Head and Neck II Flashcards
1
Q
Where does the nasal cavity extend from?
A
From nares anteriorly to choanae
2
Q
What are the 3 regions of the nasal cavity?
A
Olfactory - superiorly
Respiratory
Nasal vestibules - anteriorly and inferiorly
3
Q
Which bones make up the nasal septum?
A
Perpendicular plate of ethmoid, vomer, cartilage, nasal septum, crest of maxillary bone and palatine bone
12 bones all together
Perpendicular plate attached directly to vomer bone at middle part of septum
4
Q
What are the choanae?
A
Opening at the back of the nose
Allows air to pass through the nose and pass down respiratory tract - once aerated, warmed up and humdified
5
Q
Where are the meatuses?
A
Run between superior, middle and inferior choncha
6
Q
What is the cell lining of the meatuses?
A
Contain pseudostratified cilated columnar epithelium
Cilia help beat and remove bacteria/unwanted particles
7
Q
What are the choncha?
A
Bony structures - shell shaped superior, middle and inferior
8
Q
What is the alar fibro fatty tissue?
A
Outer alar margin and sidewall are made of fibro-fatty soft tissue.
9
Q
What are the cartilages of the nose?
A
Nasal septum (left + septal processes) Major ala (medial + lateral) Minor ala
10
Q
What is the crista galli?
A
Attachment of falx cerebri (dura mater)
Splitting cerebral hemisphere
11
Q
What does the cribiform plate contain?
A
Houses olfactory nerves
12
Q
What is the uncinate process?
A
Projection of the ethmoid bone
Connection point
Can be attached to either the lateral nasal wall
Superior attachment of the uncinate process determines the drainage pattern of the frontal sinus.
13
Q
How is the frontonasal sinus drained?
A
Drains via infundibulum under middle concha
Frontonasal sinus connects frontal sinus to nasal cavity and allows it to drain there
14
Q
What are the entry ways of the maxillary sinus?
A
Only one entry point (also exit point)
Uncinate process = opening
15
Q
Which sinuses open into the middle meatus?
A
Frontal, maxillary and anterior ethmoidal sinus open into middle meatus
16
Q
Where does the nasolacrimal duct drain?
A
Runs down from nasal aperture and opens into inferior meatus
17
Q
What other structures open into the inferior meatus?
A
Eustachian tube - allows middle ear to equalise with atmospheric air pressure
18
Q
What is the function of the paranasal sinuses?
A
Lightening the weight of the head, humidifying and heating inhaled air, increasing resonance speech
Serves as crumple zone to protect vital structures in event of trauma
19
Q
What is significant about the sinuses in children?
A
Poorly developed in children
20
Q
Describe the frontal sinus
A
May be multiple
Each w/ frontonasal duct
Drains into middle meatus via frontonasal duct, opens into frontal recess or ethmoidal infundibulum
21
Q
What are the ethmoidal air sinuses?
A
Ethmoid bulla and ethmoid air cells - on medial wall of orbit
22
Q
What are the practical implications of the ethmoid air cells?
A
Ethmoid air cell infection
If drainage blocked, infections may break through fragile orbital wall
Severe infections can cause blindness as some ethmoidal cells very close to optic canal - transmits optic nerve and opthalmic artery
23
Q
What is the practical significance of the sphenoidal air sinus?
A
Trans-sphenoidal surgery can be formed (through nose) to remove tumours from hypophysis gland
24
Q
Where is the maxillary air sinus located?
A
V. large and v. close in proximity to molars and pre-molars
25
What is the significance of having only 1 opening to the maxillary sinus?
Patients w/ sinusitus can get block
Maxillary sinus often infected and mucous membrane can get congested
Obstruction can cause chronic sinusitis ˙.˙ high location opening maxillary sinus, when head erect, impossible for sinus to drain until they're full
If positioned on medial side, sinus will only allow upper sinus to drain eg. right sinus drains if lying on left side
26
How can a tooth ache/abcess affect the maxillary sinus?
Can cause referred pain in maxillary sinus and polyps in sinus can cause tooth ache
27
How can you treat polyp growth in the maxillary sinus?
Polypectomy - open bone to allow drainage from maxillary sinus and remove polyps
May have chronic fluid build up in area can't be treated by antibiotics
28
What is an oroantral fistula?
