Head Neck and Spine 3

Question 1

Anterior view of the oral cavity

Answer 1

Question 2

What should you look for when asking a patient to say ‘aaa’ during an examination of the oral cavity?

Answer 2

• Observe the uvula, it should move directly up along it’s midline
• If it deviates to one side then this suggests impairment in one of the vagus nerves
• If there is a lesion on one of the vagus nerves, the uvula will deviate away from the side of the lesion. right side lesion = left side deviation

Question 3

What can you tell by looking at a palatine tonsil?

Answer 3

• Get an idea if there has been any infection or inflammation.
• Can make a diagnosis of tonsillitis.

Question 4

Midsagittal section of the head

Answer 4

Question 5

What does the epiglottis do when food is swallowed?

Answer 5

It retroflexes to cover the laryngeal inlet - the opening of the trachea.

Question 6

Posterior view of the pharynx

Answer 6

Question 7

What is the piriform fossa? What happens when bits of food is stuck there?

Answer 7

• It is an area with quite a strong sensory innervation
• Bits of food can get stuck in it and leave a person in distress.

Question 8

What are the 3 sets of muscles in the pharynx? What nerves innervate them?

Answer 8

• Superior, middle and inferior constrictors
• Sensory innervations: IX,X (glossopharyngeal and the vagus together form the pharyngeal plexus)
• Motor innervations: X (some contribution from the accessory nerv as well XI)

Question 9

What is the purpose of the pharyngeal muscles?

Answer 9

Aid in swallowing the bolus of food from the mouth into the oesophagus via their coordinated sequential contraction.

Question 10

What are the three salivary glands and what nerves are they innervated by?

Answer 10

Question 11

How does saliva from the parotid gland get into the mouth?

Answer 11

• Parotid glad saliva passes through parotid duct into the upper part of the mouth.
• It passes through the buccinator muscle and opens up next to the second upper molar in the mouth.

Question 12

Identify the extrinsic muscles and other structures around the tongue and recall what nerve innervates the tongue and the extrinsic muscles around it.

Answer 12

• Tongue has its own intrinsic musculature, the itrinsic muscles which are innervated by the hypoglossal nerve (XII)
• CN XII also supplies other extrinsic muscles to the tongue

Question 13

What should you look for when you ask a patient to stick out their tongue?

Answer 13

• Normal hypoglossal function will make it protract straight down
• But if there is a lession in one of the hypoglossal nerves, the tongue will protract towards the side of the lesion.

Question 14

Recall the afferent innervations of the tongue and distinguish which ones are responsible for touch and which ones are responsible for taste?

Answer 14

• Trigeminal nerve responsible for sensory touch in the anterior 2/3 and glossopharyngeal nerve for sensory touch in the posterior 1/3.
• Anterior 2/3 facial for taste, posterior 1/3, glossopharyngeal nerve responsible for taste.
• The glossopharyngeal and facial nerve send fibres back to the nucleus solitarius in the brainstem - taste perception centre.

Question 15

Taste map

Answer 15

Question 16

What is the first stage of the swallowing process?

Answer 16

• The oral preparatory phase

Question 17

What is the second stage of swallowing?

Answer 17

• Oral transit

Question 18

What is the second stage of the swallowing process?

Answer 18

• Pharyngeal phase 1
• Reflex from IX and X in the pharynx and XII in the tongue.

Question 19

What is the third stage of the swallowing process?

Answer 19

• Pharyngeal phase 2

Question 20

What is the fourth stage of the swallowing process?

Answer 20

• Oesophageal phase
• Ventilation/breathing resumes not respiration.

Question 21

How does videofluoroscopy work? What would you expect to see in a normal swallow?

Answer 21

• Give the patient a bolus of barium through the mouth
• The passage of barium is monitored as it undertakes pharyngeal transit.
• No residue in mouth/pharynx and no spillage from lips or into the airway during normal swallow.

Question 22

1st case of impaired swallowing is from an individual with cerebellar haematoma affecting coordination - how will this impair swallowing? What can be done to prevent this?

Answer 22

• Will result in Ataxic swallow
• Uncoordinated tongue reaction to propel food into the pharynx
• Delayed airway closure leading food into the airway
• Delayed and ineffective cough to clear airway -> food aspirated to lungs
• Flex neck forwards during swallow to prevent aspiration

Question 23

2nd case of swallowing impairment has a patient with excised acoustic neuroma but left with lower motor neurone lesion how will this affect swallowing and what can be done to prevent it?

