Книга_4440_Библиотеки_им_академика_М_И_Перельмана

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5 History andExamination ofNasopharynx

(e) Severity of symptoms

• Mild—adenoid (grades 1 to 2), NPC stage 1, Thornwaldt cyst

• Moderate—NPC stage 2, JNA stage 2

• Severe—NPC stage 4, JNA stages 3 and 4

(f) Progression of symptoms

• Progressive—Thornwaldt cyst, adenoid (grades 1–3), JNA, NPC

• Non-progressive—adenoid (grade 4)

(g) Family h/O nasopharyngeal carcinoma (h) History of predisposing factors for PNC

Are male Eat a diet rich in salt-cured sh and meats Have a family history of nasopharyngeal cancer Have certain genes linked to cancer development Have come in contact with EBV Smoke Drink a lot of alcohol Work around wood dust or a chemical called formaldehyde

5.2 Examination ofNasopharynx andAssociated Examination

1. Examination of nasopharynx

(a) Posterior rhinoscopy—This is the exami-

nation of nasopharynx and posterior part of nose (choana) with the help of a posterior rhinoscopy mirror or nasal endoscope.

Procedure—Patient is seated in infront of an examiner and headlight or head mirror is used for illumination. Patient is asked to open mouth with tongue inside and advised to breathe through nose to maintain patency of nasopharyngeal isthmus. A tongue depressor is used to depress the tongue not to touch the posterior part of the tongue to avoid gag reex and a posterior rhinoscopy mirror is inserted in the

oropharynx posterior to the uvula. The mirror should be facing the nasopharynx. If any patient is having gag reex or uncooperative, the oropharynx can be anaesthetized with xylocaine spray. In this examination, various anatomical sites such as posterior end of inferior and middle meatus, nasal septum, eustachian tube opening, torus tuberosity, fossa of rosenmuller, roof of nasopharynx, lateral wall of nasopharynx, Fossa of rosenmuller’s are visualized (Fig.5.1).

Clinical ndings/structures/anatom-

ical variations visualized (Fig. 5.2)

• Choana (posterior nasal aperture) – Normal—It is the posterior nasal

opening which connects the nasal

cavity to the nasopharynx – Narrow—stenosis, mass, growth – No opening—choanal atresia – Wide—atrophic rhinitis – Mass present—AC polyp, angio-

matous polyp, JNA, ethmoidal

polyp, sphenochoanal polyp

• Eustachian tube opening – Normal—It is closed but opened

intermittently while swallowing, speaking

– Narrow—It may be to oedema,

growth, swelling

– Wide (patulous)—It is a closed

structure but, in some cases, it is wide open termed a patulous Eustachian tube

• Mass/growth/swelling/bulging – Type of growth

Endophytic—NPC, SCC Exophytic—NPC, JNA, Papilloma

– Position of mass/growth/swelling

Filling nasopharynx—AC polyp, JNA, ethmoidal polyp Lateral (one side)—JNA, choanal part of AC polyp, NPC, sphenochoanal polyp Middle of nasopharynx—adenoid

yngeal

Super

5.2 Examination ofNasopharynx andAssociated Examination

Fig. 5.1 (a) Procedure of posterior rhinoscopy and (b) structure visualized on posterior rhinoscopy

221

Adenoids

Posterior

free margin

of septum

ior meatus

Middle meatus

Eustachian

cushion

Superior turbinate

Middle turbinate

Inferior turbinate

Phar opening of eustachian tube

Fig. 5.2 Disorders of choana. (a) Choanal atresia (nasal view), (b) Choanal atresia (posterior view), (c) Choana

222

5 History andExamination ofNasopharynx

– Site of origin nasopharynx

Posterior wall—Thornwaldt cyst Lateral wall—JNA, NPC Superior wall—adenoid

– Surface of mass/swelling

Smooth—AC polyp, JNA, Thornwaldt cyst, sphenochoanal polyp Irregular—ethmoidal polyp, NPC, adenoid

– Colour of mass

White—AC polyp Yellow—ethmoidal polyp, sphenochoanal polyp Reddish—JNA

– Types of insertion

Sessile—adenoid, Thornwaldt cyst, NPC, SCC Pedunculated—AC polyp, JNA, sphenochoanal polyp, ethmoidal polyp

– Side

Unilateral—NPC, sphenochoanal polyp Bilateral—adenoid, ethmoid polyp

(b) Anterior rhinoscopy—It is described in

the examination of the nose.

