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ESA 4 > Head And Neck Week 9 > Flashcards

Head And Neck Week 9 Flashcards

1
Q

What are the functions of the oral cavity?

A

Digestion - receives food and prepares it for digestion
Communication - modifies the sound produced int he larynx to create a range of sounds
Breathings - air inlet in addition to nasal cavity

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2
Q

How can the oral cavity be divided?

A

Into two parts:
Oral vestibule - slit like space between the teeth and gingivae and the lips and cheeks
Oral cavity proper - space between upper and lower dental arches or arcades (maxillary and mandibular alveolar arches and the teeth they bear) - limited anteriorly and laterally by the dental arches

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3
Q

Describe the oral fissure

A

Opening of the oral cavity to the exterior
Size controlled by peri-oral muscles - orbicularis oris, buccinator, risorius, and depressors and elevators of the lips (dilators of the fissure)

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4
Q

What fully occupies the oral cavity when the mouth is closed and at rest?

A

The tongue

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5
Q

What are the boundaries of the oral cavity?

A

Roof - formed by the palate - hard palate covered inferiorly by oral mucosa (stratified squamous epithelium) - soft palate muscle that can lower to close the oropharyngeal isthmus and elevate to separate the nasopharynx and oropharnyx
Posterior - communicates with the oropharynx at the oropharyngeal isthmus
Floor : - Muscular diaphragm - comprised of the bilateral mylohyoid muscles. It provides structural support to the floor of the mouth, and pulls the larynx forward during swallowing.
- Geniohyoid muscles – pull the larynx forward during swallowing.
- Tongue – connected to the floor by the frenulum of the tongue, a fold of oral mucosa.
- Salivary glands and ducts
Lateral - The cheeks - formed by the buccinator muscle, which is lined internally by the oral mucous membrane.
The buccinator muscle contracts to keep food between the teeth when chewing, and is innervated by the buccal branch of the facial nerve (CN VII).
Anterior - oral fissure

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6
Q

Describe the oral vestibule

A

The horseshoe-shaped vestibule is situated anteriorly. It is the space between the lips/cheeks, and the gums/teeth.

The vestibule communicates with the mouth proper via the space behind the third molar tooth, and with the exterior through the oral fissure. The diameter of the oral fissure is controlled by the muscles of facial expression – principally the orbicularis oris.

Opposite the upper second molar tooth, the duct of the parotid gland opens out into the vestibule, secreting salivatory juices.

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7
Q

What structures make up the oropharyngeal isthmus?

A

Palatopharyngeal arch, uvula and tip of the epiglottis

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8
Q

What are alternative names for the palatopharyngeal arch and the palatoglossal arch?

A

Posterior and anterior arch, respectively

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9
Q

Which bones form the hard palate?

A

Maxilla

Palatine bones

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10
Q

Describe the muscles of the soft palate

A

Tensor veli palatini - medial pterygoid nerve (CNV3) - tenses soft palate and opens mouth of pharyngotympanic tube during swallowing and yawning
Levator veli palatini - Pharyngeal branch of vagus - elevates soft palate during swallowing and yawning
Palatoglossus - Pharyngeal branch of vagus - elevates posterior part of tongue and draws soft palate onto tongue - forms anterior arch
Palatopharyngeus - Pharyngeal branch of vagus - tenses soft palate and pulls walls of pharynx superiorly, anteriorly and medially during swallowing - forms posterior arch
Muscular uvulae - Pharyngeal branch of vagus - Shortens uvula and pulls superiorly

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11
Q

Which way does the uvula deviate in a pharyngeal branch (CN X) lesion?

A

Away from the affected side (unopposed muscles pulling it)

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12
Q

Describe the gag reflex

A

Afferent limb - Glossopharyngeal - back of tongue/throat, uvula, tonsillar area
Efferent limb - Vagus - pharyngeal muscles of soft palate

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13
Q

Draw and label a diagram of the teeth

A

>

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14
Q

Why can you sometimes get a numb tongue during dental procedures?