Pathological abnormal communication between oral cavity and maxillary sinus
29
Why may an oroantral fistula occur?
May be due to failure of healing a primary OAF, dental infections, osteomyelitis, radiation therapy, trauma
Iatrogenic complications develop when oro-antral communication fails to close spontaneously so remains patent and gets epitheliated
30
How does the maxillary sinus and teeth change as grow older?
Grow as the skull grows
| Teeth whittle away - can cause issues
31
Where does the procerus muscle attach?
Attaches onto nabella
32
Where does the nasalis muscle attach?
Runs over the full aspect nasal bone w/ attachment to maxilla around fibrofatty cartilage
33
What is the function of the levator labii superioris alaeque nasi?
Enables to scrunch nose
34
What are the adenoids?
Pharyngeal tonsils
Malt tissue (protective)
Mucosal cell associated lymphatic tissue - grow and help to protect kids
Can be removed with tonsils if inflammed
35
Where is the pharyngeal tonsil located?
On the posterior wall and roof of the nasopharynx
36
What is the torus tobarius?
Ridge in nasopharynx lies posterior to opening of auditory tube
37
What is the significance of the tubal tonsil/ opening auditory tube?
Connects middle ear cavity to back nasopharynx
| Bacteria can get trapped here
38
What is the hypophysis?
Pituitary gland
39
What is the nasal vestibule?
Lined with small, coarse hairs
| Area just inside nostril that leads into nasal cavity, supported by cartilage of nose
40
What is the foramen cecum?
Embryological remnant of back of tongue
| Maxillary sinus by middle ear
41
Where is the opening of the frontonasal duct?
Empties into middle nasal meatus
Drains directly from above
Close to ethmoid air cells -
very thin - if get fractured = problem
42
Where does the nasopharynx get to?
The entire superior portion
| Once get to uvula = oropharynx
43
What does the external carotid supply?
Gives off maxillary artery
3rd portion terminal branches supplies the nasal cavity
Supplies upper maxilla, lower mandible, deep facial areas and nasal cavity
Supports both hard and soft tissues
44
What are the other blood vessels that supply the nasal cavity?
Terminal branches of the facial artery - palatine tonsils, soft palate, submandibular gland
Ethmoidal arteries - branches of ophthalmic artery (originates from ICA)
Passes through optic canal
Supply anterior and posterior inside nose, eyeballs, ocular muscles and surrounding structures
45
What is Little's area?
Area on nasal septum where branches facial, maxillary and ophthalmic arteries anastomose
Common site nose bleeds
Aka. Kiessellbach's plexus
46
Where does the venous drainage go to?
Goes into cavernous sinus
| Eventually goes into internal and external jugular veins
47
Where do the lymphatics drain?
Drain along the same venous aspect
48
What is the innervation of the nasal region?
Olfaction - olfactory nerve CNI
Goes through cribiform plate
General sensation:
Ant. region - opthalmic nerve V1
Post. region - maxillary V2
Where maxillary artery is
All glands are supplied by PS fibre in greater petrosal nerve @ back - branch of facial nerve VII
Anteriorly = ethmoidal nerve external branch
Greater palatine nerves @ front go through foramena
and have nasopalatine nerves
49
Describe the course of the greater petrosal nerve
It goes through and hits the pterygopalatine ganglia
Runs alongside where V2 branch exits - through olfactory bulb through cribiform plate
Other nerves also join the ganglia - Post. superior lateral nasal branches from V2
50
Where do the greater and lesser palatine nerves run along?
Runs along palatine aspect, goes through palatine foramena, have greater foramena at front
51
Which nerves supply the meatus?
Branches of maxillary nerve
Ant aspect - V1
Post aspect - V2
52
What is the supply of the concha?
Apart from cribiform plate have sensatory nerves
| Branches of V2 - posterior via pterygopalatine ganglion
53
What do the great and deep petrosal nerves supply?
Help supply the auditory tube
54
Which nerve is at the back?
Glossopharyngeal nerve CNIX
55
List the nerve supply of the paranasal sinuses
Frontal sinus - supraorbital V1, anterior. ethmoidal sinuses
Ethmoidal sinus - anterior and posterior ethmiodal branches of nasocilliary nerve
V1 + V2 blood supply same as frontal
Maxillary sinus - infra-orbital and alveolar nerves (V2)
and superior alveolar arteries (maxillary artery)
Sphenoidal sinus - posterior ethmoidal nerve from V1+V2 pterygopalatine ganglion
Blood supply = pharyngeal arteries (maxillary artery)
56
What type of cartilage is the larynx made up of?
