Download Blue Boxes Anatomy Pg 984—Bones of Neck Cervical pain: inflamed

Blue Boxes Anatomy
Pg 984—Bones of Neck
Cervical pain: inflamed lymph nodes (possible cancer), muscle strain, protruding IV discs
Chronic: by osteoarthritis, trauma—affected in movement of head and neck, exaggerated in cough/sneeze
Fracture and dislocate cervical vertebrae injure SC and/or vertebral arteries and sympathetic plexuses
Hyoid bone fracture: manually strangled by compression of throat, results in depression of body into thyroid cartilage
Inability to elevate hyoid and move it anteriorly beneath the tongue makes swallowing and maintenance of
alimentary and respiratory tracts difficult aspiration pneumonia
Pg 988-989—Cervical Fascia
Paralysis of Platysma: injury to Cervical branch of CN 7 skin fall away from neck in slack folds
Spread of infections in neck: investing layer of deep cervical fascia prevents spread of abscesses
Btwn investing layer of deep cervical fascia and muscular part of pretracheal fascia (surrounds infrahyoid):
infection will not spread beyond the superior edge of manubrium
Btwn investing fascia and visceral part of pretracheal fascia spread to thoracic cavity anterior to pericardium
Abscess posterior to prevertebral layer of deep cervical fascia may extend laterally in neck SCM swelling
Pus may perforate the prevertebral layer of deep cervical fascia and enter retropharyngeal space
bulge in pharynx (dysphagia and dysarthria)
Infection in head spread inferiorly posterior to esophagus and enter posterior mediastininum or anterior spread
to trachea and enter anterior mediastinum
Retropharyngeal space infections inferiorly into syperior mediastinum
Air from ruptured trachea, bronchus, esophagus can pass superiorly through neck
Pg 1007-1011—Superficial Cervical Region
Congenital torticollis: contraction or shortening of the cervical muscles twisting of neck and slanting of head
MC type from fibrous tissue tumor that develops in SCM around birth, occasionally from pulling a babys head in
childbirth
Face will turn away from affected side
Surgical release of SCM from inferior attachments to manubrium and clavicleinferior to CN XI
Spasmodic torticollis: begins in adulthood, bilaterally, sustained shifting of head
Subclavian vein puncture: central line placement
Right cardiac catheterization: puncture IJV to introduce catheter through right brachiocephalic vein into SVC and right
side of heart (preferred through IJV but can be done in EJV)
Prominence of External Jugular Vein: serves as an internal barometer
Normal pressure: EJV is visable above clavicle for short distance
Increased pressre: vein is prominent through its course (heart failure, increased intrathoracic pressure)
Severance of EJV: if severed on posterior border of SCM bear cervical region its lumen is held open through fascia and
negative pressure sucks air in leading to churning noise in thorax and cyanosis (excessive reduced hemoglobin)
Venous air embolus will fill the right heart with froth and stop blood flow dyspnea
Lesions of Spinal Accessory Nerve (CN XI): uncommon, by penetrating trauma, surgical procedures, tumors, fractures
of jugular foramen
Weakness in turning head, atropy of trapezius, drooping of shoulder
Severance of Phrenic nerve, phrenic nerve block, phrenic nerve crush: paralysis of corresponding half of diaphragm
Block: short period of time (for operation)
Crush: longer period of paralysis (weeks)
Nerve blocks in lateral cervical region: cervical nerve block inhibits nerve impulse conduction along posterior SCM
Phrenic nerve usually paralyzed, thus not used on persons with cardiac and pulmonary disease
Anesthetic agent in supraclavicular brachial plexus block injected to block upper limb (sup to clavicle)
Injury to Suprascapular nerve: in fracture of middle 1/3 of clavicle loss of lateral rotation of humerus
Waiters tip position
Ligation of External Carotid Artery: control bleeding from inaccessible branches, blood flows retrograde to other
