Download 24 yo male baseball game, struck on lateral head by thrown ball, x

24 yo male baseball game, struck on lateral head by thrown ball, x-ray shows fracture through midpetrous ridge
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Could have damage to sigmoid sinus- will see bleeding on CT
Opening on posterior aspect of petrous ridge- internal acoustic meatus
CN 7 & 8 run through acoustic meatus
Pt now conscious- test CN 8 by testing hearing by rubbing fingers next to their ear
Test CN 7- look at face, ask pt to smile
If pt can’t smile or hear- damage to CN 7 & 8- IAM is only place 7 & 8 run together
If CN 7 & 8 damage- may also have labryinthe artery damage (branch of ICA)
Contrast CT & neurosurgery consult
25 yo WDWNWF in MVA, chief complaint neck pain
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Whip lash
No other major issues
X-rays, seems to be ok
Next day- secondary complaint = food tastes bland
Can detect sour, sweet, salty, bitter, basic tastes
60% of what we taste is actually smell- olfactory nerve
Look for damage in cribriform plate
Neurons project axons up through cribriform plate to 2nd order neurons in olfactory bulb
Can shear off axons passing through cribriform plate in MVA = traumatic anosmia
Olfactory neurons die & are replaced so odds are her axons will regrow
Takes 6 months to rest of your life
Fighters, anatomists anosmic
47 yo obese oriental male
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Complains of dizziness upon standing, inability to think clearly
Auscultation of aorta- detect bruit over ICA on left side
Contrast- enhanced CT- angiogram shows aneurysm in ICA
Aneurysm superior to bifurcation of common carotid
Restricted blood flow through aneurysm- get dizzy when stand up
Test large abdominal aneurysm- put finger on abdominal wall & can feel heart beat
What do you do? Graft
Secondary symptoms to aneurysm:
IAM- labryinthe artery- could be dizzy b/c labryinthe a supplies inner & middle ear, could be
dizzy b/c no blood supply
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Look for ophthalmic a.- 1st branch once ICA exits skull, look for visual deficits
Pt at science fiction convention. Involved in a fight. Got stabbed by a light saber under chin, pulled it out
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could hit facial & lingual arteries (2 of the largest branches of ECA)
if damage lingual artery- could also damage hypoglossal nerve & lingual nerve
clamp proximal & distal cut ends of artery
test hypoglossal nerve- ask pt to stick tongue out & pull back in
if R side damaged- will deviate to same side (left muscles push tongue to right)
test lingual nerve- test general sense of anterior 2/3 of tongue- hard to test b/c a lot of damage
(could drop sugar water on tongue & see if they can detect it)
if lingual nerve & hypoglossal nerve are damaged- can sew them back together if catch in time
if can’t get function back to hypoglossal nerve- muscle reassignment, cut part of genioglossus on
left & move it to right side
pt is 17 yo high school senior, developed bacterial meningitis, caught early on, gave antibiotics, under
control, pt returns 2 weeks later & still has stiff sore neck (nuchal rigidity due to inflamed meninges, can
affect CN 11- traps & SCM gets stiff)
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no sign of infection, has cleared
only 1 side of neck appears to be stiff, swelling running down mid-lateral portion of neck
look into throat- notice R side appears to be distended
R tonsil & palatoglossal arches are deviated
Soft palate deviated
Trouble swallowing
Xray chest
Aortic arch displaced towards left
Abscess
Fascia attaches to nuchal line posteriorly & base of skull anteriorly (anterior to foramen
magnum)
Danger space- goes down to superior mediastinum (retropharyngeal space)
Pericranium- different than periosteum of other bones b/c it is an extension on outside of skull
of dura mater (periostal layer of dura mater is continuous through foramen magnum to outside
of skull)
Retropharyngeal space connects to pericranium- passage way from inside of skull to
pericranium to retrophayngeal space, can go all the way down to heart (potential space)
2 layers of fascia next to each other for movement
Space is immune privileged- no vascular access, no immune response
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What blood vessel would you have to worry about this abscess popping? Aorta or pulmonary
trunk, other blood vessels: vertebral artery
Aortic bleed- exsanguinate really fast, most likely can’t control
Level of C6- vertebral arteries punch through fascia as they go to transverse foramina
Vertebral arteries- 20% of blood flow to brain
Rupture artery related to this space- bleed into danger space- gets big as it can, compress
structures around it
o Esophagus
o Trachea
o Thyroid
o Carotid sheath- CCA, ICA, IJV, vagus nerve
o Blood will stop flowing in vein before the artery
o Cut off blood flow out of cranial cavity, while still pumping blood into cranial cavity
o Respiratory problems
o Early complaint- can’t swallow
Drain abscess- go through neck between fascial planes
Most common cause of retropharyngeal abscess- bad teeth
o Molars next to retropharyngeal space
70 yo patient, slipped & fell, struck side of face on rim of tub, struck left side of face, major complaintcheek is depressed, trouble expressing this is a problem b/c can’t move jaw well, since this accident
happened 5 days ago has developed nose bleeds on that side
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Dent in cheek- fractured zygomatic
Massater attaches to zygomatic, closes jaw with temporalis
When open mouth, pull on broken bone, hurts (so she doesn’t want to move jaw)
Bone fragments in infratemporal fossa
o Muscles of mastication, branches of maxillary artery, branches of trigeminal nerve
o Trigeminal- sensory, motor to muscles of mastication, innervating nasal cavity & sinuses
(V1, V2), parasympathetic innervation to mucosa- secrete mucus
She has - Lost parasympathetic innervation to nasal cavity, damage to maxillary artery
Muscles of mastication- in their own fascia, small, very tight space
11 yo child, persistent chronic complaint of sore throat, WDWNAAAA
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Palatine tonsils look normal
Soft palate inflamed & displaced inferiorly into oropharynx
Pharyngeal tonsils (adenoids) grossly swollen, erythematous & pulsatile
Tonsillar abscess due to chronic infection
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Has been through numerous antibiotics- so resistant bug
Most likely- strep
Surgically remove pharyngeal tonsils
Immediately lateral & superior & anterior to pharyngeal tonsils: torus tubarius- internal auditory
tube
Likely to have middle ear infections from drainage
Muscle off of torus tubarius and descends into neck: salphingopharygeus
Muscle off of lateral side of soft palate medial to torus tubarius: palatopharyngeus
Longitudinal muscles of the pharynx- assist with swallowing and speech b/c attach to posterior
lamina of thyroid cartilage
Elevate thyroid cartilage during speech and deglutition
pharyngeal plexus: CN 9 (sensory) & 10 (motor, except for stylopharyngeus), & sympathetics
structures that could be affected: ear, pharynx, nasal cavity, soft palate
only 2 things that don’t receive sympathetics: nails & hair b/c not alive
pt who was a sword swallower, sneezed & tore the right lateral wall of his phaynx, bleed but healed
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external arterial and venous plexuses on pharynx
his voice hoarse & raspy & h has trouble enunciating
have him say ahhh- notice that his vocal cords are not moving, flaccid & displaced during midline
should always be slightly open
at what point did he damage the wall of his pharynx?
