Transcript Clinical Notes of Head & Neck

Dr. Mujahid Khan
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The skin, the subcutaneous tissue, and the epicranial
aponeurosis are closely united to one another and are
separated from the periosteum by loose areolar tissue
The skin of the scalp possesses numerous sebaceous
glands
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The ducts are prone to infection and damage by combs
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Therefore sebaceous cysts of the scalp are common
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The scalp has a profuse blood supply to nourish the hair follicles
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Even a small laceration of the scalp can cause severe blood loss
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It is difficult to stop the bleeding because the arterial walls are
attached to fibrous septa in the subcutaneous tissue
Are unable to contract or retract to allow blood clotting to take
place
Local pressure applied to the scalp is the only satisfactory method
to stop the bleeding
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All the superficial arteries supplying the scalp ascend
from the face and the neck
In an emergency situation, encircle the head just above
the ears and eyebrows with a tie, shoelaces, or even a
piece of string and tie it tight
Insert a pen, pencil, or stick into the loop and rotate it
so that the tourniquet exerts pressure on the arteries
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Infections of the scalp tend to remain localized
Are usually painful because of the abundant fibrous tissue in the
subcutaneous layer
Infection may spreads by the emissary veins, causing
osteomyelitis
Infected blood may travel by the emissary veins into the venous
sinuses and produce venous sinus thrombosis
Blood or pus may collect in the potential space beneath the
epicranial aponeurosis
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The facial skin receives its sensory nerve supply from
the trigeminal nerve
Trigeminal neuralgia is a relatively common condition
Patient experiences severe pain in the distribution of
the mandibular or maxillary division
The ophthalmic division usually escaping
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The area of facial skin bounded by the nose, the eye,
and the upper lip is a potentially dangerous zone to
have an infection
A boil in this region can cause thrombosis of the facial
vein
Causing spread of organisms through the inferior
ophthalmic veins to the cavernous sinus
Resulting cavernous sinus thrombosis may be fatal
unless adequately treated with antibiotics
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The facial muscles are innervated by the facial
nerve
Damage to the facial nerve causes distortion of
the face, with drooping of the lower eyelid, and
the angle of the mouth will sag on the affected
side
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The temporomandibular joint lies immediately in front
of the external auditory meatus
Temporomandibular ligament prevents the head of the
mandible from passing backward and fracturing the
tympanic plate when a severe blow falls on the chin
The articular disc of the temporomandibular joint may
become partially detached from the capsule
Its movement become noisy and producing an audible
click during movements at the joint
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Dislocation occurs when the mandible is depressed
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In bilateral cases the mouth is fixed in an open position
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Both heads of the mandible lie in front of the articular
tubercles
Reduction of the dislocation is achieved by pressing the
gloved thumbs downward on the lower molar teeth
and pushing the jaw backward
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The parotid duct is a comparatively superficial
structure on the face
May be damaged in injuries to the face or by
cut during surgical operations on the face
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It develops after penetrating wounds of the parotid gland
If patient eats, beads of perspiration appear on the skin covering the
parotid
Caused by damage to the auriculotemporal and great auricular nerves
During the process of healing, the parasympathetic secretomotor fibers in
the auriculotemporal nerve grow out and join the distal end of the great
auricular nerve
These fibers reach the sweat glands in the facial skin
A stimulus intended for saliva production produces sweat secretion
instead
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The submandibular gland is a common site of calculus
formation
It is rare in the other salivary glands
Examination of the floor of the mouth reveals absence
of ejection of saliva from the orifice of the duct of the
affected gland
Stone can be palpated in the duct, which lies below the
mucous membrane of the floor of the mouth
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The sublingual salivary gland lies beneath the
sublingual fold of the floor of the mouth
It opens into the mouth by numerous small
ducts
Blockage of one of these ducts is believed to be
the cause of cysts under the tongue
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At the junction of the mouth with the oral part
of the pharynx, and the nose with the nasal
part of the pharynx, are collections of lymphoid
tissue of considerable clinical importance
The palatine tonsils and the nasopharyngeal
