Head and neck Flashcards
What is the superior boundary of the neck?
Superior – mandible
What is the inferior boundary of the neck?
Inferior – clavicle
What is the anterior boundary of the neck?
Anterior – anterior midline
What is the Posterior boundary of the neck?
Posterior – trapezius
What are the contents of the anterior triangle?
Common carotid – external, internal as well
Facial artery, vein
Hypoglossal, vagus, accessory, laryngeal, glossopharyngeal nerves
Internal jugular vein
Submandibular nodes, submental
What are the contents of the posterior triangle?
Accessory nerve, cervical nerve plexus
Occipital artery
External jugular vein
Lymph nodes
What are the main arteries of the neck?
Common carotid (divides at C4) Internal carotid – straight to brain, no branches External carotid – branches into Superior thyroid Ascending pharyngeal Lingual Occipital Facial Posterior auricular Maxillary Superficial temporal
What are the indications for a central line?
Central venous pressure monitoring Drug administration Cardiac pacing Blood sampling Fluid resuscitation Haemodialysis IV nutrition
What are the possible complications of a central line?
Pneumothorax Haematomoa Cardiac tamponade Air embolism Chylothorax False passage Thrombosis Sepsis Line blockage
What are the lymph node levels?
I submental/submandibular
II-IV along sternocleidmastoid
V – posterior triangle
Where do the parotid lymph nodes drain?
Parotid nodes-scalp, face & parotid gland
Where do the occipital lymph nodes drain?
Occipital nodes-scalp
Where do the superficial cervical lymph nodes drain?
Superficial cervical nodes-breast & solid viscera
Where do the deep cervical nodes drain?
Deep cervical nodes-final drainage pathway to thoracic duct
Where do the submandibular lymph nodes drain?
Submandibular nodes-tongue, nose, paranasal sinuses, submandibular gland, oral cavity
Where do the submental lymph nodes drain?
Submental nodes-lips, floor of mouth
What are the three potential causes of lymphadenopathy?
Infective
Inflammatory
Malignant
Describe the thyroid gland
(Lobes, products, location, arterial supply)
Two lobes (right+left) joined by isthmus
Produces thyroid hormone and calcitonin
Calcitonin acts to lower calcium and raise phosphate
Located beneath the thyroid cartilage
Supplied from superior thyroid artery (branch of external carotid artery)
What are the types of thyroid mass?
Solitary nodule
Diffuse enlargement
Multi-nodular goitre
What are the types of solitary thyroid nodules?
Cyst: due to localised haemorrhage Adenoma: benign follicular tissue Carcinoma Lymphoma Prominent nodule in multi-nodule goirre
Who is most likely to get a solitary thyroid nodule?
F> M 30-40 yrs
What two types of thyroid cancer can FNA not distinguish between?
Follicular adenoma
Follicular carcinoma
Need a tissue sample for diagnosis
What are the types of thyroid cancer?
Papillary – lymphatic metastasis
Follicular – haematogenous metastasis
Medullary – familial association (10%) arise from parafollicular C cells
Anaplastic – aggressive, local spread, normally old, poor prognosis
What can cause a diffuse thyroid enlargement?
Colloid goitre: Due to gland hyperplasia >Iodine deficiency >Puberty >Pregnancy >Location >Grave’s disease Throiditis
What is Grave’s disease?
Autoantibodies against thyroid stimulating hormone receptor stimulate receptor
Hyperthyroidism results
Thyroid eye disease, acropachy/clubbing, pre tibial myxoedema
More likely in females
What is the treatment for grave’s disease?
antithyroids,
beta blockage,
radio iodine
surgery
What are the indications for a thyroidectomy?
Airway obstruction Malignancy (or suspected) Thyrotoxicosis Cosmesis Retrosternal extension
What are the possible complications of a thyroidectomy?
Bleeding-primary or secondary Voice hoarseness Thyroid storm Infection Hypoparathyroidism Hypothyroidism Scar (keloid/hypertrophic)
What do the parathyroid glands do?
Regulate calcium and phosphate levels
Located to poles of thyroid
Can be injured in neck surgery
What is multi-nodular goitre?
Due to grave’s disease or toxic goitre
Graves – women, middle-aged, over activity leads to hyperthyroidism
Toxic goitre – older, no eye signs, AF
What do you do to test multi-nodular goitre?
Thyroid function tests,
FNA,
CXR
What are the symptoms of parathyroid disease?
Painful stones?
Aching bones
Psychic moans
Abdominal groans
Renal calculi, polyuria, renal failure
Pathological fractures, osteoporosis, bone pain
Abdominal pain, constipation, peptic ulceration, pancreatitis, weight loss
Anxiety & depression, confusion, paranoia
What tests are used to investigate parathyroid disease?
Urea & electrolytes, creatinine, calcium, phosphate
Parathyroid hormone, bicarbonate
Vitamin D
Ultrasound scan
CT/MRI: identify ectopic glands
Isotope scanning: detect diseased glands
-Only treat for Hyperparathyroidism
What can cause parathyroid disease?
