Applied Anatomy of Head and Neck

Question 1

What are the possible complications of endotracheal intubation?

Answer 1

1) Hoarseness and sore throat due to inflammation caused by instrumental trauma
2) Laceration to the root of the tongue
3) Damage to the upper teeth, especially if laryngoscope is levered against them

Question 2

Which veins are most often used for a central venous cannulation?

Answer 2

Internal jugular and subclavian veins.

Question 3

Where does the IJV originate? Where does it terminate?

Answer 3

Originates at the jugular foramen.

Terminates posterior to the sternoclavicular joint, where it joins the subclavian vein

Question 4

Where can access to the IJV be obtained?

Answer 4

In the triangle formed by the two heads of sternocleidomastoid and the clavicle.

Question 5

Where can access to the subclavian vein be obtained?

Answer 5

A needle is inserted at a point about 1cm inferior to the midpoint of the clavicle.

Question 6

Why must a chest x-ray be performed after central venous cannulation?

Answer 6

To check the position of the catheter tip and exclude a pneumothorax.

Question 7

What are risks and complications of a central venous cannulation?

Answer 7

Pneumothorax, injury to the common carotid artery, chylothorax (leakage of lymph fluid, risk may be decreased by avoiding the left side) and infection.

Question 8

What causes CSF rhinorrhoea?

Answer 8

A fracture of the skull base, most likely the anterior cranial fossa with involvement of the cribiform plate.

Question 9

What is the most serious complication of CSF rhinorrhoea?

Answer 9

Purulent meningitis, potentially fatal.

Question 10

What other problems may occur with CSF rhinorrhoea?

Answer 10

The patient may have anosmia (loss of sense of smell) due to tearing of the fine olfactory nerve filaments (CN I) which pass through the cribiform plate.

Question 11

What would be indicators of right sided CN III damage?

Answer 11

Right pupil dilated, eyeball shows lateral deviation (divergent squint), drooping of the eyelid (ptosis).

Question 12

What causes partial ptosis and a constricted pupil?

Answer 12

Sympathetic disruption, e.g. Horner’s syndrome.

Question 13

What can trigger trigeminal neuralgia?

Answer 13

Touch - as the trigeminal nerve is mainly sensory

Mastication - as the trigeminal branch has motor fibres to the muscles of mastication

Question 14

What is a major cause of Horner’s syndrome?

Answer 14

A Pancoast tumour (tumour at the apex of the lung) which goes into the sympathetic chain.

Question 15

What are the symptoms of trigeminal neuralgia?

Answer 15

Paroxysmal attacks of intense face pain that occur unilaterally and may last from several seconds to a few minutes.

Question 16

What can cause facial nerve (VII) damage?

Answer 16

Causes include Bell’s Palsy, pontine vascular accidents, lesions at the cerebellopontine angle, herpetic infections and parotid tumours.

Question 17

What are the symptoms of facial nerve palsy?

Answer 17

Unilateral facial paralysis
Patients may also present with dribbling due to paralysis of buccinator
Sounds may seem louder as the dampening effect of stapedius is lost
Taste to the anterior 2/3 of the tongue may be affected if damage before chorda tympani has been given off.

Question 18

Which tests might someone perform on a patient presenting with facial nerve palsy?

Answer 18

Tests of lacrimation and salivation (parasympathetic, rarely used)
Taste to the anterior 2/3 of the tongue

Question 19

Describe a hypoglossal nerve palsy.

Answer 19

In a right hypoglossal nerve palsy, the tongue will be deviated to the right with the right side appearing wasted, as unopposed action of genioglossus on the unaffected side deviates the tongue towards the side of the lesion.

Question 20

Describe acute tonsillitis. Where will there be referred pain?

Answer 20

The palatine tonsils are red, enlarged, and covered with purulent exudate. There will be referred pain to the middle ear, as the tonsils are supplied by the glossopharyngeal nerve, which also gives a tympanic branch to the middle ear.

Question 21

What is a quinsy? What are the symptoms?

Answer 21

Also known as a peritonsillar abscess, a quinsy is a complication of tonsillitis, with displacement of the uvula towards the affected side.
The patient will have a sore throat, pain on swallowing, enlarged painful jugulodigastric nodes, referred pain to the ear, and may also have trismus (inability to open the mouth normally).
Airway obstruction is a serious but rare complication.

Question 22

What is the treatment of choice for a benign parotid tumour?

Answer 22

Surgical excision, management in an elderly patient.

Question 23

How is a Towne’s view taken?

Answer 23

With the neck flexed, the chin on the chest.

Question 24

How is a Water’s view taken?

Answer 24

With the neck extended.

Question 25

What is a Towne’s view used for?

Answer 25

It shows the occiptial region, and is useful in suspected fractures of this region or in mastoiditis.

Question 26

What is a Water’s view used for?

Answer 26

To show the maxillary sinuses.

Question 27

What can occur alongside an extradural haematoma?

Answer 27

A scalp haematoma at the fracture site.

Question 28

Which haemorrhage of the skull is associated with a characteristic lucid period after the initial loss of consciousness?

Answer 28

Extradural haemorrhage.

Question 29

What is the margin of a subdural haemorrhage like radiologically?

Answer 29

Irregular inner margin.

Question 30

What is a concha bullosa? What does a large concha bullosa cause?

Answer 30

An abnormal air pocket. Severe deviation of the nasal septum, with the convexity to the right and mucosal thickening in both maxillary sinuses indicative of chronic inflammation

Question 31

What would an opacity on the inferior aspect of the mandible on x-ray suggest? How would a patient with this present?

Answer 31

Submandibular calculus. They would present with painful swelling of the gland, especially when eating.

Question 32

What can an abnormal barium swallow indicate in the pharynx?

Answer 32

A pharyngeal pouch, which is an abnormal protrusion of the pharyngeal mucosa between the 2 parts of the inferior constrictor (thyropharyngeus and cricopharyngeus).

Question 33

Who is normally affected by a pharyngeal pouch?

Answer 33

Elderly males.

Question 34

How might a patient with a pharyngeal pouch present?

Answer 34

They may present with dysphagia, regurgitation of previously ingested food, chronic cough, aspiration pneumonia and weight loss.

Question 35

What might be seen on examination of a pharyngeal pouch?

Answer 35

A lump in the neck, halitosis from decaying food debris in the pouch.

Question 36

How is a parotid sialogram performed? Why is it performed?

Answer 36

A small metal cannula is inserted into the parotid duct opening, and a small amount of contrast medium (1-2ml) is injected along the duct and into the gland. The patient is asked to take some lemon or citric acid to induce salivation and empty the ducts. This investigation is used to identify any obstruction in the duct or to visualise the ducts withing the gland, as these can become irregular in inflammatory conditions.