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SE book revision > Neck anatomy > Flashcards

Neck anatomy Flashcards

1
Q

How are the fascial layers of the neck broadly divided into?

A

-Superficial cervical fascia
-Deep cervical fascia

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2
Q

Where is the superficial cervical fascia found?

A

Beneath dermis. Surrounds neck, muscles of facial expression and platysma. Contains fat, neurovascular bundles and lymphatics

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3
Q

Name the different layers of the deep cervical fascia

A

External investing layer
Pretracheal
–> parietal
–>visceral
–> buccopharyngeal
–> carotid sheath

Prevertebral fascia

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4
Q

Where is the external investing layer of deep fascia found?

A

-Surrounds neck and surrounds trapezius, sternocleidomastoid, muscles of mastication, parotid and submandibular glands

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5
Q

Describe how the middle layer of the deep fascia is subdivided

A

Middle layer of the deep fascia is subdivided into two parts: carotid sheath and pre-tracheal fascia:

-Carotid sheath contains internal jugular vein, carotid artery (common and internal), vagus nerve and deep lymph nodes

Pretracheal fascia is divided into
-Muscular: infrahyoid muscles
-Visceral: thyroid and parathyroid glands
-Buccopharyngeal: pharynx and oesophagus

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6
Q

Describe internal layer of deep fascia (prevertebral fascia)

A

-Deepest layer of cervical fascia
-Limited to the posterior neck
-thicker than pretracheal fascia, encloses the vertebral muscles and prevertebral muscles

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7
Q

Identify the structures on this image (fascial layers of the neck)

A

-A: Cervical vertebra
-B: prevertebral muscles
-C: Pretracheal fascia
-D: Internal jugular vein
-E: Vagus nerve
-F: Investing layer deep cervical fascia
-G: Scalenus Medius
-H: trapezius
-I: Semispinalis colli
-J: Skin and superficial fascia
-K: Levator scapulae
-L: Scalenus anterior
-M: Spinal nerve
-N: Splenius capitis
-O: Semispinalis capitis
-P: Prevertebral fascia
-Q: Spinal cord
-R: carotid sheath
-S: Common carotid artery
-T: sternocleidomastoid

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8
Q

What is the role of fascia in the neck?

A

-Provides attachments to various muscles in the neck
-Allows certain structures to glide (larynx and trachea) or expand (pharynx and oesophagus
-Acts as a barrier to prevent spread of infection/malignancy

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9
Q

What is the retropharyngeal space?

A

Posterior to the pharynx and oesophagus, between the pretracheal and prevertebral fascia

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10
Q

What is the clinical significance of the retropharyngeal space?

A

Infection of retropharyngeal space can extend from skull to T1-T2 and can therefore result in mediastinitis or empyema

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11
Q

What is meant by the ‘danger space?’

A

-Lies posterior to retropharyngeal space
-Infection in this space can be extensions of retropharyngeal, parapharyngeal or prevertebral infecitons

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12
Q

What is the clinical significance of the ‘danger space’?

A

Infection in this space tends to occur rapidly due to presence of loose areolar tissue. This can result in retropharyngeal abscess, mediastinitis, cutaneous emphysema and sepsis

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13
Q

Describe the presentation of a patient with a retropharyngeal abcess

A

neck swelling, difficulty swallowing, sepsis, drooling, neck stiffness. Definite diagnosis is made on CT

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14
Q

What are the principles of management of a retropharyngeal abscess?

A

Investigations: Bloods for inflammatory markers, imaging with CT scan

Treatement: IV antibiotics. If required, surgical drainage can be performed via oropharynx
In patients with airway obstruction due to oedema, a surgical tracheostomy may also be indicated

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15
Q

How many levels of lymph nodes are there in the neck?

A

7

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16
Q

Where are level 1 nodes found?

A

1a: submental (between anterior bellies of digastric muscle
1b: submandibular (between anterior and posterior bellies of digastric muscle)

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17
Q

What is the clinical significance of the enlargement of level 1 nodes?

A

-1a: infections/tumour of tongue/floor of mouth/lower lip
-1b: infections/tumour of mouth, anterior nasal cavity, submandibular gland, soft tissue structures of mid face

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18
Q

What is meant by the jugular group of lymph nodes

A

-Group of nodes that run along internal jugular vein from base of skull to clavicle
-Divided into three levels by two transverse lines at level of hyoid bone and cricoid cartilage

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19
Q

Where are the level two nodes found?

A

-Upper jugular (or level 2) nodes can be found in anterior triangle at following anatomical locations:

–> Anterior to posterior border of sternocleidomastoid
–> Posterior to posterior border of submandibular gland
–> Along a line from the base of the skull to the lower border of hyoid bone

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20
Q

What is the clinical significance of the enlargement of the level two lymph nodes?

A

Tumours/infections of:
–> oral cavity, nasal cavity, nasopharynx, oropharynx, larynx, parotid gland, soft tissue of face and ear

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21
Q

Where are the level 3 lymph nodes found?