3 paired and 3 unpaired cartilage
57
List aspects of the cartilaginous skeleton of the larynx
```
Epiglottis
Thyroid
Cricoid
Aytenoid - attachment point for vocal cords
Corniculate and cuneiform - paired
Cricoarytenoid joint
Crico-thyroid joint
```
58
What is significant about the hyoid bone?
Doesn't articulate with other bones
Instead has lots muscles and structures attach to it
Has anterior and posterior horns
59
Describe thyroid cartilage
Has horns superiorly and inferiorly
Composed of two halves, which meet in the middle at a peak called the laryngeal prominence, also called the Adam's apple
Above the thyroid gland
60
What is the thyroepiglottic ligament?
Connects thyroid to epiglottis
61
What is the hyoepiglottic ligament?
Helps close airway - so don't bring anything up
| When swallow larynx moves up - strap muscles help facilitate this movement
62
What does the cricoid cartilage allow?
Larynx attached to cricoid - allows movement
| Free movement between thyroid cartilage and cricoid cartilage
63
Where are the cricotracheal ligaments?
Between cricoid and tracheal rings
64
What are the arytenoids?
A structure
| Attachment of vocal cord
65
What is superior to the arytenoids?
Corniculate cartilage - vestibular ligament attaches to it
66
What are the piriform recess?
At the side of the throat
| Fishbones can lodge
67
What is around the pharyngeal recess?
Have opening of auditory tube
Surrounded by torus tubarius
Cartilaginous portion w/ back nasopharynx
68
What is the laryngeal inlet?
Remaining portion
69
What are the structures of the anterior triangle?
Have vagus nerve, internal jugular, common carotid
| All in carotid sheath
70
What is the course of the superior laryngeal nerve through the thyroid cartilage?
Superior laryngeal nerve goes through aperture in thyohyoid membrane
Passes through on left and right side
71
What does the recurrent laryngeal nerve supply?
Helps supply vocal cord for inferior aspect
72
What is significant about the thyroid prominence?
More prominent in males because of increased testosterone
73
What do the arytenoids do?
Help form vowel sounds-vocal aspect
74
What happens during speaking on expiration?
Get air to pass over the vocal cords
Need adduction of the vocal ligaments (arytenoids)
Do pivoting and twisting action
Can identify laryngeal inlet
Epiglottis don't permanently close .˙. can choke when talk, as larynx raises up when swallow
Epiglottis tries to come down as far as it can in the laryngeal inlet to cover - towards the arytenoid when need to swallow
75
What happens during forced inspiration?
Posterior crico-arytenoid muscles will contract and allow opening of vocal ligaments
Arytenoids pivot out to allow air to be passes down into lungs - widens glottis to open
Vocal folds abducted
Rima glottidis wide open
Vestibule open
76
What is the purpose of the vocalis and thyroarytenoid muscle?
Act to help w/ pivoting vocal sounds
Make a,e,o
Different sounds have different ways that the vocal cords work in
77
What do the lateral cricoarytenoid muscles allow?
Contract to allow closure
| Pivot the arytenoid to close vocal ligaments
78
What is dehescience of Killion?
Triangular shaped weakness in the muscular wall of pharynx
| Between transverse and oblique bundles of inferior pharyngeal constrictor
79
What is the pharyngeal pouch?
Pouch tissue forms where pharynx meets oesophagus
| Can cause dysphagia
80
What is the significance of a laryngeal skeleton fracture?
May lead to submucous heamorrhage and oedema, resp obstruction, hoarsenes and temporary inability to speak
81
How could a fracture of the laryngeal skeleton occur?
May result from blows received in sports eg. Kickboxing, hockey
Or from compression by seatbelt during car accident
82
List some structures in the area?
Thyrohyoid membrane
Median and lateral thyrohyoid ligaments
Hypoepiglottic and thyroepiglottic ligaments
Cricotracheal ligament
Intrinsic ligament
Quadrangular ligament
Cricothyroid ligament -
ant. part = conus elasticus - connects thyroid to cricoid
inferior part attaches to cricoid cartilage
Superior part is free edge, vocal ligament where vocal cords run in between thyroid and arytenoid cartilages
83
What are the extrinsic muscles of the larynx?
