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Surgery > Surgical Anatomy of Scalp > Flashcards

Surgical Anatomy of Scalp Flashcards

1
Q

SCALP

A

Hair-bearing skin and subcutaneous tissue covering the
neurocranium
•From the occipital bone → Supra-orbital margins on the
frontal bones
•Extends over temporal fascia → zygomatic arches

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2
Q

•5 LAYERS of SCALP

A 
1st three layers → intimately connected and
function as UNIT
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3
Q

S – SKIN

A 
o Thin (except in occipital region)
o Contains many sweat and sebaceous
glands and hair follicles
o ↑ arterial supply
o Good venous and LN drainage
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4
Q

C – CONNECTIVE TISSUE

A

o Thick, ↑ vascularized subcutaneous layer

o ↑ cutaneous nerves

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5
Q

A – APONEUROSIS

A 
o A.k.a. EPICRANIAL
APONEUROSIS/EPICRANIUM
o Broad, strong tendinous sheet
o Covers calvaria and attachment for muscle
bellies converging from:
 Forehead and occiput
(Occipitofrontalis Muscles)
 Temporal Bones
(Temporoparietalis and
Superior Auricular Muscles)
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6
Q

Frontal Belly of

Occipitofrontalis

A

Pulls scalp anteriorly,
wrinkles forehead, raises
eyebrows

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7
Q

Superior Auricular Muscle

part of temporoparietalis

A

Elevates auricle of
external ear (wiggle the
ears)

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8
Q

SCALP PROPER = First 3 Layers of the Scalp

A

•Clinically regarded as a single layer
•Remain together when scalp flap is made
surgically/avulsed

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9
Q

L – LOOSE AREOLAR CONNECTIVE TISSUE

A

o Spongy layer
o Allows free movement of the scalp proper over the calvaria
o Has potential spaces that may distend with fluid (injury/infection)

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10
Q

 P – PERICRANIUM

A 
o Dense Layer CT
o Forms external periosteum of the
neurocranium
o Firmly attached, can be stripped off in vivo
except at attachments to cranial sutures
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11
Q

BLOOD SUPPLY OF THE SCALP

A

 Highly vascularized, vessels anastomoses freely
 Blood vessels arises from anterior, lateral, and
posterior scalp regions
 Blood vessels to the scalp supply little blood to
the calvaria
o CALVARIA is supplied by the MIDDLE
MENINGEAL ARTERIES
 Loss of scalp does not produce necrosis of the
calvarial bones

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12
Q

ARTERIES of Scalp

A 
INTERNAL CAROTID arteries → OPHTHALMIC
arteries
o Supratrochlear arteries
o Supraorbital arteries
 EXTERNAL CAROTID arteries
o Posterior auricular arteries
o Occipital arteries
o Superficial temporal arteries
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13
Q

Venous Drainage of S

A 
 Supratrochlear veins
 Supraorbital veins
 Superficial temporal veins
 Posterior auricular veins
 Occipital veins
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14
Q

Epicranial Aponeurosis is strong

A

 Prevents superficial scalp wounds from gaping
 Holds margins of the wound together
 Does not need deep sutures

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15
Q

Deep Scalp Wounds

A

 Gape widely when aponeurosis is lacerated in coronal plate

 From pull of frontal and occipital bellies of occipitofrontal muscle in A-P direction

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16
Q

LOOSE CONNECTIVE TISSUE (Layer 4)

A

 Danger area of the scalp – fluid can collect
 Pus/blood spreads easily
 Infection spreads → cranial cavity from emissary
veins → calvaria → meninges

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17
Q

Infection is limited by

A

 Occipitofrontalis muscle attachment at neck
 Temporal fascia at zygomatic arches
 Occipitofrontalis muscle inserts into skin and SQ
o Fluid can enter eyelids and root of the
nose
o Even slight injury/inflammation → ↑fluid
in periorbital region
o Fluid collection should be limited
laterally and posteriorly, but flows easily
anteriorly

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18
Q

PERIORBITAL ECCHYMOSSES:

A

“black eyes”,
can result from injury to scalp and/or forehead.
o From extravasation of blood into SQ and skin

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19
Q

SCALP LACERATIONS

A

 Most common type of head injury requiring surgical care
 Bleed profusely
 Arteries entering periphery of scalp bleed from both ends (from anastomoses)
o Do not retract, held open by dense CT
layer
o Occipitofrontalis muscle spasms ↑ wound gape open if 3rd layer is injured