Adenoma (80%)
Hyperplasia (12%) - common in secondary hyperparathyroidism due to low calcium
Eg renal failure. Calcium levels normal but phosphate levels high
Malignancy
How do you treat parathyroid disease?
Surgery easier if patient fit
Remove single adenomas, or multiple
Carcinomas removed with thyroid gland and lymph nodes
What are the four fascia layers of the neck?
Pre-tracheal
Pre-vertebral
Deep cervical
Carotid sheath
What are the indications for a tracheostomy?
Airway obstruction
Airway protection
Poor ventilation to reduce dead space
Need suctioning, humidifcation and long term care
What is stridor?
Clinical sign of airway obstruction
Inspiratory - laryngeal
Expiratory - tracheobronchial
Biphasic – glottic/subglottic
How do you treat stridor?
Treat with O2, Nebulised Adrenaline, IV Dexamethasone, (Heliox), (Definitive) airway management
What is Branchial cyst?
Remnant of fusion failure of branchial arches OR lymph node cystic degeneration
Transilluminates
Anterior to sternocleidomastoid at junction between upper and middle thirds
Becomes infected, enlarging
Excised to prevent further infection
What is a pharyngeal pouch?
Herniation of pharyngeal mucosa between:
thyropharyngeus and cricopharyngeus
(muscles of the inferior constrictor of the pharynx)
What are the symptoms of pharyngeal pouches?
Voice hoarseness Regurgitation Dysphagia Weight loss Aspiration pneumonia Neoplasia 1%
How do you treat a pharyngeal pouch (+ diagnose)?
Diagnose with barium swallow
Excision
Dilation
What is the presentation of a reactive lymph node?
Oval Soft Smooth Mobile Tender
What is the presentation of malignant neck node?
Round Firm Irregular Fixed Non-tender
What can cause hoarseness?
Nodules Cysts Vocal abuse Laryngitis Infection Smoking Reflux Laryngeal cancer
What are the benign H&N disorders?
Congenital Infective Inflammatory Trauma Neoplasia
What are the malignant H&N disorders?
Cancer
90% squamous carcinoma
What are the guidelines for removing tonsils?
Bacterial Tonsillitis: (pus covering, neck nodes, fever, no cough)
6-7 attacks in 1 year (5 per year over two years, 3 per year over three years)
Disrupting daily activities
More than 1 quinsy
What is the function of the nose?
Respiration, filtration, humidification/ warming of air
Olfaction Reception of sinus and eye secretions Continuous mucosal lining with sinuses Rhino–sinusitis
Describe the mucosa of the nasal passage
Columnar, ciliated
Squamo-columnar junction
Nasal hair in vestibule
What makes up the external nose?
Dorsum (bridge) root to tip
1/3 bony
2/3 cartilaginous
What are the cartilages of the nose?
Septal cartilage (middle) Lateral (two of them) Alar cartilage (also two)
What processes can cause nasal deformity?
Trauma
Fractures
What forms the midline partition of the internal nose?
Septal cartilage
Perpendicular plate of ethmoid
Vomer (bone)
What forms the lateral walls of the nose?
Turbinates >Superior >Middle >Inferior >Meati
What forms the roof of the internal nose?
Cribriform plate
What forms the floor of the internal nose?
Hard palate
What are the common pathologies of the internal nose?
Nasal septum deviation
>Through trauma
>Congeital
>Has risk of septal haematoma
Swelling
>Rhinitis
>Infection
>Can block nose, treated with steroid sprays
What are the boundaries of the nasopharynx?
Choana
Sphenoid sinuses
Prevertebral fascia and muscle
Soft palate
What are the contents of the nasopharynx?
Eustachian openings
Adenoids
Has muci-ciliary lining
What is the blood supply to the nose? (5)
Sphenopalatine artery >Branch of maxillary artery from external carotid Greater palatine artery Ascending labial artery Ethmoid arteries (internal carotid) Capillary plexus - littles area
What is epistaxis?
Haemorrhage from:
>Nostril
>Nasal cavity
>Nasopharynx
What nerves supply the nose?
Olfactory nerve (olfactory epithelium) Infraorbital nerve (branch of 5th cranial - trigeminal)
What conditions can affect the olfactory nerve?
Hyposmia or anosmia Via: >trauma >Virus >Tumour >Rhinitis
What conditions can affect the infraorbital nerve of the nose?
Paraesthesia in trauma
Iatrogenic damage in tumours
What are the sinuses?
Air filled spaces
Continous muco-ciliary lining with nose
Development is age dependent
What sinuses are there?
Frontal x1 + septal partition
Maxillary x2
Ethmoid x2
Sphenoid 1
How + where does the frontal sinus drain?
Via frontonasal duct
Into middle meatus
Where does the posterior ethmoid sinuses drain?
Into superior meatus
Where does the middle and anterior ethmoid sinuses drain?