• Mass—U/L or B/L, site

• Bowing of septum

• Bleeding

• Pus

Oral examination—Deviation of the uvula, gag reex, atrophy and deviation of the tongue, bulging of the soft palate.

Examination of neck—This is done for Lymph node enlargement in the cervical region and any weakness of the sternocleidomastoid muscle.

Facial examination—To rule out any numbness over the face or facial fullness.

Orbital and eye examination—To rule out third, fourth and sixth cranial

nerve palsy and corneal reex, proptosis, ptosis, pupillary reex.

Examination of ear—Otoscopy done to rule out any glue ear and conductive hearing loss.

Cranial nerve examination—This examination is done to know the involvement of III, IV, V, VI, IX, X, XI, XII cranial nerves.

Other examination—Trismus, darth vader breathing, cracked lips and dry mouth.

5.3 Dierential Diagnosis ofFindings/Mass/Growth onPosterior Rhinoscopy

• Choana (posterior nasal aperture)

• Size/diameter (Fig.5.2)

Narrow—stenosis, mass, growth. No opening (atresia)—choanal atresia; it can be unilateral or bilateral. Wide—atrophic rhinitis, post posterior septectomy.

• Eustachian tube opening—It is present around 1.25cm behind and slightly above the posterior end of inferior turbinate (Fig.5.3).

Normal—It is collapsed opening at rest can be seen open up on swallowing and yawning. Narrow—It may be to oedema, growth, swelling. Wide (patulous)—It is closed structure but, in some cases, it is wide open termed as patulous eustachian tube.

5.3 Dierential Diagnosis ofFindings/Mass/Growth onPosterior Rhinoscopy

ab c

Fig. 5.3 Eustachian tube in nasopharynx (endoscopic view). (a) Normal, (b) Narrow, (c) Wide (patulous)

ab c

223

Fig. 5.4 Clinical pictures of nasopharyngeal disease and tumour. (a) Thornwaldt cyst, (b) Nasopharyngeal carcinoma, (c) Juvenile nasopharyngeal angiobroma, (d) Adenoid

• Growth/mass/swelling – Type of growth

Endophytic—NPC, SCC Exophytic—NPC, JNA, Papilloma

– Position of mass/growth/swelling

Filling nasopharynx—AC polyp, JNA, Ethmoidal polyp Lateral (one side)—JNA, Choanal part of AC polyp, NPC, sphenochoanal polyp Middle of nasopharynx—adenoid

– Site of origin nasopharynx

Posterior wall—Thornwaldt cyst

Lateral wall—JNA, NPC Superior wall—adenoid

– Surface of mass/swelling

Smooth—AC polyp, JNA, Thornwaldt cyst, sphenochoanal polyp Irregular—ethmoidal polyp, NPC, adenoid (Fig.5.4d)

– Colour of mass

White—AC polyp, ethmoidal polyp Yellow—ethmoidal polyp, sphenochoanal polyp Reddish—JNA, angiomatous polyp

224

5 History andExamination ofNasopharynx

Pinkish—adenoid

– Types of insertion

5.4 Syndromes Aecting theLast Four Cranial Nerves

Sessile—adenoid, Thornwaldt cyst (Fig.5.4a), NPC, SCC (Fig.5.4b) Pedunculated—AC polyp, JNA, sphenochoanal polyp, ethmoidal polyp

– Side

Unilateral—JNA (Fig. 5.4c), sphenocho-

1. Types of extramedullary syndrome (Table

5.1)

2. Type of intramedullary syndrome (Table

5.2)

3. Other cranial nerve syndrome (Table 5.3)

anal polyp Bilateral—adenoid, ethmoid polyp

Trotter’s triad—conductive hearing loss+palatal paralysis+trigeminal neuralgia

Table 5.1 Extramedullary syndrome

Types of Jugular foramen syndrome Denition Causes Collet-Sicard syndrome It is dened as unilateral palsy of

lower cranial nerves ix, x, xi, and xii. In 1915, Frederic Collet described this syndrome. This is due to posterior lateral condylar space involvement

Villaret’s syndrome (retroparotid space syndrome)

The involvement of IX, X, XI, XII cranial nerves and sympathetic chain (Horner’s syndrome) is known as Villaret’s syndrome. It was rst described by Maurice Villaret. It is due to the involvement of retropharyngeal space involvement. Presented as dysphonia, dysphagia, loss of taste over post 1/3rd of the tongue

