Clinical Notes Flashcards
Zones of Penetrating Neck Trauma are divided by the Angle of the __ and ___ Cartilages
- Mandible
- Cricoid
Zones of Penetrating Neck Trauma: Zone I
- Includes the Root of the Neck (extends inferiorly from the cricoid cartilage)
- Structures at risk include the Cervical Pleurae, Apices of the Lungs, Thyroid Glands, Parathyroid Glands, Trachea, Esophagus, Common Carotid A, Jugular V, Cervical Vertebrae
Zones of Penetrating Neck Trauma: Zone II
- Extends from the cricoid cartilage to the angle of the mandible
- Structures at risk include Laryngeal cartilages, Larynx, Laryngopharynx, Carotid A, Jugular V, Esophagus, Cervical Vertebrae
Zones of Penetrating Neck Trauma: Zone III
- Extends from the angle of the Mandible superiorly
- Structures at risk include the salivary glands, oral and nasal cavities, and the Oro- and Naso-Pharynx
Injuries to what Zone of Penetrating Neck Trauma are the most common?
Zone II (also easy to access and repair)
Another name for Hangman’s Fracture
Traumatic Spondylolysis of C2
What is Hangman’s Fracture?
- Fracture through the Pars Interarticularis of C2
- Typically result of severe hyperextension
Jefferson (Burst) Fracture of C1
- Fracture of one or both of the Anterior and Posterior Arches
- Result of blow to the top of the head from a falling object or diving accident
- This type of fracture alone typically does not injure the spinal cord, but if the Transverse L is ruptured then the Odontoid Process may injure the spinal cord
Thoracic Outlet Syndrome
- Results from compression of neuromuscular bundle (subclavian artery or inferior trunk brachial plexus) from superior thoracic aperture
Why are cervical vertebrae more likely to be dislocated?
Horizontal orientation of articular facets leave them less tightly interlocked
The cervical vertebrae can be dislocated in neck injuries with ___ force than is required to fracture them
Less
Due to the large ___ ___ in the cervical region, slight dislocation can occur here without damaging the spinal cord
Vertebral Canal
Dislocation of Cervical Vertebrae: Stage I
Flexion sprain
Dislocation of Cervical Vertebrae: Stage II
Anterior subluxation (hyperflexion sprain; localized, purely ligamentous disruption of the cervical spine caused by a limited flexion force) with 25% anterior translation
Dislocation of Cervical Vertebrae: Stage III
Anterior subluxation with 50% translation
Dislocation of Cervical Vertebrae: Stage IV
Complete dislocation
Severe Dislocations or Dislocations combined with Fractures of the Cervical Vertebrae
- Result in injury to the spinal cord
- if the dislocation does not result in “facet jumping” with locking of the displaced articular processes, the cervical vertebrae may self-reduce so that a radiograph may not indicate that the cord has been injured – would need MRI to see resulting tissue damage
Fracture of the Hyoid Bone
- Typically result of strangulation by compression of the throat
- Results in depression of the Hyoid onto the Thyroid Cartilage
- Experience difficulty swallowing and maintaining the separation of the alimentary and respiratory tracts
Congenital Torticollis
- Disorder produced by fibrous tissue tumor which forms in the Sternocleidomastoid which causes the head to turn and the face to look away from the affected side (contraction of cervical muscles that produces twisting of neck and slanting of head)
- Hematoma may arise and impinge on the Spinal Accessory N which denervates the Sternocleidomastoid
Spasmodic Torticollis
- Typically occurs in adults
- Involves abnormal tonicity of the cervical muscles, usually the Sternocleidomastoid and the Tracoezius muscles
chemoreceptors exist at the carotid __ and monitor the ___ content of blood before it reaches the brain.
- Body
- Oxygen
Adjustments to heart rate, respiratory rate, and BP can be made accordingly based on the oxygen content in the Carotid Sinus via the ____ nerve.
Glossopharyngeal N
The __ sinus is also hypersensitive to pressure (baroreceptors); therefore excessive pressure to the __ sinus can produce ___ heart rate, drop in BP and fainting.