A

-middle jugular nodes (level 3) can be found in anterior triangle at following levels:
–> Anterior to posterior border of sternocleidomastoid
–> Along a line from the lower border of cricoid cartilage and lower border of the hyoid bone

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22
Q

What is the clinical significance of enlargement of level 3 nodes?

A

Infections or tumours in:
–> oral cavity, nasopharynx, oropharynx, larynx

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23
Q

Where can level 4 (lower jugular) nodes be found?

A

Between lower border of cricoid cartilage and clavicle

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24
Q

What is the clinical significance of enlargement of level 4 nodes?

A

larynx, thyroid, cervical oesophagus

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25
Q

Where can level 5 lymph nodes be found?

A

-Posterior triangle of the neck
-Va: above the level of the spinal accessory nerve
-Vb: below the level of the spinal accessory nerve

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26
Q

What is the clinical significance of enlargement of level 5 nodes?

A

-Nasopharynx, oropharynx, skin of scalp and neck

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27
Q

Where are the level 6 nodes located?

A

-Inferior border of hyoid to manubrium in midline. Anterior to 3 and 4

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28
Q

What is the clinical significance of the enlargement of level 6 nodes?

A

Thyroid gland, larynx, Cervical trachea, cervical oesophagus

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29
Q

Where are the level 7 (superior mediastinal) nodes located?

A

Between common carotid arteries and manubrium sternum

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30
Q

What is the clinical significance of enlargement of level 7 nodes?

A

Lung, chest wall and thyroid

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31
Q

What are the different types of neck dissections?

A

Radical neck dissection
Modified radical
Selective
Extended radical

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32
Q

Describe what structures are sacrificed in radical neck dissection

A

-Lymph nodes 1-5
-Internal jugular vein
-Spinal accessory nerve
-Sternocleidomastoid muscle

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33
Q

What structures are sacrificed in modified radical?

A

-Lymph node groups 1-5
-One of the vital structures is spared (SCM, spinal accessory nerve, internal jugular vein)

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34
Q

What structures are sacrificed in selective neck dissection?

A

-Removal of one or more levels of lymph nodes
-No vital structures are sacrificed

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35
Q

What structures are sacrificed in extended radical neck dissection?

A

Removal of additional structures not normally sacrificed during radical neck dissection. These may include:

-Parapharyngeal/paratracheal lymph nodes
-Carotid artery
-hypoglossal nerve
-Vagus nerve

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36
Q

Describe the boundaries of the anterior triangle of the neck

A

Anterior: midline of the neck
Posterior: sternocleidomastoid anterior border
Superior: Mandible inferior border
Roof: platysma and subcutaneous tissue
Floor: pharynx, larynx, thyroid gland

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37
Q

Describe the boundaries of the posterior triangle of the neck:

A

Posterior: anterior border of trapezius
Anterior: posterior border of sternocleidomastoid
Inferior: clavicle
Roof: investing layer deep cervical fascia
Floor: muscles covered by prevertebral fascia

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38
Q

Identify the structures marked A-I on the image

A

A: posterior belly of digastric
B: carotid triangle
C: Anterior belly of digastric
D: Superior belly of omohyoid
E: Occipital triangle
F: Sternocleidomastoid
G: Inferior belly omohyoid
H: Trapezius
I: Stylohyoid

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39
Q

Name the boundaries of the occipital triangle

A

Anterior: posterior border sternocleidomastoid
Posterior: anterior border trapezius
Inferior: Inferior belly of omohyoid

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40
Q

What are the contents of the occiptial triangle?

A

Vessels:
–> Transverse cervical artery, external jugular vein

Nerves:
–Spinal accessory nerve
–Cutaneous branches cervical plexus
–trunks brachial plexus

Occipital lymph nodes

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41
Q

Name the boundaries of the supraclavicular (subclavian) triangle?

A

Superior: inferior belly of omohyoid
Inferior: clavicle
Anterior: posterior border SCM

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42
Q

What are the contents of the supraclavicular (subclavian) triangle?

A

Vessel: suprascapular artery, subclavian artery , subclavian vein
Nerves: Lower trunk of brachial plexus
Other: supraclavicular lymph nodes, apex of lung and phrenic nerve medially, thoracic duct on left side

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43
Q

What are the differential diagnoses of a swelling in the anterior triangle of the neck?

A

Thyroglossal cyst
Thyroid pathology
Salivary gland swelling
Skin condition including malignancy
Lymph node
Carotid artery aneurysm/carotid body tumour
Branchial cyst

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44
Q

What are the differential diagnoses of a swelling in the posterior triangle of the neck

A

Cystic hygroma
Pharyngeal pouch
Subclavian artery aneurysm
Cervical rib
Skin conditions including malignancy
Lymph node

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45
Q

Describe the risks of inserting a central line

A

-Bleeding/haematoma
-Infection
-Pneumothorax
-malposition
-Thrombosis
-Air embolus
-Arrhythmia

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46
Q

What is the clinical deficit associated with injury to the spinal accessory nerve? What is the most common cause for accessory nerve palsy?