Run between thyroid and arytenoid cartilages in larynx
| Infrahyoid and suprahyoid muscles and stylopharyngeus
84
What are the intrinsic muscles of the larynx?
Mostly paired (except transverse arytenoid)
1. Cricothyroid (straight and oblique part) - superior laryngeal nerve
2. Posterior and lateral cricoarytenoid
3. Oblique and transverse arytenoid
4. Vocalis and thyroarytenoid - recurrent laryngeal nerve
Mainly for controlling sound production
85
Which muscles are the only ones that abduct the vocal cords?
Posterior cricoarytenoid muscles
86
What is the action of the posterior cricoarytenoid muscles?
Separate vocal cords and assists other intrinsic muscles in lengthening vocal cords
.˙. allows passage of air during inspiration and expiration
87
What is the nerve supply of the intrinsic muscles?
Recurrent laryngeal nerve - branch of vagus nerve
88
Which intrinsic muscle is not supplied by the recurrent laryngeal nerve and what is it supplied by?
Posterior cricothyroid muscle
| Innervated by superior laryngeal nerve
89
Describe the course of the superior laryngeal nerve
Branch of the vagus nerve
Goes through aperture between membrane and hyoid bone
Hard to find but runs near sup. thyroid artery .˙. could be damaged in thyroid surgery
90
What do the internal laryngeal nerves supply?
Internal branch of superior laryngeal nerve
| Carries sensation from mucosa above the vocal cords
91
What is the effect of the injury of recurrent laryngeal nerve by cancer?
Larynx cancer high incidence in people who smoke cigarettes/chew tobacco
Cancer may damage the nerve - especially on the left, where it runs into the thorax
Symptoms:
Patients present w/ hoarseness w/ earache and dysphagia
Enlarged pretracheal/paratracheal lymph nodes may indicate presence laryngeal cancer
92
How can vocal rehabilitation be conducted?
Can be done by electrolarynx, tracheo-esophageal prosthesis or eosophageal speech (regurgitation ingested air)
93
What can happen during injury of the superior laryngeal nerve?
Injury of the external branch superior laryngeal nerve = monotonous voice ˙.˙ paralysed cricothyroid muscle supplied by it - means unable to vary length and tension vocal cord
94
What can compression of the cricopharyngeus cause?
Cricopharyngeus is v. highly vascularised + intrinsic to be able to talk
Any compression of area (eg. by nodules) affects ability to speak
95
How can injury of recurrent laryngeal nerve occur?
Can occur during thyroidectomy and other surgical operations in anterior triangle of neck
˙.˙ inferior laryngeal nerve innervates muscles moving vocal fold .˙. injury = paralysis vocal fold
96
What is the blood supply to the laryngeal area?
Superior and inferior thyroid arteries
Sup thyroid = 1st branch external carotid
Inf thyroid = branch thyrocervical trunk
Possible thyroid ima artery
97
What is the venous drainage of the laryngeal area?
Superior, middle and inferior thyroid veins - often 3 each side
98
What are some structures that need to be identified in the larynx area?
Laryngeal orifice (aditus laryngis)
Aryepiglottic folds
Vestibule
Ventricle
Infraglottic cavity - directly underneath vocal cords
Vocal fold
Laryngeal inlet - goes from epiglottis to fold
99
Describe the vocal cord
Very thin
| True and false
100
What structures are in the glottic region?
Contains vocal cords
101
What does the middle pharyngeal constrictor muscle do?
Helps support posterior aspect of oesophagus
102
What is a common complication in the vocal cords of singers?
Polyp growth on vocal folds
103
What is effort closure?
Complete adduction of vocal folds and vestibular folds (glottidis too)
104
What is a cricothyroidotomy?
Emergency procedure used to obtain an airway when other methods are ineffective
105
When is a laryngeal mask airway used?
Trauma causing oral, pharyngeal or nasal haemorrhage
Make incision in membrane where insert layngeal mask - as trauma causes haemorrhage need to create an airway through to the area
106
What is stridor?