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20
Q

SCALP INJURIES

A

 Arteries arising at sides of head area wellprotected by dense CT
o Anastomose freely
 Partially Detached Scalp/avulsed scalp injuries
common among motorbike vehicular accidents can
be replaced with good healing if 1 vessel supplying
scalp is intact

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21
Q

SCALP INCISIONS

A

ATTACHED CRANIOTOMY
 Surgical removal of calvarial segment + soft tissue
scalp
 Incisions are made convex and upward
 SUPERFICIAL TEMPORAL ARTERY is included
in tissue flap

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22
Q

CEPHALHEMATOMA

A

 Bleeding between the baby’s pericranium and
calvaria → blood trapped
 Usually over parietal bone
 Will resolve on its own without interventions
 After difficult delivery
o Birth trauma that ruptures multiple minute
periosteal arteries to the calvaria → fluid
collection under the scalp

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23
Q

CRANIUM

A 
 a.k.a. SKULL
 Skeleton of thehead
 Most complicated bony structure in the human
body
 28 INDIVIDUAL BONES:
o 11 = paired
o 6 = single
 2 PARTS:
o NEUROCRANIUM (protects thebrain)
o VISCEROCRANIUM (skeleton in the
face)
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24
Q

THE EAR

A

Organ of hearing and balance

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25
Q

AURICLE

A

 Collects air vibrations
 Thin plate of elastic cartilage covered by skin
 Possesses extrinsic & intrinsic muscles
 N: Facial Nerve

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26
Q

TEMPORAL BONE (2)

A

o Help form the base and lateral walls of the skull
o Contain auditory and vestibular apparatuses
o Contain mastoid air cells

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27
Q

PARTS of Temple

A

o Squamous
o Petrous
o Tympanic
o Styloid

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28
Q

TEMPORAL BONE FRACTURES

A

o Occur in 1/5 of the skull fractures

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29
Q

CAUSE of TBF

A

 Blunt trauma (VA/Assault)

 GSW (gunshot wound)

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30
Q

DIAGNOSIS of TBF

A

Cranial CT

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31
Q

2 PATTERNS of TBF

A

Longitudinal and Transverse

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32
Q

Longitudinal TBF

A 
s (80%):
 Associated with:
o Lateral Skull
Trauma
o Facial Nerve
Injury (20%)
 S/SX
o Conductive
hearing loss
o Ossicular Injury
o Bloody Otorrhea
(ear discharge)
o Labyrinthe
Concussion
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33
Q

Transverse TBF

A 
(20%):
From fronto-occipital trauma
 Associated with:
o (+) Facial nerve
injury (50%)
o (+) Otic capsule
injury
S/SX: Sensorineural
hearing loss, ↓ vestibular
function, hemotympanum,
CSF leak in the nose or
ears
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34
Q

Oblique TBF

A

– combination of the
two patterns; most fractures in
practice

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35
Q

FACIAL NERVE STATUS

A 
Most significant
in management
 (+) Delayed/Partial Paralysis →
usually resolve in 1 week, with
conservative management
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36
Q

INDICATIONS FOR SURGERY of TB

A 
 Persistent facial nerve
paralysis after 1 week
post injury → Nerve
Decompression
 >90% degeneration >72
hours after onset of
complete paralysis
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37
Q

SURGICAL TREATMENT of TBF

A 
 Facial Nerve
Decompression
o If persistent, may
have to sacrifice
hearing
 Manage any severe
intracranial/vascular
injuries first
 Protect the eye from
desiccation
o (-) blink reflex
o Artificial tears,
lubricant eye
taping
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38
Q

PTERION

A

 Junction between sphenoid, squamous
temporal, frontal and parietal bones

 2 fingerbreadths superior to zygomatic
arch

 Thumb’s breadth posterior to frontal
process of zygomatic bone

 Overlies the frontal branches of the middle meningeal vessels

 Hard blow to side of head → fracture →
rupture frontal branch of middle
meningeal artery or vein

 Bleed from middle meningeal artery →
EPIDURAL HEMATOMA

 Hematoma exerts pressure on underlying cerebral cortex

 White concave lesions (blood) seen on CT scan that reflects the shape of the epidural hematoma

 It causes brain herniation wherein, it
pushes the brain parenchyma to one side
and the brainstem herniates downward to
the foramen magnum

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39
Q

LANDMARKS OF AURICLE

A 
 Helix
 Crura
 Anti-Helix
 Concha
 Tragus
 Antitragus
 External Acoustic Meatus
 Lobule of the Auricle
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40
Q