A

-Atrophy of sternocleidomastoid/trapezius
-Inability to shrug shoulders/turn head to affected side

Most common cause of accessory nerve palsy is:
–> lymph node biopsy to posterior triangle
–> Radical neck dissection

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47
Q

How would carotid body tumour present?

A

-Asymptomatic palpable neck masses
-10% can have cranial nerve palsy (hypoglossal/glossopharyngeal/recurrent laryngea/spinal accessory)

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48
Q

What are the indications for carotid endarterectomy?

A

-Stable neurological symptoms from acute non-disabling stroke or TIA who have carotid stenosis of 50-99%
-Can be considered in asymptomatic patients with moderate to severe stenosis (50-99%)

https://www.nice.org.uk/guidance/ng128/chapter/Recommendations?fbclid=IwAR0D4BH7Rv4pGkn7PPC0-d2w83RB2i9eaK15xFtBuinIIRQ98jKqfU8B2ag#surgery-for-people-with-acute-stroke

https://www.bradfordhospitals.nhs.uk/wp-content/uploads/2022/07/179679-WYVAS-CAROTID-Booklet.pdf

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49
Q

What are the boundaries of the submental triangle?

A

-Superior: mandible
-Lateral: anterior belly digastric
-Anterior: midline

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50
Q

What are contents of the submental triangle?

A

-Anterior jugular vein
-Lymph nodes

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51
Q

What are the boundaries of the digastric (submandibular) triangle?

A

-Anterior: anterior belly digastric
-Posterior: posterior belly digastric
-Superior: inferior border of the mandible

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52
Q

What are the contents of the digastric (submandibular) triangle?

A

Vessels:
–> Submental artery
–> Facial artery
–> Facial vein

Nerves
–> hypoglossal nerve
–> marginal mandibular branch of facial nerve
–> nerve to mylohyoid
–> lingual nerve

Other
–> submandibular gland
–> lymph nodes

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53
Q

What are the boundaries of the carotid triangle?

A

-Anterior: superior belly omohyoid
-Posterior: sternocleidomastoid
-Superior: posterior belly digastric

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54
Q

What are the contents of the carotid triangle?

A

-Vessels
—> internal carotid
–> common carotid bifurcaiton, branches external carotid
–> Internal jugular vein

Nerves:
–> vagus nerve
–> ansa cervicalis

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55
Q

What are the boundaries of the muscular triangle?

A

Medially: midline
Lateral superior : superior belly omohyoid
Lateral inferior: scm
Superior: hyoid bone

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56
Q

What are the contents of the muscular triangle?

A

Strap muscles: sternohyoid, sternothyroid and thyrohyoid

Larynx, thyroid, parathyroid, lymph nodes
Recurrent laryngeal lies in tracheo-oesophageal groove

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57
Q

Describe the anatomy of the cervical plexus

A

-Plexus of the first 4 cervical spinal nerves located from C1-C4 in the neck
-Located laterally to the transverse processes and emerge from posterior triangle midway on the posterior border of SCM
-They anastomose with the accessory nerve, hypoglossal nerve and sympathetic trunk
-The cervical plexus has two types of branches: cutaneous and muscular

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58
Q

Name the four cutaneous branches of the cervical plexus and their innervations

A

Lesser occipital: C2 only–> lateral occipital region
Greater auricular: C2, C3–> inferior auricle, parotid
Transverse cervical: C2, C3–> anterior region of the neck
Supraclavicular: C3, C4–> supraspinatus, shoulder, upper thoracic region

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59
Q

Name the four muscular branches of the cervical plexus and their innervations

A

-Communicating branches (C1): geniohyoid and thyrohyoid
-Ansa cervicalis (C1-C3): sternohyoid, sternothyroid, omohyoid
-Segmental branches (C1-C4): Supplies anterior and middle scalene muscles
-Phrenic (C3-C5): diaphragm and pericardium

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60
Q

Name the suprahyoid and infrahyoid strap muscles in the neck

A

Suprahyoid
-Digastric (anterior and posterior belly)
-Geniohyoid
-Stylohyoid
-Mylohyoid

Infrahyoid
-Sternohyoid
-Sternothyroid
-Thyrohyoid
-Omohyoid (superior and inferior belly)

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61
Q

What is the nerve supply of the digastric muscle?

A

-Anterior belly: Nerve to mylohyoid, branch of V3
-Posterior belly: digastric branch of facial nerve

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62
Q

What is Erb’s point?

A

-Halfway along posterior border sternocleidomastoid
-Where cutaneous branches of cervical plexus emerge to become superficial and supply the skin
-These nerves include: lesser occipital, greater auricular, transverse cervical, supraclavicular
-Additionally branches of supraclavicular nerve and nerve to subclavius (from upper trunk of brachial plexus)

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63
Q

What is the clinical significance of Erb’s point?

