Head And Neck Flashcards
Where does the RCC arise from
Brachii cephalic trunk, behind the right sternoclavicular joint.
Which blood vessels make up the upper systemic vascular loop?
Internal, external and anterior jugular veins and common carotid and vertebral arteries
Where do the common carotids terminate?
Between angle of mandible and mastoid upper boarder of thyroid cartilage. C4 is bifurcation
Uses of carotid massage
Alleviate supra ventricular tachycardia
What is the carotid body
Location of peripheral chemoreceptors which detect arterial O2. Different from baroreceptors. Between internal and external. CNIX (glossy pharyngeal nerve)
Where does ICC enter skull?
Carotid canal
Branches of external carotid.
SALFOPMS Superior thyroid Ascending pharyngeal Lingual Facial Occipital Posterior auricular Maxillary Superficial temporal
Nerves and arteries in parotid?
External to maxillary and superficial temporal. Also facial nerve and retro mandible vein.
Describe the vertebral arteries
From the subclavian. Through the transverse foramen of 1-6. Supply brain
Describe the carotid triangle.
Superior digastric Laterally SCM Medially- superior belly of omohyoid. Also has vagus and hypoglossal nerves, Larynx, Pharynx Thyroid gland Cervical plexus
Layers of scalp
Skin Loose connective tissue Aponeurosis Loose connective tissue (with vessels) Periosteum
Blood supply of scalp
Occipital, superficial temporal and posterior auricular. Also supratrochlear and supra orbital from ophthalmic from internal carotid. All anastomose.
Lacerations made worse by contraction of occiptofrontalis.
Same veins but deep parts can drain to the pterygoid venous plexus.
Also valveless emissary veins to the diploic vein to the dural venous sinuses.- infection
Blood supply to skull and dura
Middle meningeal artery (ant and post) a branch of the maxillary. Near to the pterion.
Describe the angular vein
Supra orbital and supratrochlear veins drain into it. Located medial to eye socket?. Drains into facial vein
Describe craniotomies
Access to cranial cavity
Bone and skin flap reflected inferiorly to preserve blood supply.
Explain dural venous sinuses
Endothelium lined spaces between the periosteum and meningeal layers of Dura forming dural septal which receive blood from the large veins draining the brain. Eventually drain into jugular.
Origin of lateral nasal and angular arteries?
Facial
Describe the cavernous sinus
A plexus of extremely thin-walled veins on the upper side of the sphenoid bone. (Above pterygoid plexus which it drains into)
Also contains internal carotid artery.
CN3,4,6,5
Positions of jugular veins in neck
Internal under SCM, external is on top/across
Terminal group of lymphatics?
Deep cervical- all afferent lymph vessels of the head and neck.
Then to jugular lymph trunk then to brachiocephalic between SC and IJV
How are the cranial nerves numbered and what is the exception?
Rostro-cranial. CNXII before CNXI
Name CNI
Olfactory Nerve
Function CNI
Sense of smell (olfaction) - entirely senosry
Anatimy CNI
Through cribiform plate of the ethmoid bone where they form the olfactory bulb
Loss of sense of smell is known as?
Anosmia (can occur in URTI)
Does CNI go through thalamus? clinical significance?
No, can ‘reboot’ brain with strong stimulus
Name CNII
Optic
Function CNII
Sensory, sub serves vision. Colour, visual acuity, visual fields, reflexes, fundoscopy
ANatomy CNII
Brain tract not nerve. Crossing over e.c.t.
Uses of CNII assessment
Visual field defects, early signs of meningitis, tumours, elevated CSF pressure
Name CNII
Oculomotor
Function CNIII
somatic motor and autonomic.
Somatic motor - all extraocular muscles apart from lateral rectus and superior oblique. Levator palpaebrae superioris muscle.
Parasympathetic toconstrictor pupillae of eue
CNIII palsy?
eye is down and out due to extraocular muscles. dilated pupil any no pupillary light reflex
Name CN IV
Trochlear
Anatomy CN IV
Dorsal aspect of midbrain
Function IV
Motor - superior oblique
Damage CN IV
Diplopia occurs on looking down and in
Cranial nerve VI name
Abducent
Function CNVI
Motor - Lateral Rectus
How might damage occur to CNVI
Intercranial pressure increases, it has a long intracranial course. If damaged then patient cannot look outwards (squint)
Name CN V
Trigeminal
Anatomy CN V
LArgest CN, 3 divisions - opthalmic (i) Maxillary (ii) Mandibular (iii)
Function CN V
Sensory - whole face, cornea and conjunctiva- divisions at nose/ angle of ete and mouth angle.
Motor - Only iii (mandibular), mastication - temporalis, masseter, medial pterygoids, anterior belly of diagastric
What does corneal reflex test
CNVi and CNVII - sensory or motor damage, if one eye produces a blink in opposite eye then facial nerve is defective.
Sensory innervation by CNVii
Skin lower eyeld - upper lip, mucosa of nasal cavity, paranasal sinuses, palate and roots of upper teeth.
Sensory CNViii
Skin temples, cheeks chin
mucosa inner cheek, anterior 2/3 tongue
roots of lower teeth
Name CN VII
Facial
Function CN VII
Motor - facial nerve, facial expression and stapedius
Sensory - Nervus intermedius, concha of the auricle and behind ear, taste in anteror 2/3 via chorda tympani (temperature)
Autonomic - nervus intermedius (greater petrosal nerve) - glands lacrimal, submandibular, sublingual, mucous membranes of nasopharynx, paranasal sinuses, hard and soft palate.
