Disorders of the Head and Neck Flashcards
What does a CN III Nerve Palsy do?
Causes?
“Down and Out” Eyeball, Ptosis, Blown Pupil
Increase of intracranial pressure -> Compresses
Aneurysm
Cavernous Sinus Trauma
What does a CN IV Palsy do?
Causes?
Can’t look “Down and In”, Double Vision, Head Tilt
Congenital Palsy
Diabetic Neuropathy
Thrombophelbitis of Cavernous Sinus
Increase in intracranial pressure
What does a CN VI Palsy do?
Causes
Can’t look laterally, medially rotated eye and diplopia
Any increase in downwards pressure
ICA Atherosclerosis in CS
What are the Common Problems with the Orbit?
Cranial Nerve Palsy Fractures Mass Lesions Cellulitis Thyroid Eye Disease Glaucoma Retinal Detachment and Abrasion Cataracts Papilloedema
What are the 2 Types of Orbital Fractures?
Rim - Fracture of a bone on the rim, happens at the suture join of the Maxilla, Zygomatic and Frontal bones
“Blowout” Fracture - Most common in Maxillary as it’s weak. Herniates into the Maxillary Sinus. Can be Medial or through the Floor
What does an Orbital Fracture Cause?
Increase intraorbital pressure
Exophthalmos
Haemorrhage into Sinuses (Blowout)
What are some symptoms of Orbital Fractures?
Lid Swelling Pain Diplopia Reduced Vision or Eye Movements Trauma
What are the 2 Types of “Blowout” Fracture?
1) Medial - Ethmoid, Rarely Isolated, Horizontal Diplopia and Surgical Emphysema
2) Floor- Maxilla, Weak, Goes into the Sinus. Causes Vertical Diplopia
Can also get Lateral -> Zygomatic Arch
What is Thyroid Eye Disease?
Signs and Symptoms?
Organ-Specific Autoimmune disease
Symptoms: Redness, Irritation of Eye and Diplopia
Signs: Proptosis, Lid Retraction and Lag, Restrictive Myopathy, Optic Neuropathy
What is Orbital Cellulitis?
Inflammation of the Eyelids
Pain, Fever
Restricted Movement, Vision and Colour, RAPD
Sticky Discharge, Proptosis
What causes Orbital Mass Lesions?
Inflammation
Cysts
Vascular
Metastatic Mass
What is an Orbital Mass Lesion?
Any swelling in and around the orbit
Can present with pain, inflammation and diplopia
What is a Cataract?
Causes?
Lens becoming Opaque, develops slowly and with old age
Lens is flatter and harder so it can’t focus
Age, Diabetes, Smoking, Steroids
What is Open-Angle Glaucoma?
Increase in intraoccular pressure due to an increase in aqueous humour
Due to a blockage in the trabecular network
Increases the angle between the corneo and cris (pushes into vitreous humour)
What can Open-Angle Glaucoma cause?
Optic Nerve damage
Compression of Retinal Arteries
Lose Peripheral Vision
What is Papilloedema?
Swelling of the Optic Disc due to increased intracranial pressure
High Pressure -> No venous return = fluid retention = swollen disc
Compression -> Visual Impairment
What is Retinal Detachment?
Trauma to the eye causes the neural and pigmented layers to seperate
What is Corneal Abrasion?
Dirt/Particles cause Lacerations
If the sensory supply (V3) is damaged, the Patient may not notice the abrasion
What is Conjunctivitis?
Inflammation of the Conjunctiva (thin film on sclera)
Infection and Allergy
Contagious, “Red-Eye”, Dischange
What is a Meibomian Cyst?
Infection of Tarsal Glands
Non-painful swelling
Not Serious
What is a Sty?
Infection of the Ciliary Glands
Normally caused by Staphyloccus
Can be Severe, Antibiotics
What happens in Central Vessel Occlusion?