Metastasis at skull base— adenocarcinoma prostate, CA cervix, clear cell RCA, Colon CA, disseminated adenocarcinoma Vascular lesions— Internal carotid artery (ICA) dissection, ICA aneurysm, ICA dysplasia, thrombosis IJV Trauma—basilar skull fracture, C1 fracture (Jefferson fracture), obstetric Tumours—neurilemmoma of 12th nerve, glomus jugulare tumour, multiple myeloma, haemangiopericytoma, brosarcoma neck Iatrogenic—cervical angiography, cardiovascular surgery Inammatory—PAN, osteolyelitis

Trauma, osteomyelitis of the skull base, jugular vein thrombosis

(continued)

5.4 Syndromes Aecting theLast Four Cranial Nerves

Table 5.1 (continued)

Types of Jugular foramen syndrome Denition Causes Vernet’s syndrome Involvement of cranial nerves IX, X,

XI nerves presented as dysphonia, soft palate dropping, dysphagia, decreased parotid secretion, loss of gag reex, SCM and Trapezius muscle paralysis

Eagle’s syndrome IX cranial nerve involvement,

presented as glossopharyngeal pain

Schmidt’s syndrome X, XI cranial nerves involvement

presented as paralysis of soft palate, vocal cords, sternomastoid muscle and trapezius muscle

Tapia syndrome X, XII cranial nerve, retroparotid

space involvement

Lesion involving jugular foramenlike tumour, vascular lesion, trauma Primary tumours—glomug jugulare, meningioma, vestibula schwannoma, CP angle metastasis Inammation—meningitis, malignant O.E., sarcoidosis, GB syndrome Trauma Cholesteatoma Giant cell arteritis, post-carotid endartectomy, SLE Narrowing of Jugular foramen due to bone disease

Elongated styloid process, ossied Stylohyoid ligament

Extra axial lesion, intramedullary ds

Tumour of the parotid and skull base Carotid aneurysm, high neck injury

225

Table 5.2 Intramedullary syndrome

Intramedullary syndrome Nerve involve Causes Jackson’s syndrome Involvement of X and XII nerve,

and contralateral hemiparesis

Avellis syndrome X cranial nerve and contralateral

hemiparesis

Wallenburg’s syndrome V, IX, X, XI cranial nerve,

Ipsilateral hemiparesis, cerebellar ataxia, contralateral loss of pain and temperature

Dejerine syndrome XII nerve, and contralateral

hemiparesis

Table 5.3 Other syndromes

Name of lesion Nerve involvement Causes Cavernous sinus thrombosis ICA, sympathetic chain, III, IV, VI

and V nerve (rst and second division)

Superior orbital ssure syndrome III, IV, V (rst division) and VI

nerve Petrous apex syndrome Pain in V and VI nerve dermatome Petrositis Petrosphenoidal region II, III, IV, V, and VI cranial nerves Trauma

Infarct/tumour, in the brain stem or peripheral pyramidal tract

Infarct/tumour of the brain stem or peripheral pyramidal tract

Lesions involve lateral medulla, nucleus ambiguus, nucleus and spinal tract of trigeminal, vestibular nuclei, inferior cerebellar peduncle (occlusion of PICA, vertebral artery)

Lesions involve the medial medulla, pyramidal tract or medial lemniscus (occlusion of vertebral artery)

Infection of Lip, teeth, sinus

Trauma, infection, inammation

226

5 History andExamination ofNasopharynx

5.5 Dierential Diagnosis ofTumours ofNasopharynx

1. Benign tumour of nasopharynx (Table 5.4)

2. Malignant tumour of nasopharynx (Table

5.5)

Table 5.4 Benign tumours of nasopharynx

Types Name Clinical features Developmental Thornwaldt cyst

Hairy polyp Teratoma

Ectodermal Papilloma

Adenomatous polyp

Mesodermal JNA

Fibro myxomatous polyp Choanal polyp Osteoma Fibrous dysplasia Craniopharyngioma Solitary brous tumour Desmoid bromatosis, Schwannoma

Benign salivary gland tumour Pleomorphic adenoma

Monomorphic adenoma

Mostly asymptomatic, or halitosis, ETD, postnasal drip, nasal obstruction

B/L Nasal obstruction, post nasal drip

Nasal obstruction, nasal bleeding, lower four cranial nerve syndrome, nasal mass

Nasal obstruction

Table 5.5 Malignant tumours of nasopharynx

Types of tumours Name of tumour Presentations/clinical features Epithelial Nasopharyngeal carcinoma,