A

-Cervical plexus block can be achieved by infiltrating LA here (can provide block for procedures involving neck, occipital region, shoulder, upper pectoral region
-Spinal accessory nerve can be found 1cm above erb’s point

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64
Q

What is the most likely diagnosis in a child presenting with a small pit on the anterior neck present since birth and having a recurrent mucinous discharge?

A

-Right second branchial cleft sinus/fistula

-Second branchial cleft anomalies account for the majority of branchial anomalies (up to 90%)
-They are most frequently identified along anterior border of SCM (junction of middle and lower 1/3rd)

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65
Q

What is the likely anatomical course of a second branchial cleft sinus/fistula?

A

-Runs from skin of lateral neck, pierces platysma
-Ascends between internal and external carotid arteries
-Close relation of the hypoglossal and glossopharyngeal nerve
-Opens into the oropharynx (usually palatine tonsil)

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66
Q

Describe the nerves, muscles and bony structures of the six pharyngeal arches: 1st

A

Nerve:
-CN V3

Muscles:
-Muscles of mastication, tensor palatini, tensor tympani, mylohyoid, anterior belly of digastric

Bones/cartilages:
-From maxillary process: Maxilla, zygoma, squamous part of temporal bone
-From mandibular process: mandible, malleus, incus, sphenomandibular ligament

Arteries:
-maxillary artery

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67
Q

Describe the nerves, muscles and bony structures of the six pharyngeal arches: 2nd

A

Nerve:
-CN VII

Muscles
-Muscles of fascial expression, stapedius, stylohyoid, posterior belly of digastric

Bones/cartilages:
-Stapes, styloid process, part of body and lesser horn of hyoid bone, stylohyoid ligament

Artery:
-Stapedial artery

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68
Q

Describe the nerves, muscles and bony structures of the six pharyngeal arches: 3rd

A

-Nerve: 9
-Muscles: stylopharyngeus
-Bones/cartilagres: body and greater horn of hyoid bone
-Artery: CCA and part of ICA

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69
Q

Describe the nerves, muscles and bony structures of the six pharyngeal arches: 4th

A

-Nerve: X
-Muscles: cricothyroid, pharyngeal constrictor, levator veli palatini
-Bones/cartilages: Thyroid cartilage
-Arteries: left: arch of aorta, right: sub-clavian

70
Q

Describe the nerves, muscles and bony structures of the six pharyngeal arches: 6th

A

Nerve: RLN (X)
Muscles: all laryngeal muscles except cricothyroid
Bones and cartilages: Cricoid, arytenoid, corniculate and cuneiform cartilages
Arteries; pulmonary arteries

71
Q

Describe the anatomy of the thyroid gland

A

-Two lobes with central isthmus
-Lobes at level of C5-T1 vertebrae
-Isthmus lies anterior to second and third tracheal rings
-Thyroid gland is surrounded by a capsule
-The capsule is surrounded by pretracheal fascia

72
Q

What is the function of the thyroid gland?Which cells produce what hormone?

A

-Produces T3 and T4 via the colloid cells which is involved in regulating metabolism and growth
-Parafollicular C cells also produce calcitonin which is involved in calcium metabolism

73
Q

Describe the blood supply of the thyroid gland

A

-Superior thyroid (external carotid)
-Inferior thyroid (thyrocervical trunk from subclavian)
-Thyroid IMA (<10%) usually originates from brachiocephalic trunk but can originate from common carotid, subclavian or aorta directly

74
Q

What is the lymphatic drainage of the thyroid gland?

A

-Paratracheal/deep cervical lymph nodes

75
Q

What are complications of surgery to the thyroid gland?

A

General
-Pain, infection, bleeding, scarring, haematoma, seroma

Specific:
-Hypocalcaemia (removal of parathyroid gland)
-damage to recurrent laryngeal nerve (hoarse voice, stridor if bilateral)
-Damage to superior laryngeal nerve (difficulty with high pitched voice)
-Need for long term thyroxine replacement therapy

76
Q

Describe the nerve supply of the larynx?

A

Nerve supply to larynx divided into superior and recurrent laryngeal nerve

Superior laryngeal divided into internal and external:
-Internal: Sensory mucosa above vocal cords
-External: cricothyroid muscle which is adductor and tensor of the cords

Recurrent laryngeal:
-sensory to mucosa below the cords
-all intrinsic muscles except cricothyroid

77
Q

How would you investigate a thyroid lump?

A

-Triple assessment: Clinical examination, USS, FNA

Thyroid function tests + thyroid autoantibodies
Flexible nasoendoscopy to assess for movement of the cords (recurrent laryngeal nerve function)

78
Q

What is the most common type of thyroid cancer? what are its features?

A

Papillary carcinoma

Features: 65-70% of thyroid malignancy, 3rd-4th decade, more common in women, lymphatic metastasis

79
Q

What are the other types of thyroid cancers?

