Face and Neck Flashcards
1
Q
What are the articulations of the temporomandibular joint?
A
Articulation of three surfaces the mandibular fossa and the auricular tubercle of the temporal bone and the head of the mandible.
The two areas are separated by an articular disk, which splits the joint into two synovial joint capsules.
2
Q
What type of joint is the mandible?
A
Fibrocartilage joint (NOT hyaline)
3
Q
What are the ligaments of the mandible?
A
Lateral ligament: auricular tubercle to the mandibular neck.
Sphenomandibular ligament: sphenoid to mandible.
Stylomandibular: thickening of fascia of the parotid gland. This supports the weight of the jaw.
4
Q
What muscles move the jaw?
A
The lateral pterygoid: allows the jaw protrusion.
The posterior fibres of the temporalis: retraction.
The temporalis and masseter and medial pterygoid: close the jaw.
5
Q
What is the arterial supply to the jaw?
A
The superficial temporal branch of the ECA
6
Q
What is the innervation to the jaw?
A
The auriculotemporal branch of the CNV3
7
Q
What passes through the mandibular foramen?
A
The inferior alveolar nerve and artery travel into the mandibular canal, they then exit below the 2nd premolar tooth as the mental nerve. This acts to innervate the skin of the lower lip and chin.
8
Q
What are the muscles of mastication?
A
Lateral pterygoid
Medial pterygoid
Temporalis
Masseter
9
Q
What nerve innervates the muscles of mastication?
A
The mandibular nerve.
10
Q
What are the attachments and action of the lateral pterygoid?
A
Origin: Superior head is on the greater wing of the sphenoid. Inferior head is on the lateral pterygoid plate of the sphenoid.
Insertion: Neck of the mandible.
Action: protracts the mandible and depresses the chin, and moves jaw side to side.W
11
Q
What are the attachments and action of the medial pterygoid?
A
Origin: The superior head is on the maxillary tuberosity and the deep head on the medial aspect of lateral pterygoid plate sphenoid.
Inserts: attaches to the angle of the mandible.
Acts to elevate the jaw.
12
Q
What are the attachments and action of the temporalis?
A
Originates in the temporal fossa
Inserts onto the coronoid process of the mandible.
Acts to elevate the jaw and retract the mandible.
13
Q
What are the attachments and action of the masseter?
A
Originates on the maxillary process of the zygomatic bone and zygomatic arch of the temporal bone.
Inserts into the external aspect of the vertical mandibular rami.
Acts to elevate the mandible.
14
Q
What arch do the muscles of facial expression come from?
A
The 2nd pharyngeal arch.
15
Q
What nerve innervates the muscles of facial expression?
A
The facial nerve.
16
Q
What are the terminal branches of the facial nerve?
A
Temporal, Zygomatic, Buccal, Marginal Mandibular, Cervical branch.
17
Q
Which muscles are part of the orbital group of the facial muscles?
A
Orbicularis occuli: originates from medial orbital margin, the medial palpabral ligament and the lacrimal bone. It insets onto the skin of margin of orbit and the tarsal plates of the eyelid.
It acts to close the eye and drain tears.
It is innervated by the temporal and zygomatic branches of the facial nerve.
The Corrugator supercilli: located posterior to the obicularis occuli. It attaches from the medial aspect of the siperciliary arch to the skin of the eyebrow.
Acts to draw the eyebrows together.
Innervated by the temporal branch of the facial nerve.
18
Q
What are the muscles of the nasal group of the facial muscles?
A
The Nasalis:
The transverse part originates from the maxilla, immediately lateral to the nose and attaches to the aponeurosis of the dorsal aspect of the nose. The alar part originates from the axilla overlying the lateral incisor and attaches to the alar cartilage.
IT acts to compress (transverse part) and widen (the alar part) the nasal opening.
It is innervated by the buccal branch of the facial nerve.
The Procerus:
Originates on the nasal bone and inserts onto the skin of the lower medial forehead. Pulls the eyebrows down.
The Depressor septi Nasi:
Originates at the maxilla and inserts onto the nasal septum. Pulls nasal septum inferiorly to widen the nasal opening.
Innervated by the buccal branch.
19
Q
Which muscles are part of the oral group of the facial muscles?
A
The obicularis ori:
Arises from the maxilla and other cheek muscles and inserts onto the lips.
The Buccinator: Originates from the maxilla and the mandible and it runs inferomedially in the direction blending with the orbicularis oris.
Acts to pull the cheeks inwards against the teeth.
20
Q
What are the terminal branches of the mandibular nerve and what do they supply?
A
The auriculotemporal: sensation to the temple, external meatus and anterior tympanic membrane. Also carries parasympathetic fibres to the parotid gland from the glossopharyngeal.
The Buccal Nerve: passes between the two heads of the lateral pterygoid. Supplies sensation to the second and third molar teeth.
The Inferior Alveolar Nerve: Innervates the myelohyoid and the anterior belly of the digastric and sensation to the mandibular teeth, lower lip and chin.
The Lingual nerve: sensation to the anterior 2/3 of the tongue. Carries autonomic fibres from CNVII for taste, and to submandibular and sublingual glands.
21
Q
What are the boundaries of the Mouth proper?
A
This is bounded by the hard palate/soft palate superiorly, the buccinator muscles laterally, and the tongue/glenohyoid muscles inferiorly
22
Q
What is the innervation to the oral cavity?
A
The Hard palate: greater palatine/nasopalatine (branches of V2)
The soft palate: the lesser palatine (branch of V2)
The Floor: the lingual nerve (V3) and the chorda tympani (CNVII)
Cheeks: buccal nerve (V3)
23
Q
What are the muscles of the tongue?
A
It has 4 paired intrinsic muscles.
The extrinsic muscles include:
The genioglossus: protrusion of the tongue.
Attaches from the mandibular symphysis to the hyoid bone to the entire tongue length.
The hypoglossus:
Depresses/ rretracts the tongue.
