Session 12

Question 1

Imging madilities used to look at head and neck pathology

Answer 1

• Radiographs – X Ray beam onto a plate detector – Quick, Cheap, Readily Available, Low ionising radiation dose – Low Contrast (see different things), 2D images • US – Handheld probe using soundwaves – Cheap, No ionising radiation – Operator Dependent, Limited by Bone – Useful for thyroid and superficial soft tissue only • CT – X Ray beam from passing through a doughnut shaped scanner – Quick, Readily Available – High Radiation Dose • MRI – Images acquired from within a magnet • Usually shaped like a long tunnel. – Best contrast, No ionising radiation – Slow, Expensive, Limited availability

Question 2

Uses – Radiographs

Answer 2

• Minor skull trauma – Not meeting NICE criteria for CT for head injuries. • Cervical spine trauma • Foreign bodies within neck

Question 3

Uses – US

Answer 3

• Thyroid evaluation • Superficial head and neck masses (low or indeterminate malignancy • Superficial infection • Carotid doppler

Question 4

Uses – CT

Answer 4

• Trauma – NICE criteria • Acute focal neurological symptoms – Particularly to evaluate for haemorrhagic strokes • Malignancy – CT Head not routine for non-melanoma staging. – Neck for tumours which spread to neck nodes. • Infection • Angiographic imaging of the arteries and veins.
Use panopto to go over nice guidelines and use LOs

Question 5

Uses - MRI

Answer 5

• Best imaging of the brain – Tumour evaluation – Epilepsy • Cervical spinal cord traumatic injury • Head and Neck tumours

Question 6

Orientation for imaging

Answer 6

• For Radiographs describe where you are standing in relation to the patient (if they are stood up) • Frontal (in front) • Lateral (to the side) • Oblique (at an angle)

Question 7

Skull Radiograph

Answer 7

• Skull # (sharp lines / depressed) – Remember sutures • Pneumocranium • Fluid level • Deposits ‐ Mets / Myeloma / Pepperpot skull • Paget’s

Question 8

Facial Radiograph - What to look for?

Answer 8

• Tripod # • Black eyebrow • Gas in orbit • TMJ dislocation • Mandible #

Question 9

Orthopantomogram

Answer 9

panopto

Question 10

Cervical spine Radiograph what to look for?

Answer 10

• Fractures / subluxation • Atlanto‐axial subluxation • Facet dislocation ‐ unilateral / bilateral • Vertebral erosion • Soft tissue widening • Lung lesion/pneumothorax.

Question 11

Cervical spine imaging overview

Answer 11

use panopto

Question 12

Jefferson fracture

Answer 12

panopto

Question 13

Denis spinal columns

Answer 13

panopto

Question 14

Caution for spinal radiographs

Answer 14

• RADIOGRAPHS CANNOT SEE LIGAMENTOUS INJURY • Therefore significant injury can be present with normal radiographs – Consider CT if significant mechanism of injury – Consider MRI if spinal cord injury suspected (neurology)

Question 15

Subarachnoid space - Ventricles

Answer 15

panopto

Question 16

Meningeal layers from deep to superficial

Answer 16

Pia mater
subarachnoid space / leptomeningeal space filled with cerebrospinal fluid
arachnoid mater
Subdural space
dura mater
extra Dural space

Question 17

Extradural haemorrhage

Answer 17

• Defined Traumatic cause • Usually Arterial Bleed – Middle meningeal artery • Biconvex • Associated with fractures (75%) • ‘Lucid interval’ • Neurosurgical emergency
slide 69 lec 1

Question 18

Subdural haemorrhage

Answer 18

• Causes – Paediatric • Trauma or NAI – Adult • Trauma – Elderly • Trauma (often mild)
• Usually venous Bleed – Bridging veins • Crescentic • Acute – History of trauma and symptoms • Chronic – Confusion
• Correct anticoagulation – Associated with Warfarin • Small can be managed conservatively – Futher CT if deteriorate • Large or symptomatic – Neurosurgical emergency
slide 72 lec 1

Question 19

Subarachnoid haemorrhage

Answer 19

• Causes – Trauma – Rupture Aneurysm
Subarachnoid - Trauma
• Small vessel bleeds • Peripheral hyperdensity following sulci • Can be asymptomatic • Small with normal GCS can be managed conservatively – Correct anticoagulation – Further CT if deteriorate • Consider neurosurgical opinion

Subarachnoid – Ruptured Aneurysm • Arterial bleed due to aneurysm • Central hyperdensity within subarchnoid space • Thunderclap headache • LP if normal • Neurosurgical emergency – Require angiographic imaging and treating of aneurysm
slide 76

Question 20

A 47 year old woman presents with a right-sided facial droop. She first noticed this at breakfast when some juice fell out of the side of her mouth. She breaks down in tears stating her salmon tasted very bland and she is worried she is having a stroke. On further questioning, she also reports sensitivity to loud noises.
The doctor suspects a facial nerve lesion.
Where is the lesion most likely to have occurred?

