, larger (T3 and T4) lesions and primary tumours associated with neck nodes greater than 2cm in diameter. Primary endoscopic excision of laryngeal carcinomas with a carbon dioxide laser is now being undertaken by some surgeons.
Following total laryngectomy the patient may be able to speak again by:
Learning oesophageal speech (swallowed air is voluntarily regurgitated through the pharynx)
Using an artificial larynx, which transmits vibrations into the pharynx and oral cavity while the patient articulates
Surgical provision of a tracheo-oesophageal fistula, which is fitted with a button or valve. The button has a one-way flutter valve, which allows airflow from the trachea into the pharynx when the tracheostome is occluded. In selected patients this enables the development of good voice.
Patients require close follow-up. Recurrences can develop in the larynx, pharynx, stoma or neck. Further surgery or radiotherapy may be indicated. The expected 5-year survival for a T1 laryngeal cancer is about 95%. This falls to about 50% for T4 disease.
Common. Usually associated with vocal abuse, smoking or sepsis elsewhere in the respiratory tract, e.g. chronic sinusitis.
Hoarseness may be accompanied by sore throat. Indirect laryngoscopy may distinguish localized forms, e.g. singer’s nodules, Reinke’s oedema or laryngeal polyps, from the generalized forms, e.g. chronic hypertrophic laryngitis.
Treatment involves the removal of any precipitating factors and speech therapy is important. Localized polyps or nodules may merit endoscopic removal.
Chronic specific laryngitis (慢性特異性喉炎)
Rare. Most of the granulomatous diseases can involve the larynx, e.g. tuberculosis, syphilis, sarcoidosis, scleroma or Wegener’s granulomatosis.
The lesions may mimic a carcinoma and a direct laryngoscopy and biopsy is mandatory. Treatment is that of the underlying systemic condition.
Usually affects the true cords. The aetiology is as for chronic non-specific laryngitis. Microscopically, the findings of hyperkeratosis and dysplasia are common, although in situ or invasive carcinoma can only be excluded by an adequate biopsy.
Endoscopy should be undertaken in all cases. Leukoplakia should be regarded as having the potential to undergo malignant change.
If symptoms of hoarseness, dysphagia, chronic sore throat or a lump in the neck continue for longer than 6 weeks, careful examination of the upper airway is mandatory.
Listen to the patient’s voice: is it intermittently or permanently dysphonic?
The former might suggest a functional problem, the latter an organic one. A breathy voice is a typical of a vocal cord palsy. Also, listen for evidence of stridor. A “hot potato” voice is indicative of supraglottic or oropharyngeal pathology.
When assessing the oral cavity and oropharynx, particular attention should be paid to mucosal ulceration or swelling. If the patient has a particularly brisk gag reflex, the palate and oropharynx should be sprayed with Lidocaine prior to attempting indirect laryngoscopy.
A warmed laryngeal mirror is used to visualize the larynx while the doctor gently holds the patient’s protruded tongue. The patient should mouth breathe. Vocal cord movement is assessed by asking the patient to say “Hey!” or “eeee…”. If the technique is not tolerated, then the patient’s better nasal airway is locally anaesthetized and a fibre-optic scope is used to examine the larynx and pharynx.
Both the nose and neck should be routinely examined as part of the assessment of the upper airway.
Mucous retention cysts, tonsilloliths or cysts of inspissated epithelial debris may occur. They are smooth and localized to one portion of the tonsil.
Symptomatic cysts may be helped by tonsillectomy.
Unilateral tonsillar swelling with an intact overlying mucosa may cause dysphagia and is suspicious of a lymphoma. The tonsil feels rubbery. Excision biopsy confirms the diagnosis.
After staging the disease, treatment involves radiotherapy for localized disease, with chemotherapy being added in more advanced cases.
Squamous carcinoma of the tonsil presents as otalgia, sore throat or dysphagia in heavy drinkers and smokers. More than 50%of cases have involved neck nodes ipsilaterally: this may be the mode of presentation. The tonsil is hard and ulcerated.