Attaches from the hyoid bone to lateral tongue.
The styloglossus: acts to retract and elevate the tongue.
Attaches from the styloid process of the temporal bone.
The palatoglossus:
Acts to elevate posterior tongue.
Attaches from the palatine aponeurosis to the tongue.
24
Q
What is the innervation of the muscles of the tongue?
A
All are innervated by the hypoglossal nerve, except the palatoglossus which is innervated by the vagus nerve.
25
What is the sensory innervation to the tongue?
The lingual branch of V3 provides general sensation to the anterior 2/3.
The Chorda tympani of the facial nerve supplies the taste sensation to the anterior 2/3.
The lingual branch of the glossopharyngeal nerve supplies the sensation and taste to the posterior 1/3.
26
What is the sulcus terminalis?
This is a line that splits the tongue into its anterior 2/3 and posterior 1/3.
The anterior drains lymph into the submandibular lymph nodes, and the posterior drains lymph into the deep cervical nodes.
27
What is the blood supply and venous drainage of the tongue?
Arterial: lingual branch of carotid artery.
Venous: sublingual vein into the IJV.
28
What are the ganglia of the head and neck?
The Otic ganglion: sits in the infratemporal fossa.
Recieves parasympathetic fibres from the lesser petrosal nerve (branch of CNIX) and post-synaptic fibres travel to the parotid gland via the auriculotemporal nerve.
The Ciliary ganglion: Pre-ganglionic fibres from CNIII
Post ganglionic fibres travel with the ICA to innervate the iris.
The Pterygopalatine: Preganglionic fibres are via CNVII and post ganglionic travel via the lacrimal branch of V1 to the lacrimal gland for tear production.
The geniculate ganglion:
Parasympathetic fibres from the chorda tympani of CNVII provide taste to the anterior 2/3 of the tongue via the lingual branch of the trigeminal nerve.
The submandibular ganglion: CNVII fibres travel with the lingual nerve to the sublingual and submandibular glands.
29
What are some risk factors for SCC of the oral cavity?
Smoking/alcohol
Leukoplakia
Dental cavities
Chronic gastritis
Malnutrition
Cirrhosis
HIV
30
How do you manage an SCC of the oral cavity?
<3cm = surgery or radiotherapy
>3cm = hemiglossectomy and adjuvant radiotherapy.
31
What are the risk factors for oropharyngeal cancer?
Smoking/ alcohol
Dental sepsis
Ionising radiation
HPV 8 and HPV 16
Male sex
32
How would you investigate for oropharyngeal cancer?
FNAC and pan-endoscopy with bilateral tonsillectomy
Staging with CT TAP and USS liver.
33
How would you manage an oropharyngeal cancer?
If it is at the base of the tongue then radiotherapy or chemotherapy + resection with adjuvant radiotherapy.
If it is soft palate: resection.
If it is pharyngeal: resection and radiotherapy.
If it is tonsillar: resection, radiotherapy +/- neck dissection
34
Define tonsillitis
Inflammation of the palatine tonsils
35
What are the 4 sets of tonsils?
Palatine, tubal, pharyngeal and lingual
36
What is the centor criteria?
This is a criteria regarding the diagnosis of tonsillitis.
If you have a score =/> 2 then you should prescribe abx.
It includes:
- Hx of pyrexia
- Tonsillar exudate
- Anterior cervical lymphadenopathy
- NO cough
37
What are the indications for tonsillectomy?
A) >/= 7 episodes in 1 year, >/= 5 per year in 2 years, >/=3 per year in 3 years.
B) suspected malignancy
C) presence of sleep apnoea
D) 2x peritonsillar abscesses
38
How may a quinsy present?
++ sore throad, odonophagia, trismus, erythema, unilateral swelling, deviated uvula
39
How do you manage a quinsy?
IV abx and I&D or aspiration.
40
Define primary vs secondary tonsillectomy haemorrhage?
Primary: 6-8 hours post op
Secondary: 5-10 days post op. Associated with infection and needs admission for abx +/- surgery
41
What type of saliva do the three salivary glands produce?
The sublingual gland produces the most mucinous saliva, the parotid gland the most serous and the submandibular is in between.
42
Where does the sublingual gland sit anatomically?
It sits in the floor of the oral cavity, underneath the tongue.
The lateral border is the mandible and the medial is the genioglossus. The two glands unite anteriorly in a horseshoe shape.
43
Where does the sublingual gland drain into the oral cavity?
Via the minor sublingual gland of Rivinus which opens out into the sublingual folds.
44
What is the arterial supply to the sublingual gland?
The sublingual and submental arteries, arising from the lingual and facial branches of the ECA respectively.
45
What is the innervation to the sublingual gland?
Parasympathetic is via the chorda tympani fibres of CNVII which travel with the lingual branch of the mandibular nerve. Parasympathetic innervation increases saliva production.
Sympathetic is via the cervical ganglion.
46
Where is the submandibular gland located?
This is in the submandibular triangle
47
What are the boundaries of the submandibular triangle?
Superior: mandible
Anterior: Anterior belly digastric
Posterior: posterior belly of the digastric
48
Describe the structure of the submandibular gland and its duct.
It has a superficial arm and a deep arm which hooks around the myelohyoid muscle.
It secretes saliva into the oral cavity via Wharton's duct which emerges from the deep arm between the myelohyoid, hypoglossus and the genioglossus. Opening via the sublingual papilla at the base of the lingual frenulum.
49
What is the innervation to the submandibular gland?
Parasympathetic is via the chorda tympani fibres of CNVII which travel with the lingual branch of the mandibular nerve. Parasympathetic innervation increases saliva production.
Sympathetic is via the cervical ganglion.
50
What is a rannula?
This is a mucocele which occurs in the floor of the mouth due to a blockage in the sublingual duct. It needs excision.
51
What are some of the important anatomical relations to consider with the submandibular gland?