A

Close relationship between the inferior alveolar and the lingual nerve

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15
Q

Describe the sensory supply of the lower jaw

A

Inferior alveolar nerve (branch of CN V3)
Can lose sensation during a mandibular fracture
Used as the site of anaesthesia in dental procedures

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16
Q

What are the extrinsic muscles of the tongue?

A

Genioglossus
Styloglossus
Hyoglossus
Palatoglossus

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17
Q

Where do the extrinsic muscles of the tongue attach?

A

Hyoid bone and mandible

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18
Q

What are the functions of the extrinsic tongue muscles?

A

Allow the tongue to change position

Anchor

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19
Q

What is the innervation of the tongue muscles?

A

Hypoglossal nerve except palatoglossus which is innervated by the vagus

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20
Q

What are the intrinsic muscles of the tongue and what are their actions?

A

Superior longitudinal - curling
Inferior longitudinal - curling
Vertical - flatten
Transverse - pull in/make thinner

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21
Q

What is the sensory innervation of the tongue?

A

Anterior 2/3:
General - lingual nerve (CN V3)
Special - chorda tympani (CN VII)

Posterior 2/3:
General and special - glossopharyngeal nerve (CN IX)
General - Internal laryngeal nerve (CN X)

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22
Q

Which way does the tongue deviate in a unilateral lesion of the hypoglossal nerve?

A

Towards the side of the lesion

Normal tongue muscle pushes harder than the affected side, overpowering it

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23
Q

Through what openings do the salivary glands open?

A

Parotid gland and duct - Stenson’s duct
Submandibular gland and duct - Wharton’s duct
Sublingual gland opens via multiple duct

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24
Q

What are salivary gland stones and which duct do they most commonly affect?

A

Saliva crystallises and blocks the salivary ducts - usually calcium based
Unknown aetiology
Most commonly affects the submandibular duct - saliva produced is comparatively thicker than other glands
Sublingual stones very rare

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25
Q

What are the signs and symptoms of salivary gland stones?

A

Pain or swelling of the gland at meal times

May be able to see wharton’s duct stone

26
Q

How are salivary gland stones managed?

A

Small stones may resolve spontaneously

Commonly need removal

27
Q

Which tonsils are usually affected by tonsillitis, how do patients present and what is the common pathogen?

A

Palatine tonsils
Odynaphagia or dysphagia - tonsils enlarged and erythematous
Usually infective - viral - rhinovirus, adenovirus - symptoms of URTI (cough)
Bacterial - beta haemolytic strep - cervical lymphadenopathy, fever, pus

28
Q

How do you decide whether the tonsillitis is bacterial or viral?

A

Centor criteria

Fever/Pain score

29
Q

What is a peritonsillar abscess/ Quinsy, what causes it, how does the patient present and what is the management?

A

Severe complication of bacterial tonsillitis - usually strep pyogenes, can be staph aureus, H.infleunza or mixed flora
Typically systemically unwell with trismus and “hot potato voice” (painful jaw upon opening), drooling due to dysphagia
Unilateral - uvula deviates away from lesion
Immediate referral to ENT

30
Q

What kind of joint is the temperomandibular joint?

A

Modified hinge synovial joint between the cranium and the mandible

31
Q

Which structures articulate at the TMJ?

A

Condyle of the mandible
Articular tubercle of the temporal bone
Mandibular fossa of the temporal bone

32
Q

What divides the TMJ into superior and inferior compartments?

A

Articular disk

33
Q

Describe the properties of the TMJ joint capsule

A

Relatively loose - mobility>stability

34
Q

Which ligaments support the TMJ ?

A

Lateral ligament (temperomandibular ligament)
Stylomandibular ligament
Sphenomandibular ligament

35
Q

Describe the movements of the TMJ and the muscles that produce them

A

Elevation - temporal, masseter and medial pterygoid
Depression - lateral pterygoid, super/infrahyoid, gravity
Protrusion - lateral pterygoid mainly
Retrusion - temporal
Lateral movements (e.g. Chewing) - temporal on same side, lateral pterygoid of opposite side and masseter on same side

36
Q

What is the innervation of the muscles of the TMJ?

A

Muscles of mastication - temporalis, masseter, pterygoids - mandibular branch of trigeminal nerve (CN V3) - auriculotemporal nerve

37
Q

How can TMJ dislocation occur, and what are complications?