After full endoscopy and biopsy small primaries without nodes are best treated by radiotherapy. Surgery (which involves a block dissection of neck, partial mandibulectomy and excision of the primary) is reserved for radiation failures and large primaries.
Leukoplakia (舌白斑) A white patch which cannot be wiped away and for which no other diagnosis is apparent. Risk factors in the development of oral cavity or tongue leukoplakia include alcohol, smoking, spice and betel nut chewing, syphilis and dental trauma. About 5% of cases become malignant. Exclusion of an associated carcinoma is essential.
Tongue carcinoma (舌癌)
Almost all tongue carcinomas are squamous in origin. There need not be any pre-existing leukoplakia.
May present as an exophytic or infiltrative lump on the tongue. Pain and dysphagia are common. Referred otalgia (via lingual and glossopharyngeal nerves) may also occur. At presentation most tumours are greater than 2cm diameter and 50% have palpably involved lymph nodes.
Small lesions – Radiotherapy, using external beam or interstitial implant techniques, or surgery, in the form of a partial or hemiglossectomy are equally effective.
Large lesions – Treatment is with radiotherapy or surgery alone or a planned combination of the two. Both modalities produce quite severe functional disability in the oral cavity, especially regarding speech and swallowing.
Nasal obstruction in children is usually noted by parents,, particularly when accompanied by rhinorrhea and snoring. Adenoid hypertrophy is the common cause of pediatric nasal obstruction. However, the following conditions should also be borne in mind.
Posterior choanal atresia (後鼻孔閉鎖)
A congenital condition caused by persistence of the embryonic bucconasal membrane. The obstruction is at the posterior end of the nose near the edge of the hard palate.
In bilateral cases there is respiratory difficulty at birth aggravated by feeding and necessitating the use of an oral airway. Unilateral cases present later with unilateral nasal obstruction and rhinorrhea. Diagnosis is made by the inability to pass a rubber catheter through the nose into the pharynx and is confirmed by CT scanning.
Surgical division of the atretic plate by the transnasal or transpalatal route is required.
Nasal foreign body (鼻腔異物)
A common occurrence in children, e.g. with beads, pieces of sponge or paper.
Typically presents with unilateral foul blood-stained rhinorrhea, nasal vestibulitis and fetor.
A general anesthetic is occasionally required for removal in an uncooperative child.
Inflammation of the skin of the external auditory meatus.
Caused by either primary infection or contact sensitivity to topically applied substances such as cosmetics or antibiotics. Gram-negative organisms (e.g. Proteus, Pseudomonas) and fungi (e.g. Aspergillus) are often found.
Precipitating factors include impacted cerumen, local trauma, middle ear discharge through a tympanic membrane perforation, swimming and skin conditions such as psoriasis and seborrheic dermatitis.
Presents as otalgia, otorrhoea and deafness. The skin of the external auditory meatus is oedematous and inflamed. The meatus may be occluded with discharge and in fungal infections hypae may be seen. Traction on the pinna increases the otalgia, a sign not found in inflammatory conditions of the middle ear.
Debris must be removed from the meatus, either by dry mopping or by suction aided by the use of an operating microscope. A swab of the meatus is taken for bacteriology prior to the instillation of drops containing an antibiotic and steroid mixture. If the meatus is total occluded, an impregnated gauze wick may be inserted. In severe cases with cellulitis spreading onto the pinna systemic antibiotics are also needed.
Furunculosis of the external auditory meatus (外耳道癤)
Staphylococcal infection of hair follicles found in the lateral part of the meatus.
Presents as severe otalgia exacerbated by traction on the pinna, with deafness if the meatus becomes occluded. The furuncle is often visible.
Most furuncles rupture spontaneously. Ribbon gauze impregnated with glycerin/ichthammol may be inserted daily into the meatus. Systemic flucloxacillin and analgesics are also needed.
A potentially fatal Pseudomonas infection of the external auditory meatus, with spread to the skull base. It occurs in elderly diabetics and also in patients with HIV/AIDS.