Lingual nerve (passes deep to the duct)
Marginal mandibular nerve (margin of the mandible beneath the platysma, inferior to the gland)
Hypoglossal nerve (deep to the gland, superficial to the hypoglossus muscle)
Facial artery and veun
52
What enzyme is produced by the parotid gland saliva?
Amylase
53
What are the anatomical relations of the parotid gland?
Superiorly: zygomatic arch
Inferiorly: inferior border of the mandible
Anteriorly: masseter muscle
Posteriorly: external ear and sternocleidomastoid
54
What divides the deep and superficial nodes of the parotid gland?
The facial nerve
55
Via what duct does the parotid gland secrete saliva into the oral cavity and where does it emerge?
Stenson's duct which travserses the masseter muscle and pierces the buccinator before opening near the 2nd upper molar.
56
What is the vascular supply to the parotid gland?
The posterior auricular and the superficial temporal branches of the ECA.
Venous drainage is via the retromandibular vein.
57
What is the innervation to the parotid gland?
The general sensation is the auriculotemporal and the greater auricular nerve.
Parasympathetic is via the glossopharyngeal nerve which travels via the otic ganglion and fibres run with the auriculotemporal nerve.
Sympathetic is via the cervical ganglion.
58
What are the important structures which run through the parotid gland?
The facial nerve
The external carotid artery
The retromandibular vein
59
Can you name some benign parotid tumours?
Benign pleomorphic adenoma (most common).
Warthins tumour
Monomorphic adenoma
Haemangioma
60
What are some of the features of a benign pleomorphic adenoma of the parotid gland?
This is the most common tumour of the parotid gland (accounts for 80%).
Presents as a painless, smooth mass at the age of 50-60.
These tumours have a pseudocapsule of endothelial/myoepithelial cells of the ducts and stromal componants.
They are slow growing and lobular.
They can have malignant transformation in 2-10%.
61
What are the features of a Warthins tumour of the parotid gland?
This is a benign papillary cystadenolymphoma.
More common in males, and bilateral in 10%.
Associated with smoking.
They have a lymphocytic infiltrate with cystic epithelial proliferation.
Malignant transformation is rare.
62
What are some examples of malignant parotid gland tumours?
Adenoid cystic carcinoma.
Mixed lesions.
Mucoepidermoid
Adenocarcinoma
Lymphoma
63
What would your differentials be for parotid gland enlargement?
Benign:
- Pleomorphic adenoma
- Warthins tumour
- Haemangioma
- Monomorphic adenoma
Malignant:
- Adenoid cystic carcinoma
- Mixed
- Mucoepidermoid
- Adeocarcinoma
- Lymphoma
Other:
- HIV infection (causes lymphoepithelial cysts)
- Sjogrens
- Sarcoid
- Mumps
- Stones
64
How would you evaluate a parotid gland?
Full Hx and examination.
Plain XR to exclude calculi
Scialography to delineate ductal anatomy
FNAC
65
How would you manage a parotid lesion that is suspicious for malignancy?
Definitive resection and CT for staging
66
What are the resection options for parotid gland?
- Superficial parotidectomy (superficial gland only)
- Total conservative (spares the facial nerve)
- Total radical (sacrifices the facial nerve)
- Extended (also resects the tympanic membrane, mandible, zygoma and sternocleidomastoid)
67
What are the indications for radiotherapy in parotid gland malignancy?
- residual disease
-extracapsular lymph spread
- high grade tumour
- perineural disease
- any adenoid cystic tumours.
68
What is sialolithiasis?
Calculi in the submandibular gland (normally calcium phosphate or calcium carbonate)
69
What are the risk factors for sialolithesis?
Gout
Dehydration
Diabetes
HTN
70
How would you manage silolithiasis?
If the stone is in Wharton's duct then remove it via the oral cavity, if in the gland then needs duct excision
71
What is siladenitis and what normally causes it?
Infection of the submandibular gland, typically caused by Staph A
72
What are the muscles of the nose?
Nasalis:
Transverse: maxilla to dorsum of nose acts to compress the nasal opening.
Alar: maxilla to the alar cartilage, acts to widen the nose.
Procerus: nasal bone - skin on forehead, allows you to pull the eyebrows downwards.
Depressor septi nasi: maxilla to the nasal septum. Widens the nasal opening.
73
What is the arterial supply to the nose?
Angular and lateral nasal artery, which are branches of the facial artery (from the ECA)
74
What is the innervation of the nose?
Sensory via branches of the trigeminal nerve:
- centrally is a branch of CNV1
- laterally is a branch of the CNV2
Motor innervation is via the facial nerve
75
What are the functions of the nasal cavity?
- Warms and humidifies air
- removes and traps pathogens
- sense of smell
- drains and clears the paranasal sinus/lacrimal ducts
76
What are the areas of the nasal cavity?
Vestibule: surrounds the external opening
Respiratory region: lines by ciliated psuedostratefied epithelium and mucus secreting glands.
Olfactory region (at the apex of the nasal cavity)
77
What are the nasal conchae?
These are 3 projections from the lateral walls, creating pathways for airflow and increasing the surface area.
78
What are the openings into the nasal cavity?
- The frontal, maxillary and anterior ethmoidal sinus drain into the middle meatus via the crescent shaped groove on the lateral wall (the semilunar meatus)
- The middle ethmoidal sinus empties into the ethmoidal bulla in the lateral wall
- The posterior ethmoidal sinus drains into the superior meatus
- The nasolacrimal ducts drains into the nasopharynx at the inferior meatus
- The cribriform plate perforations allow CN1 fibres to pass through
- The sphenopalatine foramen is located in the superior meatus, communicating with the pterygopalatine fossa (contains the sphenopalatine artery and nasopalatine/superior nasal nerves)
- The incisive canal connects the nasal cavity and oral cavity to allow passage of the greater palatine artery and the nasopalatine nerve.
79
What is the vascular supply of the nose?
