At rest At rest with the tongue depressed
Upon phonating "AAA" Upon phonating "EEE"
[Arrow- Wharton's duct opening, 1- phrenulum,
V- lingual vein, dashed-circle- sublingual gland].
Arrow -Wharton's duct opening
Star denotes circumvallate papilla which runs over V-shaped outline with its apex
located at the obliterated foramen caecum. It divides the base of tongue (posteriory) from its anterior part.
SP- soft palate, HP- hard palate, arrow- surface marking of incisive foramen,
white dots- surface marking or greater and lesser palatine foramina. Note the corrugated surface of deeply adherent mucoperiosteum of hard palate
HP- hard palate, SP- soft palate, A- alveolus,
yellow line- junction of hard/soft palate
A clearly demarcated junction in a patient who has trismus due to
bucco-alveolar sulcus abcess. The hard palated appeared keratinized
and the tongue surface coated. Small ulcer is seen (arrow)
This figure shows the saliva secreted from minor salivary glands
of the palatal mucosa (yellow arrows).
[HP- hard palate, SP- soft palate, U- uvula, T- tonsil, blue line- junction of hard/soft palate]
Figure shows mucosal appearance of soft palate in a histologically-confirmed dysplasia. Intervening border beween nornal (anteriorly) and affected area (posteriorly) is clearly seen.
The appearance of Stensen's duct opening on inner aspect of buccal mucosa (right side in this figure).
Figure shows anabcsess involving left upper buccoalveolar sulcus.
ML- upper molar tooth, T- tongue, star- erythroplakia lesion,
arrows- intervening leukoplakia border.
This can occur secondary to poor oral hygiene, chronic heavy smoking,
and in betel quid consumption. Fungal infection need to be considered.
Staining of filiform papillae after prolonged betel leaf chewing. This leaf is usually taken together with aracea nut and mixed with mineral slaked lime (calcium hydroxide). It also predisposes to submucous fibrosis
and dysplastic changes in the oral cavity.
This elderly lady presented with left lateral border ulcer and granuloma formation. Biopsy was negative for malignacy or dysplastic changes. The culprit was the second molar tooth whic had caused recurrent traumatic abrasion most likely as a consequent of alveolar resorption which occurs with ageing process.
Inflammation of mucous membranes of oral cavity in a patient undegoing oncologic treatment of head and neck cancer is a common phenomena. Oral disinfective rinse/gargle, pain relief, and attention to hydration and nutrition are essential during this acute phase which will slowly recover with time.
The majority of submandibular salivary gland calculi are radiopaque and visible on X-ray. This patient has inflamed and swollen left floor of mouth with pus emanating from the Wharton's duct. Intraocclusal view showed at least 2 radiopaque stones with the bigger one situated more anteriorly.
Pointer- lingual nerve, M- myelohyoid muscle, D- digastric muscle,
SM- submandibular gland being reflected downward, H- towards head, T- towards thorax, ML- medial, L- lateral, interrupted yellow line- lower border of mandible.
Tonsillar crypts and clefts predispose to several conditions like peritonsillar abscess, retained food residues, and tonsillolith formations. Halitosis and
unusual tonsillar appearance are the usual presenting symptoms though it can be asymptomatic and found by chance on examination. Oropharyngeal endoscopic assessment, probing with blunt instrument, and digital palpation need to be done. Figure shows cheesy-white materials in the supratonsillar cleft due to food residue/epithelial sloughs entrapment. Beware of the underlying dysplasia/malignancy and if in doubt examination under anaesthesia
with/without excision biopsy (tonsillectomy)
will have to be performed.
This figure shows a small shallow ulcer with overlying
fibrinous exudate involving right palatoglossal fold.
Multiple larger size ulcers.
This figure shows an ulcer over the inferior pole of right tonsil
after an alleged injury caused by chicken bone fragment.
This image shows thick membranous exudate involving both tonsils in acute tonsillitis. Severe odynophagia with poor oral intake warrants hospital admission with intravenous fluid and antibiotics therapy given.
Peritonsillar abscess is a collection of pus beyond the capsule of the tonsil. Clinically, mucosal inflammation with swelling will be noted and the tonsils itself is pushed medially and the uvula can be seen off midline to the opposite site. Figure shows left peritonsillar abscess and the red dot point to the drainage spot for diagnostic aspiration/drainage.