Presents as severe otalgia, otorrhoea and deafness with progression to cranial nerve palsies (VII, IX, X, XI, XII) in advanced cases.
Treatment is by local surgery, usually mastoidectomy, combined with a prolonged course of specific antipseudomonal antibiotics. Skull base involvement and its response to treatment may be assessed by radioisotope scanning.
A very common disease particularly affecting children between the ages of 4 and 10 years.
Over 50% of the cases are due to a B haemolytic streptococcus, the majority of the others being of viral, staphylococcal or pneumococcal origin.
Sore throat, dysphagia, pain on swallowing and otalgia are associated with pyrexia and general malaise. The pharyngeal mucosa appears red and the tonsils are often enlarged and covered by discrete microabscesses or a confluent exudate.
The tonsils often remain chronically enlarged and inflamed. Lymphadenopathy is frequent, the jugulo-digastric nodes being most commonly involved. A full blood count reveals a leukocytosis but a bacteriology swab does not always grow the pathogen concerned.
Infectious mononucleosis – it may be impossible to distinguish between the two without a Paul-Bunnell test and a differential white cell count (the latter shows atypical monocytes and a lymphocytosis).
Blood dyscrasias – any white cell abnormality giving an impaired immune status may present as a severe pharyngitis, e.g. acute leukaemia.
Diphtheria – rarely seen but should always be borne in mind when there is a membranous exudate over the tonsils or when severe airways obstruction is evident.
Bed rest, antibiotics and adequate hydration. Penicillin is given (orally or intravenously) unless organism sensitivities or allergy dictate otherwise. In severe cases with grossly enlarged tonsils a tracheostomy may be necessary for airway obstruction.
Recurrent episodes over a prolonged period of time are best managed by tonsillectomy. Following surgery the tonsillar fossae heal over a period of 7-10 days during which time they are covered by a slough, which may mimic an ulcerative pharyngitis. Infection and secondary haemorrhage from the fossae can occur during this period.
Peritonsillar abscess (quinsy): hospitalization, antibiotics and intraoral incision and drainage are required
Parapharyngeal abscess: requires surgical drainage through an external neck incision
Acute otitis media
Post-streptococcal rheumatic fever/glomerulonephritis: now rare.
The hallmark of laryngeal obstruction is stridor. Inspiratory stridor indicates glottic or supraglottic obstruction, expiratory stridor bronchial obstruction and two-way stridor subglottic obstruction. If stridor is accompanied by cyanosis, tachycardia and intercostal and sternal recession, urgent measures are needed to save life. In less severe cases a hoarse voice, feeding problems and recurrent chest infections may occur.
Congenital laryngeal obstruction (先天性喉阻塞)
Congenital anomalies include laryngeal cysts, webs, stenosis, vascular rings and vocal cord paralysis. Laryngomalacia is a condition caused by abnormal flaccidity of the larynx allowing the supraglottic structures to be drawn into the airway on inspiration; the condition resolves with age.
All cases of congenital stridor should undergo direct laryngoscopy.
Acquired laryngeal obstruction (後天性喉阻塞)
Acute epiglottitis – due to Haemophilus influenzae. It causes rapidly progressive airway obstruction.
Acute laryngotracheobronchitis (croup) – due to para-influenzae virus or respiratory syncytial virus. It produces oedema, exudates and crusting of the larynx, trachea and bronchi.
Subglottic stenosis – may follow infant tracheostomy or prolonged endotracheal intubation.
Acute epiglottitis – treatment is with intravenous chloramphenicol. Endotracheal intubation or an emergency tracheostomy may be necessary.
Acute laryngotracheobronchitis – endotracheal intubation is rarely required.
Benign tumours – include papillomas, adenomas, osteomas and angiomas. The inverting papilloma may undergo malignant change.
Malignant tumours – 50% of malignant tumours are found in the maxillary sinus. Squamous cell carcinoma is the most common type. Others include adenocarcinoma, adenoid cystic carcinoma, melanoma and sarcoma.