- Carotid
- Carotid
- Slow
Carotid Sinus Hypersensitivity Syndrome
- Carotid Sinus may be hypersensitive to pressure, therefore excessive pressure to the Carotid Sinus can produce a slow HR, drop in BP, and fainting
- Best to take Radial pulse rather than Carotid pulse in these patients
Central Line Placement
Small tube can be placed in the Internal Jugular Vein OR the Subclavian Vein (most commonly this one) to administer treatment for longer periods of time, in larger quantities, or in order to draw blood easier
Characteristics of Spasmodic Torticollis
- Sustained
- Turning/tilting/flexing/extending neck
- Shoulder usually elevated and displaced anteriorly on side to which chin turns
- Shifting of head laterally or anteriorly can occur involuntarily
Muscular Torticollis
- SCM injured during birth and fibers are torn (infant’s head is pulled too much during a difficult birth)
- Hematoma forms and develops into fibrous mass that entraps CN XI (accessory spinal N)
Surgical Management of Muscular Torticollis
Surgical release of SCM inferior to the level of CN XI may be necessary to allow person to hold and rotate their head normally
What is another name used to describe Spasmodic Torticollis?
Cervical Dystonia
Subclavian Vein Puncture: Infraclavicular Subclavian Vein Approach
- Administrator places thumb of one hand on middle park clavicle
- Index finger on jugular notch in manubrium
- Needle punctures below thumb and advances medially toward tip of index finger until enters right venous angle posterior to SC joint
- Soft, flexible catheter inserted with needle as guide
Where do the Internal Jugular and Subclavian Veins merge to form the Brachiocephalic Vein?
The Right Venous Angle (posterior to the SC joint)
What might happen if the needle is not inserted carefully into the Subclavian Vein during cannulation?
The needle could puncture the pleura and lung, causing pneumothorax
If the needle is inserted too far posterior during Subclavian Vein Cannulation, it may be insertion into the ___ __ instead of the Subclavian Vein
Subclavian Artery
What is the purpose of Right Heart Catheterization (RHC)?
To measure the pressure in the Right Chambers of the Heart
What vein is punctured during RHC?
Internal Jugular Vein
Needle Route during RHC
Puncture Internal Jugular Vein -> Right BRachiocephalic Vein -> Superior Vena Cava -> Right side of heart
In some patients, it may be necessary to use the ___ ___ vein instead of the preferred Internal Jugular Vein or Subclavian Vein during RHC
External Jugular
Why is the External Jugular Vein not ideal for RHC?
Its angle of junction with the subclavian vein makes passage of the catheter difficult
Role of External Jugular Vein as an Internal Barometer
- When venous pressure is in the normal range, the EJV is usually visible above the clavicle for only a short distance
- When venous pressure rises (e.g., as in heart failure), the vein is prominent throughout its course along the side of the neck; observation of the EJVs during physical examinations may give diagnostic signs of heart failure, SVC obstruction, enlarged supraclavicular lymph nodes, or increased intrathoracic pressure
Mechanism of Venous Air Embolism
EJV is severed along the posterior border of the SCM -> disruption of lumen -> negative intrathoracic pressure air sucks air into the vein -> churning noise in the thorax -> cyanosis (a bluish discoloration of the skin and mucous membranes resulting from an excessive concentration of reduced hemoglobin in the blood) A venous air embolism produced in this way will fill the right side of the heart with froth, which nearly stops blood flow through it, resulting in dyspnea (shortness of breath). The application of firm pressure to the severed jugular vein until it can be sutured will stop the bleeding and entry of air into the blood.
What typically holds open the lumen of the External Jugular Vein?
The tough investing layer of deep cervical fascia
Consequences of Venous Air Embolism and How to Manage It
-Right side of heart is filled with froth, which nearly stops blood flow through it, resulting in dyspnea (shortness of breath)
- Management: application of firm pressure to the severed jugular vein until it can be sutured; this will stop the bleeding and entry of air into the blood
Ways the Spinal Accessory Nerve (IX) could be damaged:
- Penetrating trauma
- Surgical procedures in lateral cervical region
- Tumors at cranial base or cancerous cervical lymph nodes
- Fracture jugular foramen
Symptoms of Individuals with Damage/Lesion to their CN XI
- Weakness in turning head to opposite side against resistance
- Weakness and atrophy of the Trapezius, thus impairing neck movements
What is the most obvious sign of injury to CN XI?
Drooping of shoulder
Signs of Unilateral Paralysis of the Trapezius
- Unable to elevate and retract the shoulder
- Difficulty elevating the upper limb superior to the horizontal level
- normal prominence in the neck produced by the trapezius is reduced
What is the most common iatrogenic (injury that resulted from physician treatment) nerve injury?