Figure shows an extrinsic mass which had caused medial and downward bulge of the soft palate and pushing the right tonsil towards midline. The adjacent figure shows the excised specimen- a firm multibosselated pleomorphic adenoma.
Ulcero-fungating carcinoma involving right tonsil and its pillars.
[Circle- carcinoma lesion, U- uvula, SP- soft palate]
Solid tumour presenting as an asymmetric left tonsillar enlargement.
Figure shows a resolving lingual tonsillitis (circles).
It presents with sorethroat and pain upon swallowing.
Yellow line- median glossoepiglottic fold, red arrows- lateral glossopeiglottic folds.
View on outpatient endoscopic assessment
of a cyst originating from its lingual surface.
Cyst arising along left pharyngoepiglottic fold.
Direct laryngoscopy view showing pedicle attachment
of an aryepiglottic cyst prior to its excision.
Video showing mucoid milky content of a cyst.
Uncapping of the cyst wall was then perfomed along its perimeter to allow
re-epitelization from the normal surrounding mucosa
while minimizing risk of recurrence.
Boyle-Davis mouth gag
Before Surgery After Surgery
[By Using Cold Instruments]
Sloughs formation in the tonsillar bed is a normal phenomena after tonsillectomy.
As normal healing occurs, this will be replaced by normal epithelium
usually within 1-2 weeks.
This image shows the appearance of tonsillar fossa
after tonsillectomy performed for obstructive sleep apnoea (OSA).
Elongated uvula can be associated with habitual snoring and OSA
as well as potential cause of unexplained throat irritation and coughs.
Incidental finding in aymptomatic individual is common.
Cleft palate causes difficulty in feeding, nasal regurgitations, and hyponasality. It predisposes to eustachian tube dysfunction with formation of "glue" ear for which
insertion of a ventilation tube being commonly indicated.
The nasopharyx in a patient with cleft soft palate.
Midline mucosal fold which corresponds to the underlying midline raphe
where the constrictor muscles from either sides meet.
Figure shows the occasionally seen demarcation between superior
and middle pharyngeal constrictor muscle groups (white dots).
During spontaneous breathing Upon phonation
Upon forceful nose blowing with the mouth closed
Figure shows an internal sinus opening (arrow) in branchial arch anomaly.
These figures show anteromedial projection of right superior thyroid cartilage cornua (circle). It can be associated with foreign body sensation or globus.
This finding is mostly incidental and it rarely cause significant symptom.
Similar lesion may also be seen following laryngeal trauma.
The post-cricoid region is one of the subsite of hypopharynx. It not visualized upon indirect or rigid laryngoscopy examination as it is kept close by tonic contraction by the upper oesophageal sphincture which only opens upon second stage of swallowing.
The hypopharynx leading to upper Occasionally brisk opening seen opon
oesopageal sphincter. laryngeal examinarion (arrow).
Spontaneous upper oesophageal Upper osophageal opening
sphincter opening- a rare view. upon rigid oesophagoscopy.
Figure shows cumulation of saliva in the hypopharynx caused by pseudobulbar palsy. Dysphagia, dysphonia, and aspiration are the main issues that need wholesome management.
