Head and neck Flashcards
anatomy of the eye
ways to differentiate causes of acute red eye
- Vision- normal or reduced vision?
- Painful or painless
- Normal intraocular pressure or raised intraocular pressure
painful acute red eye
(vission N= normal , R = reduced)
- conjunctivitis (N)
- sceleritis (N/R)
- keratitis (R)
- corneal foreign body (N/R)
- epsicleritis (N)
painless acute red eye
(vission N= normal , R = reduced)
subconjunctival haemorrhage (N)
reduced vision and red eye with normal intraocular pressure
corneal abrasion
keratitis
reduced vision and red eye with increased intraocular pressure
acute angle closure glaucoma
anterior uveitis
what is the likely diagnosis
orbital cellulitis
investigations required for orbital cellulitis
- FBC
- Raised WBC and CRP
- Blood cultures
- CT with contrast
- Would show inflammation of orbital tissue deep to the septum
management of orbital cellulitis
- Abx
- Admit for IV antibiotics
how do we differentiate orbital cellulitis from periorbital cellulitis
-
Periorbital cellulitis- confined to tissues superficial to the orbital septum (and tarsal plates)
- Secondary to infection e.g. bug bite
-
Orbital cellulitis- results of an infection affecting the fat and muscle posterior to the orbital septum, within the orbit but not involving the globe
- Vision and movement affected
what is the likely diagnosis
acute closed angle glaucome
acute closed angle glaucome management
- Drugs to reduce pressure
- Surgical- use laser to make hole to allow flow of aqueous humour to the iris
- opthalmological emergency
outline how acute angle closure gluacoma occurs
- Drugs to reduce pressure
- Surgical- use laser to make hole to allow flow of aqueous humour to the iris
likely diagnosis
Right oculomotor nerve palsy
- Ptosis- LPS
- Dilation of pupil- parasympathetic fibres lie on periphery
- In diabetes usually not dilated (can receive blood supply from smaller blood vessels)
- But with compression- pressure on parasympathetic fibres and the oculomotor nerve - dilation
- Down and out
likely diagnosis
Horner’s syndrome
- Sympathetic fibres traveling up from the thoracic region
- Superior tarsal muscle
- Sweat glands
likely diagnosis
right 4th nerve palsy (trochlear)
- Superior oblique muscle affected
label these eye muscles
clinical testing of the extraocular eye muscle and their innervations
H in space for muscle isolation
most of the extraocular eye muscles are innervated by
CN3- oculomotor
- inferior oblique
- superior rectus
- inferior rectus
- medial rectus
which extraocular eye muscles are not innervated by the oculomotor nerve
Lateral rectus
Superior oblique
how to remember Lateral rectus and Superior oblique
LR6 SO4
all other CN III
lateral rectus innervated by the
CN6- abducens nerve
supeiror oblique innervated by
CN4- trochlear
muscle action of lateral rectus
abduction
muscle action of medial rectus
adduction
muscle action of superior rectus
elevation
minor muscle actions : intorsion and adduction
muscle action of inferior rectus
depression
minor muscle actions
- extorsion
- adduction
muscle action of inferior oblique
extorsion
minor muscle action
- elevation
- abduction
muscle action of supeirior oblique
intorsion
minor muscle movement
- depression
- abduction
triangles of the neck
midline neck structures
- thyroid
- submental lymph nodes
- hyoid bone
Conditions could lead to neck lump in the midline
- A cyst
- Dermoid
- Thyroglossal
- Goitre
- Hyper/hypothyroidisms
- Thyroid malignancy
structures in the anterior triangle
- Anterior border of the SCM
- Infrahyoid muscles
- Lymph nodes
- Anterior cervical chain
- Submandibular glands
- Carotid sheath
- IJV
- Carotid artery
- Vagus nerve
Conditions could lead to neck lump in the anterior triangle?
- reactive lymphadenopathy
- malignant lymphadenopathy
- branchial cyst
- carotid artery aneurysm
- carotid body tumours
- submandibular gland pathology
structures in the posterior triangle
- Trunk of the brachial plexus
- Subclavian artery and veins
- Pancoast tumour
- Scalene , omohyoid inferior belly
- Phrenic nerve
- Lymph nodes
Conditions could lead to neck lump in the posterior triangle?
- Apical lung tumour
- reactive lymphphadenopathy
- malignant lymphphadenopathy
lumps which can occur anywhere in the neck
- lipoma
- sebaceous cyst
- haemangiomas
- skin malignancy
Assessment of the lump
- Movement
- Mobile/immobile
- On swallow
- On sticking out tongue
- Texture
- Hard or soft
- Regular/irregular
lymph nodes feel
rubbery
hot lymph nodes
inflammatory
tender lymph node
not cancer
Swallow and stick out tongue
- Any lump related to thyroid will move on swallowing
- If the lump moves when tongue being stuck out- thyroglossal
why does the patient have enlarged lymph nodes
infection
lymphoma
questions to narrow down lymph nodes
Onset
- Acute- days
- Chronic- week- months
Associated symptoms
- Infection
- Fever
- Localising symptoms such as ear pain, cough or sore throat
- Inflammation
- Arthritis
- Malignancy
- Ref flag symptoms for all possible sites
- May be a primary, local or distant metastasis
- Ref flag symptoms for all possible sites
red flag symptoms
- age
- weight loss
- blood malignancy
- symptoms such as night sweats and tiredness
- local metastasis
- persistant hoarse voice
- difficulty swallowing
- persisting sore throat
- distant metastasis e.g. abdominal primary
investigations of lymph nodes
blood tests
US
refer
Describe what you see
- Hutchinson’s sign
-
Hutchinson’s sign is the presence of vesicular lesions on the side or tip of the nose. It is classically associated with acute herpes zoster ophthalmicus, which may cause loss of vision, ocular inflammation, and debilitating pain.