AURICULAR LACERATIONS

A

 Carefully align Helical Rim & Antihelix
o Apply pressure dressing
 Repair injuries so that cartilage is covered
o Cartilage has no intrinsic blood supply & is susceptible to ischemic necrosis
o Suture should be passed through
perichondrium but NOT cartilage itself!
o Suture the skin not the cartilage, no
vessels, may necrose
o Injuries are usually from earrings

41
Q

AURICULAR HEMATOMA

A 
 Occurs after injury / laceration
 Prompt drainage with needle
 And most importantly, apply pressure dressing
with bolus dressing so to prevent the fluid from
accumulating again usually:
- Recording: 24 hours at least
- Old trans: at least 3 days
- Book: at least 4 days
42
Q

EXTERNAL AUDITORY MEATUS

A

 Curved tube that leads from auricle to tympanic membrane

 lined by skin

 conducts sound waves from auricle → tympanic membrane
 outer 1/3: cartilage

 lined with hairs, sebaceous glands & Ceruminous glands (modified sweat glands) – glands that make your earwax

 inner 2/3: bone (tympanic plate)

 N: Auriculotemporal nerve

 Auricular branch of vagus nerve

 LN: Superficial parotid, mastoid & superficial cervical LN

43
Q

OTOSCOPIC EXAMINATION

A

 Straighten EAM by gently pulling auricle:
 upward and backward (adult)
 backward and downward (infant)
Tympanic membrane is pearly gray & concave

44
Q

Adult EAM

A

 length = 2.5 cm

 narrowest 5 mm from the tympanic membrane

45
Q

EAR INFECTIONS

A

 May involve external, middle, or internal ear

 May follow an acute / chronic course → otological & intracranial complications

46
Q

OTITIS EXTERNA

A

 Infection of skin in EAC

 Acute / chronic course

47
Q

ACUTE OTITIS EXTERNA / SWIMMER’S EAR

A

 Moisture in EAC after swimming remains→ skin
maceration & itching → scratching → erodes the skin
 most common organism →
Pseudomonasaeruginosa
 if prolonged, may result in Chronic Otitis Externa

48
Q

CHRONIC OTITIS EXTERNA

A

 Profound itching for prolonged periods (months to years) → gradual thickening of EAC skin

49
Q

MALIGNANT OTITIS EXTERNA

A 
 Fulminant necrotizing infection of otological soft
tissues
 Osteomyelitis of temporal bone
 PX: Diabetes mellitus, elderly,immunodeficient
 SX/ SYMPTOMS:
o (+) Cranial nerveneuropathy
o Persistent otalgia > 1 month
o Purulent Otorrhea x several weeks
o Classic PE Finding = (+) granulation
tissue along EAC Floor
50
Q

Complications of MOE

A

 Complications:
o Progress to involve skull base, soft
tissue → meningitis → brain abscess →
death

51
Q

treatment of MOE

A 
 Treatment:
o IV Antibiotics vs Pseudomonas
o Wound GS/CS
o Surgical Debridement – if no response
to medical management
52
Q

MIDDLE EAR

A

 Air-containing cavity in the petrous part of the temporal
bone (from Tympanic Membrane → Oval window)
 Lined with mucous membrane
 Contains ossicles
 Narrow, slit-like cavity

53
Q

TYMPANIC MEMBRANE

A

 Thin, fibrous, pearly gray membrane
 Obliquely placed (Down, forward, and lateral)
 Circular, 1cm in diameter
 Extremely sensitive to pain
 UMBO - Small lateral depression, from tip of the
handle of the malleus
 CONE OF LIGHT- radiates anteroinferiorly from
umbo; the otoscope is used

54
Q

 PARS FLACCIDA

A

Small triangular area bounded by

folds

55
Q

PARS TENSA

A

Tense remainder of membrane

56
Q

Nerve supply of ME

A

Auricotemporal nerve, Aurical branch of Vagus Nerve

57
Q

OSSICLES

A 
 Smallest bones in the
human body
 Transmit vibrations of the
tympanic membrane
(eardrum) to perilymph of
the inner ear
 MALLEUS (Hammer)
 INCUS (Anvil)
 STAPES (Stirrup)
58
Q

AUDITORY TUBE / EUSTACHIAN TUBE

A

 Connects anterior wall of the tympanic membrane
cavity to nasal pharynx
 Posterior 1/3 = bony
 Anterior 2/3 = Cartilaginous
 Equalizes air pressures in tympanic cavity and nasal
pharynx
 In children, Eustachian tube is shorter and more
horizontal which makes them more prone to infections
in the middle ear