Damage to CN VII
Ear surgery, tumours in petrous part of temporal
Name CN VIII
Vestibulocochlear nerve
Function CNVIII
Sensory - balance and hearing - vestibular vs cochlear nerves.
2 recognised forms of deafness?
Sensori-neural (nerve) and conductive (blockage) Rinnes and Webers tests to differentiate
What is caloric response
hot or cold water causing a nystagmus
Name CN IX
Glossopharyngeal
Function CN IX
Mixed sensory and motor motor - branchiomotor - stylopharyngeus visceromotor (parasympth) - parotid Sensory - Viscerosensory - carotid body and carotid sinus, pharynx and middle ear Special sensory - posterior 1/3 tongue.
Test for CN IX
gag reflex/pharyngeal reflex
name CN X
Vagus
Function CN X
Snsory - external ear, auditory canal eadrum, pharynx, larynx, visceral in thorax and abdomen
Motor - intrinsic of larynx and pharynx, muscles of palate, smooth muscle of bronchi and GI tract, secretomotor to thoracic and abdominal viscera.
Name CNXI
Accessory.
Anatoy of CN XI
Medulla of brain for cranial division and spinal division from spinal cord and ascends intracranially through foramen magnum to join cranial division.
Exits via jugular foramen
Function CN XI
Motor nerve supplying Sternomastoid and trapezius. To test look for muscle wasting
Name CNXII
Hypoglossal
Function CNXII
Motor - muscles of tongue, damage causes dysarthria, inspect fro tongue wasting and fasiculations. Deviates to side of weakness
What are the 4 general classes of spinal nerves?
General somatic afferents/ efferents and General visceral afferents and general autonomic efferents
Sources of parasympathetic outflow in the head and neck
CNIII, VII, IX, X (neck only)
How is parasympathetic in the head different to the rest of the body
4 discrete ganglia which do not lie in walls of target organs (unlike body)
Where do autonomic nerves in the oculomotor nerve terminate?
Ciliary ganglion (around eye) - Opthalmic division
Where do autonomic nerves in the facial nerve terminate?
Pteygopalatine ganglion (Vii) or submandibular (Viii) ganglion
Where do glossopharyngeal autonomic nerves terminate?
Otic ganlion
Where do vagus autonomic neurones terminate
No discrete ganglia (not in head and neck)
Describe the parasympathetic output of the oculomotor nerve anatomy
Pre ganglionic enters the orbit inferiorly with the infererior division of the optic nerve to the ciliary ganglion just lateral to optic nerve.
Post ganglionic fibres with short ciliary nerves to enter the eye to supply the sphincter pupillae and ciliary muscles
What is Horner’s syndrome?
Damage to sympathetic trunk. Causes miosis (constriction of pupil), ptosis (weak droopy eyelid) enopthalmus (posterior displacement) and possible anhidrosis (decreased sweating)
Sympathetic fibres of the ciliary ganglion
Innervate the 5 eye muscles
Describe the Pterygopalatine ganlion
Supplied by the greater petrosal branch of the facial nerve.
Supplies the Lacrimal gland, mucous gland of the nose and mucous glands of the palate.
Describe the submandibular ganglion
Supplied by the Chorda Tympani branch of the facial nerve. It supplies the submandibular, sublingual and mucous glands of the palate
Describe the Otic ganglion
Pre ganglion neurones are found within the inferior salivatory nucleus from CN IX which terminate via the lesser petrosal nerve. Supplies the parotid and oropharynx
Name each parasympathetic nerve and its corresponding nucleus
III Edinger-westphal
VII Superior salivatory
IX Inferior salivatory
X Dorsal vagal motor nucleus
Name the sympathetic gangla
2/3 cervical (8levels) 11 thoracic (12levels) 4 lumbar (5 neural levels) 4 sacral (5 sacral neural levels) Somatic nerves via segmental nerves Visceral along ganglionated trunks
3 sympathetic ganglion to head and neck?
Superior, middle and inferior cervical ganglions (T1-2)
How to sympathetics reach head and what they pass to?
Superior cervical ganglion along with the internal carotid nerve ascend along ICA into the cranium to form the internal carotid plexus.
Pass to the pterygopalatine ganglion, abducent nerve, glossopharyngeal, occulomotor, trochlear and opthalmic nerves adn vessels derivered from ICA
Where is the superior cervical ganglion located?
Anterior to C1,2,3,4 vertebrae
Location of middle cervical ganglion
small or absent, anterior to C6 and inferior thyroid artery
Location inferior cervical ganglion
fused with first thoracic occ. anterior to C7
How do sympathetic post ganglionic fibres reach H&N targets?
Hitchhiking on arterial system via walls of CC, EC and IC outside of carotid sheath.
Superior cervical innervation
Along ICA and ECA
Somatic - trigeminal dermatomes to sweat glands
Visceral - dilator pupillae, smoot muscle of levator palpebrae superioris, nasal glands, salivatory glands.
Middle cervical innervation
Hitch hikes along inferior thyroid artery to lower larynx, trachea, hypo pharynx, uper oesophagus
Inferior cervical innervation
Vertebral arteries
innervates subclavian and vertebral arteries.
What drives development of the face?
Expansion of the cranial neural tube
Appearance of a complex tissue system associated with the cranial gut tube and the outflow of the developing heart
Development of the sense organs and the need to separate the respiratory tract and GI tract.
What are neural cells
A forth germ line
A specialised population of cells that originate within the neuroectoderm.
Where do neural cells come from and migrate to?
