Clinical Relevance Questions

Question 1

What is the function in of the sympathetic trunk, what are the cervical ganglia and what would damage to the sympathetic trunk result in?

Answer 1

Allows transmission of nerve impulses to different levels of the spine from which they originated on.

Superior cervical ganglion at level of c1/2 - innervate head

Middle cervical ganglion c6, stellate ganglion c7 - innervate neck and upper thorax.

Damage results in horners syndrome

• miosis - pupil constriction
• ptosis - drooping eyelid
• apparent anhydrosis - decreased sweating

Question 2

What is Bell’s palsy/facial palsy What are its clinical presentations? What may cause them?

Answer 2

Paralysis of some / all facial muscles on the same side caused by damage to the facial nerve

Affected area sags

Symptoms can include lack of lacrimal fluid in the eye, saliva drooling from side of the mouth, food accumulation in oral vestibule

Can be caused by herpes virus, Epstein Barr virus, mumps, injection into facial nerve

Question 3

What is trigeminal neuralgia? What causes it? Symptoms?treatments?

Answer 3

Sensory disorder of sensory root of CNV - mostly in middle aged/elderly persons

Excruciating jabs of facial pain which can last 15 mins or more

Mostly CNV2, then V3, then V1

Often set off by touching thr face, brushing teeth, chewing or shaving.

Treatment - avulsion of nerve at infra orbital foramen

Question 4

How can herpes infect the trigeminal ganglion? Presentations?

Answer 4

Virus cause lesion at the ganglion, any division of CNV may be affected, but mostly V1. Typical corneal ulceration occurs.

Bell’s palsy too

Question 5

How do you test sensory function of CNV?

Answer 5

Closing the eyes, respond when types of touch are felt on skin of - cheek, forehead, face, and lower jaw.

Asked if one side feels different.

Question 6

How may dislocation of the TMJ occur? Whats the most likely dislocation?

Answer 6

Most common is anterior dislocation - condylar head of mandible passes anteriorly to the articular tubercle

Can be caused by yawning or taking a large bite, excessive contraction of pterygoid muscles.

Can also be caused by a lateral blow to mandible while jaw is open.

Question 7

How may arthritis of the TMJ occur / present?

Answer 7

Inflamed from degenerative arthritis causing clicking, abnormal function, issues with occlusion

Question 8

How may genioglossus paralysis occur? How does it present?

Answer 8

Caused by lesion to hypoglossal nerve

Genioglossus paralysis causes tongue to fall backwards and can obstruct the airway as genioglossus function is to protrude tongue and prevent airway obstruction

Also tongue protrudes out and deviates to the side of muscle paralysis

Question 9

How may damage to the hypoglossal occur? What would present?

Answer 9

Trauma - fractured mandible

Paralysis of one side of the tongue

Tongue diverts to paralysed side when protruded due to muscles not working on that side

Question 10

Why would a submandibular gland excision be done? Any complications?

Answer 10

Due to calculus stone or tumour

Incision is made below mandible so marginal mandibular branch is not affected.

Lingual nerve damage must be avoided during excision of the duct too as nerve passes directly superior, then inferior to the duct

Question 11

What is a submandibular sialogram? Why can’t it be done on sublingual gland?

Answer 11

Injection of contrast medium into the duct, then radiograph taken to see where blockage lies.

The radiograph taken with the medium in situ is called a sialogram

Sublingual cannot be done due to large number of small salivary ducts.

Question 12

What typical foreign body may get caught in the laryngopharynx? What would it present?

Answer 12

Items such as chicken or fish bone can get stuck in the piriform fossa in the laryngopharynx

If object is sharp it can pierce the membrane and injure the internal laryngeal nerve

Also risk of injury during removal of the object

Injury would result in anaesthesia of laryngeal mucous membrane

Question 13

What may cancer of the larynx present? What often causes it? How treated?

Answer 13

Often caused by smokers or by those who chew tobacco

Often causes persistent hoarseness, earache (otalgia), and difficulty swallowing (dysphagia), also swollen pretracheal or paratracheal lymph nodes

Removed via laryngectomy - complete or partial removal of larynx.

Question 14

How may occlusion of dural sinuses occur? What risk does this pose? What presentations?

Answer 14

Thrombi (clots) or venous inflammation or tumours.

Usually from infections in the orbit, nasal sinuses and superior face due to ophthalmic facial vein draining to cavernous sinus (from danger triangle)

Can affect adbucent nerve as travels through cavernous sinus

So sharp headache, swelling and bulging of eye, double vision, severe eye pain.

Question 15

What is an extradural haemorrhage and what symptoms?

Answer 15

Arterial, rupture of meningeal artery, typically anterior underneath Pterion

Brief concussion, later is drowsiness and possible coma

Question 16

What causes a ‘subdural’ hematoma?