Answer 20

panopto

slide 7 lec 2

Question 21

A patient presents to the Eye Clinic with a 2 month history of blurring of vision. The doctor examines the patient’s pupillary light reflexes. On shining the light in the RIGHT eye, neither pupil reacts. However, when the light is shone in the left eye both pupils constrict
On the basis of the clinical findings described, specifically where within the pupillary light reflex is the problem?
Where is the lesion most likely to have occurred?

Answer 21

panopto
slide 10

Cranial Nerve II Optic
Clinical Examination
Testing function:
• Origin- retinal ganglion cells of retina
• Route • Axons converge at optic disc • Forming optic nerve • Exit via optic canal • Merge at and mix optic chiasm • Continue as optic radiations
• Function- special sense vision

Question 22

Larynx pathology overview

Answer 22

Inflammation of supraglottis (including epiglottis)
• Epiglottitis • Rare but airway threatening! • Typical aged 2- 6 years (but also any age) • Stridor, drooling, unwell ++, ‘sniffing position’ • H. Influenzae but also Strep pneumoniae

Impaired action of vocal cords e.g. inflammation of cord(s) [laryngitis], nodule, cancer
e.g. paralysis of muscles moving vocal cord(s); injury to RLN, injury to external branch of superior laryngeal nerve, laryngospasm, laryngeal oedema

Inflammation of larynx, trachea and bronchi
• Croup (“laryngotracheobronchitis”) • Common: typically caused by parainfluenza virus • 6 months- 3 years • Characteristic ‘cough’ (seal-like bark), sometimes stridor, increased respiratory effort

Question 23

1. A man with an recent URTI and sore throat complains of ear pain. Examination of the ear is normal. What cranial nerve has mediated the sensation of otalgia?
2. A woman drinks a glass of water too quickly, and starts to cough.
   What cranial nerve(s) mediated the cough reflex?
3. A man uses a cotton wool bud (q-tip) to clean wax from his ear; he starts to gag. What cranial nerve has mediated this response?

Answer 23

use panopto

Question 24

Cranial Nerve IX and X
• Both CN IX & X have some sensory function relating to the ear, but to different parts
• IX: Eustachian tube and middle ear • X: external ear (part) and TM (part)
How do we clinically examine these CNS?

Answer 24

panopto

Question 25

A 70 year old man presents with difficulty speaking and a weak right arm. The doctor suspects a stroke.
Based on the clinical signs, which lobe has the stroke affected?

Answer 25

panopto

Question 26

Cortical Homunculus

Answer 26

• Motor (and sensory)
• Specific areas of motor cortex communicate with motor nerves to specific muscles of body, face, neck
• Neuronal communication between cortex and spinal nerves (i.e. body/trunk) • Decussation of motor nerve axons at lower medulla
• Damage to motor cortex e.g. stroke will cause weakness/paralysis on contralateral side of body
• Communication between motor cortex and cranial nerves with motor function e.g. CN V, VII, IX, X, XI, XII)…little more complicated
• Most of motor nuclei of these CNs have dual input (from both motor cortexes) • Contralateral has slightly stronger input vs ipsilateral
• Important exceptions • Part of facial nerve motor nuclei of axons destined for lower half of face (only has contralateral cortical input)
• Cortical control of extra ocular muscles is from specialised areas within different areas of brain- not represented in motor cortex

Question 27

A 65 year old man presents to the GP with a 4 month history of haemoptysis and weight loss. The patient’s chest x-ray is shown below.
On the basis of the patient’s symptoms and the chest x-ray findings what neurological signs might be noted on examination of the patient’s face?
insert pic from slide 26

Answer 27

panopto

slide 27

Question 28

Parasympathetic Innervation of head and neck : Origin, hitch hikes, ganglia, effector tissues, reponse