Lateral boarder of neuroectoderm
Become displaced and enter mesoderm
Migrate and contribute to a variety of H&N structures
What is the philtrum
Between nose and mouth from FNP
What are palpebral fissures
Difference between eye lids
Describe the face at end of week 4
Superiorly the FNP (frontonasal prominence) which contains the primordia of the eyes. Laterally the Maxillary prominence (1st arch), inferiorly the mandibular prominence (1st arch) and centrally the stomatodeum or buccopharyngeal membrane
Describe the development of the nose
Nasal placodes appear on frontonasal prominence and sink to become the nasal pits. Medial and lateral nasal prominences form on either side of the pits.
Maxillary prominences grow. This pushes nasal prominences together at the midline. Maxillary prominences and medial nasal prominences fuse. Medial nasal prominences fuse in midline.
Fusion of medial nasal prominences creates the intermaxillary segment. What does this consist of?
Philtrum, 4 incisors and the primary palate.
What is the secondary palate derived from
Maxillary prominences which give rise to palatal shelves. These grow vertically downwards into oral cavity on each side of developing tongue. Mandible grows and tounge drops. Palatal shelves fuse in midline. Nasal septum grows down and fuses with palatal shelves.
Fates if the medial and lateral prominences
Medial - philtrum, primary palate and mid upper jaw.
Lateral - Sides of nose
What do the eyes develop from and where.
Out pocketings of forebrain, make contact with overlying ectoderm (otic placodes lens).
The lens placode then invaginates into optic vesicle (from brain) and pinches off. Develop laterally on head. As facial prominences grow the eyes move to the front of the face (binocular vision)
Describe the development of the ears briefly
External auditory meatus from the 1st ph cleft and the auricles from 1st and 2nd arches surrounding it.
Begin in the neck. As mandible grows the ears ascend to the side of the head to lie in line with the eyes.
All common chromosomal abnormalities have associated external ear abnormalities
Inner ear from otic placodes which invaginate auditory vesicles to form the membranous labrynth of the cochlea and semi-lunar canal system.
Describe the articular surfaces of the temporomandibular joint
Under surface of temporal bone. Sinuous.
Superior: Mandibular fossa(posterior and concave), articular tubercle (anterior and convex) - Eminentia Articularis.
Inferior: Condyle of the mandible, superior edge and ellipsoid circumference.
2 vs 1 articular surfaces.
Lined with fibrocartilage not hyaline
What stabalises TMJ?
Fibrous capsule. permits movement. A fibrous disk or meniscus prevents bone-bone contact. Creates 2 cavities.
1 lateral ligament - temporomandibular -
2 medial ligaments
Accessory ligaments
Liable to subluxation
2 movements of the TMJ?
Gliding/ translational movement and modified hinge joint.
Describe the articular disk of the TMJ
Shape fits shape of articular surfaces.
Thicker at the periphery where it attaches to the articular capsule.
It can recoil or stretch a little with movement
Thinner centrally.
Describe the temporomandibular ligament
Lateral
Strongest
Deep fibres blend with capsule.
From lower boarder of zygomatic process to posterior board of neck and ramus of mandible.
Describe accessory ligaments of the TMJ
Sphenomandibular ligamnet
Remains constant in length and tension for all positions of mandible
Medial
Prevents inferior dislocation.
Stylomandibular joint:
Near apex of styloid process to the posterior border of the ramus of the mandible near its angle.Separates parotid from submandibular.
Muscles in glinding of TMJ
Lateral pterygoid muscles
Muscles in hinge movement of TMJ
Digastric (not a prime mover) needs work
Muscles in retracting the mandible
Posterior fibres of temporalis muscle
Closing muscles of TMJ
Temporalis (not posterior), Massater muscles, medial pterygoid
What prevents posterior displacement of TMJ?
Post glenoid tubercle
Describe some common disorders of the TMJ
Bruxism - grinding when asleep
Knacking - loud sounds when jaw displaces
TMJ pain dysfunction disorders
Mal-occlusion disorders
What is the Infratemporal fossa?
Irregularly shaped cavity.
Medial and deep to zygomatic arch behind the maxilla
Describe the boarders of the infratemporal fossa
Anterior - infratemporal surface of maxilla and descending ridge of zygomatic
Posterior - articular tubercle of the temporal bone and spina angularis of the sphenoid
Superior - Infratemporal surface of the greater wing of sphenoid.
Inferior - Alveolar border of the maxilla/ none
Medial - Lateral pterygoid plate.
Lateral- zygomatic process
Contents of the infratemporal fossa
Muscles: Temporalis, Medial pterygoid muscles, lateral pterygoid muscles
Nerves: Mandibular Viii and its branches:, Buccal, Linguinal, Inferior alveolar, Chorda tympani, auriculotemporal
Arteries: Deep- Maxillary (MMA off of this) - many branches. Superficial - Superficial Temporal artery.
Veins: Maxillary, MMV, Pterygoid venous plexus
Openings of the infratemporal fossa
Froamen ovale (Viii) Formaen spinosum (MMA) Alveolar canal Inferior orbital fissue Pterygomaxillary fissue
Clin Sig of infratemporal fossa
Mandibular nerve block site
Inferior alveolar nerve block site during dental treatment around the mandibular foramen on the medial side of the mandible.
Tumors can grow without detection for a long time - symotomatic then advanced.
Describe the axis of the orbit
Optical axis - facing forward
Orbital axis (optic nerve) - 45 deg
orbit walls - 90 deg - verticle
Where are the central artery and vein of the retina found?
