Region Condition
Neck Spread of infection
Injury to platysma
Injury of SCM
Subclavian vein puncture
Extenral jugular vein prominence
Dissections of posterior triangle
Lesions of Spinal root of CN XI
Severence of phrenic nerve/
phrenic nerve block
Cervical/Brachial plexus blocks
Ligation of ext carotid artery
Description
Investing layer of deep cervical fascia prevents spread of
abcesses.
If an infection occurs between the fascia and the infrahyoid
muscles, infection usually limited to up to superior edge of
manubrium.
If between the pretracheal and investing layers of deep cervical
fascia then spread to thoracic cavity anterior to pericardium.
Pus my extend laterally in the neck and form a swelling
posterior to SCM, may perforate the prevertebral layer of fascia
and enter retropharyngeal space producing bulge in pharynx
causing difficulty in swallowing and speaking (dysphagia and
dsyphonia respectively).
Due to injury to cervical branch of facial nerve causes skin to fall
away in slack folds. Imperative for the platysma to be
approximated in incisions of neck and preserving this nerve to
avoid postoperative skin defects.
Usually when infant’s head is pulled excessively during difficult
births, also caused by lesions to branch of accessory nerve
denervating a part of the SCM.
If untreated => torticollis (wry neck).
Stiffness caused by fibrosis and shortening of SCM.
Corrected by surgical release of partially fibrotic SCM from distal
attachments to manubrium and clavicle to enable normal
rotation and tilting of head.
Central line placement usually in R subclavian vein to administer
parenteral fluids and medication to measure central venous
pressure. Pleura and/or subclavian artery endangered in
operation.
Increase in pressure as during heart failure makes EJV
prominent throughout course along side of neck. Routine
distention reveal diagnostic signs of heart failure, obstruction of
SVC, enlarged supraclavicular lymph nodes or increased
intrathoracic pressure.
Care required inferior to accessory nerve CN XI because of many
vessels and nerves.
To preserve continuity of CN XI during dissections for removal of
cancerous lymph nodes, nerve isolated at outset and separated
from nodes.
Uncommon. But may be damaged by traumatic injury, neck
lacerations and surgical neck dissections.
Unilateral lesions may cause weakness in turning head to one
side against resistance. Drooping of shoulder is obvious sign of
injury to spinal root of CN XI. Unilateral paralysis of trapezius is
evident by patient’s inability to elevate and retract shoulder and
by difficulty in elevating arm superior to horizontal level.
Paralysis of corresponding half of diaphragm.
Nerve block will produce short period of paralysis of diaphragm
on one side eg. In a lung operation. Anesthetic is injected
around nerve where it lies on anterior surface of anterior
scalene muscle.
Regional anesthesia is often used for surgical procedures in
neck region of upper limb.
Cervical plexus block: injected at several points along posterior
border of superior and middle thirds – nerve point of neck.
Supraclavicular brachial plexus block for anesthesia of upper
limb and anesthetic is injected in axillary sheath around
supraclavicular part of brachial plexus. Main injection point is
superior to midpoint of clavicle.
Necessary to control bleeding from one of its relatively
inaccessible branches. Decreases blood flow through artery and
its branches but does not eliminate it. Blood flows retrogradely
into artery from ext carotid artery on other side through
communications between branches (in face and scalp).

Surgical dissection of carotid
triangle
Carotid pulse
Internal jugular pulse
Internal jugular vein puncture
Cervicothoracic ganglion block
Lesion of sympathetic trunk
Radical neck dissections
Pyramidal lobe of thyroid gland
Thyroidectomy/ Inadvertant
removal of parathyroid
Accessory thyroid glands
Laryngeal nerve injury
When ext carotid or subclavian arteries are ligated, descending
branch of occipital artery provides main collateral circulation
anastomosing with vertebral and deep cervical arteries.
Damage or compression of laryngeal branches of vagus nerve
during surgical dissection of triangle may produce alteration in
voice because these nerves supply the laryngeal muscles.
Felt by palpating the common carotid in side of neck in groove
between trachea and infrahyoid muscles
Deep to ant border of SCM at level of thyroid cartilage
Routinely checked during CPR, absence indicates cardiac arrest
No valves in brachiocephalic vein or SVC => wave of
contraction passes up to IJV
Presence of valves in IJV and subclavian near respective
junctions prevents backflow during heart contractions
Needle or catheter insertion for diagnostic or therapeutic
purposes by palpating the common carotid and inserting it into
the IJV just lateral at 30 degree angle aiming at the apex of the
triangle between the sternal and clavicular heads of the SCM.