Benign tumours frequently present as a unilateral nasal polyp. Malignant tumours spread medically to produce nasal obstruction or epistaxis, posteriorly to give Eustachian tube obstruction and cranial nerve palsies, inferiorly to disrupt the teeth to give proptosis or epiphora. Lateral spread produces swelling of the cheek.
Prior to treatment planning, histological diagnosis and radiological assessment of the extent of the tumour using CT scanning and sinus tomography are necessary. Benign tumours are treated by local extension, either endoscopically or by an external lateral rhinotomy approach.
Malignant tumours have a poor prognosis due to their late presentation and extensive spread. When curative treatment is possible a combination of radical surgery (maxillectomy) and radiotherapy is usually used. The resulting defect is filled with a dental plate and obturator.
Lymphoid tissue found at the junction of the roof and posterior wall of the nasopharynx, thought to be involved in the development of humoral immunity as a component of the “gut associated lymphoid tissue” (GALT). Adenoid tissue is present at birth and during childhood, beginning to atrophy before puberty.
Adenoidal hypertrophy disturbs nasopharyngeal airflow and Eustachian tube function and can also act as a focus of infection for adjacent sites. Common clinical features are nasal obstruction and discharge, deafness due to middle ear effusion and otalgia due to recurrent otitis media.
Gross adenoidal enlargement, often associated with tonsillar hypertrophy, can cause sleep apnoea syndrome in which apneic episodes during sleep are associated with daytime somnolence and in severe cases pulmonary hypertension and cor pulmonale. Clinical suspicion of enlarged adenoid can be confirmed by lateral radiography.
Surgical removal (adenoidectomy) can be undertaken if enlarged adenoids are causing sleep apnoea, nasal obstruction or are a contributing factor to persistent middle ear effusions or recurrent otitis media.
Atrophic rhinitis (萎縮性鼻炎) Aetiology: A disease of unknown aetiology, occurring mainly in developing countries. It can occur following radical turbinectomy operations or radiotherapy to the nasal cavity. Clinical features: Nasal crusting, anosmia and fetor are present. Paradoxically, although the nasal cavity is widely patent, the sensation of nasal obstruction is common. Management: Treatment is by removal of crusts and nasal douches.
Hypersensitivity to inhaled or ingested allergens causes nasal mucosal oedema and exudation. Allergy may be seasonal (e.g. pollens) or perennial (e.g. dust). Allergies may be demonstrated by skin tests.
Presents as nasal obstruction, sneezing and rhinorrhea with mucosal oedema on examination.
Treat with steroid nasal spray and oral antihistamines. Avoid any known allergens.
Traumatic – after septal surgery, nose picking, cocaine sniffing and pressure from foreign bodies and nasal polyps.
Infective – due to syphilis and tuberculosis.
Chronic inflammatory – Wegener’s granulomatosis is a non-neoplastic upper airways granuloma associated with focal lung and kidney lesions. (Lethal) midline granuloma is thought to be an atypical lymphoma occurring in the midline of the face.
Asymptomatic, or nasal crusting and epistaxis are characteristic of septal perforation.
Treatment is by removal of crusts, nasal douches and treatment of underlying systemic conditions.
Septal abscesses usually result from secondary infection of a septal haematoma.
Manifests by the development of severe pain, nasal swelling and pyrexia following a septal haematoma. Cartilage necrosis often complicates septal haematoma and abscess with the production of a saddle-nose deformity.
Treatment is by incision and drainage with appropriate antibiotic therapy.
A collection of blood beneath the mucoperichondrium and posteriorly the mucoperiosteum of the nasal septum.
Usually complicates nasal trauma, either accidental or iatrogenic following septal surgery. Rarely a spontaneous haematoma can occur in a bleeding diathesis.
Presents as nasal obstruction with widening of the septum on inspection.
In the acute stage, treat by incision and drainage, however, after 48hrs, organization of haematoma occurs and evacuation of the clot is difficult. Antibiotics are given to prevent secondary infection.