Centre of the optic nerve
Describe the bones of the orbit
Superior - Frontal
Medial - Ethmoid, lacrimal and maxilla
Lateral - Zygomatic and sphenoid
Inferior - Maxilla and zygomatic
Main fissures and fossae of orbit
Optic canal, superior and inferior orbital fissures, fossa for lacrimal gland and the fossa for lacrimal sac
Contents of the superior orbital fissure
Lat to medial - lacrimal, trochlear, frontal, superior branch occulomotor, Nasocillary, inferior occulomotorabducent nerves, superior opthalmic vein, sympathetic.
Large French Teeneagers Sit Numb In Anticipation Of Sweets
COntents of the inferior orbital fissure
Infraorbital nerve
What is papilloedema
Optic disk swelling from raised ICP
Describe fractures of the orbit
Medial and inferior walls are thin, ethmoidal and sphenoidal sinus may be involved on the medial wall and the maxillary on the inferior wall.
Blow out fracture displaces walls and contents (muslce entrapment and diplopia and inferior)
Enophthalmos (posterior displace) and infraorbital bleeding
Function of inferior obliquE
moves eye up and out (abduction and extorsion or ecternal rotation or lateral rotation)
Superior oblique function
Primary (if looking forward) - intorsion (internal rotation) Secondary action - depression in adducted postion (reading a book) Tertiary action (abduction) To test ask pt to look inwards and downward.
Arterial supply of orbit
Opthalmic artery ICA via optic canal - central artery of retina.
Orbital floor- infraorbital artery branch of ECA
Short and long ciliary arteries supply external aspect of eye.
Venous supply of the orbit
Superior and inferior opthalmic veins exit via SOF to cavernous sinus.
Superior from inner angle and inferior from plexus on floor and medial wall.
Central vein of retina to cavernous sins directly or to opthalmic veins.
Occlusion then slow painful loss of vision. Infection to brain
Branches of the opthalmic artery
Central retinal artery
Lacrimal artery - also to conjunctiva and eyelids
Posterior ciliary arteries - posterior external eye
Muscular branches to extraocular muscles
Few others e.g. ethmoidal and frontal sinses, forehead, scalp, supra orbital
Infraorbital artery is a branch of the…?
Maxillary
what is the danger triangle?
Communication between facial vein to CS - thrombosis, meningitis, brain absess in CS.
Function of eyelids
Protect from light and injury
Prevent corneal drying through controlled spread of lacrimal fluid.
Opening called palpebral fissure.
Describe the types of conjunctiva
Palpebral - back of eye lids
Bulbar - anterior sclera of eye
Fornix - between palpebral and bulbar
Describe the anatomy of the upper eyelid
Skin Areolar Tissue Fibres of orbicularis oculi Levator palpebrae superioris Superior tarsus - dense CT Tarsal (Meibomian) glands secrete oil and dry eye. Cilliary glands (end) sebacous Stye Palpebral conjunctiva
Triggers of blinking
Corneal drying
Corneal irritation or contact
Expectation of contact
Corneal (blink) reflex
Muscles opening the eyelids
Levator palpabrae superioris
Superior tarsal muscles (AKA Muller’s muscle)
Muscles closing eyelids
Orbicularis oculi (round) VII
What is Bells palsy
Orbicularis oculi paralysis - CN VII - dry eyes, loss of blink, infection likely
Paralysis of Levator Palpebrae superioris
Oculomotor - CN III - ptosis
innervation of superior tarsal muscle and clin sig
Symp - Horners - partial ptosis
Describe lacrimation
Eyes close lat to med so collect in lacrimal lake (medial canthus). Travekky through nasolacrimal duct to inferior meatus of nasal cavity.
Produced by CN VII para.
Sensory via lacrimal branch of opthalamic division of CN V
Features of the auricle
Helix, Antihelix, Crus of helix Concha Tragus Antitragus Lobule External auditory meatus Triangular fossa
Name so common pinna deformities
Antihelix deformity (not all the way round)
Pinna malformation (basically gone)
Pre-auricular Pit (small hole)
Pre-auricular skin tag
What is a pinna Haematoma
Haematoma between cartilage and perichondrium — pressure necrosis.
Result from trauma.
Results in cauliflower ear
What is cauliflower ear
Result of pinna haematoma
Outer ear becomes swollen and deformed
Describe the external auditory canal
Sigmoid shape
Lat 1/3 is cartilage with hair and medial 2/3 is bone lined
Contain ceruminous glands - ear wax
What is Otitis Externa
Like cellulitis - inflam/ infection of deep layers of skin
Describe the tympanic membrane
Pars flacida and pars tensa In middle - handle of malleus - inferior is umbo - superior is lateral process Light reflex Annulus around the outside Collagen inbetween epithelium 1cm across
Describe the contents of the middle ear
Malleus - head and handle (on typanic)
Incus (anvil) - body- short process and long process
Stapes - head and footplate, anterior and posterior crus#
Oval window (stapes), round window and eustachian tube
Muscles of the middle ear
Tensor tympani (medial pterygoid Viii) Stapedius (facial VII)
Cause of tympanic retraction
Eustachian tube dysfunction - cannot equalise.
Angle of light dissapears
Cause of pus in middle ear
Acute otitis media
What is Glue Ear
Otitis media with effusion- secondary to prolonger neg pressure results in thick effusions accumulating behind ear drum.
Conductive hearing loss
What are gommets
Ventilation tubes to equalise the middle ear pressure - placed in tympanic membrane.