CN XI
Result of severance of the Phrenic Nerve:
Paralysis of corresponding half of diaphragm
Phrenic Nerve Block
- Produces a short period of paralysis of the diaphragm on one side (e.g., for a lung operation)
- Anesthetic is injected around the nerve where it lies on the anterior surface of the middle third of the anterior scalene muscle
Surgical Phrenic Nerve Crush
- Ex. compressing the nerve injuriously with forceps
- Produces a longer period of paralysis (sometimes for weeks after surgical repair of a diaphragmatic hernia)
If an Accessory Phrenic Nerve is present, it must also be crushed to produce complete paralysis of the _____
Hemidiaphragm
Cervical Plexus Block
- Inhibits nerve impulse conduction
- Anesthetic agent is injected at several points along the posterior border of the SCM, mainly at the junction of its superior and middle thirds, the nerve point of the neck
- Typically result in paralysis of half of the diaphragm due to the inclusion of the phrenic nerve in the block
- This procedure is not performed on persons with pulmonary or cardiac disease
What block is used for anesthesia of the Upper Limb?
Supraclavicular Brachial Plexus Block
Symptoms Associated with Injury to the Suprascapular Nerve
- Loss of lateral rotation of the humerus at the Glenohumeral Joint
- Rotated limb rotates medially into “Waiter’s Tip” position
What type of injury can cause suprascapular nerve damage?
Fracture of the middle third of the Clavicle
Ligation of External Carotid Artery
Decreases blood flow through artery and branches, but does not eliminate it
Which branch provides main collateral circulation when external carotid or subclavian arteries are ligated?
- Descending branch of occipital artery
- Anastomoses with vertebral and deep cervical arteries
Surgical Dissection of Carotid Triangle
Damage or compression of vagus nerve and/or recurrent laryngeal nerve can cause alteration in voice d/t innervation to laryngeal muscles
Atherosclerotic thickening of intima of internal carotid artery
May obstruct blood flow
Partial occlusion of internal carotid artery may cause:
Transient Ischemic Attack (transient stroke)
Minor Stoke
Loss of neurological function that exceeds 24hrs, but disappears within 3 weeks
How do you observe blood flow in an artery?
Doppler color study
Carotid Endarterectomy
Procedure that opens the carotid artery at origin and strips off atherosclerotic plaque with intima
What cranial nerves can be injured during carotid endarterectomy?
- CN IX
- CN X
- CN XI
- CN XII
Carotid Pulse
Palpation of common carotid artery in side of neck where lies between trachea and infrahyoid muscles
Carotid pulse is frequently checked during administration of ____.
Cardiopulmonary Resuscitation (CPR)
Absence of carotid pulse indicates:
Cardiac arrest
Internal Jugular Pulse
Pulsations visible when patient’s head below LE (Trendelenburg position)
Cricothyrotomy
- Typically an emergency procedure where intubation is not possible
- A large needle is passed through the Cricothyroid Membrane to permit the entry of air
Tracheostomy
- Involves an incision through the skin, separation of the Infrahyoid muscles and removal or retraction of the Isthmus of the Thyroid Gland to insert a tube into the Trachea to establish an airway
Where is a tracheostomy typically performed?
At the 2nd or 3rd tracheal rings
Initial Infection of Herpes Zoster Virus
Chickenpox Virus
Herpes Zoster Virus
- Lesions due to reactivation of virus that lies dormant in ganglion following chickenpox infection
- Reactivated due to comprised immune system
- Not typically bilateral
Location of Herpes Zoster Virus
- Many produce lesions in cranial ganglia with most involving CN V
- Opthlamic division commonly affected – usual cornea involvement leading to painful corneal ulceration
Superficial Scalp Injury
- Superficial to aponeurosis
- Does not gape as aponeurosis holds edges of wound together; tends to be localized
- Bleeds profusely
Deep Scalp Injury
- Goes through aponeurosis; pierces 3rd layer of scalp
- Forms gaping wound because of pull of occipitofrontalis muscle; aponeurosis continuously gets pulled further apart
- Bleeds profusely and for a longer period of time
Spread of Scalp Infections
- Can spread into cranium via small emissary veins
- Anastomoses between intra- and extra-cranial veins – close proximity to dural venous system
Which layer of the scalp is the danger area?
Layer 4 – Loose connective tissue layer (pus and blood spread easily into this layer)
Infection in the 4th layer of the scalp can pass into the cranial cavity through small emissary veins that pass through the ___ foramina into the ___, and reach intracranial structures such as the ___
- Parietal Foramina
- Calvaria
- Meninges
Why can’t a scalp infection pass into the neck?
Because Occipital bellies of the Occipitofrontalis insert on the temporal bones in the front and back, preventing lateral and inferior spread of infection
Why can an infection or fluid (pus, blood) from an injury to the scalp enter the eyelids and the root of the nose?