Artery
Vein
Artery- Retina is pale, Macula dark
- Occurs in Old, usually due to embolus
- Instant and Total Blindness
Vein - Slow, Painless loss of Sight
- Caused by Thrombophlebitis, dehydration
- See “Stormy Sunsets” of Engorged Veins
Describe Otitis Media
Infection of the Middle Ear, could be from the Eustachian Tube
Forces the Tympanic Membrane to retract so cannot see outline of Malleus any more
Describe Otitis Media with Effusion
Draws Transudate into the Middle Ear
“Glue Ear”
Fix with Grommits
Problem with Eustachian tube = Negative Pressure
What is BPPV?
Benign Positional Paradoxical Vertigo
There is Otolith which is displaced and keeps moving after the head has stopped so vertigo symptoms
What is Mastoiditis?
Inflammation of the Mastoid Air Cells/Cavity
Due to increased back pressure
Swelling behind the ear, lose creases of pinna
Can spread to Middle Cranial Fossa and cause Meningitis
Death!
Describe Perforation of the Tympanic Membrane
Central or Subtotal
Can be 2ndary to Infection (Pressure Necrosis)
Trauma
What are some congenital defects that you can get of the Pinna?
Pre-auricular Skin Tags
Pinna Malform (Microtia)
Antihelix Deformity
Describe Cholesteatoma
When there is Negative Middle Ear Pressure = Pockets/Recesses
Collection of Necrotic Epithelial Cells
Can erode Ossicles/Ear from lytic enzymes
What is a Pinnal Haematoma
When blood accumulates between the cartilage and perichondrium of the bone
It strips the layers away from each other
Causes pressure necrosis
What is Cauliflower Ear
Due to Haematoma
Not Drained
Necrosis causes Cauliflower Shape
Describe Otitis Externa
Cellulitis of External Ear Inflamed, Red, Swollen "Swimmers Ear" Staph aureus or Pseudomonas a. Candida albicans, Aspergillus
What can cause a retraction of the tympanic membrane? General and Specific Conditions
Otitis Media (+ Effusion)
Infections
Ruptured Membrane
Eustachian Tube Dysfunction
Generally: Weak Membrane or Negative Pressure
What can cause damage to the Facial Nerve?
Any Middle Ear Disease
Compression of Facial Canal
How would you notice a problem with the Chorda tympani?
Loss of taste of 2/3 of the anterior tongue
What can cause a fracture of the Ossicles?
Trauma
Loud Noise (Blast Injuries)
Cholesteatoma
Causes sudden hearing loss
What is Menier’s Disease?
Low Pitch Tinnitus
Vertigo
Hearing Loss
Endolymphatic Hydrops distend the ducts
High Pressure damages ear membranes
What are the regions most succeptible to Epistaxis?
Kiesselbachs Plexus
Sphenopalatine (lots of blood lost)
What can cause Anosmia?
Damage/Inflammation in Cribriform Plate
Tumour in the Olfactory Groove
Tumour in Frontal Lobe/Meninges/ACF can compress the bulb
Olfactory Nerve Damage
Infection
Neurodegenerative Disease
What is a Septal Haematoma?
When there is a haematoma between the septal cartilage and pericondrium
Why is the nose so succeptable to fracture?
As it sticks out from the face (it’s prominent)
Trauma often in Sport
Sinusitis
inflammation of the mucosal lining of the sinuses, which is continuous with the vestibule of the nose
How can infection of the Frontal Sinus spread to the Maxillary Sinus?
As they both open up at the hiatus semilunaris
Frontal is above Maxillary so fluid can go down it
What is a Saddle deformity
When damage causes the septum (cartilage or bone) to collapse as structural support is lost
What is Rhinitis?
Inflammation of the mucosal lining of the nasal cavity
Allergic
Viral
Bacterial
What are Polyps?
Polypoidal masses from the Mucosa
Non-Tender and Moveable
How can infection spread from the nasal cavity to the middle ear?
Via the Eustachian Tube
How can infection spread from the nasal cavity to the Middle Cranial Fossa?
Via the Frontal Sinus (as the posterior wall is very thin)
What is Treacher Collins Syndrome?