Answer 16

There is no actual subdural space, however usually venous in nature and caused by rupture of the bridging veins (superior cerebral vein) leaving the saggital sinus. Usually caused by a strong blow which jerks the brain forward in the skull e.g. hitting head on windscreen

Question 17

What causes a subarachinoid hematoma? Symptoms?

Answer 17

Usually arterial, often aneurysm of internal carotid artery or rupture of cerebral artery or veins within the subarachinoid layer. Results in meningeal irritation, severe headache, stiff neck and often loss of consciousness

Question 18

What two types of strokes are there? What causes them?

Answer 18

Ischemic - impaired cerebral blood flow
- occlusive atherosclerotic disease
- thrombi within a vessel

Haemorhhagic - due to bleeding
- leakage or rupture of cerebral artery due to aneurysm or trauma

Question 19

What does middle cerebral artery occlusion cause?

Answer 19

Contralateral hemiparesis and hemisensory loss in face and arm

Aphasia - difficulty to comprehend language

Question 20

What does an anterior cerebral artery occlusion cause?

Answer 20

Contralateral hemiparesis and hemisensory loss of the leg and foot

Visual agnosia - Inability to identify objects correctly

Question 21

What does a posterior cerebral artery occlusion cause?

Answer 21

Contralateral homonymous hemianopia

Visual agnosia - poor object recognition

Memory impairment

Question 22

What occurs in a laryngeal skeleton fracture? How may it occur?

Answer 22

Often caused by a blow to larynx from something such a sick boxing, ice hockey goalkeepers or from seatbelt in a car.

Symptoms include sumbucous haemorrhage and oedema, hoarseness, sometimes temporary inability to speak.

Question 23

How may the inside of the larynx be viewed?

Answer 23

Laryngoscopy

Anterior tongue pulled slightly out of mouth so posterior tongue covers the laryngeal inlet less

Question 24

What is the Valsalva manoeuvre? What is it used for?

Answer 24

Pinch nose and close mouth then try to breathe out forcefully

Helps to trigger heart to go back to sinus rhythm

Question 25

What occurs in aspiration of foreign bodies?

Answer 25

Foreign body enters airway and sits above vocal folds as rima glottidis is small

Causes laryngeal muscles to go into spasm, tensing vocal folds, can completely block airway

Coughing will occur as the mucosa of vocal folds are sensitive to foreign objects.

Question 26

How can aspiration of foreign bodies be helped?

Answer 26

Heimlich manoeuvre

Closed fist and base of palm facing inwards placed below the sternum, other hand grasps and forcefully thrusts inwards and superiorly, forcing diagram superiorly creating an artificial cough

Question 27

What is a cricothyrotomy and why is it Performed

Answer 27

Used for severe airway obstruction or major facial/cervical trauma where intubation not possible

Large bore needle inserted through cricothyroid ligament to permit fast entry to airway

Question 28

What is a tracheostomy and why performed?

Answer 28

Incision made between 1st and 2nd tracheal ring.

Infrahyoid muscles retracted laterally

Isthmus of thryoid is divided or retracted superiorly.

Question 29

What is an OAC? What is usually felt?

Answer 29

Communication where maxillary molar removed exposing the maxillary sinus, causing a sinus infection

Toothache session often felt due to the sinus and maxillary molar teeth both being innervated by the superior alveolar nerve

Question 30

What is an OAF?

Answer 30

Oro-antral fistula

Where an OAC does not spontaneously close and is left open for 48-72 hours

The communication becomes epithelialised by migration of oral epithelium

Results in osteitis

Question 31

What types of pituitary tumour are there?

Answer 31

Functioning - can be small but releases enough hormones to affect pituitary function

Non-functioning - can be large but does not release enough hormones, but does press/impede surrounding structures through siz

Question 32

Signs and symptoms of a functioning tumour

Answer 32

Acromegaly (adults) or gigantism (in children and teens) from increased growth hormone

Cushings from excess cortisol (weight gain, excess back fat, more hair, decreased libido)

Breast growth in men and milk production

Irregular heartbeat, shaking and dizziness

Question 33

Signs and symptoms of a non-functioning tumour

Answer 33

Macular sparing
Issues with eye movement
Headaches
Facial numbness or pain

Diabetes from decreasing pituitary hormone ADH

Question 34

What is temporal arteritis? What does it cause?

Answer 34

Inflammation of artery on side of head - typically superficial temporal artery

Severe headaches, loss of vision in one or both eyes

Idiopathic

Question 35

What. Is occulomotor palsy?

Answer 35

Damage to occulomotor nerve resulting in palsy of eye muscles

Results in drooping eyelid (ptosis), loss of constriction to the eye (mydriasis), and a downwards and outwards turned eye as superior oblique and lateral rectus intact