59
Q

MASTOID ANTRUM

A

 Behind the middle ear in the petrous part of the
temporal bone
 bony pocket filled with air
 Communicates with the middle ear by aditus

60
Q

MASTOID PROCESS

A

 Begins to develop during 2 year of life

61
Q

MASTOID AIR CELLS

A

 Series of communicating cavities within the process that
are continuous above with the antrum and the middle
ear.
 Lined with mucous membrane

62
Q

OTITIS MEDIA

A

 Bacterial infection of the Middle ear

 Ascending infection for the URTI via Auditory tube from nasopharynx

 Acute redness, infection, bulging and fluid accumulation behind your tympanic membrane

63
Q

ACUTE OTITIS MEDIA

A 
 Bacterial infection of the middle ear (< 3 weeks)
 Most common bacterial infection of the
childhood (25%)
 ASSOCIATED WITH:
o < 2 years old
o From immaturity of the Eustachian tube
–straight, while in adults -oblique
o Craniofacial conditions (e.g. Cleft
Palate)
o Chronic URT
64
Q

S/SX of AOM

A 
o Otalgia (Ear pain) –due to pressure build up
o Fever
65
Q

PHYSICAL EXAM of AOM

A

o Bulging, opaque tympanic membrane

66
Q

Most common organisms of AOM

A

o Streptococcus pneumonia
o Haemophilus influenza
o Morazella cattarrhalis

67
Q

Treatment of AOM

A 
o Oral antibiotics for systemic absorption, otic
drops won’t penetrate tympanic membrane
 Amoxicillin
 Sulfadrugs
 Cephalosporin
 Macrolides
(+) Tympanic membrane perforation → will heal
spontaneously
68
Q

SUBACUTE OTITIS MEDIA

A

 Otitis media lasting 3-8 weeks

 From unresolved acute otitis media

69
Q

CHRONIC OTITIS MEDIA

A 
 Otitis media > 8weeks
 Same symptoms
 Chronic inflammation and
hypersecretion by middle
ear mucosa
70
Q

Associated with COM

A 
with:
 Eustachian tube dysfunction
 Ciliary dysfunction
 Viruses/allergies
 Non-healing tympanic
membrane perforation
o Erosion of the
ossicles
71
Q

Symptoms of COM

A

 Otalgia
 Middle Ear fullness
 Conductive hearing loss

72
Q

Physical exam of COM

A

 Retracted, opaque, tympanic membrane

 (+) air fluid levels / bubbles

73
Q

Treatment of COM

A 
 Removal of the debris under
otomicroscopy
 Keep ear dry
 Topical antimicrobials:
o Neomycin/ Polymixin /
Quinolone + Steroids
o 2ºAcetic acid – for mixed
bacterial + fungal infections
74
Q

INTRATEMPORAL /
OTOLOGIC
COMPLICATIONS

A 
 Acute coalescent mastoiditis
 Petrotitis (infection of the petrous bone)
 Facial Nerve Paralysis (CN VII passes
underneath this structure)
 Labyrinthitis
75
Q

INTRACRANIAL

COMPLICATIONS

A 
 Otologic meningitis (most common) –
Patients come in with neurologic dysfunction. CT scan shows brain
abscesses and is usually from a
chronic infection
 Epidural/subdural abscess
 Brain abscess
 Otitic hydrocephalus
 Sigmoid sinus
thrombophlebitisInfection channeling in to
the blood vessel
76
Q

ACUTE MASTOIDITIS

A

 Spread of infection from otitis media into the
mastoid antrum and mastoid air cells which
is right behind the brain.
 May spread beyond middle ear to meninges
and temporal lobe of the brain →
Meningitis and cerebral abscess
 Spreads to facial nerve and inner ear →
Facial nerve palsy, labyrinthitis, vertigo
 Destruction of bony lamellae secondary to
acute purulent process
 Reddish discoloration and tenderness
behind the ear
 Mastoid cells coalesce → form 1
common space filled with pus
 S/Sx
o Pain, fever
o Swelling behind the
ear

77
Q

Treatment of AM

A 
o Myringotomy + Tube placement
•To remove effusion and
ventilate middle ear
o Topical drugs – for otorrhea
o Tympanoplasty – for non-healing
tympanic membrane perforations
o Reconstruction of ossicular chain
o Mastoidectomy
78
Q

INNER EAR (LABYRINTH)