Complications of acute otitis media?(AOM)
Mastoiditis due to suppuration (discharge of pus from a wound). Can lead to intracranial infection and death
Cholesteatoma
Facial nerve dysfunction - chorda tympani may be affected
What is a cholesteatoma?
neg ear pressure - retraction pockets, dead skin cells accumulate, necrotic mass of dead skin, erosion of middle ear structures and bone via lytic enzymes
Components of the inner ear
Vestibule
Cochlea - scala vestinulu (top) Scala tympani (bot) (buns), cochlear duct/ organ of corti/ basilar membrane (hot dog), cochlear nerve
Describe vestibular disease
4 main symptoms with true rotational vertigo. Causes:
Secs-mins - Benign Paraoxysmal postional vertigo - otolith displacement
Mins-hours - Meniere’s disease - endolymphatic hydrops
24+ - labryinthine failure
Random with other symptoms - vertiginous migraine
Other causes of vertigo
Vascular Epilepsy Receiveing treatment Tumous, trauma, thyroid Infections Glial (MS) Ocular
Describe the vestibular compartment
Utricle
Saccule
3 semicircular canals (sup, pos, lat/ hori)
What does balance involve
Vestibular end organ
Vision
Sensation
Functions of the nose
Olfaction
Respiration
Filter and humidify
Drain & eliminate paranasal sinus and nasolacrimal duct secretions
Features of the external nose
Dorsum, naris and ala
Skin covers and extends into vestibule
limen (nasi) around vestibule
Skeleton of external nose?
Nasal bone superiorly
Lateral to nasal bone = frontal process of maxilla
Lateral process of septal cartilages (main part)
Major ala cartilage inferiorly
Septal cartilage in between
Minor alar cartilages laterally
Posterior to nasal bone is the lacrimal bone and nasolacrimal groove
Complications of a nasal fracture
Septal haematoma
Features of the nasal cavity
Nostrils, choanae (posterior holes into nasopharynx), mucosal lining, continuous with areas draining into the cavity.
Bones contributing to the skeleton of the nose
Frontal, nasal, ethmoid (plus its perpendicular plate), sphenoid, vomer (inferior of nasal septum), palatine process of maxilla, horizontal process of palatine bone, inferior concha
Lateral and medial walls nasal cavity
Lateral wall = conchae - creat 5 passages, one unpaired and 3 paired (sphenoethmoidal recess, superior, middle and inferior nasal meatus)
Septum = bony and cartilaginous part - Ethmoid sup, vomer inferior (palatine and maxillary), SC anteriorly
Drainage into nasal cavity?
Nasolacrimal duct into inferior
Frontal sinus and ethmoidal sinus into middle
Sphenoid - spheno-ethmoidal recess
Maxillary - middle
Describe ethmoid bone in detail
Laterally ethmoidal labyrinths joined by the cribriform plate (perpendicular plate and crista galli).
Infundibulum, groove penetrating ethmoidal labyrinth and drains frontal sinus.
Middle concha attached inferior to labyrinths (still part of bone)
Openings into the nasal cavity
Cribriform plate -olfaction, spenopalatine foramen, incisive foramen, foramen cecum (nasal veins to superior sagittal sinus (some individuals))
Blood supply to the nose
Facial artery (ECA branch of superior labial artery). - anterior. Maxillary artery (ECA sphenpalatine (sphenopalatine foramen) and greater palatine artery (inferior)) Ophtalamic artery (ICA) anterior and posterior ethmoidal (superior)
Venous drainage
Cavernous sinus superiorly Facial vein (anterior inferior) Pterygoid plexus (posterior)
Most common site for anterior epistaxis?
Kiesselbach’s plexus (little’s area)
Nasal septum clinical anatomy
Nasal septum deviation - congenital or aquired, narrowing or obstruction
Nasal septum necrosis - injury to nasal septum, saddle nose deformity
Innervation of the nasal cavity
CNI special sensory
Gen sensory to septum and lateral walls - ophthalmic (V1) and maxillary (V2).
PI - maxillary nerve - nasopalatine nerve and branches greater palatine nerve to lateral wall
AS- ophthalmic nerve- branches of nasociliary nerve
primary function of nasal sinuses
Contributes to conditioning of inspired air
Describe the maxillary sinus
roof = floor of orbit
Floor = alveolar part of maxilla- cf roots of first 2 molars, superior alveolar nerve)
Posterior = pterygopalatine and infratemporal fossae)
Enlarges from 8 years, opens into middle meatus
Describe the frontal sinus
Not present at birth, variable in size, related to anterior cranial fossa and the orbit, drains to middle through the frontonasal duct (ethmoid bone?
Describe the sphenoid sinus
Related to pituitary fossa and middle cranial fossa, cavernous sinus and ICA, posterior cranial fossa and pons, roof of nasopharynx
Ethmoidal sinus
Air cells between orbit and nasal cavity.
Anterior cells - middle meatus via infundibulum
Middle - bulla, directly into middle meatus
Posterior - superior meatus
spread of infection from nasal cavity to anterior cranial fossa
Foramen caecum and olfactory foramina
rhinitis describe
Inflammation of nasal mucosa - swelling and increased volume of secretion
Causes include - infective (viral), allergic and nasal polyps
Describe nasal polyps
Prevalence 2-4%, linked to chronic rhino sinusitis, grow close to the ostiomeatal complex of nasopharynx causing nasal obstruction resulting in snoring/ sleep apnoea
Types of sinusitis
Inflammation of the mucosal lining of the sinuses
Acute: 7-30 days
Sub acute 4-12 weeks
Chronic >90 days
infection - viral with secondary bacterial infection - S pneumoniae and H influenzae
Infection from nasal cavity to middle ear
eustachian tube
why do blood tests for epistaxis
Hb, bleeding abnormalities
Treatment for epistaxis
Lead forward - pinch cartilage
Second - cautery (silver nitrate or elctro) to ‘solder’ blood vessels
Nasal tampons (go in horizontally)
Posterior packing +/- urinary catheter
Last resort - surgerical intervention with ligation of SPA, maxillary and ECA
Radiological embolisation
Posterior bleed of nose, what artery?