Answer 23

• Ipsilateral paresis (weakened voluntary movement or slight paralysis) of pharynx, larynx and tongue.
• Weak bolus propulsion leaving pharyngeal and oral residue
• Failed airway closure leading to aspiration
• Speech therapists teat it by rotating head to direct the bolus to the strong side of the pharynx (contralateral) which helps with airway closure as well.

Question 24

3rd case of swallowing impairment is a patient with Parkinson’s disease how can this affect swallowing and what can be done to help?

Answer 24

• Difficulty initiating swallow
• Typical repetitive tongue movements linked with muscle rigidity unable to lower the back of the tongue.
• Speech therapists will do physiotherapy by training patient to practice a range of motion excercises of lips and tongue for an effective swallow action

Question 25

What are the chracteristics of a normal swallow?

Answer 25

• Epiglottis flexes back to cover the airway
• Vocal cords adduct to produce voice and to close the airway
• Saliva is cleared in a single swalllow and does not accumulate
• Water swallowed in <1 second
• No residue in pharynx or in trachea.

Question 26

What does swallowing consist of and at what neurological level is it regulated?

Answer 26

• It is essentially a series of synchronised movements of oral, pharyngeal, laryngeal and oesophageal components
• Regulated at both at cortical and brainstem level

Question 27

What is the larynx composed of? Recall it’s structure and purpose.

Answer 27

A hollow structure composed of:

• cartridges (green)
• membrane
• muscles

Purpose:

• Acts as a valve to the airway and sound produce when air passes through the vocal folds.

Question 28

Recall the names and structures of the 3 functionally relevant laryngeal cartilages (at this stage)?

Answer 28

1. Cricoid cartilage
2. Arytenoid cartilage
   
   • Important in the movement of the vocal cords in terms of their movement of the attached muscles.
3. Thyroid cartilage (laryngeal prominence or adam’s apple)

Question 29

Inside of the larynx

Answer 29

• The vestibular folds are also known as false folds.

Question 30

Endoscopic view of the laryngeal opening

Answer 30

The top bit is the back of the tongue

Question 31

What are the most important muscles in terms of the movement of the vocal folds? Recall their structure.

Answer 31

• Contraction of the posterior cricoarytenoid will open up or abduct the vocal folds.
• Contraction of the lateral cricoarytenoid muscle will close or adduct the vocal folds
• Cricothyroid muscle contraction will tense the vocal folds and will change the pitch of noise produced by airflow between them.

Question 32

What are the protective mechanisms for the airway?

Answer 32

• Swallowing
  
  • larynx raised
  • epiglottis retroflexes over the opening of the airway
• Gag reflex
  
  • Stops swallowing what you don’t want
  • By touching the pharynx at the back of the tongue
  • The glossopharyngeal nerve (IX) responsible for the reflex
• Sneezing
  
  • Expelling air through the nose to clear obstructions
• Coughing
  
  • Expelling air through the mouth to clear obstructions.
  • Reflex action to get food away from the airway and out through the mouth

Question 33

Innervation of the larynx

Answer 33

Question 34

Consequences of lesions in the vagus nerve

Answer 34

complete paralysis of the larynx

Question 35

Relationship between the thyroid and the larynx

Answer 35

Question 36

Recall structures in this diagram and identify why removal of the thyroid can be a risky procedure?

Answer 36

• Thyroidectomy can potentially damage a recurrent laryngeal nerve

Question 37

Superficial veins of the neck

Answer 37

• Prominent structures to appreciate:
• External jugular vein
• Facial vein draining into the jugular vein
• Subclavian veins

Question 38

Deeper veins of the neck

Answer 38

• Important structures:
• External jugular vein
• Deep facial vein - drain into external jugular
• Cavernous sinus
  
  • Deep within the cranial cavity
  • Ophthalmic veins drain into the sinus and risk a potential route for infections back into the cranial cavity
  • Therefore infection the orbit is a risk of infection in the cranial cavity
• Pterygoid plexus - drain into external jugular vein

Question 39

Front of the neck with superficial structures removed

• Identify potential routes for putting in a line to monitor central venous pressure.

Answer 39

• Most common through the internal jugular vein
• But insertion into the subclavian vein also possible

Question 40

Deep cervical lymph nodes

Answer 40

Question 41

Sites to palpate lymph nodes

Answer 41