collaterals, occipital artery provides main collateral circulation (anastamoses with vertebral and deep cervical a)
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Surgical Dissection of Carotid Triangle: access to IJV, vagus, hypoglossal, cervical sympathetic trunk
Damage hoarseness
Carotid Occlusion and endarterectomy: atherosclerotic thickening of intima obstruction of blood flow to brain
Partial transient ischemic attack (TIA) or minor stroke
Seen on Doppler; relieved by carotid enarterectomy (open artery at origin and strip)
Risk of damaging CN IX, X, XI, XII
Carotid pulse: deep to anterior border of SCM, checked in CPR
Carotid Sinus Hypersensitivity: exceptional response to carotid sinuses in various types of vascular diseases
External pressure slow HR, fall BP, cardiac ischemia
Carotid bodies: monitor O2 content of brain, fall occurs in high altitude or pulmonary disease
Also respond to CO2 and pH, check pulse, rate and BP
Internal Jugular Pulse: correlates with EKg recording of right atrial pressure
May be observed through surrounding tissues in trendelenberg position
Increases with mitral valve prolapsed (increases pulmonary circulation)
Internal Jugular Puncture: needle or catheter inserted into IJV for diagnostic or therapeutic purposes
Right IJV preferred (straighter and larger)
Palpate IJV, insert 30 degree angle and directed inferolaterally toward opposite nipple
Pg 1017—Deep Structures of Neck
Cervicothoracic Ganglion Block: may relieve vascular spasms involving brain and upper limb
Useful in deciding when surgical resection of ganglion would be beneficial to person with excess constriction
Lesion of Cervical Sympathetic trunk: Horner’s syndrome—contraction of pupil (miosis), ptosis, sinking of eye,
vasodilation and absence of sweating on forehead
Pg 1040-1050—Viscera of Neck
Thyroid Ima Artery: small, unpaired artery from brachiocephalic trunk
Supplies anterior trachea to isthmus of thyroid gland (potential source for bleed)
Thyroglossal Duct Cysts: development of thyroid gland begins in foramen cecum in dorsal postnatal tongue
Relocates from tongue into neck, passing anteriorly to hyoid and thyroid cartilages
Thyrodlossal duct attaches thyroid to foramen cecum—generally goes away, but some can remain
Surgical excision may be necessary if cyst occurs
Aberrant Thyroid gland: root of tongue (lingual thyroid gland) or in neck inferior to hyoid
Identify if this is the only thyroid by radioisotope scanning to avoid total thyroidectomy
Accessory thyroid glandular tissue: portions of thyroglossal duct persist to form thyroid tissue
Generally too small to be efficient and cannot be used if thyroid is removed
Pyramidal Lobe of Thyroid gland: 50% of thyroid glands; extends superiorly from isthmus of thyroid gland and
sometimes connected to hyoid by CT band
Enlargement of Thyroid Gland: goiters are caused from lack of iodine
Swelling of neck compresses the trachea, esophagus, recurrent laryngeal nerves
Thyroidectomy: excision of a malignant tumor necessitates all or partial removal
Hyperthyroidism: posterior part preserved to keep intact recurrent and superior laryngeal nerves
Injury to recurrent laryngeal nerves: hoarseness, temporary aphonia
Inadvertent removal of parathyroid glands: variable positions make them vulnerable
Can lead to tetany (spasms from lack of calcium), can be moved into arm if chemo or surgery needed
Fractures of laryngeal skeleton: direct blows, compression of seatbelt
submucous hemorrhage and edema, respiratory obstruction, hoarseness, temporary inability to speak
Laryngoscopy: to view interior larynx, vestibular folds are pink and vocal cords are white
Valsalva maneuver: forced expiratory effort against closed airway increased intrathoracic pressure
Aspiration of foreign bodies: may completely seal off larynx (die in 5 min if not fixed)
Cough to remove object, Heimlich: air in lungs used to expel object