Undifferentiated carcinoma,

Squamous cell carcinoma Embryonal Chordoma Lymphoid Lymphoma Mesodermal Haemangiopericytoma, malignant

brous histiocytoma,

rhabdomyosarcoma Malignant salivary tumour Adenoid cystic carcinoma,

mucoepidermoid carcinoma, acinic

cell carcinoma, adenocarcinoma Metastatic tumour Adenocarcinoma, papillary

carcinoma

Nasal obstruction, nasal bleeding, lower four cranial nerve syndrome, SOM

Nasal obstruction, nasal bleeding

Nasal obstruction

History andExamination ofLip andOral Cavity

6.1 Symptoms/Chief Complaint/ History ofLip andOral Cavity Disorders

6.1.1 Symptoms/Presentation/ History ofLip Disorders or Diseases

(a) Deformities of lip

• Types of deformities – Cleft deformities—U/L cleft lip, B/L

cleft lip, midline cleft, lower lip cleft

– Non-cleft deformities (Table6.1)

• Site of deformities – Upper lip—U/L cleft lip, B/L cleft lip

with or without cleft palate, congenital double lip, lipoblastomatosis

– Lower lip—Trauma, lip pits, cleft lip

• Time of onset of deformity – Congenital—Cleft lip – Acquired—Trauma, growth, swelling

• Associated symptoms—Cleft palate,

nasal deformities, mandibular and maxillary deformity and other deformities.

(b) Growth over lip

• Type of growth – Endophytic (Ulcerative)—The causes

are squamous cell carcinoma

– Exophytic (Proliferative)—SCC, ade-

noid cystic carcinoma, squamous papilloma, pyogenic granuloma

• Site of growth – Upper lip—BCC, SCC – Lower lip—Lip carcinoma – Angle of mouth—SCC

• Duration – Short—SCC, BCC, infectious lesions – Long—Benign tumour

• Mode of onset – Sudden—Trauma, infection – Spontaneous—BCC, SCC, granuloma – Progression – Progressive or not—Most of the growth

is progressive

• Associated symptoms—Smoking,

guthakha chewing, paan chewing, alcoholism, fever, fair skin, excessive sun exposure

• Site – Upper lip—Cold sores (herpetic ulcer),

aphthous ulcer (cancer sore), BCC

– Lower lip—Cold sores (herpetic

ulcer), aphthous ulcer (cancer sore),

SCC – Angle of mouth—Angular stomatitis – Both lips—Steven-Johnson syndrome,

cold sore

• Duration—Short duration or long duration

• Mode of onset—Sudden (trauma, burn, herpes) or gradual (aphthous ulcer)

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025 S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck Surgery, https://doi.org/10.1007/978-981-96-1765-4_6

227

228

Table 6.1 Shows non-cleft deformities of lip

Deformity Denition

Deformities of both lips

Lip pits Depression located on the vermilion of the lower lip, usually paramedian Commissural pit Depression located at an oral commissure Lip freckle Increase lip focal pigmentation of the vermilion of the lip Prominent nasolabial

fold

Underdeveloped

nasolabial fold

Deformities of lower lip

Everted vermilion of

lower lip

Thick vermilion of

lower lip

Thin vermilion of lower

lip

Deformities of upper lip

Everted vermilion of

upper lip

Tented vermilion upper

lip

Thick vermilion upper

lip

Thin vermilion upper lip Height of the vermilion of the upper lip in the midline is more than 2 SD above the

U-shaped vermilion

upper lip

The exaggerated bulkiness of the crease or fold of skin running from the lateral margin of the nose, where the nasal base meets the skin of the face, to a point just lateral to the corner of the mouth

Reduced bulkiness of the crease or fold of skin running from the lateral margin of the nose, where the nasal base meets the skin of the face, to a point just lateral to the corner of the mouth

Inner aspect of the lower lip vermilion (normally opposing the teeth) is visible in a frontal view.

Height of the vermilion of the lower lip in the midline is more than 2 SD above the mean.

Height of the vermilion of the medial part of the lower lip is more than 2 SD below the mean.

Inner aspect of the upper lip vermilion (normally opposing the teeth) is visible in a frontal view.

Triangular appearance of the oral aperture with the apex in the midpoint of the upper vermilion and the lower vermilion forming the base

Height of the vermilion of the upper lip in the midline is more than 2 SD above the mean.

mean. Gentle upward curve of the upper lip vermilion such that the Centre is placed well

superior to the commissures.