A

During yawning, taking a large bite - excessive contraction of the lateral pterygoids may cause the heads of the mandible to dislocate anteriorly - mandible remains depressed and the person is unable to close his or her mouth - lock jaw
A sideways blow to the chin of an open mouth by a fist - dislocates the mandible on the side that received the blow
May accompany fractures of the mandible
Posterior dislocation uncommon due to postglenoid tubercle and the strong intrinsic lateral ligament
In falls or direct blows to the chin the neck of the mandible fractures before dislocation occurs (usually)
Care must be taken during surgery - to preserve both branches of the facial nerve overlying it and the auriculotemporal nerve
Injury to articular branches of auriculotemporal nerve supplying the TMJ - in traumatic dislocation, rupture of the articular capsule and lateral ligament –> laxity and instability of the TMJ

38
Q

In a suspected TMJ dislocation, what else should be checked for?

A

Fracture to the opposite side of the jaw

39
Q

What are the differential diagnoses for TMJ pain?

A

Temporal arteritis - type of vasculitis (serious - can go blind)
Bruxism- teeth grinding
Osteoarthritis of TMJ
Inter-articular disk derangement (younger age - can normally operate)
Pathophysiology poorly understood
Multifactoral causes - anatomical, psychological and social - anxiety, alcohol, smoking, sleep disorders

40
Q

Describe the borders of the infratemporal fossa

A

Laterally: Ramus of the mandible
Medially: Lateral pterygoid plate
Anteriorly: Posterior aspect of the maxilla
Posteriorly: Tympanic plate and the mastoid and styloid processes of the temporal bone
Superiorly: the inferior (infratemporal) surface of the greater wing of the sphenoid
Inferiorly: Where the medial pterygoid muscle attaches to the mandible near its angle

41
Q

What is the infratemporal fossa?

A

An irregularly shaped space deep and inferior to the zygomatic arch, deep to the ramus of the mandible and posterior to the maxilla
Communicates with the temporal fossa through the interval between (deep to) the zygomatic arch and (superficial to) the cranial bones

42
Q

Describe the contents of the infratemporal fossa

A 
Inferior part of the temporalis muscle
Lateral and medial pterygoid muscles
Maxillary artery
Pterygoid venous plexus
Mandibular, inferior alveolar, lingual, buccal and chorda tympani nerves
Otic ganglion
43
Q

Where do the nerves of the infratemporal fossa branch from?

A

Mandibular branch - inferior alveolar nerve (continues as mental nerve), lingual (chorda tympani and general sensory to anterior 2/3), buccal (sensory to cheek and buccal gum)
Otic ganglion - parasympathetic supply to parotid gland

44
Q

What is the clinical relevance of the infratemporal fossa?

A

Isolated infections e.g. Diabetic patients
Tumours (rarely)
Infection –> cavernous sinus thrombosis due to communication with pterygoid venous plexus
Can be used as site for mandibular nerve block

45
Q

What are neural crest cells?

A

A specialised subpopulation of cells that originates within the lateral border of the neuroectoderm and migrates throughout the mesoderm
Contribute to a variety of H+N structures
Fourth germ lineage

46
Q

What are the main features of the face?

A

Palpebral fissures
Oral fissure
Nares
Philtrum

47
Q

What is the embryological origin of the facial skeleton?

A

Neural crest of 1st pharyngeal arch

48
Q

What is the embryological origin of the muscles of mastication?

A

Mesoderm of 1st pharyngeal arch

49
Q

What is the embryological origin of the muscles of facial expression?

A

Mesoderm of 2nd pharyngeal arch

50
Q

What structures constitute the facial primordia?

A

1st pharyngeal arch:
- maxillary prominence
- mandibular prominence
Frontonasal prominence:
- surrounds ventrolateral part of the forebrain
- primordia of eyes
Stomatodeum - buccopharyngeal membrane - no mesoderm between endoderm and ectoderm

51
Q

What facial features develop from the frontonasal prominence?

A

FNP:

  • forehead
  • bridge of the nose
  • nose
  • philtrum
52
Q

What facial features develop from the maxillary prominence?

