Download Elise Hyser Dr. Paulman`s Review Session Case 1: Your patient

Elise Hyser
Dr. Paulman’s Review Session
Case 1: Your patient presents with a headache. He feels hot & cold, his heart pounds, and his
temples throb. Surprise!! You pull a nail out of the patient’s nose. You observe dark venous blood
because you just popped the cavernous sinus. The blood was thin in consistency. Clear discharge
emerges from the nose. What is that clear discharge that began to leak out/ what is its significance?
-The patient was leaking CSF!! You must have penetrated the skull somewhere… more specifically, the
hypophyseal fossa. The sella turcica has been damaged.
-Other potential symptoms the patient might explain: Cycling blood pressure, rapid changes in body
temperature. There could be a hole in the pituitary (not too good). Why is this important? The pituitary
is a prime regulator of metabolism. Damage to the pituitary gland leads to death.
Case 2: Your patient suffers from chronic sinusitis. She takes antihistamines and antibiotics. You
notice that the right side of the hard palate is just bone. Where’s the mucosa? It is GONE. The patient
also communicates that she has had the same problem inside the nose.
-What can chronic infection here lead to? Bone deterioration and abscesses. Necrosis is due to lack of
blood supply (thank you, pathology).  If the palatine arteries are compromised, then the blood supply
of the palate has died. The descending palatine artery could be disturbed on the posterolateral aspect of
the nose (I believe).
-You order a CT scan and look for an abscess in the posterolateral nasal wall. A large abscess from the
maxillary sinus is found bulging out of the posterolateral nasal wall. Tissue sloughs off, and you get down
to bone. What to do?
-“Graft something.” It is not okay to have that bone exposed. Problems that could potentially arise:
bacteremia, septicemia. Observe the integrity of the periosteum.
-Recall that the greater palatine artery is the BIGGEST artery to Kiesselbach’s plexus.
Case 3: Your patient uses tobacco and has developed a squamous cell tumor at the lower
angle of the lip on the left side. Inside of the mouth you observe that the tumor has invated
through the gingiva and has taken out the first and second molars. Additionally, the tumor has
obstructed the alveolar bone of the mandible and has caused damage to the root of the
tongue. The tumor is a squamous cell tumor, so you send it to the pathologist to evaluate it for
metastasis.
-What could be the tumor’s route of metastasis? Oral cavity to the lung: Floor of the mouth
drains to the superficial lymphatic channels. Then it could go to the collar nodes. Then the
jugulodigastric node. Then the jugulomohyoid node. Let’s say the tumor does not cross the
midline. It could travel to the left thoracic trunk, go to the thoracic duct, and spread to the left
venous angle. Then it could go to the vena cava. (Tumor could go to the right or left lung). From
the vena cava it could travel to the atria, followed by the tricuspid valve, right ventricle,
pulmonary semilunar valve, pulmonary trunk, and left and right main pulmonary arteries.
Case 4: Your patient is a 2-year-old child whose mother is concerned because he is not
speaking. You evaluate his vocal folds using a laryngoscope. The vocal folds are intact, but you
fail to observe their elevation. No hillock or bulge is present. Vocal folds do not move when
stimulated. Vibration occurs and air passes through, but again, no movement can be elicited.
Vocal folds tense and loosen but cannot adduct or abduct. The rima glottidis stays the same
size.
-Problems: Failure of the neural crest cells to migrate properly leads to failure of neural crestderived cartilages to develop appropriately. Arytenoid cartilage is derived from neural crest
cells. Significance? Without arytenoid cartilages you can’t move vocal folds. Thus, you can’t
phonate. The child must learn sign language.
Case 5: Your patient suffers a gunshot wound to the right lateral neck. The bullet emerges
superior to the lamina of the thyroid cartilages, penetrates through the pharynx, and lodges into the left
pharyngeal wall. Life threatening injury? Yes. You would like to take a pulse at the external carotid
artery, but you observe that blood is spurting out of it.
-Things that could be damaged: Vagus nerve. Anterior and lateral to the carotid: Internal jugular vein.
You rarely bleed to death from venous injuries, though. What else do you hit? Superior thyroid artery.
Also, the superior laryngeal artery. The blood supply to the larynx and pharynx has been compromised.
-Side note: what allows you to sing in a high pitched voice? Cricothyroid! Innervated by the external
branch of the superior laryngeal nerve.
Case 6: Your patient presents with an impacted wisdom tooth that the dentist can’t remove. You
attempt to remove that tooth. You order an X-ray. What might you see?
- You observe that the root of the tooth has passed up the lateral wall of the maxillary sinus. In fact, it
has gone to the roof of the maxillary sinus. If the dentist yanked it, that tooth would’ve traveled to the
floor of the orbit. Air passes into the maxillary sinus. You don’t want to expose that orbit to bacteria!
Immunocompromised. Posterior to the orbit what do you see? The ophthalmic artery and optic nerve.
Case 7: Your patient punched a pen in the floor of his mouth. Structures penetrated by the pen:
-Mucosa.
-Hyoglossus muscle (deep to that lateral to root of tongue; nearby neurovasculature at risk: hypoglossal
nerve and lingual artery).
-Toward midline and down: geniohyoid. C1 to ansa cervicalis accompanies hypoglossal nerve.
- Mylohyoid. Object may miss the nerve to the mylohyoid if the object angles back down and moves
anteriorly.
-Anterior belly of the digastric if the object travels underneath the mylohyoid.
Side note: Open mandible against resistance! Not against gravity!
-You may hit other suprahyoid muscles in addition to the anterior belly of digastric.
-Submandibular salivary gland if the pen travels in a direction that is inferior and lateral to the
mylohyoid.
-Investing fascia and platysma.
-Facial nerve
-Skin and subcutaneous tissue.
*Larger issues to consider: This is a “potentially life threatening injury.” Loss of function? But of course.
If there is damage to the hypoglossal nerve which impairs tongue mobility, a peripheral nerve graft can
be performed. However, the patient will probably not regain function.