A

Follicular carcinoma: 5th decade, haematogenous metastasis, more common in women, 30% of thyroid malignancy

Anaplastic: 7th decade, very aggressive, local invasion

Medullary: MEN 2, equally common in both genders, 5th decade, lymphatic metastasis, tumour of parafollicular c cells, neuroendocrine rather than thyroid tumour

80
Q

What investigations can be used to follow-up patients following thyroid cancers?

A

-Thyroglobulin (papillary and follicular carcinomas)
-T4
-TSH
-Calcitonin (medullary)
-CEA (medullary: secreted by C cells)

81
Q

Describe how the parathyroid glands are subdivided

A

-4 parathyroid glands: 2 on posterior surface of each thyroid gland lobe
-2 inferior and 2 superior

82
Q

Where are the superior and inferior parathyroid glands normally found?

A

-superior glands are in more consistent position compared to inferior
-Superior are at inferior border of cricoid cartilage 1cm superior to entry point of inferior thyroid artery into thyroid gland
-Inferior: near inferior pole of thyroid gland or >1cm inferior to entry of Inferior thyroid artery into thyroid gland
-~5% lie in atypical positions e.g. mediastinum or within thyroid gland

83
Q

What is the embryological origin of the parathyroid gland?

A

-Superior parathyroid: from 4th pharyngeal pouch
-Inferior parathyorid: from 3rd pharyngeal pouch

84
Q

What is the blood supply to the parathyroid gland?

A

-Supplied by inferior thyroid artery
-Branch of thyrocervical trunk from subclavian artery

85
Q

What are the functions of the parathyroid glands?

A

-The major function of the parathyroid gland is the homeostasis of calcium metabolism
-Increase in parathyroid hormone causes increased calcium absorption from the gut, increased activity of osteoclasts and increased calcium absorption from the kidneys
-Also plays a role in phosphate metabolism

86
Q

What is the role of calcitonin on the parathyroid gland?

A

-Rise in calcium causes increase in calcitonin secretion
-Results in reduced effect of parathyroid hormone
-Reduction in amount of calcium absorbed in gut and kidney, and reduced activity of osteoclasts to release calcium from bone
-However like parathyroid hormone, calcitonin reduces phosphate absorbed by kidney

87
Q

What are the clinical signs of hypocalcaemia?

A

CATs go numb

-Convulsions,Chvostek’s
-Arrhythmias
-Tetany, Troisseau’s
-Perioral numbness and tingling

Troisseau’s sign: Muscular contraction following inflation of sphygmomanometer cuff for several minutes (neuromuscular excitability caused by hypocalcaemia)

Chvostek’s (tapping on facial nerve causes twitching of facial muscles)

88
Q

Name some causes of parathyroid gland enlargement

A

-Adenoma
-Carcinoma
-Hyperplasia

89
Q

How would you investigate a patient with an enlarged parathyroid gland?

A

Bloods: PTH, calcium, U + E, vitamin D
Urine: calcium
USS
MRI
Bone density
Sestamibi scan

90
Q

What are the indications for parathyroidectomy?

A

-Hypercalcaemia in patients <50
-Symptomatic hypercalcaemia in any age group
-Hypercalcaemia >3 in any age group
-Excessive urinary excretion of calcium in any age group
-Deterioration in renal function
-Progressive reduction in bone density
-Any suspicion of malignant disease

91
Q

Describe the anatomy of the pharynx

A

-Fibromuscular tube extending from the base of the skull to the inferior border of the cricoid cartilage

92
Q

Describe how the pharynx is further subdivided:

A

From superior to inferior:

  1. Nasopharynx (base of skull to soft palate)
  2. Oropharynx (Soft palate to epiglottis)
  3. Laryngopharynx (Epiglottis to cricoid cartilage)
93
Q

How are the muscles of the pharynx arranged?

A

The pharynx contains an external circular and internal longitudinal group of muscles

Note: this is the opposite to elsewhere in the alimentary tract

94
Q

Name the internal longitudinal muscles

A

-Palatopharyngeus
-Stylopharyngeus
-Salpingopharyngeus

95
Q

What is the function of the internal longitudinal muscles?

A

Elevate the pharynx and larynx during speech and swallowing

96
Q

What is the origin and insertion of the external circular muscles?

A

Superior constrictor:
-O: pterygoid posterior border, pterygomandibular raphe
-I: Median raphe

Middle constrictor:
-O: Stylohyoid ligament
-I: median raphe

Inferior constrictor
-O: thyroid cartilage, cricoid cartilage
-I: median raphe

97
Q

What is the function of the external circular group of muscles?