6 History andExamination ofLip andOral Cavity

• Progression—Increasing in numbers and severity or not

• Numbers

– Single—Self bites, trauma – Multiple—Aphthous ulcer, stomatitis,

Behcet’s disease, cold sores, StevenJohnson syndrome

• Associated symptoms—H/o fever, physical stress, hormonal changes in female, blood disorder, Behcet’s disease, anaemia, dental work, using oral hygiene products containing lauryl sulphate, poor oral hygiene, food allergy

(d) Swelling over lip

• Site

– Upper lip—Injury, allergic contact der-

matitis, granulomatous cheilitis (Crohn’s disease, sarcoidosis, cancer, infection), cystic acne, furunculosis,

broma, retention cyst, furunculosis, pleomorphic adenoma, canalicular adenoma, lipoma, leiomyoma, nerve tumour (neurilemmoma/schwannoma, neurobroma), benign brous histiocytoma, oral focal mucinosis, granular cell tumour, periapical abscess, tuberculosis, syphilitic gumma, deep fungal infection

– Lower lip—Injury (cuts, bites, burns or

trauma), cheilitis glandularis, retention cyst

– Both lips—Allergies, oral allergy syn-

drome, angioedema, anaphylaxis, Miescher- Melkersson-Rosenthal syndrome, cellulitis

– Angle of mouth—Cold sores, herpes

infection

• Side of lesion

6.1 Symptoms/Chief Complaint/History ofLip andOral Cavity Disorders

Table 6.2 Shows associated symptoms with swollen lips

Associated symptoms with swollen lips Diagnosis Wheezing, urticaria, sneeze, stuffy nose Allergic reaction Vomiting, stomach cramp, dyspnoea, wheezing, cough, swollen tongue, dizziness,

cough Rashes, itchy eyes, swelling of tongue or face, vomiting, feeling sick, diarrhoea,

headache Breathing difculty, dizziness, swelling eye and face, diarrhoea and vomiting, anxiety

and headache Swelling (hands, around eyes, genital) Angioedema History of injury Trauma

Food allergy

Insect bites, stings, drug allergy

Anaphylaxis

229

– Localized—Injury, cyst, ca lip, furun-

culosis, braces, surgery, retention cyst, broma, pleomorphic adenoma, canalicular adenoma, lipoma, leiomyoma, nerve tumour (neurilemmoma/schwannoma, neurobroma), benign brous histiocytoma, herpes infection, syphilis

– Generalized—Angioedema, allergy,

oral allergy syndrome, anaphylaxis, cellulitis, sunburn, drug allergy, vitamin B12 def., Miescher-MelkerssonRosenthal syndrome

• Duration

– Short—Injury, angioedema, allergy,

furunculosis, cold sores, herpes infection

– Long—Benign tumour (broma, reten-

tion cyst, pleomorphic adenoma, canalicular adenoma, lipoma, leiomyoma, nerve tumour (neurilemmoma/schwannoma, neurobroma), benign brous histiocytoma)

• Mode of onset

– Sudden—Angioedema, allergy, injury,

angioedema, allergy, furunculosis, cold sores, herpes infection

– Spontaneous—Benign tumour

(broma, retention cyst, pleomorphic adenoma, canalicular adenoma, lipoma, leiomyoma, nerve tumour (neurilemmoma/schwannoma, neurobroma), benign brous histiocytoma)

• Progression

– Progressive—Angioedema, allergy

– Non-progressive—Retention cyst

• Diurnal variation – Morning—Food allergy (milk, peanut,

eggs, tree nuts, soya, wheat)

• Associated symptoms—Burning sensa-

tion, redness, rashes, itching, hives, cough, wheezing, pimple (Table6.2)

(e) Discolouration of lip—Lip discolouration

can occur as a result of a fungal infection, iron deciency anaemia, sun exposure or an allergic reaction.

• Types of discolouration – Blue lips—Cyanosis – Black spot on lips—Vitamin B12 de-

ciency, dehydration, excessive intake of iron, drugs (chemotherapy, chlorpromazine, quinine, phenytoin, amiodarone)

– Brown or greyish—Melasma, Laugier-

Hunziker syndrome

– Dark spot—Lipstick, facemask, green

tea, hair dye or hair lightening cream, hypothyroidism, venous lake, sun spot, Peutz-Jeghers syndrome, smoking

– White spot—It is due to leukoplakia,

candidiasis, Fordyce spot – Pale lip—Anaemia – Congested/red lips—Plummer-Vinson

syndrome

(f) Other symptoms of lip disorders

• Perioral hyperpigmentation—Increased pigmentation, either focal or generalized, of the skin surrounding the vermilion of the lips.

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