Sometimes cricothyrotomy needed to allow air into lungs until the object can be removed
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Tracheostomy: incision through skin of neck and anterior trachea to establish an airway in patients with resp failure
Avoid: inferior thyroid veins, thyroid ima artery, left brachiocephalic vein, thymus
Injury to Laryngeal nerves: lose voice or hoarse (other side can compensate if only 1 side lost)
Paralysis of superior laryngeal berve: anesthesia of superior laryngeal mucosa (loss of protective mechanism for
aspiration)
Superior laryngeal nerve block: with endotracheal intubation
Cancer of larynx: smoking hoarseness, otalgia, dysphagia
Laryngectomy performed in severe cases and electrolarynx used to speak
Age changes in larynx: larynx grows steadily until approximately 3 years of age, then a little until age 12
In boys, all the cartilages enlarge and vocal cords lengthen to create deeper voice
Foreign bodies in laryngopharynx: may lodge in recess of piriform fossae, superior laryngeal and internal are vulnerable
Sinus tract from piriform fossa: sinus tract may pass from piriform fossa to thyroid and cause inflammation
Tonsillectomy: dissect palatine tonsil from tonsillar bed (bleed from external palatine vein)
Adenoiditis: inflammation of pharyngeal tonsils obstruction of air from nasal cavities to nasopharynx
Infection can spread to middle ear otitis media
Branchial fistula: abnormal cnal that opens internally to tonsillar fossa and externally on side of neck (saliva can infect)
Branchial sinuses and cysts: embryonic cervical sinus fails to disappear and retains connection with lateral neck
Form cyst if not attached to exterior neck
Esophageal injuries: cause most complications after surgery (hidden and difficult to detect)
Occurs with airway injury, death in almost all pts without surgery, 50% pts with surgery
Tracheo-Esophageal Fistula: MC congenital anomaly of esophagus
Superior esophagus blends with trachea aspiration
Esophageal cancer: MC presenting trait is dysphagia, enlargemtn of inferior deep cervical lymph nodes
Zones of penetrating neck trauma:
Zone 1: root of neck (clavicles and manubrium) to level of inferior border cricoids cartilage
Cervical pleurae, apices of lungs, thyroid, parathyroid, trachea, esophagus, common carotid, jugular
Zone 2: Cricoid cartilage to angles of mandible
Superior thyroid, thyroid and cricoid cartilages, larynx, laryngopharynx, carotids, jugulars, esophagus
Zone 3: angle of mandible up
Salivary glands, oral and nasal cavity, oropharynx, nasopharynx
Zones 1 and 3 have greatest risk for morbidity and mortality due to difficult vascular control
Pg 926-927—Parotid, Temporal Regions
Parotidectomy: 80% salivary gland tumors occur here, most are benign
CN VII embedded in parotid
Infection of Parotid Gland: mumps, anything that passes in blood stream
Severe pain due to parotid sheath not allowing swelling (pain in auricle, EAM, temporal resion, TMJ)
Abscess in Parotid Gland: bacterial infection localized; from poor dental hygiene
Accessory Parotid Gland: on masseter muscle btwn parotid and zygomatic arch
Blockage of Parotid Duct: by calcified (calculus) pain due to buildup of fluid
Mandibular Nerve block: anesthetic nerve agent injected near where enters infratemporal fossa
Needle passthrough notch of ramus into fossa (anesthetizes: CN v3—auriculotemporal, inferior alveolar, lingual
and buccal branches)
Inferior Alveolar nerve block: branch of CN V3) around mandibular foramen (inf alveolar nerve, artery, vein) all
mandibular teeth are anesthetized
Dislocation of TMJ: yawn or large bite, blow to chin (usually occurs with fracture of mandible)
Arthritis of TMJ: crepitus (joint clicking)
Pg 963-965—Nose
Nasal Fractures: common in sports and accidents, epistaxis usually occurs
Direct blow could affect cribriform plate of ethmoid bone