Branches of the internal carotid artery:
- Anterior and Posterior ethmoidal arteries
Branches of the external carotid:
- sphenopalatine
- greater palatine
- superior labial
- lateral nasal x2
80
What is the venous drainage of the nose?
pterygoid plexus, facial vein and the cavernous sinus
81
What are the paranasal sinuses?
These are air-filled extensions of the nasal cavity, lined by pseudo-stratefied epithelium and mucus secreting goblet cells.
4x:
- sphenoid
- frontal
- ethmoid
- maxillary
82
Where do the paranasal sinuses drain to?
The ethmoidal sinus, the frontal sinus and the maxillary sinus drain via the semilunar hiatus in the middle meatus of the nose?
The sphenoid sinus drains into supero-posterior aspect of the nasal cavity known as the sphenoethmoidal recess
83
Where does epistaxis typically occur?
At Keisselbachs plexus (confluence of the anterior and posterior ethmoidal arteries, sphenopalatine, greater palatine, superior labial artery).
84
What are the causes of epistaxis?
Trauma
HTN
Rhinosinusitis
Iatrogenic
Foreign body
Malignancy
Coagulopathy
AV malformation
Drug use
85
How would you manage epistaxis?
1. ABCDE, resus
2. Position the patient sat upright and forward and compress the nares for approximately 20 minutes.
3. Examine the oropharynx and nasal septum
4. Silver nitrate and adrenaline soaked gauze
5. Anterior packing
6. If fails then need ligation surgically or radiological embolisation.
86
When do nasal septal haematoma occur?
Traumatic shearing forces separating the pericardium from the nasal septum causing submucosal blood vessels to tear.
87
How do nasal septal haematoma present?
Boggy, red/purple swelling that is fluctuant.
88
How would you manage a nasal septal haematoma and why?
They need incision and drainage due to the risk of avascular necrosis of the septal cartilage. This can then develop infection, abscess or perforation and saddle nose deformity.
If infection occurs there is risk of cavernous sinus syndrome.
89
How do you test for CSF?
Beta-2-transferrin
90
What are the complications of a nasal fracture?
- CSF leak
- Anosmia
- Cosmetic deformity
91
What are the red flags of rhinosinusitis?
Eye signs (periorbital swelling, erythema, visual changes), severe unilateral headache or frontal swelling, neurological signs.
92
What are the complications of rhunosinusitis?
Peri-orbital cellulitis
Oestomyelitis
Potts putty tumour (osteomyelitis of the frontal sinus)
Venous sinus thrombosis
Mucocele
93
What is periorbital cellulitis?
Infection of the eyelid and surrounding skin/subcutaneous tissue.
94
What organism classically causes periorbital cellulitis?
Haemophilus influenzae, strep pneumoniae, staphylococcus
95
What are the features of periorbital cellulitis?
Acute onset of pain and swelling
Tenderness and erythema
NO signs of CN palsy/ meningism
96
What is chandlers classification of periorbital cellulitis?
1 - pre orbital cellulitis
2 - orbital cellulitis (posterior to orbital septum)
3 - Subperiosteal abscess (displaces globe)
4 - Orbital abscess (within the orbital tissues)
5 - Cavernous sinus thrombosis
97
What is Samters triad?
Triad for nasal polyps:
Nasal obstruction
Rhinorrhoea/ sneezing
Poor sense of smell/taste
98
What are the features of nasal polyps that need a two week wait referral?
Bleeding or unilateral symptoms
99
What conditions are associated with nasal polyps?
Asthma
Aspirin sensitivity
Infective sinusitis
Cystic fibrosis
Kartageners
Churg strauss
100
What are the risk factors for nasopharyngeal Ca?
Genetics: HLA/A2
EBV
Salt preserved fish (nitrosamines)
Vit C deficiency
Male
101
What are the features of nasopharyngeal Ca?
Epistaxis, nasal obstruction, otalgia, neck lump (due to lymphatic spread) , otitis media (due to anterior spread), horners (due to posterior spread)
102
What is the vasculature of the external ear?
Posterior auricular, superficial temporal, occipital, deep auricular branch of maxillary artery (for tympanic membrane)
103
What is the innervation to the external ear?
Skin of the auricle= greater auricular nerve, lesser occipital nerve, auriculotemporal nerve
External meatus = auriculotemporal nerve
Deep external meatus/tympanic membrane = auriculotemporal, facial and vagus nerves
104
What are the boundaries of the middle ear?
Lateral wall: tympanic membrane
Medial wall: oval and round window
Anterior: thin plate of bone separating it from the ICA
Posterior: mastoid antrum
Floor: thin plate of bone overlying the jugular bulb
Roof: tegmen tympani of the temporal bone
105
What are the contents of the middle ear?
3x ossicles: malleus, incus and stapes
2x muscles: tensor tympani and stapedius
2x nerves; tympanic plexus (made from CNVII and CNIX) and the chorda tympani (CNVII)
106
What type of joints exist between the ossicles?
Synovial joints
107
What are the mastoid air cells?
These are located posteriorly to the epitympanic recess. They are air filled cells within the temporal bone which act as a pressure buffer system by releasing air into the tympanic cavity.
108
Describe the attachments, innervation and function of the muscles of the middle ear.
These muscles have a protective function. They contract when loud noise is heard inhibiting vibrations of the ossicles and reducing sound transmission.
Tensor tympani: auditory tube to handle of the malleus.
Innervated by CNV3.
The stapedius: attaches to the stapes muscle and is innervated by CN7.
109
What is the eustachian tube?
This is a cartilagenous/bony tube connecting the middle ear to the nasopharynx, acting to equalise the pressure.
110
Why are middle ear infections more common in children?
This eustachian tube is straighter and shorter and therefore more susceptible to passage of pathogens.
111
What is the blood supply to the middle ear?
Tympanic branches of the maxillary artery
Stylomastoid branch of the posterior auricular
Petrosal branch of the middle meningeal
112
Describe the anatomy of the Eustachian tube.