Noisy breathing ˙.˙ obstructed air flow through a narrowed airway
Can occur during anaphylactic shock - airways narrow and ˙.˙ low BP, prevents heart from receiving enough O2
107
What should be done in the case of a larynx obstruction?
Cricthyrotomy/ tracheostomy
ie. Openings in airway to bypass the obstruction
OR
Do Heimlich manoeuvre
108
Describe the morphology of the thyroid gland
2 pear shaped lobes united by isthmus
| Have L+R lobe + pyramidal lobe
109
Where is the isthmus attached?
To 2nd and 3rd tracheal rings
110
Describe the location of the thyroid gland
Lies between C5-T1
Located anteriorly in the neck, lower aspect
Top of the manubrium and clavicle but does NOT sit on the larynx
Have to go under the clavicle and manubrium to get there
111
Describe the pyramidal gland and how many people have the pyramidal lobe?
Approx. 50% people have a small prominence = pyramidal lobe
| On the superior surface isthmus - usually to the left of the medial plane
112
What is the function of the thyroid?
Responsible for secretion of thyroxine, calcitonin and parathyroid hormone (PTH)
113
Describe the development of the thyroid gland
Arises from the floor of the pharynx
Develops as a median thickening of the endoderm between 1st ad 2nd pharyngeal pouches
Area later invaginates to form median diverticulum
Gland develops as bi-lobed extension from distal end of the thyroglossal duct
Duct grows caudally and the bifurcation gives rise to thyroid lobes and isthmus (remnant) - passes underneath hyoid, loops and wrap around
114
What usually occurs with regards to the thyroglossal duct and what is the significance of this?
Usually disappears early in development
BUT remnants may persist as a cyst
If ask a patient to stick tongue out will pull up glands and any attachment on the tongue (swelling midline on the neck) will be visible
Duct may persist as connection to foramen cecum
Fistula = connection of 1 surface of 1 structure to another surface on another structure
.˙. fluid can enter the foramen cecum
May cause hyperthyroidism
115
What is a lingual thyroid?
Functional thyroid gland associated w/ tongue
Abnormal mass ectopic thyroid tissue at the base of the tongue
˙.˙ embryological aberrancy in development of the thyroid gland
Most of the ectopic tissue is seen on the tongue
116
Where can polyps occur?
Can occur anywhere along the path of migration and extending upward from the gland along the path of the thyroglossal duct (pyramidal lobe)
Must do neck exam to check
117
How can the recurrent laryngeal nerve (both sides) be damaged?
Closely related to the thyroid
| Hence, during thyroidectomy may damage the nerve - get hoarseness voice/loss voice
118
Which vessels are related to the thyroid gland?
Inferior thyroid artery (left) runs close to the thyroid
| Branch of the common carotid artery
119
Where does the superior thyroid artery come from?
Superior comes from common carotid
| Penertrates the thyroid membrane with superior laryngeal nerves
120
Where do the middle branches of the external carotid go?
Go down anteriorly
121
What other vessels are in the area?
Thyrotrunk - branches off the subclavian
Supplies the area
thyroid is a highly vascularised structure
122
How may the thymus gland relate to the thyroid gland?
Young people the thymus gland may extend to the lower poles of the thyroid gland
123
What is the neck bounded by?
Superior: mandible, mastoid process, superior nuchal lines
Inferior: clavicle, manubrium of sternum
124
What is the difference of the posterior and anterior surface of the neck?
Posterior surface is longer than the anterior surface of the neck
Due to the upper 3 cervical vertebrae (ant) overlapped by facial skeleton
125
Which muscles are in the neck area?
```
Scalene muscle (anterior, middle, posterior)
SCM
```
126
What are the suprahyoid muscles?
4 muscles above the hyoid
| Act to elevate the hyoid bone - required for swallowing
127
List the 4 suprahyoid muscles
Digastric - posterior belly = digastric branch CNVII, anterior belly = branch CNV3, mylohyoid nerve
Geniohyoid - narrow muscle superior border of mylohyoid muscle
Mylohyoid - Paired muscle, runs from the mandible to the hyoid, floor of the oral cavity of the mouth
Stylohyoid - anterior and superior to posterior belly of the digastric
128
What is present at the bifurcation of the common carotid artery?