Because the Occipitofrontalis inserts into the skin and subcutaneous tissue, and does not attach to the bone
What is a common presentation associated with scalp infections?
Ecchymoses
- purple patches that develop as a result of extravasation of blood into the subcutaneous tissue and skin of the eyelids and surrounding regions
Facial Nerve Injury: Bell’s Palsy
- Damage typically occurs due to infection or surgery
- Muscles weakness/paralysis including inability to close eyelids thus making these individuals prone to cornea ulcerations
- The closer the infection/injury to the source of the Facial N, the more muscles impacted
Botox Injections (Botulinum Toxin)
- Blocks neuromuscular transmission by inhibiting ACh release
- Used to treat eye disorders, migraines, muscle spasms, or used cosmetically
Le Fort I Fracture
- Horizontal fracture of Maxilla
- Passes superior to maxillary alveolar process, crosses bony nasal septum and possible pterygoid plates of sphenoid
Le Fort II Fracture
- Posterolateral part of maxillary sinuses, superomedially through infra-orbital foramina, lacrimals, or ethmoids to bridge of nose
- Entire central face including hard palate and alveolar processes is separated from cranium
Le Fort III Fracture
- Horizontal fracture passing through superior orbital fissures, ethmoid and nasal bones
- Extends laterally through greater wings of sphenoid and frontozygomatic sutures
- Concurrent fracture of zygomatic arches causes maxillae and zygomatic bones to separate from cranium
Fracture of Pterion
- Life-threatening
- Often caused by hard blow to side of head
- Results in rupture of frontal branches of middle meningeal A
- Hematoma exerts pressure on underlying cerebral cortex which can lead to death within a few hours
How to locate the Pterion
2 fingers breadth superior to Zygomatic Arch; thumb’s breadth posterior to frontal process of zygomatic bone
A broken mandible typically involves __ fractures
2
Fractures of Coronoid Process of Mandible
- Uncommon
- Usually single
Fractures of Neck of Mandible
- Often transverse
- May be associated with TMJ dislocation on same side
Fractures of Angle of Mandible
- Usually oblique
- May involve bony socket or alveolus of 3rd molar tooth
Fractures of Body of Mandible
Frequently pass through socket of canine tooth
Resorption of Alveolar Bone
- Extraction of teeth causes bone resorption (sockets fill in with bone and alveolar process resorbs)
- Often age related
- In some cases mental foramina disappear due to resorption of mandibular bone
- Not as severe if dentures are used
Craniotomy
- Section of neurocranium (bone flap) is elevated or removed
- Bone flaps are put back into place and wired to other parts of calvaria or held in place with metal plates due to poor bone regrowth in adults
Craniectomy
Permanent plastic or metal plate replaces the flap in a craniotomy
The ___ Fontanelle begins to close during the first few months after birth, and by the end of the __ year, it is small and no longer clinically palpable
- Posterior
- First
When does the Anterior Fontanelle close?
No longer clinically palpable by 18 months of age
Primary Craniosynostosis
Premature closure of cranial sutures
Incidence of Primary Craniosynostosis
1/2,000 births
Scaphocephaly
- Premature closure of the sagittal suture
- Anterior fontanelle is small/absent
- Results in long, narrow, wedge-shaped cranium
Plagiocephaly
- Premature closure of coronal or lambdoid suture on one side only
- Results in cranium that is twisted and asymmetrical
Oxycephaly
- Premature closure of the coronal suture on both sides
- Results in high, tower-like cranium
- More common in females
Premature closure of sutures usually ___ ___ affect brain development
does not
Rupture of the Middle Meningeal Artery (generally due to head trauma) results in a:
Epidural Hematoma
Excessive Nasopharyngeal bleeding (nose bleeds) from the branches of the ___ artery may necessitate ligation of the ___ Artery in the ___ Fossa.
- Sphenopalatine
- Maxillary
- Pterygopalatine
Cavernous Sinus Syndrome
- Gravity allows venous blood from the danger triangle region of the face to drain into the cavernous sinus via the valveless Ophthalmic veins
- Squeezing a pimple or boil in this facial region can result in infections thrombi being forced into the venous system and passing back into the cavernous sinus
How can Cavernous Sinus Syndrome be diagnosed?