tonsils are the most important
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The palatine tonsils reach their maximum normal size in early
childhood
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Gradually atrophy after puberty
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Palatine tonsils are a common site of infection
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Producing the characteristic sore throat and pyrexia
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The deep cervical lymph node is usually enlarged and tender
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Recurrent attacks of tonsillitis are best treated by tonsillectomy
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A peritonsillar abscess is caused by spread of
infection from the palatine tonsil to the loose
connective tissue outside the capsule
This is called quinsy
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Excessive hypertrophy of pharyngeal tonsils are
referred to as adenoids
Marked hypertrophy blocks the posterior nasal
openings and causes the patient to snore loudly at
night and to breathe through the open mouth
It may be the cause of deafness and recurrent otitis
media
Adenoidectomy is the treatment of choice for
hypertrophied adenoids with infection
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The piriform fossa is a recess of mucous membrane
situated on either side of the entrance of the larynx
It is bounded medially by the aryepiglottic folds and
laterally by the thyroid cartilage
It is a common site for the lodging of sharp ingested
bodies such as fish bones. The presence of such a
foreign body immediately causes the patient to gag
violently
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Palpation of the fontanelles enables to know the progress of
growth in surrounding bones
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The degree of hydration of the baby
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The state of intracranial pressure
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Samples of cerebrospinal fluid can be obtained by passing a long
needle obliquely through the anterior fontanelle into the
subarachnoid space or even into the lateral ventricle
It is usually not possible to palpate the anterior fontanelle after 18
months
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At birth, the tympanic membrane faces more
downward and less laterally than in maturity
If examined with the otoscope it lies more
obliquely in the infant than in the adult
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Mastoid process is not developed in the
newborn infant
The facial nerve emerges from the stylomastoid
foramen and is close to the surface
It can be damaged by forceps in a difficult
delivery
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In these fractures the cribriform plate of the ethmoid bone may be
damaged
This usually results in tearing of the overlying meninges and
underlying mucoperiosteum
Patient bleeds from the nose (epistaxis) and leakage of
cerebrospinal fluid into the nose (cerebrospinal rhinorrhea)
Fractures involving the orbital plate of the frontal bone result in
hemorrhage beneath the conjunctiva and into the orbital cavity,
causing exophthalmos
The frontal air sinus may be involved, with hemorrhage into the
nose
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These fractures are common, because this is the weakest part of
the base of the skull
This weakness is caused by the presence of numerous foramina
and canals in this region
Cavities of the middle ear and the sphenoidal air sinuses are
particularly vulnerable
Leakage of CSF and blood from the external auditory meatus is
common
Blood and cerebrospinal fluid may leak into the sphenoidal air
sinuses and then into the nose
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In these fractures blood may escape into the
nape
Later, it tracks between the muscles and
appears in the posterior triangle, close to the
mastoid process
The mucous membrane of the roof of the
nasopharynx may be torn, and blood may
escape there
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Nasal Fractures
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Maxillofacial Fractures
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Blowout Fractures of the Maxilla
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Fractures of the Zygoma or Zygomatic Arch
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Extradural hemorrhage results from injuries to the meningeal
arteries or veins
Subdural hemorrhage results from tearing of the superior cerebral
veins at their point of entrance into the superior sagittal sinus
Subarachnoid hemorrhage results from leakage or rupture of a
congenital aneurysm on the circle of Willis or, less commonly,
from an angioma
Cerebral hemorrhage is generally caused by rupture of the thinwalled lenticulostriate artery, a branch of the middle cerebral
artery
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Otoscopic examination of the tympanic
membrane is done by first straightening the
external auditory meatus by gently pulling the
auricle upward and backward in the adult, and
straight backward or backward and downward
in the infant
Normally, the tympanic membrane is pearly
gray and concave
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Pathogenic organisms can reach the middle ear
by ascending through the auditory tube from
the nasal part of the pharynx
Acute infection of the middle ear called otitis
media