Sphenopalatine
Describe innervation by the oculomotor nerve proper
Somatic efferent
Supplies all extra-ocular muscles except lateral rectus and superior oblique.
Supplies lavator palpebrae superioris
Damage to just the oculomotor nerve proper?
Ptosis, down and out movement of eye
BUT pupil is a-okay
Origins and course of oculomotor proper and symapthetic portion of CN3
Oculomotor nucleus (midbrain) - cavernous sinus- lateral wall, uncus (art of brains) and tentorial notch, ciliary ganglion. Exits from superior OF. Edinger-Westphal Nucleus, Same path but terminates in ciliary ganglion - short ciliary nerve
Describe dorsal and ventral branches of oculo proper
Dorsal - levator palp and superior Rectus
Ventral - med and inf rectus, inf oblique. Only inferior oblique division goes past/ through ciliary ganglion
Sensory to meinges
Vii
diff between facial nerve and CNVII
Motor vs motor, special sensory and parasymp
Origins of CNVII
facial from the facial motor nucleus in pons
Solitarious - taste efferents
Geniculate ganglion - primary senosry neurons to solitarious?
Roots of CNVII
Facial motor nucleus - motor root
Nervus intermedius - pons (part of nucleus solitarious), taste and sensory
Autonomic - superior salivatory nucleus (also called nervus intermedius)
Geniculate ganglion -gen sensory - nervus intermedius
Know the 4
Terminal branches of the motor root of the facial nerve
TO Zanzibar by motor car Temporal Zygomatic Buccal Marginal mandibular Cervical branch Posterior auricular
Bilateral damage to facial nerve?
Parkinsons, Medication, bilateral damage (rare)
What is torticolis?
Presenting sign in SCM injury - rotated and tilted towards normal side
What is Paget’s disease
Middle ages, repair reabsorption of bone, pain, enlargement, dental complications
Clin sig of inferior alveolar nerve
Enters via mental foramen. Sensory to mucous membranes of lower lip/ mouth
Main muscles of facial expression
Orbicularis oris/ oculi
Describe the jugulo-omohyoid and jugulodigastric lymph nodes
Jugulodigastric aka tonsilar, drainage of tonsils and tongue.
Jugulo-omohyoid - tounge, oral cavity, trachea, oesophagus and thyroid gland
What is proptosis
Bulging of the eyes forward - thyroid dysfunction or a mass in the orbit
what is the cervical sinus?
Formed when flap from second covers 3-6. Normally obliterated
Main derivative of the 3rd/4th arches
Hypobranchial eminence, becomes
epiglottis
Fate of the pouches
POUCH BECOMES 1 Eustachian tube and middle ear cavity 2 Crypts of palatine tonsil 3 Dorsal part – inferior parathyroid Ventral part - thymus 4 Dorsal part – superior parathyroid Ventral part (ultimobranchial body) – C cells of thyroid
Name of one eye, no eyes and small eyes
Gross anomalies of eye development may occur during these early stages. They
include cyclopia (single midline eye), anophthalmia (absence of eye or eyes) and
microphthalmia (abnormally small eyes).
Blood supply to neurocranium
Internal carotid and vertebral arteries
describe the two chambers of the eyeball
Anterior- cornea and iris
Posterior - ciliary body and lens
Secretions of the cilliary body
Aqueous humour
Describe the middle layer of the eye ball
Choroid - cilliary body- iris
Describe the lens
Biconcave, attached to the cilliary body by the suspensory ligament
What supports the lens and holds the retina in place?
Vitreous humour found posterior to lens
What is the fovea
centralis?
Depression in macula lutea, lateral to optic disk responsible for visual acuity
What is presbyopia?
During old age, the lens becomes harder and more flattened and these changes
slowly reduce their focusing capacity
What is hyphema
Blunt trauma to the eyeball may result in haemorrhage into the anterior chamber
of the eye
Where do the extrinsic eye muscle attach?
Common tendinous ring, surrounds optic canal
Arterial supply to eye
Opthalamic artery - Internal carotid
Pupillary enlargement, name and causes
Mydriasis- glaucoma, sympathetic agents
Depressors and elevators of eye
Depress - IR & SO
Elevat - SR & IO
Medial and lateral rotation of eye
Medial - SO and SR
Lateral - IO & IR
How is a Meibomian cyst
different from a stye?
Meibomian cyst- blocked tarsal gland (posterior eye lid)
Style - infection of sebaceous gland tat readily forms a cyst (End of eyelid)
Does the facial vein have valves?
No
What is thrombophlebitis
Inflammation of a vessel with secondary thrombosis
What is ecchymosis
The term refers to the discoloured patch produced by extravasation of blood into the subcutaneous tissues
What is a motor unit
A combination of a motor nerve and all the fibres it innervates
What causes bilateral proptosis of the eyes
Grave’s disease (hyperthyroidism does not)
Apart from a tumor, what other pathologies may cause
unilateral proptosis?
Retrobulbar haemorrhage
ii) Swelling of soft tissues of the orbit
What bony structure is the carotid pulse palpated against?
Transverse process of C6 Vertebra (termed the carotid tubercle)
Bifurcation of carotid at which level?
C4
Paget’s disease
Misshapen bones
Describe the epitympanic recess
Superior to tympanic membrane in middle ear
Location of mastoid air cells and eustachian tube compared with middle ear
MAC post.
Eu ant
What is exstosis of the outer year?