Damageo Above SC
o Between SC & MC
o Between MC & IC
o Below IC- recurrent laryngeal nerve- supplies motor to all of larynx
So damaged pharynx below inferior constrictor b/c damaged motor to larynx
Complaint after heart surgery- back pain , harsh raspy voice
o Left recurrent laryngeal nerve loops around aorta
o Can take 6 months to 2 years to heal
Pt with a swelling underneath mandible, anterior to anterior border of SCM, 16 yo, complains of no pain,
annoying to have mass sticking out of side of neck, bad taste in mouth especially if they burp
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Lump relatively firm, non-mobile, fluid filled, painless
Xray- fluid filled cyst on lateral side of neck
has taken quite a while to develop, 1st noticed 3 years ago
cervical sinus cyst
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internal fistula- food builds up & leaves bad smell & taste
Operate on pt for squamous carcinoma on lateral neck, discover that ventral rami of C1-C4 are invested
in the tumor, you take them out, what symptoms would you expect to see from removing C1-C4?
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Infrahyoid muscles affected- innervated by ansa cervicalis C1-C3
Help position hyoid bone, help with swallowing & speech
Sensory- numb from posterior ear (auricular) all the way down lateral side of neck, across
clavicle, to lateral side
Soft Palate
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Bony hook- hamulus
Midline- soft palate
Palatoglossus, palatopharyngeus, levator veli palatini, tensor veli palatine
PG, PP, LVP, MU- motor innervation from CN 10
Move palate- levator pulls it out of way
MU- pull uvula up & back
Nodose tumor of CN 10
As CN 10 comes out of internal jugular foramen- 2 nodose ganglia
Families prone to developing tumors in ganglia
Take out ganglia- may be able to preserve bits on CN 10 on that side
Recurrent nodose CN 10 ganglioma
Take out entire CN 10 on one side- will affect ability to swallow b/c half of soft palate will just sit
there
Fix- muscle relocation
TVP- innervated by CN 5
Remove hamulus, shorten tendon, now TVP will lift soft palate up & out of way
Only have 1 muscle moving soft palate
Swallowing
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Muscles of mastication
First- relax orbicularis oris, relax masseter & temporalis
Chew
o Masseter, temporalis, medial & lateral pterygoids
o Move mandible up & down & side to side
o Also involved: buccinator, intrinsic & extrinsic muscles of tongue
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o Buccinator & tongue hold bolus of food in between teeth
Swallow
o Use buccinators to push bolus out from teeth
o Collect into mass on center of tongue
o Intrinsic tongue muscles push up between incisor teeth
o Push rest of tongue up against palate
o Use intrinsic tongue muscles to cup tongue to keep food in midline & push backwards
o Get to posterior 1/3 of tongue
o Soft palate muscles lift soft palate up
o Force into oropharynx
o Now use palatoglossus & palatopharyngeus to pull soft palate down
o Bolus form oropharynx to laryngopharynx
o Superior constrictor contracts- peristaltic action
o Push food downward
o At base of superior constrictor- middle constrictor overlaps
o Middle constrictor pushes bolus down
o Inferior constrictor overlaps base of middle constrictor
o At bottom of inferior constrictor- enter esophagus
o Peristaltically constrict from top to bottom
o From skeletal muscle to smooth muscle- at transition from IC to esophagus
o Catastrophic reverse peristalsis- throw up
o Can throw up all the way down to bottom 2/3 of anal canal
Anastomoses b/w ICA & ECA- eye, nose, ear
Damage inferior thyroid- not too many problems b/c collateral flow from superior thyroid
If lose superior & inferior thyroid- could have problem (b/c right & left don’t anastamose much
If lose anterior branch of anterior superficial temporal- other arteries will feed, scalp doesn’t
need a whole lot of blood
Will not always see 3 branches off of arch of aorta- can see as many as 5 or 6
o Right vertebral, CCA, SC, etc can come off of arch of aorta
Venous return questions
What would you expect to see if you occluded one artery? Slowly occluded one artery, where
would you see deficits?
Cross-section images that show orientation in various planes through neck
Longitudinal images
Knife in neck- what did it hit?