A

Maxillary:

  • cheeks
  • lateral upper lips
  • lateral upper jaw
53
Q

What facial features develop from the mandibular prominence?

A

Mandibular:

- lower lip and jaw

54
Q

Describe the development of the nose and palate

A

Nasal placodes develop on the frontonasal prominence
Sink to become nasal pits
Medial and lateral nasal prominences form on either side of the pits - oronasal membrane initially forms between the nasal pit and oral cavity but then quickly ruptures
Maxillary prominences grow medially, pushing the nasal prominences closer together in the midline
Maxillary prominences fuse with medial nasal prominences
Medial nasal prominences fuse in the midline - forms the intermaxillary segment :
- labial component: philtrum
- upper jaw: 4 incisors
- palate: primary palate
Main part of definitive palate is secondary palate - derived from palatal shelves which develop from the maxillary prominence - grow vertically downwards into oral cavity on each side of the developing tongue
Mandible grows large enough to allow the tongue to drop
Palatal shelves grow towards each other and fuse in the midline
Nasal septum develops as a midline down-growth and ultimately fuses with the palatal shelves

55
Q

Describe some developmental conditions involving the nose, lip and palate and the clinical consequences

A

Lateral cleft lip - failure of fusion of medial nasal prominence and maxillary prominence - can involve the primary palate
Cleft lip and cleft palate - failure of fusion of medial nasal prominence and maxillary prominence combined with failure of fusion of the palatal shelves at the midline - lip, primary and secondary palate involved
Difficulty with suckling - needs to be treated ASAP
Difficulty with speech development

56
Q

Summarise the fates of the prominences

A

Frontonasal - forehead, bridge of nose, medial and lateral nasal prominences
Medial nasal - philtrum, primary palate, mid upper jaw
Lateral nasal - sides of nose
Maxillary - cheeks, lateral upper lip, secondary palate, lateral upper jaw
Mandibular - lower jaw and lip

57
Q

Describe the development of the eyes

A

Development begins in week 4
Out-pocketing of forebrain - optic vesicle
Grow out to make contact with overlying ectoderm- Optic placodes - lens
Optic placode invaginates and pinches off
Retina - develops from optic vesicle (diencephalon/forebrain)
Optic nerve - transformed optic stalk
Eyes are initially on the sides of the head but move to the front as the prominences grow - binocular vision

58
Q

Describe the development of the ears

A

External auditory meatus develops from 1st pharyngeal cleft (only cleft that remains)
Auricles develop from proliferation within the 1st and 2nd pharyngeal arches surrounding the meatus
Initially develop below the mandible (in the neck)
As the 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 anomalies
Otic vesicles - 22 days - thickening of the surface of ectoderm on each side of the rhomboencephalon - invaginate rapidly and form the otic/auditory vesicles (otocysts) - cells from here differentiate to form ganglion cells for the vestibulocochlear ganglia - later each vesicle divides into a ventral component that gives rise to the saccule and cochlear duct and a dorsal component that forms the utricle, semicircular canals and endolymphatic duct - together these epithelial structures form the membranous labyrinth

59
Q

What is foetal alcohol syndrome and alcohol related neurological disorder?

A

Association between maternal alcohol ingestion and congenital abnormalities - may induce a broad spectrum of defects, ranging from intellectual disability to structural abnormalities of teh brain, face and heart
FAS - severe end of the spectrum - indicates structural defects, growth deficiency and intellectual disability
ARND - cases with evidence of involvement of the CNS that do not meet the criteria for FAS
Together incidence estimated at 1 in 100 live births
No safe levels of alcohol during pregnancy - but dose and timing during gestation are both critical
Neural crest migration and brain development extremely sensitive to alcohol
No barrier to alcohol crossing the placenta

60
Q

What is a placode?

A

Area of ectoderm that starts to thicken and differentiate itself from the surrounding tissue to give rise to sensory structures

61
Q

When can cleft lip and palate be diagnosed and what is the incidence?

A

20 week scan or after birth

1 in 700 babies born - most common facial birth defect in UK

ESA 4 (28 decks)

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