Deviation of Nasal Septum: birth or trauma, can obstruct breathing and be corrected surgically
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Rhinitis: nasal mucosa inflamed; may spreas to: anterior cranial fossa (via cribriform plate), nasopharynx and
retropharyngeal soft tissues, middle ear through pharyngotympanic tube, paranasal sinuses, lacrimal apparatus
and conjunctiva
Epistaxis: nosebleed, rich blood supply makes fairly common (from infection and hypertension)
Sinusitis: paranasal sinuses are contiguous with nasal cavities through apertures
Infection of ethmoidal cells: nasal drainage blocked, ethmoidal cells can break and fracture medial wal of orbit and
could damage optic nerve and ophthalmic artery
Infection of Maxillary sinuses: high location of ostia (holes) make them easily obstructed and impossible for sinuses to
drain until they are full
Cold makes you roll from side to side at night to keep the sinuses drained
Transillumination: used to see if the sinuses are obstructed (less glow)
Pg 946-950—Oral Region
Cleft Lip: congenital abnormality 1/1000, 60-80% males, unilateral or bilateral
Cyanosis of Lips: lose body heat in cold with heat going to core
Decreased blood flow in superior and inferior labial arteries, increased extraction of O2
Large labial frenulum: may cause space between central incisor teeth
Frenulectomy allows approximation of teeth; large lower frenulum recessive gingival
Gingivitis: improper oral hygiene with food in crevices inflammation
Can spread periodontitis (inclammation and destruction of bone and periodontium)
Dental Caries, Pulpitis, Tooth Abscesses: acid, enzymes, both produced by oral bacteria
Neglected caries invade and inflame tissues toothache due to pulp
Treatment involves removal of decayed tissue and filling
Can lead to abscess if spreads to alveolar bone
Supernumerary Teeth: more teeth than normal 32 (look like normal teeth)
Mesiodens: malformed, peg-like tooth between maxillary central incisor teeth
Accessory tooth: does not resemble form or disposition of normal teeth
Extraction of Teeth: when lost blood, overwhelming caries
Lingual nerve close to medial aspect of 3rd molar teeth (if damaged altered sensation of tongue)
Unerupted 3rd molars: late teens, early 20s—often not enough room for these, if painful they are removed
Dental implants: metal surgically implanted in alveolar bone and have prosthetic crown placed on top
Nasopalatine block: inject anesthetic into incisive fossa in hard palate
Inserted posterior to incisive papilla (affects mucosa, lingual gingival, alveolar bone of 6 anterior maxillary teeth
and hard palate
Greater Palatine Block: anesthetized by injecting into greater palatine foramen (btw 2nd and 3rd molar teeth
All palatal mucosa, lingual gingival posterior to maxillary canine teeth and underlying bone
Inject slowly so it doesn’t strip the mucosa off the hard palate
Cleft Palate: 1/2500 births, more common in females, May involve uvula
Gag reflex: CN IX, X with posterior part of tongue touched
Paralysis of Genioglossus: tongue falls posteriorly, obstructing airway
Happens in general anesthesia—airway inserted to prevent
Injury to Hypoglossal nerve (CN XII): fractured mandible paralysis of tongue (deviates to paralysed side during
protrusion)
Sublingual Absorption of Drugs: enters deep lingual veins in <1min
Lingual carcinoma: posterior part of tongue metastasizes to superior deep cervical lymph nodes on both sides
Close to IJV so can be distributed through blood
Frenectomy: overly large frenulum of tongue interferes with tongue movements
Excision of Submandibular Gland and removal of calculus (stone): not uncommon, skin incision made inferior to neck of
mandible to avoid injury to the marginal mandibular branch of facial nerve
Caution not to hit lingual nerve (duct is over the nerve inferior to the neck of 3rd molar tooth)
Sialography of Submandibular ducts: injection of contrast into ducts demonstrates salivary ducts and secretory units