Opens in the middle ear via the tympanic orifice. It is anterolateral to the canal by which the chorda tympani leaves.
The ICA is closely associated with its medial wall.
The canal has an osseous portion formed by the petrous part of the temporal bone, and a cartilaginous which extends into the nasopharynx opening into the pharyngeal recess, posterior to the inferior concha.
113
Where is the inner ear located in the head?
Within the petrous part of the temporal bone
114
What is otitis externa?
This is erythema, swelling and tenderness of the external auditory canal. Causes debris and discharge accumulation.W
115
What are the common pathogens in otitis externa?
Psuedomonas
Staph epidermis
116
What would your differentials for otitis externa be?
Otitis media with perforation, ramsay hunt and furuncle (abscess from an infected hair follicle)
117
How would you manage otitis externa?
Simple analgesia and topical antibiotics
118
What is malignant otitis externa and how would you manage this?
Extension of the infection into the mastoid air cells (typically seen in immunocompromised patients). It may involve the facial nerve.
It needs urgent CT, debridement and IV antibiotics. Consider hyperbaric O2
119
What are the common organisms causing otitis media?
Step P.
Haemophilus influenzae
120
What are some complications that may occur from otitis media?
Facial nerve palsy
Sigmoid sinus thrombosis
Chronic otitis media
Intracranial abscess
Meningitis
Mastoiditis
121
When should grommits be considered for otitis media?
NICE states than in a case of otitis media with effusion in those over the age of 3 months with hearing difference of 25-30 decibels.
122
What is a cholesteatoma?
Chronic squamous otitis media causing a cyst like structure.
They can induce an inflammatory process in adjacent temporal bone causing destruction of the ossicles which may blead to conductive hearing loss, however if the destruction continues into the canals/cochlear then it may lead to sensorineural hearing loss
123
How would cholesteatoma look on otoscopy?
Pearly white mass in the attic region/
124
How would you manage a cholesteatoma?
Surgical resection
125
How may mastoiditis present?
This is an infection of the mastoid air cells posterior to the ear.
Causes a painful swelling behind the ear with erythema of the mastoid process.
126
What organisms are commonly associated with mastoiditis?
Staph A, Strep Pyogenes, and Haemophilus influenzae
127
How would you manage a mastoiditis?
This requires urgent IV antibiotics as it may spread into the dural venous sinus causing meningitis or cerebral abscess.
If no improvement after 24 hours of IV abx then need to consider mastoidectomy.
128
Describe how you would assess hearing.
Gross hearing assessment: rustle fingers/paper by ear.
Rhinnes test: tuning fork infront of auditory meatus and then on mastoid process.
Normally air > bone. If bone is louder than air then suggests that there is conductive hearing loss.
Webers test: place in the forehead. Should be equal on both sides.
If sound is louder in one ear then either:
- sensorineural hearing loss in quieter ear
- conductive hearing loss in the affected ear
129
What are some causes of conductive hearing loss?
Otitis externa
Otitis media and effusion
Wax impaction
Tympanic perforation
Cholesteatoma
130
What are some causes of sensorineural hearing loss?
Noise induces
Presbycusis (age related degeneration)
Acoustic neuroma
Infection
Ototoxic drugs
Autoimmune
131
How can the pharynx be divided?
Nasopharynx: between base of the skull and the soft palate.
Oropharynx: soft palate and superior border of epiglottis
Laryngopharynx: epiglottis to cricoid cartilage
132
What anatomical features sit in the nasopharynx, oropharynx and laryngopharynx?
Nasopharynx: Adenoid tonsils.
Oropharynx: posterior 1/3 of tongue, lingual tonsils, palatine tonsils, superior constrictor muscles.
Laryngopharynx: middle and inferior constrictor muscles
133
What is the pathophysiology of a pharyngeal pouch?
The inferior pharyngeal constrictor is split into 2 parts: thyropharyngeus and cricopharyngeus (Cilians dehiscence). Normally as the first contracts, the second relaxes to propel food and prevent pressure. It is doesn't a midline diverticulum occurs between the two parts of the muscle.
134
What nerve innervates the muscles of the pharynx?
Generally it is the vagus nerve except for the stylopharyngeus which is the glossopharyngeal nerve.
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What are the muscles of the pharynx?
Circular muscles: superior constrictor, middle constructor and inferior constrictor.
The longitudinal muscles: stylopharyngeus, palatopharyngeus, salpingopharyngeus
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What is the blood supply of the pharynx?
Arterial supply is via branches of the ECA:
- ascending pharyngeal
- branches of facial
- branches of lingual and maxillary artery
Venous drainage is via the pharyngeal venous plexus to the IJV.
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What is the innervation to the pharynx?
Sensory is mainly via the glossopharyngeal nerve.
Motor is via the vagus nerve except the stylopharyngeus which is innervated by the glossopharyngeal
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Where is the larynx located in the neck?
Anterior neck, spanning C3-C6. Suspended by the hyoid bone.
It is formed by a cartilagenous skeleton.
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How can the larynx be anatomically divided?
Supraglottis: inferior surface of the epiglottis - vestibular folds
Glottis: contains the trye vocal cords.
Subglottis: inferior border of glottis to the cricoid cartilage
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What is the epithelial lining of the larynx?
Pseudo-stratefied ciliated columnar epithelium, apart from the vocal cords which are stratefied squamous.
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What is the blood supply to the larynx?
Superior laryngeal artery: branch of the superior thyroid (runs with the superior laryngeal nerve)
Inferior laryngeal artery: branch of the inferior thyroid artery
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What is the innervation to the larynx?
Vagus nerve is both motor and sensory.
- Recurrent laryngeal nerve: sensory to the subglottis region and motor to all the muscles except cricothyroid.
- Superior laryngeal: sensory to the supraglottis via the internal branch and the external branch is via the motor to the cricothyoid muscle.
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What is the path of the recurrent laryngeal nerve?