Surfer’s ear, bone growth, can lead to infection
Meaning of supperative
Produces pus
Refferred pain in ear?
It is important
to realise that pain from the teeth, pharynx or cervical spine is commonly referred
to the ear. Inflammation, trauma, or neoplasms anywhere along the course of the
trigeminal, facial, glossopharyngeal and vagus cranial nerves or cervical nerves C2
and C3 may be responsible for referred pain to the ipsilateral (same side) ear.
Pruritis (itching) of the ear may result from primary disorder of the external ear
Superior and inferior to Middle ear
Superior floor of middle/ posterior cranial cavities (posterior part contains internal acoustic meatus containing the facial and vestibulocochlear nerves)
Inferior - irregular and contains carotid canal
What is cerumen?
Modified sebum secreted by cartilaginous part of external ear (forms wax with discarded cells)
Fluid in inner ear labyrinth
endolymph
Where is perilymph found
Between bony and membranous labyrinths
The outer aspect of
the auricle is
supplied by:
auriculotemporal
nerve(Viii) and cervical plexus
Innervation of tympanic membrane
The External Surface a)Auriculotemporal nerve, a branch of the mandibular division of the fifth nerve b) Small branch of the Vagus (CN X) Internal Surface Supplied by the Glossopharyngeal nerve (CN IX). (think about arches)
Danger of mastoid infection
sigmoid venous sinus and cerebellum anteriorly
3 branches of facial nerve given off in parotid gland
Greater petrosal nerve, chorda tympani and the nerve to stapedius
When can the lingual (Viii) nerve become anaethetised and what is the clin sig?
inferior alveolar nerve block - sensory ant 2/3 tongue
How to treat haematoma in ear?
Drain
describe tympanosclerosis
calcification, conductive
How long does tympanic membrane take to heal?
6-8 weeks
Origins of malleus, incus and stapes?
1st and 2nd arches
Innervation of stapedius
Facial nerve (2nd arch)
Result of bells on hearing
Louder due to stapedius
What is otosclerosis
Fusion - immovable, deafness, aut dom
Acquired forms of sensorieural hearing loss?
Meniere’s disease, oxytocin drugs (Gentimycin), infection e.g. rubella
Muscle that extends and flexes the head?
Extension - splenius capitis
logissimus capitis - flex
Treatment surgial for glue ear
Myringotomy (drain)
Mastoidectomy
Which bone is the pituitary gland located in?
Sphenoid
Describe the developmental origin of the pituitary gland
Ant = ectoderm(normal gland) Post= neuroectoderm
Describe the development of the pituitary gland
Downward outgrowth of forebrain towards the roof of the pharynx known as the infundibulum.
Grows towards Rathke’s pouch (ectoderm of the stomatodeum) which is an envagination of the roof of the oropharynx. This is pinched off and becomes the anterior pit whilst the infundibulum becomes the posterior pit and the connecting stalk
What is the lingual frenulum
Attaches tongue to floor
Describe the development of the tongue
Forms from 2 lateral swellings of the 1st pharangeal arch, and 3 median swellings from arches 1 (tuberculum impar), 2&3 (cupola) and 4 (epiglottal swelling).
Lateral swellings overgrows the tuberculum impar and the 3rd part of the cupola overgrows the second arch.
Apoptosis (apart from lingual frenulum) frees tongue from pharyngeal base.
Name the three median lingual swellings
Tuberculum impar, cupola, epiglottal swelling
Explain the innervation to the tongue
Ant 2/3 from 1 and 3 arches so gen sensory innervation from V and IX
Posterior 1/3 from 3 (&4) so general (and special) sensory CN IX and X
taste buds bedelop in papillae so CNVII.
Myogenic precurs migrate from somites so CN XII
Why does the chorda tympani pass through the middle ear?
From second arch to first as branch of CNVII
Describe development of the thyroid
From primitive pharynx and neuroectoderm
Originate at foramen cecum.
Bifurcates and descends - remains conected by thyroglossal duct. Forms pyramidal lobe potentionally.
Follicular cells from thyroid diverticulum
Parafollicular cells from ultimobranchial body of the 4th arch
What is the foramen cecum
Mediun sulcus in tongue
What are the sulcus terminalis
Divide ant and post tongue - V shape
What is first arch syndrome.
Spectrum of defects in eyes, earch and mandible and palate due to failure of colonisation of the 1st arch with neural crest cells
What is treacher-collins syndrome
Hypoplasia of manduble and fascial bones. resulting in low set ears
Aut dom
What is CHARGE syndrome
CHD7 - production of multipotent NC Coloboma (gap in eye) Heart defect Choanal atresia (back of nasal passage is blocked) Growth and development retardation Genital hypoplasia Ear defects
Describe the boundaries of the nasopharynx
Superior - skull base
Inferior - level of the doft alate
Anterior - Posterior choanae (nasal apertures)
Posterior - nasopharyngeal tonsil, C1
What are choanae
2 parts separated by vomer
Channels that allow breathing when the mouth is closed
Nasocavity to nasopharynx
Epithelium of nasopharynx
Ciliated psuedostrat (resp) and strat squamous
What are adenoids?
Nasopharyngeal tonsils - part of Waldeyer’s ring
Can obstruct eustachian tube orifice.
Produce IgA, IgG and IgM
Describe the boundaries of the oropharynx
Superior - level of the softpalate
Inferior - superior edge of epiglottis
Posterior - C2&3
Anterior- oral cavity
Contents of the oropharynx
Palatine tonsils (within the tonsillar fossae between anterior and posterior tonsilar pilars)
Anterior pillar - boundary between buccal cavity and oropharynx. Fuses with lateral wall of tongue, contains palatoglossal muscle.