A 
 Working part of the Ear
 Neurologic
 2 Parts:
o Bony Labyrinth
o Membranous Labyrinth
79
Q

BONY LABYRINTH

A

￮Series of cavities within the petrous bone
￮Cavities of dense bone that contain PERILYMPH
(which suspends the membranous labyrinth)
￮3 PARTS:
o VESTIBULE (entrance hall)
o SEMICIRCULAR CANALS
o COCHLEA (Snail shell)

80
Q

MEMBRANEOUS LABYRINTH

A
  • Series of membranous sacs with bony labyrinth
  • Lodged within the bony labyrinth
  • Filled with ENDOLYMPH
  • Surrounded by Perilymph
81
Q

•PARTS of Labyrinth

A

○UTRICLE and SACCULE
○3 SEMICIRCULAR DUCTS
○COCHLEAR DUCT

82
Q

LABYRINTHITIS

A

 Inflammation of the inner ear
 SEROUS LABYRINTHITIS
 Bacterial products/inflammatory mediators transudate → through round window → inner ear

83
Q

SUPPURATIVE LABYRINTHITIS

A

Purulent bacterial infection extends →
inner ear → destroys sensory hair cells &
CN VIII → Meningitis

84
Q

CHOLESTEATOMA

A

•Epidermoid cyst or infection of the middle ear &/or
mastoid through enzymes
•Destroys or erodes bone due to expansion &
enzymatic destruction

85
Q

•ETIOLOGY

A

Retraction of squamous elements of
tympanic membrane into middle ear \ →
causes Eustachian tube dysfunction &
chronic otitis media

86
Q

TREATMENT

A

MASTOIDECTOMY
if (+) chronic mastoiditis that
failed medical management/
develops cholesteatoma

87
Q

OTOLOGIC MENINGITIS

A

•Most common intracranial complication of ear infections associated with Haemophilus Influenzae Type B

88
Q

EAR & TEMPORAL BONE CA

A

•Uncommon, < 1% of all H&N malignancies
•Usually delayed diagnosis (You don’t you’re your
ears talaga everyday e, usually somebody else
points it out to you)
•Most common CA = Squamous Cell CA
If (+) involvement of middle ear & EAC = 50%
5-year survival rate

89
Q

Pinna

A

most common for 1º CA because it

is the most common site of sun exposure

90
Q

Petrous Bone

A

most common for

metastasis (breast, kidney, lung)

91
Q

LIPS

A 
 2 fleshy folds that surround the oral surface
 outside = skin
 inside = mucous membrane
 Made of Orbicularis OrisMuscle
 Radiatefrom thelips intothe
face
92
Q

Landmarks of Lipa

A
  • PHILTRUM: shallow vertical groove in midlineon
    outer surface oftheupper lip
  • Vermillion Border
  • Lateral Commissure- corners of your lips
  • Cupid’s Bow
  • Nasolabial Crease
93
Q

Lip Injuries

A
  • Close Orbicularis Oris in a separate layer
  • Vermillion Border must be carefully approximated
  • 1º Closure - done if injury involves 1/3 of width of lip, otherwise, might need flap or graft
94
Q

Lip Cancer

A

Most common in Caucasian men (less melanin) 50-70

y/o

95
Q

RISK FACTORS of LC

A 
Prolonged sunlight exposure
Fair complexion
Immunosuppresion
Tobacco use
LN metastasis -> Submandibular & Submental LN
(<10%)
Most Common Sites:
Lower lip (98%)
Upper lip (2%)
Oral Commissure (<1%)
96
Q

Histology of LC

A

Squamous Cell CA (most common)
Basal Cell CA (more common in upper lip) – from shaving due to repetitive trauma
Kerato acanthoma, Verrucous CA melanoma,
minor salivary gland CA, sarcoma

97
Q

Physical Exam of LC

A

l Exam
- Ulcerated lesion vermillion/ cutaneous
surface
- Palpation -> determine actual size & extent
of lesion
- Paresthesia adjacent to lesion – indicates
mental nerve involvement

98
Q

Vestibule

A

•Slit-like space, communicates with exterior through oral
fissure between the lips
External: Between lips and cheeks
Internal: Between gums & teeth
•R&F: mucous membrane covering lips, cheeks & gums

99
Q

Oral Cavity Proper

A

•Roof: Hard Palate (ant) & Soft Palate (post)
•Floor: Anterior 2/3 of the tongue + mucous membrane
of gums (gingiva

Surgery (3 decks)

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