Neck Supplement

Question 1

Retropharyngeal abcess

Answer 1

• infection btwn CV and pharyngeal wall
• most common in children under 6, immunocomp adults
• infections from oral cavity (dental abcess), nasopharynx (tonsillitis, peritonsillar abcess)
• signs = fever, sore throat, dysphagia, odynophagia, neck/back pain
• complications = airway obstruction, sepsis, mediastinitis, pneumonia, empyema

Question 2

Subclavian Artery

Answer 2

• compressed/injured by trauma/fracture involving rib 1

- anastomoses around scapula prevent ischemic injury to upper limb

Question 3

External Jugular Vein Issues

Answer 3

• vein distended during intrathoracic pressure (valsava maneuver), heart failure, tricuspid stenosis/regurgitation, SVC obstruction, enlarged supraclavicular nodes
• lacerated EJV held open by investing fascia -> neg thoracic pressure = air sucked into vein = cyanosis, air embolism, dyspnea

Question 4

Internal Jugular Vein Issues

Answer 4

• pulsations (on right side) seen in mitral valve disease, right ventricular failure
• right IJV punctured lateral to common carotid btwn sternal/clavicular heads of SCM (superior to clavicle)
• jugular body: like carotid body (chemoreceptor) but in IJV in jugular foramen = glomus jugular tumors

Question 5

Phrenic Nerve

Answer 5

• SC lvls C3-5 (for diaphragm)
• along ant surface of ant scalene muscle (w/ascending cervical art)
• 60% ppl have accessory phrenic nerve from nerve to subclavius -> damaged in cervical/thoracic procedures

Question 6

Nerve blocks via anesthesia

Answer 6

• cervical plexus - anes at post edge of middle 1/3 of SCM (cutaneous cervical plexus branches)
• brachial plexus - anes above clavicle (Erb’s point)
• stellate gang - impact symp fn

Question 7

Suprascapular Nerve

Answer 7

• middle 1/3 clavicle fractures can damage nerve = weakness in lateral rotation of shoulder + initiation of abduction

Question 8

Ligation of external carotid

Answer 8

• in surgical ligation of ECA to control bleeding, have anastomoses to compensate
• in descending branch of occipital art [anastomoses w/vertebral + deep cervical arteries]
• across midline (e.g. facial to facial anastomoses)

Question 9

Carotid endarterectomy

Answer 9

• • removal of plaque in internal carotid artery; CNs IX, X, XI, XII and sympathetic
• trunk most at risk of iatrogenic injury

Question 10

Carotid pulse

Answer 10

palpated btwn trachea and ant border of SCM

Question 11

Carotid sinus syncope

Answer 11

hypersensitivity of carotid sinus = diminished cerebral blood flow and fainting spells

Question 12

Sympathetics Issue

Answer 12

• excessive vasoconstriction in upper limb/head relieved by block of stellate/inferior -> cervical ganglion symp to upper limb = T5-7 and ascend symp chain]

Question 13

Horner’s Syndrome

Answer 13

• lesions of cervical symp trunk
• cause FAMP = flushing, anhydrosis, ptosis, miosis
• w/o anhydrosis + flushing = lesion affecting internal carotid nerve

Question 14

Thyroid gland

Answer 14

• 10% ppl -> thyroid ima artery
• 40% ppl -> pyramidal lobe [from thyroglossal duct]
• ectopic thyroid tissue in midline course of thyroglossal duct as high as tongue

Question 15

Thyroidectomy

Answer 15

• ligation of superior thyroid artery (inferior to origin of superior laryngeal artery) endangers external laryngeal nerve
• ligation of inferior thyroid artery endangers recurrent laryngeal nerve

Question 16

Thyroid Lymph Drainage

Answer 16

• isthmus – prelaryngeal/tracheal -> paratracheal -> deep cervical (superior + inferior)
• lateral lobes – directly to superior + inferior deep cervical

Question 17

Parathyroid Glands

Answer 17

• typical # = 4 but can be 2 - 6 glands from hyoid bone to superior mediastinum
• outside thyroid capsule (malignancies can spread in fascial compartments of neck)
• inadvertent removal results in tetany

Question 18

Anisocoria

Answer 18

• left-right asymmetry in pupil size

- 10/20% pts have benign anisocoria -> slight pupillary asymmetry in lighting conditions

Question 19

CN III injury

Answer 19

mydrasis in affected eye + ptosis + diplopia

Question 20

Argyll-Robertson pupil

Answer 20

• assoc w/neurosyphilis (“prostitutes pupil”), “light-near dissociation” = pupils respond to accommodation but not light (accommodate, but don’t react)

Question 21

Afferent Pupils

Answer 21

• retina, optic nerve) – pupils symmetric, pt may complain of blindness/blind spots
• Marcus Gunn pupil – in swinging flash light test, when light moved from normal eye to affected eye, affected eye dilates

Question 22

Laryngocele

Answer 22

• normal larynx fn needed for Valsava maneuver
• pathological obstruction/expansion of laryngeal ventricle -> expand to vallecula
• infections in fascial compartments of neck

Question 23

tracheostomy

Answer 23

• trachea incised in midline (btwn infrahyoid muscles) and btwn 1st/2nd or 2nd-4th rings
• structures in danger = inferior thyroid veins, thyroid ima artery, left brachiocephalic vein, thymus [infants and children]

Question 24

Piriform recess

Answer 24

• small depression on either side of laryngeal inlet
• common site for objects to get stuck (e.g. fishbone)
• removal may injure internal laryngeal nerve

Question 25

Recurrent Laryngeal nerve

Answer 25

• innervates all muscles larynx except cricothyroid muscle - lesions = hoarseness
• in progressive lesions abduction lost before adduction
• in recovery, adduction returns before abduction

Question 26

internal laryngeal nerve

Answer 26

• sensory innervation to larynx above vocal folds - injury = aspiration of food/liquids
• injury via removal of laryngeal foreign body at piriform recess
• nerve blocked [for intubation] by injecting anesthesia thru thyrohyoid mem

Question 27

external laryngeal nerve

Answer 27

• innervates cricothyroid muscle (and inferior constrictor) - injury = monotonous speech