Rare, Autosomal Dominant Disorder
Failure of Neural Crest Cells to invade the 1st Arch
Results in Hypoplasia of Maxilla, Mandible and Zygomatic arches
Ear and Palate developmental defects
What is DiGeorge Syndrome?
CATCH 22?
Failure of the development of the Pharyngeal Pouches 3 and 4 Cardiac Problems Abnormal Facies Thymic Aplasia Cleft Palate Hypocalcaemia (Chromosome) 22 Deletion
What is Bell’s Palsy?
Palsy of Facial Nerve,
From Swelling of the Nerve
Usually Unilateral
Paralysis of Facial Muscles of Expression
If Extra-cranial, only Motor is affected
If Intracranial, can also affect salivation, taste, hearing and tear production
What is Harlequin Syndrome?
Asymmetric sweating and flushing of the chest, face and neck
Caused by damage to pre-ganglionic sympathetic neurons of the Ciliary Ganglion, at the level of the thoracic cord
What is Trigeminal Neuralgia?
A Chronic Pain Disorder, where the Trigeminal Nerve is extremely sensitive, thought to be due to compression by enlarged nearby blood vessel
Normally affects V2 and V3
Gives episodes of extreme pain
How can a Varicella Zoster infection affect the Head and Neck?
As it remains dormant in the dorsal root ganglia, and also most commonly affects the Trigeminal Nerve, especially CN V1
Produces a Rash, Conjunctivitis, Optic Nerve Palsy/Vision Loss, Pain and Inflammation
How can Herpes affect the Head and Neck?
Can cause Bell’s Palsy
What is Horner’s Syndrome?
Damage to the Sympathetic Trunk
Get decreased sweating (anhydrosis), miosis, ptosis and sunken eyeball on the same side as the lesion
What does RAPD mean?
When does it appear?
Relative Afferent Pupillary Defect
When Pupil constricts less when a bright light is shone from unaffected eye to the affected eye
Give some Inflammatory examples of Orbital Mass Lesions
Describe them briefly:
Wegener’s Granulomatosis - Vasculitis
Dacryoadenitis - Inflammation of the Lacrimal Glands
Pseudotumour- Idiopathic Condition, involving extra-ocular muscles
Rapid Onset, Unilateral, Painful Proptosis and Diplopia
Give some Vascular examples of Orbital Mass Lesions
Describe them briefly:
Capillary Haemangioma: Infants, most common orbital tumour of infancy It is a Neoplasm Subcutaneous Mass Known as a "strawberry haemangioma"
Cavernous Haemangioma:
Most Common Vascular Lesion in Adults
Slow Flow Venous Malformations
Normally results in Proptosis, Can have Diplopia and Visual Field Defects
What is Fetal Alcohol Syndrome?
Signs?
Incidence?
When the development of a foetus has been affected by maternal drinking during pregnancy
It affects brain development and neural crest cell migration
It occurs in 1/100 births
Flat Midface
Less prominent Philtrum and Thin Upper Lip
Small Nose and Nasal Bridge
Small Palpebral Fissure
What are the types of Cleft Lip and Palate?
Unilateral Cleft Lip (can involve primary palate)
Bilateral Cleft Lip
Isolated Cleft Palate
Combined Cleft Lip and Palate
What is a Branchial Cyst?
When the 2nd Pharyngeal Cleft fails to grow over the other Pharyngeal Arches
What isn’t usually affected by Bell’s Palsy?
The Forehead Muscles
As it has Bilateral Innervation
What are some causes of Bell’s Palsy?
Bilateral?
Intracranial:
Middle Ear Pathology
Extracranial: Parotid Gland Pathology Nerve Infection (Herpes Virus) Forceps Delivery Idiopathic
Parkinsons
What is Epistaxis?
A Nose Bleed
Where does Epistaxis occur?
90% in Kiesselbachs Plexus, where the arteries anastomose on the septum, also known as Little’s Area
10% Other areas, more problematic as they tend to be harder to reach areas
Sphenopalatine (Problems with Warfarin, High Pressure)
What are some Risks for Epistaxis
Trauma Coagulation Defects Vascular Abnormalities NSAIDs - Ibuprofen, Asprin Warfarin Tumours Granulomas Mucosal Drying EToH (Alcohol) Infections
How do you Manage Epistaxis?