A

-They are involved in constricting the pharynx during swallowing

98
Q

Name all the constrictor muscles of the pharynx

A

-Palatopharyngeus
-Stylopharyngeus
-Salpingopharyngeus

-Superior constrictor
-Middle constrictor
-Inferior constrictor

99
Q

Name the structures which passes between the middle and inferior constrictors

A

Membrane between the middle and inferior constrictor is pierced by the internal laryngeal nerve and superior laryngeal vessels

100
Q

Name the structure which passes below the inferior constrictor

A

Recurrent laryngeal nerve and inferior laryngeal vessels

101
Q

Describe the nerve supply to the pharynx

A

-Motor and sensory innervation of most of pharynx (except nasopharynx) is supplied by pharyngeal plexus

Pharyngeal plexus is formed by:
-Pharyngeal branches vagus nerve
-Pharyngeal branches glossopharyngeal nerve
-External laryngeal nerve
-Sympathetic fibres from superior cervical ganglion

Sensory:
-Predominantly glossopharyngeal nerve
-nasopharynx innervated by maxillary nerve

Motor
-All vagus except stylopharyngeus (glossopharyngeal)

102
Q

What is the blood supply to the pharynx?

A

-Ascending pharyngeal (external carotid)
-Facial (external carotid)
-Inferior thyroid (thyrocervcial trunk)

103
Q

What is a pharyngeal pouch?

A

-Pharyngeal diverticulum which occurs through killian’s dehiscence: area of weakness in inferior constrictor muscle of pharynx between thyropharyngeus and cricopharyngeus muscles

(inferior pharyngeal external constrictor consists of two parts)

104
Q

What are the clinical symptoms of a pharyngeal pouch?

A

-Regurgitation, halitosis, cough, dysphagia

105
Q

What investigations can aid the diagnosis of a pharyngeal pouch?

A

-Barium swallow
-Endoscopy

106
Q

How would you manage a pharyngeal pouch?

A

-Conservative: if pt unfit for surgery
-Endoscopic stapling (most common)
-open/external approach (if endoscopic stapling has failed)

107
Q

What is the pharyngeal lymphoid ring or waldeyer’s ring?

A

-Collective anatomical term for the annular arrangement of lymphoid tissue in the pharynx.
-Surrounds the nasopharynx and oropharynx

108
Q

What forms the pharyngeal lymphoid ring?

A

Formed by:
-2 palatine tonsils
-1 adenoid (nasopharyngeal tonsil)
-1 lingual tonsil
-2 tubal tonsils
-2 lateral pharyngeal lymphoid bands

pharyngeal lymphoid ring is collectively referred to as nasal associated lymphoid tissue

109
Q

What is the function of the pharyngeal lymphoid ring?

A

-Lymphoid tissue of pharyngeal lymphoid ring is situated at entrance to respiratory and alimentary tract
-Belongs to mucosa associated lymphoid tissue (MALT)
-Main function is production of antibodies against common environmental antigens
-help in production of B cells and plasma responses

110
Q

Which vertebral level corresponds to the position of the larynx?

A

-C3-C6 vertebral level

111
Q

What are the cartilages of the larynx?

A

3 paired and 3 unpaired

Unpaired:

Superior to inferior:
–> Epiglottis
–> Thyroid
–> Cricoid

Paired:
-Arytenoid x2
-Corniculate x2
-Cuneiform x2

112
Q

What is the blood supply to the larynx?

A

laryngeal branches of superior and inferior thyroid arteries

113
Q

Name the intrinsic and extrinsic membranes of the larynx

A

The extrinsic membranes connect the laryngeal cartilage to surrounding structures for support (hyoid bone and trachea)
–> Thyrohyoid membrane
–> Hyoepiglottic ligament
–> Cricotracheal membrane

Intrinsic: hold cartilages of larynx together as one functional unit
-Cricothyroid ligament
-Quadrangular membrane
-Thryoepiglottic ligament

114
Q

Name the extrinsic muscles of the larynx and their function?

A

Suprahyoid (elevates larynx)
-Digastric
-Stylohyoid
-Mylohyoid
-Geniohyoid

Infrahyoid (depresses larynx)
-Omohyoid
-Sternohyoid
-Sternothyroid
-Thyrohyoid

115
Q

Extrinsic muscles of larynx

A
116
Q

Extrnisic muscles of larynx

A
117
Q

membranes of the larynx

A
118
Q

membranes of the larynx

A
119
Q

Name the intrinsic muscles of the larynx

A
  1. Abductors/adductors:
    –> Adductor: lateral cricoarytenoid muscle (main), transverse arytenoids muscles
    –> abductor: posterior cricoarytenoid muscles-only muscle able to open the vocal cords
  2. Sphincters (Muscles to close laryngeal inlet during swallowing)
    -Lateral cricoarytenoid
    -Transverse arytenoids
    -Oblique arytenoids
  3. Tensors (muscles to raise pitch of voice)
    -Cricothyroid
  4. Relaxers (muscles altering pitch of voice)
    -Thyroarytenoid
    -Vocalis
120
Q

What is the funciton of the intrinsic muscles of the larynx?