Posterior pillar - Blends with wall of pharynx, cotains palatopharyngeus muscle
Describe the palatine tonsils
Encapsulated
Tonsillar fossa floor - superior constrictor muscel
Lymphoid tissue covered with squamous epithelium
Contains crypts
atophies after puberty
Describe components of Weldeyers ring
MALT Adenoids (only called with when inflamed)/ pharyngeal tonsils Palatine tonsils Tubule tonsils (by eustachian tube) Lingual tonsils (posterior tongue)
Blood supply to the palatine tonsils
Facial artery - tonsillar branch
Venous - pharyngeal plexus
Lymph drainage of the palatine tonsils
Jugulodiagastric nodes
Describe the boundaries of the laryngopharynx
Superior edge of epiglottis
Inferior - level of inferior edge of cricoid cartilage
Anterior - larynx
Posterior- C3-6
Inferiorly opens into oesophagus and larynx
Stat squamous epithelium
Describe the pharyngeal musculature
Superior, middle and inferior constrictors overlap each other (inferior on top). Open anteirorly. Attached posteriorly by median raphe. Inferior constrictor = cricopharyngeus
Describe mechanisms of swallowing
Tongue and suprahyoid muscles pull hyoid and larynx up, soft palate elevates - nasophasrynx closed
Superior constrictors contract.
Middle and inferior - food bolus passes into hypopharynx by middle and inferior constrictors.
Tongue, epiglottis, vocal cords protect the larynx.
Cricopharyngeus relaxes
Describe the blood supply to the pharynx
Superior thyroid artery,
Ascending pharyngeal artery
Ascending and descenging palatine arteries
Branches of lingual, facial and maxillary arteries (ECA)
Pharyngeal nerve supply
Motor: X IX XII VII Senory: Nasopharynx = Vii Oropharynx = IX Hypopharynx= XII
Describe the levels of the vertebrae to the larynx/ pharynx
C1 - hard palate C2 - Angle of mandible C3 - hyoid bone C4/5 - thyroid cartilage C6 - cricoid cartilage
Effects of adenoid enlargement
Nasal obstruction: Mouth breathing Hyponasla speech Feeding difficulties Snoring/ obstructive sleep apnoea
Eustachian tube obstruction - recurrent otitis media, chronci otitis media with effusion (glue ear)
Descrube assessment of the adenoids
Difficult Post-nasla space x-ray Post-nasal mirror Fibre optic endoscope Theatre
Describe obstructive sleep apnoea
Tiredness
Impaired breathing during sleep - 5 episodes an hour
Describe adenoidectomy
Curettage (blind and old fasioned)
No suction diathermy )mirror)
Complications include bleeding, atlanto-occipital joint dislocation and eustachian tube stenosis
Describe Nasopharyngeal carcinoma
SCC
Chinese
Describe tonsillectomy
In: Recurrent tonsillitis (5/year for 2 years) Previous peritonsillar abcess (quinsy) Suspected cancer (unilateral) Obstructive sleep apnoea Risks - GA, bleeding, infection Many techniques
Describe pharyngeal pouch
Posterior herniation of pharyngeal mucosa (true diverticulum so all mucosa layers)
Killian’s degiscence - weakness between inferior constrictor and cricopharyngeus.
Due to weakness, incoordination of pharyngeal phase and cricopharyngeal spasm
How are children different from small adults?
Anatomy: Head:body Small face Large tongue Adenotonsilar hypertrophy Short/soft trachea high SA: Wgt
Physiology: Different baseline smaller resp reserve compliant chest wall Greater metabolic rate/ O2 consumption Cannot rely on specific commands (AVPU)
Why do children have more airway resistance?
Due to radius
Poiseuille’s law
How are why are children’s larynxs different?
Adult - circular, Children - funnel due to narrow underdeveloped cricoid cartilage
Describe visualisation of larynx
Fexible nasasl endoscope, microlaryngoscope and bronchoscopy (under GA but allow spontaneous breathing so no muscle relaxants), laryngoscope (rigid?)
Describe stidor
Lower airway obstruction, sound on insiration
Describe acute epiglottitis presentation
Children
Bacterial (usually Haemophilis influenzae type B (now vaccine)
Sepsis/ pyrexial
Leaning forward and drooling
Tripod position (assisted breathing)
Rare
Epiglottis obstructs larynx due to inflam
Describe management of acute epiglottis
Secure airway
Anaesthetist and surgeon
Tracheostomy rarely needed
Swab and steroids
Describe laryngotracheobronchitis/ Croup
Stridor
Viral throat infection
Harsh cough (bark) subglottic
Infective oedema narrows subglottis
Describe management of laryngotracheobronchitis/ croup
Mild - home with oral abx and steam inhalation Mod-sever admit for obs IV abx, humidified O2, dex, adren neb Worsening - intubate Varyrare-tracheostomy
Describe foreign bodies presentation
.5-4 year olds male
choking, coughing bout or playing with FB
Often unwitnessed
Sometime svague symptoms.
Describe FB radiology
Opaque FB Segmental/ lobar collapse Locallised emphysema (ball-valve effect Insipatory/ expiratory films Normal
FB management
Bronchoscopy
May have post-instrumental oedema needing steroids and inhaled bronchodilators
Occassionally ventilation on PICU for 24 hours
Descrbe laryngomalacia
Epiglottis is soft and covers larynx on inspiration
Describe aryepiglottoplasty
treatment for laryngomalacia
Describe sterdor
Like a snore insp. Often due to upper obstruction