At the bifurcation have carotid sinus
| Dilated superior part of common carotid and inferior part of the internal carotid arteries
129
What is the carotid sinus?
Thinner walled area and more elastic than the arteries
| Reflex area of the carotid arteries and has baroreceptors which monitor blood pressure
130
What is the carotid body?
Cluster of chemoreceptors
Near bifurcation of the carotid artery
Fn = responds to stimulus - oxygen partial pressure
detected by type 1 (glomus) cells, relays info to CNS
Both the carotid sinus and the carotid body send afferent impulses to the medulla oblongata via CNIX (glossopharyngeal nerve)
131
What is the carotid pulse?
"Neck pulse" felt at side of neck
Lies in the groove between trachea and infrahyoid muscles
Absence = cardiac arrest
132
What is the significance of carotid sinus hypersensitivity?
External pressure on the carotid artery in people w/ condition may cause slowing heart rate, fall in blood pressure, cardiac ischema with fainting (syncope)
133
What is the carotid sinus massage?
Gently massaging carotid artery for 5 seconds whilst monitoring heart rhythm and blood pressure
Used to investigate unexplained dizziness/faints
134
How does the internal carotid artery enter the skull?
Enters through the carotid canal
135
List the branches of the external carotid artery
1. Superior thyroid
2. Ascending pharyngeal
3. Lingual
4. Facial
5. Posterior auricular
6. Occipital
7. Maxillary
8. Superficial temporal
She Always Likes Friends Over Pappa Mamma Sister
136
Where does the inferior thyroid artery originate?
Thyrocervical trunk off subclavian
137
What is the relation of the anterior scalene muscle to the subclavian arteries?
Divides the subclavian artery into 3 parts
138
What are the branches of the subclavian artery?
```
Vertebral artery
Internal thoracic artery
Thyro-cervical trunk
Costo-cervical trunk
Dorsal scapular
Common carotid arteries - bifurcate at the level of the upper border thyroid cartilage (C4)
```
139
What are the veins of this area?
Facial vein
Anterior division of the retromandibular vein
Internal jugular vein
Anterior jugular - drains the anterior neck and joins the external jugular just before it joins the subclavian vein
140
From where does the external jugular vein arise from?
Arises at the level of hyoid bone from the confluence of the posterior branch of the retromandibular vein and posterior auricular vein - these 2 are small and variable therefore, often lacered during dissection
141
Where may pulsation of the internal jugular be felt?
Transmitted through surrounding tissue and observed deep to SCM
Superiot to the medial end of the clavicle - helps inform about the heart cavity
As no valves in brachiocephalic vein or SVC - wave of contraction passes up these vessels to IJV
142
Where do the subclavian veins begin?
At the lateral border of the 1st rib
Left brachiocephalic vein usually longer than the right
Anterior scalene muscle attaches to 1st rib and separates subclavian vein and artery
143
What is a function of the external jugular vein?
Internal barometer
Venous pressure = normal - only visible above clavicle
In heart failure (raised venous pressure) - prominent throughout its course
Jugular venous pressure increased on right side of heart failure
144
Describe the course of the thoracic duct
Lymph in thoracic duct enters venous system at point where left internal jugular vein joins subclavian
Right lymphatic duct attache to equivalent point on RHS
Difficult to see these structures
145
What is the significance of the cervical rib?
Can press on brachial plexus and subclavian vessels
| Causes neck pain and numbness in arm
146
What is subclavian steal syndrome?
Steno-oclusive lesion proximal to the sibclavian artery
| Causes retrograde flow in vertebral artery away from brain stem -->vertebrobasilar insufficiency
147
What is Horner's Syndrome?
Caused by damage to the sympathetic nerves of the face
| 3 main symptoms
148
Describe the accessory nerve
Enters SCM in upper part of posterior triangle
Can be damaged during biopsy of lymph nodes in post. triangle
Supplies SCM and trapezius
149
Describe the hypoglossal nerve CNXII
```
Innervates extrinsic and intrinsic muscles of tongue
except palatoglossus (CNX - vagus nerve)
```
150
What is the ansa cervicalis?
Loops from C1 via hypoglossal, C2 + C3 roots
| Lies w/in carotid sheath, superficial to internal jugular vein
151
Which muscle is the phrenic nerve closely related to?
C3,4,5 related to scalene muscle
| Need to note topography of nerve