The L loop around the arch of the aorta.
The R around the R subclavian and the R carotid
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What would damage to the recurrent laryngeal nerve cause?
Unilateral: hoarseness of voice
Bilateral: breathing is impaired and phonation cant occur.
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What are some causes of damage to the laryngeal nerve?
Apical lung tumours
Thyroid cancer
Iatrogenic
Aneurysm
Cervical lymphadenopathy
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What are the intrinsic muscles of the larynx and what is there role?
Cricothyroid: role in altering voice.
Thyroarytenoid- relaxes the vocal ligaments
Posterior cricoarytenoid- abduction of the vocal cords
Lateral cricoarytenoid- adduction of the vocal cords
Transverse and oblique arytenoids - narrow the laryngeal inlet
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What are the suprahyoid muscles?
The anterior and posterior belly of digastric, the mylohyoid, the stylohyoid and the geniohyoid
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What are the infrahyoid muscles?
Thyrohyoid, Omohyoid, sternohyoid and sternothyroid
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What are the laryngeal cartilages?
Unpaired:
- Thyroid cartilage: articulates with the hyoid bone via the superior cornu and the cricoid cartilage via the inferior cornu
- Cricoid cartilage: ring of hyaline cartilage, broad posteriorly and narrow anteriorly.
Makes the inferior border of the larynx and C6, It articulates with the arytenoid cartilage and the thyroid cartilage.
- Epiglottis: elastic cartilage attached via the stalk to the thyroid cartilage.
Paired:
- Arytenoid cartilages: sit on the cricoid cartilage and provide arttachment for the posterior and lateral cricoarytenoid muscles.
- Corniculate
- Cuneiform
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What are the sub-occipital muscles?
These muscles sit under the occipital bone, deep to the sternocleidomastoid, trapzius, splenius and semispinalis.
They act to extend and rotate the head.
They are innervated by the suboccipital nerve (C1).
Include;
Rectus capitus posterior minor
Rectus capitus posterior major
Obliquus capitus inferior
Onliquus capitus superior
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What is the suboccipital triangle?
This is a triangle formed by the borders of:
Superomedial: rectus capitus posterior major
Inferior: Obliquus capitus inferior
Superolateral: obliquues capitus superior
Floor: atlanto-occipital membrane
Roof: semispinalis
Contents: vertebral artery, venous plexus, suboccipital nerve
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What are the suprahyoid muscles and what is their function?
These muscles act to elevate the hyoid during swallowing.
They include: stylohyoid, digastric, mylohoid and geniohyoid.
153
What is the attachment, insertion and innervation of the stylohyoid?
Styloid process and attaches to the lateral hyoid bone.
Innervated by the stylomastoid branch of CNVII
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What is the attachment, insertion and innervation of the digastric muscle?
The anterior belly arises from the digastric fossa of the mandible.
The posterior belly arises from the mastoid process of the temporal bone.
They are connected by a tendon that attaches to the hyoid.
The anterior belly is innervated by the inferior alveolar nerve of the mandibular.
The Posterior belly is innervated by a branch of the facial nerve.
155
What is the attachment, insertion and innervation of the myelohoid?
This is a broad, triangular muscle that forms the floor of the oral cavity.
It attaches from the myelohyoid line of the mandible to the hyoid bone.
It is innervated by the inferior alveolar nerve (trigeminal).
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What is the attachment, insertion and innervation of the geniohyoid?
This sits deep to the mylohyoid.
It attaches from the mental spine of the mandible to the hyoid bone. It is innervated by C1 fibres that run with the hypoglossal nerve
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What are the infrahyoid muscles?
Omohyoid, sternohyoid, sternothyroid and the thyrohyoid.
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What is the attachment, insertion and innervation of the omohyoid?
Superior belly arises from the hyoid bone, inferior belly arises from the scapula.
Combines by a tendon anchored to the clavical.
Acts to depress the hyoid.
Innervated by the anterior rami of the C1-3 via the ansa cervicalis.
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What is the attachment, insertion and innervation of the sternohyoid?
Sternum to hyoid.
Acts to depress hyoid.
Innervated by the rami of the C1 to C3 carried by the ansa cervicalis.
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What is the attachment, insertion and innervation of the sternothyroid?
Sits posterior to the sternohyoid.
Attaches from the manubrium to the thyroid cartilage.
Depresses the thyroid cartilage.
Innervated by the C1-C3 of the ansa cervicalis.
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What is the attachment, insertion and innervation of the thyrohyoid?
This is a continuation of the sternothyroid, attaching the thyroid cartilage to the hyoid.
Depresses the hyoid and elevates the larynx.
Innervated by the anterior rami of C1 via the ansa cervicalis.
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What is the function of the scalene muscles?
They act as accessory muscles of respiration.
163
What is the anatomical significance of the scalene muscles?
The brachial plexus and the subclavian artery pass between the anterior and middle scalene.
The subclavian vein and phrenic nerves pass anterior to the anterior scalene.
164
What are the origins, insertions and innervation of the scalene muscles?
Anterior: anterior tubercle of the transverse processes of vertebra C3-C6 to the scalene tubercle on the first rib.
Innervated by nerves C5-6
Middle: posterior tubercles C2-C7 to the first rib.
Innervated by C3-C8.
Posterior: posterior tubercles of C5-C7 to the second rib.
Innervated by the C6-C8 nerves.
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What are the borders of the anterior triangle?
Superior: Inferior border of the mandible
Lateral: anterior birder of the sternocleidomastoid
Medial: the midline
Roof: investing fascia
Floor: visceral fascia
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What are the contents of the anterior triangle?
Muscles: suprahyoid and infrahyoid muscles
Blood Vessels: common carotid + bifurcation, IJV
Nerves: facial nerve, glossopharyngeal, vagus, accessory and hypoglossal
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What are the subdivisions of the anterior triangle?
The carotid triangle
The submental triangle
The submandibular triangle
The muscular triangle
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What are the borders and contents of the carotid triangle?