A

Move and alter length and tension of vocal cords, and size and shape of rima glottidis

121
Q

Name the subdivisions of the laryngeal cavity

A
  1. Vestible
  2. Middle (ventricle/laryngeal sinus)
  3. infraglottic space
122
Q

Name some causes of vocal cord palsy

A
  1. Malignancy (30%): bronchus, oesohpagus, thyroid, nasopharynx
  2. Iatrogenic (25%): thyroid, parathyroid, oesophageal, pharyngeal pouch, left lung surgery
  3. External trauma (15%)
  4. Idiopathic (15%)
  5. Others (15%): neurological disorders, myopathies
123
Q

What are the different types of vocal cord palsies?

A

-Unilateral or bilateral
-Temporary or permanent

124
Q

What is the clinical significance of a bilateral vocal cord palsy?

A

Bilateral vocal cord palsies present with stridor

125
Q

What forms the superior laryngeal aperture?

A

-Anterior: epiglottis
-Posterior: arytenoid cartilages
-Lateral: aryepiglottic fold

126
Q

Label this external anterior view of the larynx

A
127
Q

Label this saggital view of the larynx

A
128
Q

Label this endoscopic view of the larynx

A
129
Q

Label the laryngeal cartilages

A
130
Q
A
131
Q
A
132
Q
A

Arytenoid cartilages can move laterally and medially, and about a vertical axis. When muscular process moves backwards and forwards, the vocal process is abducted and adducted

133
Q
A
134
Q
A
135
Q
A

Arytenoid cartilages can move laterally and medially, and about a vertical axis. When muscular process moves backwards and forwards, the vocal process is abducted and adducted

136
Q
A
137
Q
A

Vocal ligaments run from thyroid cartilage to the tips of the vocal processes of the arytenoid cartilages. Between them is the vocal opening, or rima glottidis. Tension is affected by the tilt of the cricoid cartilage. Gap between them (rima glottidis) is affected by the rotation of the arytenoid cartilage

Vocal opening shape:
Diamond shaped in quite breathing
Widens to triangle in deep breathing
Narrows to slit during speech

138
Q

What is the action of the cricothyroid muscle?

A

-The cricothyroid muscle pulls the arch of the cricoid cartilage upwards.
- In doing so, it pulls the arytenoid cartilages backwards, making the vocal folds longer and tighter.

139
Q

What is the action of the posterior and lateral cricoarytenoid? label this picture.

A

Right side of thyroid cartilage and cricothyroid have been removed

Both muscles converge on muscular process of arytenoid cartilage

The posterior crico-arytenoid pulls the muscular process backwards. This rotates the arytenoid cartilage, thus widening the vocal opening.

The lateral crico-arytenoid pulls the arytenoid cartilage forwards and laterally, drawing the vocal ligament towards the midline

140
Q

What are the actions of the thyro-arytenoid and transverse arytenoid muscles?

A

The next two muscles that we’ll see, the thryro-arytenoid and transverse arytenoid muscles, act to shorten
and narrow the vocal opening.

The thyro-arytenoid muscle arises
from here on the inner aspect of the thyroid cartilage. It inserts here in front of the lateral border of the
arytenoid cartilage.

The transverse arytenoid muscle, also called
the arytenoideus, is a sheet of muscle that bridges the gap between the posterior surfaces of the two
arytenoid cartilages.

Contraction of the thyro-arytenoid muscle rotates the arytenoid cartilage inward and pulls it forward, along with the cricoid cartilage. This action slackens the vocal
ligament, and shortens the vocal opening from front to back.

Contraction of the transverse arytenoid muscle brings the two arytenoid cartilages closer together, thus
closing the posterior part of the vocal opening.

141
Q

Describe vocalis

A

The most medial part of the thyro-arytenoid muscle, which is attached to the vocal ligament, has a special
function. It’s known as the vocalis muscle. It makes fine adjustments to the tension of the vocal ligament.

142
Q

Describe the anatomy of the parotid gland

A

Parotid gland is in the parotid area
-Superior: Zygomatic arch
-Inferior: ramus of manidle
-Anterior: masseter muscle
-Posterior: sternocleidomastoid and external ear

Parotid gland is divided into a deep and a superficial lobe and is encased in parotid sheath from investing layer of deep cervical fascia

143
Q

Describe the surface markings of the parotid duct

A

-Lies in middle 1/3rd of a line drawn from the tragus of the ear to midway between the alar of the nose and the lateral commisure of mouth.
-Traverses masseter, pierces buccinator and opens into buccal vestibule at level of second upper molar

144
Q

Describe the blood supply to the parotid gland

A

Arterial supply:
-From external carotid via superficial temporal and posterior auricular arteries

Venous drainage
-Via retromandibular vein

145
Q

What is the nerve supply to the parotid gland?

A

-Sensory fibres from auriculotemporal and greater auricular nerve
-Parasympathetic from glossopharyngeal nerve

146
Q

Name the structures within the parotid gland

A

For REAL (superfiical to deep)
-Facial nerve
-Retromandibular vein
-External carotid artery
-Greater auricular nerve
-Lymphatics

147
Q

What are the complications of parotid gland surgery

A

-Pain
-Infection
-Bleeding
-Haematoma
-Scarring

-Salivoma/parotid fistula
-Frey’s syndrome (gustatory sweating)
-Facial nerve/greater auricular nerve injury

148
Q

How would you investigate parotid lump?