The 5 steps and the last resorts
1) Compression and Hypocratic Position for 20 mins
2) Try Again
3) Cautery (Silver Nitrate or Electo)
4) Anterior Packing + Bolster (24-48 hours)
5) Posterior Packing
Surgical Ligation - Sphenopalatine, Maxillary or ECA
Radiological Embolism
What tests do you do when investigating an Epistaxis?
Blood Test- Coagulation, Hb Count, INR (Clotting Time)
Blood Pressure
Heart Rate
Capillary Refill (Shock)
What is 1st arch syndrome?
Failure of Neural Crest Cells to migrate into the 1st arch
Can cause facial anomolies
What is CHARGE syndrome?
Mtuation of Chromosome 7
Affects NCC production
Coloboma Heart Defects Atresia of Choana Retardation Genital Hypoplasia Ear Defects
Describe Adenoid Hypertrophy
Hypertrophy of the Adenoid Tonsils
Can block the Eustachian tube- deafness and infections
Can obstruct the nasal cavity
Describe Tonsillitis
Inflammation of the Palatine Tonsils
Most common viral and bacterial (Streptococcus)
Fever, Pain, Chills, Headaches
What is a Pharyngeal Pouch?
A true diverticulum
Part of the pharynx herniates through Killian’s dehiscence
What can happen in the Piriform Fossa?
Malignancy
Foreign Bodies
What kind of cancers occur in the Larynx?
Most squamous cell carcinoma
Poorer Prognosis the further you go down
What kind of cancers occur in the laryngopharynx?
Piriform Fossa
Describe Ectopic Thyroid Tissue
Can occur anywhere on path of descent
Tongue is the most common site (lingual thyroid)
May be functional
Gives dyspnoea, dysphagia and dysphonia
What is a thyroglossal cyst?
A remnant of the thryoglossal duct
What is CSF Rhinorrhoea?
Damage to the cribriform plate, causes tearing of the meningeal layers, causing CSF to leak from the nose
What can affect the Optic Nerve?
Think brain and nearby structures
Demyelination by CNS Dieases e.g. Multiple Sclerosis
Pituitary Tumours
What can cause damage to CN III?
Compression
Increase in intracranial pressure, compresses against petrous part (affects ANS first)
Aneurysm of the Superior/Posterior Cerebral Artery
Cavernous Sinus Infection
Why can the trochlear nerve be affected easily?
As it has a very long course can be damaged in head injuries
But is rarely affected on its own
General increase in intracranial pressure
Goes through the cavernous sinus
What can go wrong with the Vestibulocochlear nerve?
Sensorineural Deafness - Cochlear disease of anywhere in its path to the brain
Vertigo
Acoustic Neuroma
What is Acoustic Neuroma?
What does it cause?
A neurofibroma- a slow growing tumour of Schwann cells
Occurs to CNVIII in the IAM or the cerebellopontine angle so it also affects the facial nerve
Get hearing loss, tinnitus etc
What can damage to CN X cause?
Dysphagia - injure pharyngeal branches Superior Laryngeal - Upper anaesthetic, weak voice Recurrent Laryngeal: One-side- hard to speak, hoarse Two-sided- lose voice, stridor
What can damage the recurrent laryngeal nerve?
Aneurysm of the Arch of the Aorta
Neck Operations
Malignancy of Larynx, Thryoid
Apical Lung Tumour
Why can bleeding from the scalp track into the orbit and cause a black eye?
Why not go into neck or laterally?
As the aponeurosis of the scalp of occipitofrontalis only connects into the skin and connective tissue and not the bone, as it does in other directions, anteriorly
Occipital –> Occipital bone and mastoid process (not into neck)
Epicranial Aponeurosis is continuous with temporal fascia (lateral)
Therefore bleeding in the loose connective tissue layer/under the aponeurosis can go into the nasal bridge and around the orbit