Superior: Posterior belly of digastric
Inferior: Superior belly of omohyoid
Lateral: Sternocleidomastoid
Contents: common carotid bifurcation, vagus nerve and hypoglossal nerve
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What are the borders and contents of the submental triangle?
Inferior: Hyoid bone
Medial: midline
Lateral: anterior belly of the digastric
Floor: mylohyoid
Contents: submental lymph nodes
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What are borders and the contents of the submandibular triangle?
Superior: mandible
Anterior: anterior belly of the digastric
Posterior: posterior belly of the digastric
Contents: submandibular gland, lymph nodes and facial artery/vein
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What are the borders and contents of the muscular triangle?
Superior: hyoid bone
Medial: midline
Superolateral: omohyoid
Inferolateral: sternocleidomastoid
Contents: infrahyoid muscles, pharynx, thyroid and parathyroid.
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What are the borders of the posterior triangle?
Anterior: sternocleidomastoid
Posterior: trapezius
Inferior: middle 1/3 of the clavicle
Roof: investing fascia
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What are the contents of the posterior triangle?
Muscles: inferior belly of omohyoid, splenius capitus, scalene muscles and levator scapular
Blood vessels:
external jugular vein (formed by retromandibular and posterior auricular), subclavian vein, transverse cervical vein, suprascapular vein and the subclavian artery
Nerves: cervical plexus, trunks of brachial plexus
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Where is the cervical plexus located and why is the clinically important?
In the posterior triangle, halfway up the sternocleidomastoid, within the prevertebral fascia.
It is clinically useful as it can be used for local nerve block (at Erbs point) for carotid surgery or lymph node excision. m
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When is a cervical plexus block contraindicated?
In the case of cardio-respiratory disease due to the proximity of the phrenic nerve.
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What is the course of the phrenic nerve?
From nerve roots C3-C5. It passes down the anterior aspect of the scalenus anterior, deep to the pre-vertebral fascia, and posterior to the subclavian vein.
It enters the throacic aperture and descends anteriorly to the lung, over the right atrium and then pierces the diaphragm. (The left crosses the aortic arch and the left ventricle)
177
What re the motor branches of the cervical plexus and what nerve roots do they have?
- Phrenic nerve (C3-5)
- Nerve to the geniohyoid and thyrohyoid (C1)
- Ansa cervicalis (C1-C3)
Other:
- C1-2 innervate the rectus capitus anterior and lateralis
- C1-C3: innervate the longus capitus
- C2-C3 innervate the prevertebral muscles and the sternocleidomastoid.
- C3-C4: innervate the levator scapulae, trapezius and scalene muscles.
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What nerve roots does the cervical plexus arise from?
C1-C4
179
What are the sensory branches of the cervical plexus?
- greater auricular (C2-C3)
- transverse cervical (C2-C3)
- lesser occipital (C2)
- Supraclavicular nerve (C3-C4)
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What does the ansa cervicalis innervate?
C1-C3
Innervates the omohyoid, sternohyoid and sternothyroid
181
What are the fascial layers of the neck?
Superficial cervical fascia
Platysma
Deep cervical fascia (includes; investing fascia, pretracheal fascia, prevertebral fascia)
carotid sheath
182
What is the platysma?
This is a muscle which originates from the fascia of the pectoralis major and deltoid, cross over the clavical and inserts into the mandible.
Innervated by the cervical branch of the facial nerve.
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What does the investing layer of fascia of the neck surround?
Attaches to the superior nuchal line of the skull, the hyoid bone and the spine of the acromium of the scapular, clavical and sternum.
It surrounds all the structures in the neck and it divides and envelopes the sternocleidomastoid and the trap muscles.
184
What does the pre-tracheal fascia of the neck enevelope?
This is in the anterior neck. Spans the hyoid bone to the thorax where it fuses with the pericardium.
The muscular part encloses the infrahyoid muscles. The visceral part encloses the thyroid, trachea and oesophagus.
185
What does the pre-vertebral fascia of the neck enevelope?
This surrounds the vertebral column, scalene muscles and the deep muscles of the back.
186
What sits inside the carotid sheath?
Enclose the common carotid, internal jugular vein, vagus nerve and cervical lymph nodes.
187
What level does common carotid bifurcate?
At the level of C4 (within the carotid triangle)
188
What are the branches of the carotid artery?
Superior thyroid artery
Ascending pharyngeal artery
Lingual artery
Facial artery
Occipital artery
Posterior auricular artery
Maxillary artery
Superficial temporal
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What are the branches of the ICA in the neck?
None
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How does the internal carotid artery enter the skull?
Via the carotid canal and into the foramen lacerum, via the cavernous sinus, medial to the anterior clinoid process.
191
What are the branches of the internal carotid artery?
Ophthalmic artery, anterior choroidal artery, posterior communication artery, anterior cerebral artery, middle cerebral artery
192
What are the signs and symptoms of a deep neck space infection?
Sore throact
Dysphagia
Trismus
Drooling
Stridor
Hoarse voice
Neck stiffness
Swelling
Lymphadenopathy
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What are the types of deep neck space infection?
Parapharyngeal (posterior to the nasopharynx)
Retropharyngeal (anterior to the prevertebral fascia)
Submandibular - leads to tongue swelling and airway obstruction. Also known as Ludwigs angina/
194
What is Ludwigs angina?
This is a deep neck space infection in the submandibular, submental or sublingual area which leads to tongue swelling and airway obstruction
195
How would you manage Ludwigs angina?
Broad spectrum antibiotics
Dexamethasone
Surgical drainage and washout
196
What would be your differentials of hoarse voice?