It produces bulging and redness of the
tympanic membrane
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If not treatment otitis media can result in the spread of
the infection into the mastoid antrum and the mastoid
air cells called acute mastoiditis
It may be followed by the further spread of the
organisms beyond the confines of the middle ear
Meninges and the temporal lobe of the brain lie
superiorly
Spread of the infection in this direction could produce
a meningitis and a cerebral abscess in the temporal lobe
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Beyond the medial wall of the middle ear lie the facial
nerve and the internal ear
A spread of the infection in this direction can cause a
facial nerve palsy and labyrinthitis with vertigo
Posterior wall of the mastoid antrum is related to the
sigmoid venous sinus
If the infection spreads in this direction, a thrombosis
in the sigmoid sinus may well take place
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A physician must be able to recognize all the structures visible in
the mouth and be familiar with the normal variations in the color
of the mucous membrane covering underlying structures
The sensory nerve supply and lymph drainage of the mouth
cavity should be known
The close relation of the lingual nerve to the lower third molar
tooth should be remembered
The close relation of the submandibular duct to the floor of the
mouth may enable one to palpate a calculus in cases of periodic
swelling of the submandibular salivary gland
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A wound of the tongue is often caused by the teeth
following a blow on the chin while the tongue is partly
protruded from the mouth
It can also occur when a patient accidentally bites the
tongue while eating, during recovery from an
anesthetic, or during an epileptic attack
Bleeding is halted by grasping the tongue between the
finger and thumb posterior to the laceration, thus
occluding the branches of the lingual artery
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It may be carried out by inserting a speculum
through the external nares or by means of a
mirror in the pharynx
In the latter case, the choanae and the posterior
border of the septum can be visualized
A severely deviated septum may interfere with
drainage of the nose and the paranasal sinuses
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Fractures involving the nasal bones are
common
Blows directed from the front may cause one or
both nasal bones to be displaced downward
and inward
Lateral fractures also occur in which one nasal
bone is driven inward and the other outward;
the nasal septum is usually involved
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Infection of the nasal cavity can spread in many of
directions
Paranasal sinuses are especially prone to infection
Organisms may spread via the nasal part of the
pharynx and the auditory tube to the middle ear
It is possible for organisms to ascend to the meninges
of the anterior cranial fossa, along the sheaths of the
olfactory nerves through the cribriform plate, and
produce meningitis
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Foreign bodies in the nose are common in
children
Presence of the nasal septum and conchae
make impaction and retention of balloons,
peas, and small toys
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Epistaxis, or bleeding from the nose, is a frequent
condition
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Most common cause is nose picking
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Bleeding may be arterial or venous
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Most episodes occur on the anteroinferior portion of
the septum and involve the septal branches of the
sphenopalatine and facial vessels
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Infection of the paranasal sinuses is a common complication of
nasal infections
Rarely, the cause of maxillary sinusitis is extension from an apical
dental abscess
The frontal, ethmoidal, and maxillary sinuses can be palpated
clinically for areas of tenderness
The frontal sinus can be examined by pressing the finger upward
beneath the medial end of the superior orbital margin
Here the floor of the frontal sinus is closest to the surface
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The ethmoidal sinuses can be palpated by pressing the
finger medially against the medial wall of the orbit
The maxillary sinus can be examined for tenderness by
pressing the finger against the anterior wall of the
maxilla below the inferior orbital margin
Directing the beam of a flashlight either through the
roof of the mouth or through the cheek in a darkened
room often enable a physician to determine whether
the maxillary sinus is full of inflammatory fluid rather
than air
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Radiologic examination of the sinuses is
helpful in diagnosis. One should always
compare the clinical findings of each sinus on
the two sides of the body
The maxillary sinus is innervated by the
infraorbital nerve and, in this case, pain is
referred to the upper jaw, including the teeth
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Recurrent laryngeal nerves are vulnerable
during operations on the thyroid gland
Left recurrent laryngeal nerve may be involved
in a bronchial or esophageal carcinoma or in
secondary metastatic deposits in the
mediastinal lymph nodes
The right and left recurrent laryngeal nerves
may be damaged by malignant involvement of
the deep cervical lymph nodes