Into middle meatus
How + where does the maxillary sinus drain?
At hiatus semilunaris
Into middle meatus
Drainage near frontal drainage
Where does the nasolacrimal duct drain?
inferior meatus
What are the potential dangers to sinisitus?
intracranial sepsis cerebrospinal fluid (CSF) leak damage to the orbit optic nerve carotid artery
What sinuses drain into the middle meatus?
Frontal sinus
Middle ethmoidal sinus
Anterior ethmoidal sinus
Maxillary sinus
What sinuses drain into the superior meatus?
Posterior ethmoidal sinus
What drains into the inferior meatus?
Nasolacrimal duct
What structure can be damage in frontal sinusitis due to its close relation?
Anterior cranial fossa
What structure can be damage in ethmoidal sinusitis due to its close relation?
Anterior cranial fossa (cribriform plate)
What structure can be damage in maxillary sinusitis due to its close relation?
Orbits
Oral cavity/teeth
What structure can be damage in Sphenoid sinusitis due to its close relation?
Optic nerve
Internal carotid artery
Pituitary gland
What makes up the external ear?
Auricla /pinnea
External acoustic meatus
Ceruminous + sebacous glands
>Make wax
What makes up the Auricle/pinnea?
> Stratified keratinising squamous epithelium
>Elastic cartilage
What makes up the external acoustic meatus?
> Lateral 1/3 cartilage and skin
>Medial 2/3 bone and skin
Describe is the tympanic membrane
The eardrum
Roughly 1 cm in diameter
Part of sound conduction
3 layers
What are the three layers of the tympanic membrane?
Outer squamous epithelial
Middle - fibrous connective tissue
Inner - columnar ciliated mucus membrane
What can cause tympanic membrane perforation?
Trauma
Suppuration
What is the function of the ossicular chain?
Important in sound conduction
What can disrupt the ossicular chain?
Trauma
Chronic suppuration
Bony sclerosis (otosclerosis)
What are the important relations of the middle ear?
Middle cranial fossa
Internal jugular vein
Internal carotid artery
Describe the middle ear
Area that connects the
>mastoid system via aditus
>Post nasal pace via eustachian tubes
Lined by cilunar ciliated epithelium
>Produce mucus, catarrh and glue
What does the middle eat contain?
Ossicles
Facial nerve
Chorda tympani
What is found in the middle ear?
Vestibulo-cochlear organ: Bony labyrinth Membranous labryinth Fluid >Perilymph >Endolymph
What makes up the bony labyrinth?
Cochlea
Vestibule
Semi-circular canal
What is the function of the membranous labyrnth?
Is the sensory epithelium for hearing
What nerves supply hearing?
Cochlear fibres/nerves
>Travels through Internal auditory meatus
>Joins brainstem at pontomedullary junction
Cochlear+ vestibular = vestibulococclear nerve (CN VIII)
What supplies mixed innervation to the ear?
Cervical root branches
Cn V - trigeminal
CN IX - glossopharyngeal
CN X - vagus
What are potential complications of infection or trauma to the ear?
Intracranial sepsis
Facial nerve damage
Deafness
Dizziness
What is the internal auditory meatus?
Junction of inner ear to brainstem
1cm long bony canal CN VII and CNVIII
What is the internal auditory meatus the clinical site of?
Acoustic neuroma
Vestibular schwannoma
What are the main things that affect hearing?
Wax/physical obstructions >Minimal unless impinging on TM TM perforation >relatively small Loss of ossicular continuity >Very large effect
What is the types of hearing loss?
Conductive
Sensioneural
How does the cochlea hear sound?
Hairs within organ of corti produce electrical activity via vibrations
>Transmitted by endolymph and perilymph
Activity becomes neural impulse and travels to brain
How is balance interpreted?
Via vestibule and semicircular canals
Hair cells + otoconia produce electricla activity
>Becomes neural impulse
What are the three semicircular canals?
Lateral
Posterior
Superior
Connected via saccule and utricle
How is loudness interpreted by the ear?
Produces increased intensity for increased loudness
0 decibals minimum hearing
Pain at 130
How is pitch interpreted by the ear?
500-2000Hz - range of speech
Due to turns in cochlea
>Basal turn - high freq
>Apical turn low freq
What is audiometry?
Subjective test which measures amplitude or intensity of sound and frequency in the ear
What is tympanometry?
Measure of tympanic membrane compliance involving middle ear and ear canal pressureBecause of Eustachian tube function
canal pressure should = middle ear pressure
What is tympanometry useful to diagnose?
Eustachian tube dysfunction
Middle ear effusion (glue-ear)
What pitches tend to be lost in conductive + sensioneural loss?
Conductive - low notes lost
Sensorioneural - high notes lost
Why is sound input important in children?
Key in development of auditory complex
Links to speech cortex
Children born deaf in one ear will grow up with element of auditory cortex “adaptation”
Severely deaf - unable to develop normal speech
If prfound deaf, never speak unless achieved before age of 4