By the loss of eyeball movement due to the various cranial nerves associated with the cavernous sinus becoming infected
Trigeminal Neuralgia
- Sensory disorder of the sensory root of CN V that occurs most often in middle-aged and elderly persons
- Characterized by sudden attacks of excruciating, lightening-like jabs of facial pain; pain can be so intense that the person winces thus the common term tic
- Pain is often initiated by touching an especially sensitive trigger zone, frequently located around the tip of the nose or the cheeks
- In most cases this is caused by pressure of a small aberrant artery (when aberrant A is moved away from sensory root of CN V the sxs should resolve)
What is the most common nontraumatic cause of facial paralysis?
Inflammation of the facial nerve near the stylomastoid foramen often as a result of a viral infection – produces edema and compression of the nerve in the facial canal
Injury of the Facial N may result from fracture of what bone?
Temporal Bone
If the Facial N is complete sectioned due to an injury, the chances of complete or even partial recovery are ___
remote
Muscular movement usually improves when damage to the Facial N is associated with:
Blunt head trauma (however, recovery may not be complete)
Facial paralysis may be a complication of:
Surgery
(common during Parotidectomy; identification of Facial N and its branches are essential during surgery)
Paralysis of Facial Muscles: Bells Palsy
- Injury to the Facial N (CN VII) or its branches produces paralysis of some or all facial muscles on the affected side
- Affected area sags, and facial expression is distorted, making it appear passive or sad
Impact of Paralysis of Facial Muscles/Bells Palsy on the Orbital
- Injury of Facial N can affect the Orbicularis Oculi (loss of tonus to this muscle) which causes the inferior eyelid to evert/fall away from the surface of the eyeball
- Lacrimal fluid is not spread over the cornea, preventing adequate lubrication, hydration, and flushing of the surface of the cornea
- Can cause a corneal laceration
Cranial Nerve Lesion: CN I - Fracture of Cribiform Plate
- Anosmia (loss of smell)
- Cerebrospinal fluid rhinorrhea
Cranial Nerve Lesion: CN II - Direct trauma to orbit or eyeball; fracture involving Optic Canal
Loss of pupillary constriction
Cranial Nerve Lesion: CN II - Pressure on optic pathway; laceration or intracerebral clot in temporal, parietal, or occipital lobes in brain
Visual field defects
Cranial Nerve Lesion: CN III - Pressure form herniating uncus on nerve; fracture involving cavernous sinus; aneurysms
- Dilate pupil
- Eye turns down and out
- Pupillary reflex on side of lesion will be lost
Cranial Nerve Lesion: CN IV - Stretching of nerve during its course around brainstem; fracture of orbit
Inability to look down when eye is abducted
Cranial Nerve Lesion: CN V - Injury to terminal branches (particularly CN V2) in roof of maxillary sinus; pathological processes affecting trigeminal ganglion
- Loss of pain and touch sensations
- Paresthesia
- Masseter and Termporalis muscles do not contract
- Deviation of mandible to side of lesion when mouth is opened
Cranial Nerve Lesion: CN VI - Base of brain or fracture involving cavernous sinus or orbit
- Eye fails to move laterally
- Diplopia on lateral gaze
Cranial Nerve Lesion: CN VII - Laceration or contusion in Parotid region
- Paralysis of facial muscles
- Eye remains open
- Angle of mouth droops
- Forehead does not wrinkle
Cranial Nerve Lesion: CN VII - Fracture of Temporal Bone
- Paralysis of facial muscles
- Eye remains open
- Angle of mouth droops
- Forehead does not wrinkle
- Dysfunction of cochlear nerve and chorda tympani
- Dry cornea
- Loss of taste on anterior 2/3 of tongue
Cranial Lesion: CN VII - Intracranial Hematoma (“Stroke”)
- Forehead wrinkles because of bilateral innervation of Frontalis muscle, otherwise paralysis of contralateral facial muscles
Cranial Nerve Lesion: CN VIII - Tumor of neck (Acoustic Neuroma)
- Progressive unilateral hearing loss
- Tinnitus
Cranial Nerve Lesion: CN IX - Brainstem lesion or deep laceration of neck
- Loss of taste on posterior 1/3 of tongue
- Loss of sensation on affected side of soft palate
Cranial Nerve Lesion: CN X - Brainstem lesion or deep laceration of neck
- Sagging of soft palate
- Deviation of uvula to normal side (Ex. if lesion on right, then deviates to left)
- Hoarseness owing to paralysis of vocal cord
Cranial Nerve Lesion: CN XI - Laceration of neck
- Paralysis of SCM and descending fibers of Trapezius
- Drooping of shoulder
Cranial Nerve Lesion: CN XII - Laceration of neck; fractures of cranial base
- Protruded tongue deviates toward the affected side
- Moderate dysarthria (disturbance of articulation)