- Nasociliary nevre (branch of V1)
- Infection extends to the tip of the nose- sight threatening
-
Hutchinson’s sign is the presence of vesicular lesions on the side or tip of the nose. It is classically associated with acute herpes zoster ophthalmicus, which may cause loss of vision, ocular inflammation, and debilitating pain.
- Unilateral
- Va lesion- ophthalmic
what other questions do you want to ask?
- Onset/duration
- Sensation
- Pain
- Immunocompromised
- Contact with anyone with the same condition
likely diagnosis
- Varicella zoster infection causing ophthalmic shingles
- Lies dormant in the trigeminal ganglion
- Ophthalmic emergency- sight threatening
key symptoms
- Tinnitus- vestibulocochlear
- Facial tingling
- Facial nerve involvement
- Progressive worsening
differentials
- Vestibulocochlear lesion
- Schwannoma
- Acoustic neuroma (vestibular schwannoma)
Acoustic neuroma (vestibular schwannoma)
- Compression of other structures
- Facial nerve
- Trigeminal nerve
- Cerebellum
- Very slow growing tumour
positive rinnes test
AC>BC
Normal response or sensineural hearing loss on tested side
negative rinnes test
BC >AC
conductive hearing loss on tested side
what does Rinnes test compare
compares BC to AC at each ear
what does webers test compare
compared BC bilaterally
normal webers test
sound heard in both ears equally
how will sound lateralise in sensinoural hearing loss in a Webers test
sounds lateralises to unaffected side
ow will sound laterlase with conductive hearing loss in webeers test
lateralised to affected side
- Vid shows tongue pointing to the right-likely diagnosis?
- Right hypoglossal nerve palsy - the tongue never lies
C- MIDDLE EAR (grey part on diagram)
Explanation:
- Right sided facial droop
- Juice falling out of the mouth- orbicularis muscle weak
- Crying- greater petrosal intact
- Chorda tympani not functioning
- Sensitivity to loud noises- nerve to stapedius not working
Think about this
- If you have a lesion before the internal acoustic meatus- all functions affected
- Once we get to the geniculate ganglion- first branch of facial nerve leavesà (1)greater petrosal nerve- parasympathetics to a number of glands
- 2 more intrapetrous branch
- Nerve to stapedius (2)
- Chordae tympani – special sensory taste and parasympathetic (3)
- Once leaving stylomastoid foramen- motor to muscles of facial expression
A
B
C
D
Facial nerve lesion where the lesion is related to the Geniculate ganglion
- Ramsay hunt syndrome
- Look for vesicular rash on the ear
inflammation of the supraglottis (including epiglottis
epiglottitis
- rare but airway threatening
- 2-6 years
- stridor, drooling, unwell, sniffling position
- H . infuenzae but also strep pneumoniae
examples of conditions which would caused impaired actions of vocal cords
- inflammation of cords (laryngitis), nodule cancer
- paralysis of muscles moving vocal cords
paralysis of muscles moving vocal cords
- injury to external branch of superir laryngeal enrve
- laryngospasm
- laryngeal odema
inflammation of the larynx, trachea and bronchi
- croup
- parainfluenza virus
- 6 months - 3 years
- seal like bark (sometimes stirdor, increased resp efffort)
innervation of the pharynnx
maxillary division of the trigeminal nerve (V)- sensory
innervation of the Oropharynx
*
- Sit behind oral cavity
- Includes posterior third of tongue
- Glossopharyngeal (IX)- sensory and special sensory taste, some motor contribution (stylopharyngeus)
- Glosso- tongue
- O- oropharynx
- Pharangeal-pharynx
innervation of the laryngopharynx and laryx
- Vagus (CN X)
- Motor
- Laryngopharynx
- Larynx
- Sensory
- Laryngopharynx
- Motor
- Most important for swallowing
Glossopharyngeal also innervates
- Middle ear and ET
- Carotid sinus and bodies (carotid massage)
- Parasympathetic to the parotid gland
Vagus also innervates
- Soft palette
- External ear
- Parasympathetic
- B vagus (Q tip shouldn’t be able to get in to the middle ear)
both CNIX and CNX have some sensory function relating to the
ear, but different parts
- IX- eustachian tube and middle ear
- X- external ear (part) and external suface TM (part)
how do we clinically examine CN IX and X
- Speech
- Swallow
- Cough
- Gag reflex
- Uvula deviation