BENIGN=
- Vocal cord nodules (benign lesions due to overuse)
- Intercordal cyst (due to trauma or blocked duct)
- Muscle tension/dysphagia
- Vocal cord polyps (benign but need excision)
- papilloma (benign but needs excision, related to HPV)
- Reflux
- Reinkes Oedema (secondary to smoking)
INFECTION
- Laryngitis
- Epiglottitis/ Supraglottits
MALIGNANCY
- SCC of pharynx
- Thryoid Ca causing compression of recurrent laryngeal
- Apical lung Ca causing compression of the recurrent laryngeal
IATROGENIC
- damage to recurrent laryngeal
NEUROLOGICAL
- MS
- Stroke
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What investigations would you perform to investigate a hoarse voice?
- Flexible naso-endoscopy
- CT head and neck
- Laryngeal electromyography
- Thyroid function tests
- SALT assessment
198
How do you differentiate between an UMN and LMN lesion of the facial nerve.
UMN are forehead sparing
199
What are the causes of stridor?
Foreign body
Epiglottis
Croup
Laryngitis
Anaphylaxis
Neck space abscess
Laryngomalacia
Subglottic stenosis post intubation
Vocal cord paralysis
Malignancy
200
What is the bernoulli Principle?
An increase in the velocity of fluid through a tube will decrease the linear pressure on the tube walls. Therefore as the airway narrows, the velocity of air increases and the linear pressure falls which can lead to airway collapse.
201
What is the acute management for a patient presenting with stridor?
Resus, high flow O2, ABG
Suction secretions, or clear foreign body
Adrenaline and steroids
Consider surgical airway
202
What causes epiglottitis?
Haemophilus Influenzae
203
How do you manage epiglottitis?
Nebulised adrenaline and IV dexamethasone and IV antibiotics
204
What is croup?
This is inflammation of the larynx, trachea, bronchus and vocal cords.
Characteristically gives a barking cough at age 6 months to 2 years.
Normally due to parainfluenza or RSV
205
What are the red flags of a neck lump?
- hard, painful, fixed lump
- associated otalgia, dysphagia, stridor, hoarse voice
- unilateral nasal symptoms
- unexplained weight loss, night sweats, fevers
- CN palsy
206
What are the differential diagnosis of a neck lump?
Infective:
- reactive lymphadenopathy
- sialdentitis
Neoplastic:
- lymphoma
- Salivary gland tumour
- Head and neck SCC
- Skin cancer
Vascular:
- carotid body tumour
Inflammatory:
- sarcoid
Traumatic:
- haematoma
Autoimmune:
- graves disease
Congenital:
- Cystic hygroma
- Thyroglossal cyst
- Branchial cyst
- Desmoid cyst
207
What is a cystic hygroma?
This is a benign fluid filled sac caused by a malformation of the lymphatic system.
Classically in the posterior triangle, often on the left side.
Presents as a soft painless, fluctuant, illuminating mass.
Only treated if its symptomatic.
208
How do you clinically differentiate a carotid body tumour from other neck lumps?
- Pulsatile
- Will be movable side to side but not up and down (Fontaines sign)
209
What is the branchial cyst?
This is typically an anterior triangle neck lump. Formed by incomplete obliteration of the branchial arches.
210
What is tinnitus?
This is the perception of sound in the absence of external auditory stimulus.
211
What are the causes of tinnitus?
Primary: no underlying cause
Secondary:
- conduction: impaction/osetosclerosis
- sensorineural: menieres
- medications: NSAIDs, tetracyclines, sodium valporate
- Metabolic: hyperthyroid, zinc deficiency
- Neurological: acoustic neuroma, MS
- MSK: TMJ dysfunction, tensor tympani
- Psychological
- Vascular: pulsatile tinnitus due to AV malformation
212
When is tinnitus an emergency?
Sudden onset pulsatile tinnitus
Severe vertigo
Secondary to trauma
Unexplained sudden hearing loss
213
What is an acoustic neuroma?
This is a vestibular scwhannoma of the CNVIII at the cerebello-pontine angle.
Arise due to abnormalities in the tumour supressor gene on p22, or if bilateral associated with neurofibromatosis type 2.
Features include:
- sensorineural hearing loss
- tinnitus
- vertigo
- SOL symptoms depending on size
214
What is the management of acoustic neuroma?
If small then monitor with serial MRI
Steotactic radiotherapy
Surgical resection
215
What are the embryological arches of the head and neck and the innervation?
Arch 1: mandibular arch = trigeminal nerve.
Arch 2: hyoid arch = facial nerve
Arch 3: glossopharyngeal nerve
Arch 4: superior laryngeal nerve
Arch 5: recurrent laryngeal nerve
216
Where are salivary gland stones most commonly located?
In the submandibular gland as the secretions are the thickest.
217
What is the sensory nerve supply to the ear?
6 nerves:
- Greater auricular (from cervical plexus) supplies the inferior 2/3 of the ear.
- Lesser occipital (from cervical plexus) supplies the superior 1/3 of posterior ear
- Auriculotemporal (from V3) supply the superior third of the anterior ear
- Auricular branch of Vagus nerve (concha and part of the antihelix)
- Facial nerve (canal and tympanic membrane)
- Glossopharyngeal (main nerve to middle ear, supplies a small proportion of the external ear.
218
What are the sensory branches of the cervical plexus?
lesser occipital
great auricular
transverse cervical
supraclavicular.
219
What are the dermatomal areas for C1-C4?
C1 – there is no C1 dermatome
C2 – superoposterior scalp
C3 – upper neck and behind ear
C4 – lower neck down to clavicle.
220
What is the clinical significance of the omohyoid?
This can be used as a boundary between lymph levels 3 and 4 in the anterior triangle. This is useful for neck dissection as with no evidence of metastases it is standard practice to dissect levels 1-3.
221
What are the surface markings for the cervical vertebra?
C1 = hard palate
C2 = angle of the mandible
C3 = hyoid bone
C4 = superior thyroid notch
C5 = thyroid cartilage
C6 = cricoid cartilage
C7 = upper tracheal rings
222
At what age does the frontal sinus develop?
Age 8 and then fully forms at puberty
223