Normal symmetrical function in all areas Grade II Slight weakness noticeable only on close inspection Grade III Obvious weakness, but not disfiguring May not be able to lift eyebrow Complete eye closure and strong but asymmetrical mouth movement with maximal effort Obvious, but not disfiguring synkinesis, mass movement or spasm Grade IV Obvious, but not disfiguring synkinesis, mass movement or spasm Grade V Obvious disfiguring weakness Grade VI No movement, loss of tone, no synkinesis, contracture, or spasm House, J.W. and Brackmann, D.E. (1985) Facial nerve grading system. Otolaryngol. Head Neck Surg., 93, 142-147
Complete eye closure with minimal effort
Slight asymmetry of smile with maximal effort
Synkinesis barely noticeable, contracture, or spasm absent
Inability to lift brow
Incomplete eye closure and asymmetry of mouth with maximal effort
Severe synkinesis, mass movement, spasm
Slight weakness noticeable only on close inspection
Obvious weakness, but not disfiguring
May not be able to lift eyebrow
Complete eye closure and strong but asymmetrical mouth movement with maximal effort
Obvious, but not disfiguring synkinesis, mass movement or spasm Grade IV Obvious, but not disfiguring synkinesis, mass movement or spasm Grade V Obvious disfiguring weakness Grade VI No movement, loss of tone, no synkinesis, contracture, or spasm House, J.W. and Brackmann, D.E. (1985) Facial nerve grading system. Otolaryngol. Head Neck Surg., 93, 142-147
Obvious, but not disfiguring synkinesis, mass movement or spasm
Obvious disfiguring weakness
No movement, loss of tone, no synkinesis, contracture, or spasm
House, J.W. and Brackmann, D.E. (1985) Facial nerve grading system. Otolaryngol. Head Neck Surg., 93, 142-147
The eyeball on the affected side turn up when the patient
attempts to close the eyelid (right side in this figure).
T- Parotid tumour, P- pinna lobule, S- sternomastoid muscle.
Arrow- tragal pointer.
Facial nerve stimulator tip is pointing to the main trunk of right facial nerve as it exits the stylomastoid foramen
The main branches of left facial nerve.
White arrow- main trunk, Blue arrow- upper trunk, Green arrow- lower trunk,
T- parotid tumour
Figure shows facial nerve course in relation to posterior belly of digastric.
The superficial lobe still attached and retracted inferiorly. [SP- sternomastoid muscle, M- masseter muscle, SP- superficial lobe of parotid gland, L- lobule of left ear, yellow arrow- posterior belly of digastric tendon, green arrow- intraparotid veins, black arrow- main trunk of facial nerve before its branches]
The full extracranial branches of right facial nerve after total conservative parotidectomy.
Yellow rubber retracting the main trunk of facial nere.
Angle of mandible (M) and preserved intraparotid vein were seen clearly.
An intraparotid lymph node [circle] occasionally seen and need to be sent for histopathological diagnosis.
N- neck, H- head, sm- sternomastoid muscle,
green arrow- tragal pointer,blue arrows- main brainches of facial nerve.
The probable aetiologies of a neck lump in this area includes lymph nodes enlargement, branchial cyst, and parotid mass. CT-scan and FNAC are usually carried out prior to its surgical intervention.
Swelling caused by benign parotid tumour.
H- head, T- thorax, S- sternomastoid, CA- common carotid artery, T- trachea, E- oesophagus, TH- thyroid gland, arrow- recurrent laryngeal nerve.
SP- soft palate, PW- posterior pharyngeal wall,
T- tonsils, BOT- base of tongue, L- Larynx
Johns MW. A new method for masuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.
Palatal & oropharynx view before surgery.
Quadrangular mid-soft palate partial Palatal & oropharynx view
mucosal and soft tissue excision. at completion of surgery.
Healed post-operative view of palate showing scar line
and widened nasopharyngeal opening.
SP- soft palate, PW- posterior pharyngeal wall, stars- scar line.
The widely used forceps for the purpose of foreign body removal in the oropharynx, especially at the tongue base and vallecula areas. Suited for linear or slim foreign objects. Slender tip, serrated, with sideway movements. Blackened/ebonized to reduce reflections from lights use and differentiate better with the surrounding mucosa and foreign material. Alternatively, other angled instruments
like Negus tonsil artery forceps can be use.
Cricoid and thyroid cartilages undergo calcification as the age increases. It significance occurs in traumatic injury to the larynx and in cases of foreign body impaction in the upper oesophagust. The former can result in fractures and in the latter it may be mistaken with a radiopaque foreign body. This soft tissue X-ray of the neck show calcifications primarily involving the cricoid cartilage.
Figure shows a radiopaque foreign body in the post-cricoid/upper oesophageal segment. [Red arrow- vertebral body, Green arrow- vertebral body + prevertebral soft tissue swelling, circle- impacted foreign body, inset image- the recovered foreign body]
Impacted meat bolus with surrounding Submucosal haematoma.
oedema and muscular spasm.
These images show the normal barium swallow appearance
during pharyngeal and upper oesophageal phases of swallowing
in a patient presented with dysphagia.