A

Triple assessment:
-History and examination
-US
-FNA

149
Q

What is Frey’s syndrome?

A

-Parasympathetic disruption: fibres which normally supply parotid gland join with sympathetic fibres which supply scalp and face
-Results in gustatory sweating (erythema and sweating instead of salivation)

150
Q

What is the blood supply to the parotid gland?

A

-Submental artery (from facial artery)
-Lingual artery (from external carotid)

151
Q

What is the sensory supply to submandibular gland?

A

-Secretomotor from facial nerve
-Carried by chorda tympani (facial) and lingual nerve (from V3)

152
Q

Describe where the submandibular duct opening lies

A

-Duct is 5cm long
-Opens lateral to the lingual frenulum

153
Q

Name the nerves at risk during submandibular gland surgery

A

-Marginal mandibular branch of facial neve
-Hypoglossal nerve
-Lingual nerve
-Nerve to mylohyoid

154
Q

Where are the sublingual glands found?

A

-Deep in the floor of the mouth between the mandible and genioglossus muscle
-Small sublingual ducts open into floor of mouth between the sublingual folds

155
Q

Describe the arterial supply to the sublingual glands

A

Sublingual artery (from lingual artery)
Submental artery (from facial artery)

156
Q

Describe the nerve supply to the sublingual glands

A

-Secretomotor from facial nerve via chorda tympani and lingual nerve

157
Q

Why are stones in the submandibular gland more common than in the parotid gland?

A

-Parotid saliva is serous, submandibular gland saliva is thicker and mucoid
-Submandibular duct is longer, travels against gravity and has a smaller orifice

158
Q

What is the rule of 80s of parotid gland tumours?

A

80% of parotid gland tumours are benign
80% of parotid tumours are pleomorphic adenomas
80% of salivary pleomorphic adenomas occur in the parotid
80% of parotid pleomorphic adenomas occur in superficial lobe

159
Q

Cauises of salivary gland enlargment

A

Infection
-Viral (HIV, mumps)
-Bacterial (staph)

Inflammation
-Autoimmune (e.g. sjogren’s)

Drugs
-Alcohol
-Thiouracil

Metabolic
-Diabetes
-Cirrhosis

Sialectasis

Benign tumour
-Pleomorphic adenoma
-Warthin’s tumour
-Lymphangioma
-Haemangioma

Malignant conditions
-Adenoid cystic carcinoma
-Adenocarcinoma
-Lymphoma

160
Q

Identify the following features of the cervical vertebra on the image

A

A: transverse foramen
B: Vertebral foramen
C: Transverse process
D: vertebral body
E: Pedicle
F: superior articular process
G: lamina
H: bifid spinous process

161
Q

What are the characteristic features of a typical cervical vertebra (C3-c6)?

A

-Broad body
-Transverse foramen (for vertebral artery, vertebral vein and sympathetic fibres)
-Small bifid spinous process
-Plane of facet joints is oblique

162
Q

How does C1 differ from a typical cervical vertebra?

A

-Occipital condyles to articulate with the skull
-Kidney shaped
-No verbtebral body
-No spinous process

163
Q

How does C2 differ from typical cervical vertebra?

A

-Has odontoid process (dens)
-Does not have bifid spine

164
Q

How does C7 differ from typical spinous process?

A

-Vertebra prominens
-Long and non bifid spinous process
-Large transverse process but small transverse foramen, does not transmit vertebral artery

165
Q

What type of joint is the atlanto-occipital joint?

A

Synovial joint. Surrounded by loose capsule

166
Q

Which joint permits flexion/extension of the neck?

A

Atlanto-occipital joint, articulation between C1 and the occipital condyles

167
Q

What prevents excess rotation at the atlanto-occipital joint?

A

Alar ligaments: connect the dens to the occipital condyles

168
Q

What is the function of the dens of C2?

A

Allows the atlas and base of skull to rotate around it as a unit

169
Q

Describe the clinical significance of a fracture of the dens

A

-Can impact spinal cord, injurying or even severing it resultoing in quadriplegia
-Dens extends superiorly inro ring of C1, is therefore susceptible to shearing forces and fracture from C1 in neck injuries

170
Q

What is a hangman’s fracture?

A

Bilateral fracture of pars interarticularis of C2. Results from hyperextension/distraction injury

171
Q

Identify the following features of the spinal cord on the image below:

A

A: Posterior median sulcus
B: Dorsal horn
C: grey commissire
D: Lateral column
E: Lateral horn
F: ventral horn
G: Anterior median fissure
H: ventral coloumn
I: Ventral root spinal nerve
J: Spinal nerve
K: dorsal root ganglion
L: Centarl canal
M: dorsal root of spinal nerve
N: dorsal column

SE book revision (6 decks)

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