Answer 28

insert slide 28

Question 29

Picture overview of pharyngeal arches

Answer 29

slide 32 lec 2

Question 30

Venous Drainage of Head and Neck

Answer 30

• Internal jugular vein: main vein receiving venous drainage from head and neck • Provides measure of pressures in right side of heart- measure venous pulsation to determine JVP
• External jugular vein • More superficial and more readily seen in the neck • Receives some blood from face and scalp • Easily misinterpreted for IJV and inadvertently used to measure JVP
• Cavernous sinus = space created by splitting of dural layers- full of a plexus of veins: not like paranasal ‘sinus’ = space full of air found in bone – Many structures run through the cavernous sinus too (internal carotid artery, a number of cranial nerves!)
• Pterygoid venous plexus lies in infratemporal fossa • Drains nasal cavity/maxilla • Has links with veins draining the face and orbit (inferior ophthalmic vein) • Has links with cavernous sinus too!
• Key clinical importance: link between superficial veins draining scalp, orbit and face, with intracranial veins (dural venous sinuses including cavernous sinus)
• Potential route for infection to spread from superficial structures (e.g. face/orbit/nasal cavity- ‘danger triangle’) to intracranial structures via these venous connections – Development of cavernous sinus thrombosis or meningitis

Blood in veins draining the face and orbit can flow bidirectionally (lack valves)
If blood draining an area of the face/orbit that is infected there is a risk this can be carried intracranially (into cavernous sinus)
slide 39 and 40

Question 31

Embryology of Head and Neck

Answer 31

slide 34

Question 32

Thyroglossal Duct Cyst, Ectopic Thyroid Tissue and Pyramidal Lobes

Answer 32

slide 35
• Thyroid gland develops from the developing tongue (in floor of early pharynx)
• Descends down through ‘pit’ opens into a duct
• Bifurcates (connected by isthmus) and descends neck in thyroglossal duct- attached to tongue

Question 33

Branchial Cyst

Answer 33

Remember, all except 1st pharyngeal groove obliterate as 2nd pharyngeal arch grows down over them. However, if a space persists can lead to formation of a sac (branchial cyst)
• Congenital abnormality, byt usually present in early adulthood (2nd decade of life). • Often arise after an infection or minor trauma, causing cyst to swell • Typically smooth, non-tender soft masses along the anterior border of the SCM
slide 36

Question 34

Cleft Lip and Cleft Palate

Answer 34

• Thickening of ectoderm forming nasal placodes
• Invaginate to form nasal pits
• Horseshoe shape ridge around the pit • Medial and lateral nasal prominence
• Fusion of medial nasal prominence with maxillary prominence (failure = cleft lip)
• Main part of palate then formed by palatal shelves from maxillary prominences fusing (failure = cleft palate)

Question 35

Arterial Supply to Head and Neck

Answer 35

• Origin of the common carotid artery on right and left? – Level of bifurcation: C4 (superior border of thyroid cartilage) – Terminal branches: internal and external carotid artery
• General route of internal carotid artery in neck – Continues in carotid sheath • Relationship to other structures of sheath? – No branches in neck – Through carotid canal, into cavernous sinus – Carries sympathetic nerves so these can reach orbit – Gives rise to ophthalmic artery on exiting cavernous sinus – Gives other branches which join Circle of Willis (Nervous System Sem 4)
• Branches of the ECA provide main arterial supply to face, neck, nasal and oral cavities: – Facial artery= main blood vessel supplying face – Superior thyroid artery* supplies thyroid gland (relationship with superior laryngeal n) – Lingual artery supplies tongue – Terminal branches are superficial temporal artery and maxillary artery
• Branches from both ICA and ECA contribute to blood supply of scalp – Rich anastomosis
• *Note that the inferior thyroid artery arises from the thyrocervical trunk (a branch of the subclavian artery)

Question 36

Labelhe arteries of the head and neck insert slide 43

Answer 36

insert filled out slide 43

Question 37

From which blood vessel does the vertebral artery arise?

Answer 37

panopto/research

Question 38

Neck Lumps history and examination

Answer 38

History • Age of patient (children >likely reactive secondary to infection)! • Duration, progression, associated symptoms/signs (including red flags)
Examination • Anterior or posterior triangle? Midline? • Relate location to knowledge of underlying structures • Movement with swallowing and sticking out tongue • Palpation features o Hard/soft/ smooth/irregular/ o Deep or superficial? o Fixed to surrounding tissue or mobile? o Tender (inflamed/infected lumps likely painful)? o Overlying skin changes e.g. red?