Needle inserted inferolaterally towards the ipsilateral nipple
Anesthetic injected around cervicothoracic (stellate) ganglion
blocks transmission of stimuli through cervical and superior
thoracic ganglia
Relieve vascular spasms involving brain/upper limb
Useful when deciding if surgical resection of ganglion would be
beneficial to person with excess vasoconstriction of ipsilateral
limb
Results in Horner syndrome:
Pupillary constriction due to paralysis of dilator pupillae
Ptosis resulting from paralysis of smooth muscle intermingled
with striated muscle of levator palpebrae superioris
Sinking of eye due to paralysis of orbitalis in floor of orbit
Vasodilation and absence of sweating on face and neck due to
lack of symp nerve supply to blood vessels and sweat glands
When cancer invades lymphatics, deep cervical nodes and
tissues around them removed.
Major arteries, brachial plexus CN X and phrenic are preserved,
most cutaneous branches removed
Aim to prevent cancerous cells from escaping and circulating
causing metastasis
On sup surface of isthmus usually to left of median plane
Connective tissue from hyoid to pyramidal lobe
Parathyroid glands in danger of being inadvertently removed/
damaged.
Safe in subtotal thyroidectomy because post part of gland
usually preserved
If inadvertently removed during surgery => tetany, due to fall in
calcium levels due to low PTH
Lateral to thyroid cartilage usually in thyrohyoid muscle.
Funcitonal but insufficient to maintain normal function if thyroid
gland removed.
Originates from thyroglossal duct – transitory endodermal tube
extending from post tongue region of embryo carrying thyroid –
forming tissue at descending distal end
Vulnerable to injury during thyroidectomy and other procedures
of anterior triangle
Paralysis of vocal cord results
Initally poor voice, when paralysis of both folds occurs, almost
absent because cannot be adducted sufficiently
Dyspnea (difficulty breathing) during exertion because of
inability to abduct vocal folds to permit increase respiration =>
stridor (high pitched noisy respiration), and panic
Tracheostomy may be required
Hoarseness most common symptom of disorders of larynx esp
carcinoma
Fracture of laryngeal skeleton
Laryngoscopy
Aspiration of foreign bodies
Tracheotomy/tracheostomy
Tonsillitis/Tonsillectomy
Adenoiditis
Foreign bodies in laryngopharynx
Zones of penetrating neck
trauma
Due to blows in sports and compression by shoulder strap in
automobile accidents.
Produce submucous hemorrhage and edema, respiratory
obstruction, hoarseness, temporary inability to speak.
Calcification of laryngeal cartilage in elderly people => more
likely to fracture during compression
Used to examine the interior of the larynx.
Indirect – using a laryngeal mirror
Direct – using endoscopic laryngoscope
Trapping of foreign objects sup to vestibular folds in the larynx.
Laryngeal muscles go into spasm tensing the vocal folds.
Rima glottides closes and no air enters the trachea.
Emergency therapy – Heimlick maneuver. Sudden compression
of the abdomen which causes the diaphragm to elevate and
compress the lungs, expelling air from the trachea into the
larynx.
Opening the trachea by making a median incision sup or inf to
thyroid isthmus. Emergency tracheotomy (vertical incision,
temporary) more difficult inf to isthmus.
Surgical tracheostomy (more permanent airway, transverse
incision) for persons with upper airway obstruction/ respiratory
failure. First the sternothyroid and sternohyoid muscles
retracted laterally and isthmusof thyroid either avoided or
retracted superiorly. Opening made between 1st/2nd tracheal
rings or through 2nd -4th rings.
Complications:
• Inf thyroid veins descend on anterolateral surface
• Thyroid ima artery may be present and descend on
isthmus
• L Brachiocephalic vein, jugular venous arch and pleurae
• Thymus covers inf part of trachea in infants and children
• Trachea is small, mobile, soft in infants and easy to cut
through and damage esophagus
Inflammation of tonsils especially palatine – tonsillitis.
Removal by dissecting tonsil from tonsil bed – tonsillectomy.
Involves removal of tonsil and fascial sheet covering tonsillar
bed.
Bleeding usually due to large ext palatine vein or tonsillar
artery.
Glossopharyngeal CN IX vulnerable to injury due to thinness of
lateral wall of pharynx.
Int carotid vulnerable when tortuous because directly lateral.
Most complications of operation are vascular/septic
Inflammation of pharyngeal tonsils. – can obstruct passage of air
from nasal cavities through chonae into nasopharynx => mouth
breathing necessary.
Infection from enlarged pharyngeal may spread to tubal tonsils
=> closure of pharyngotympanic tubes => impairment of
hearing due to blockage/obstruction. Causes otitis media which
may produce temporary/permanent hearing loss.
Pierce mucous membrane and injure the superior laryngeal
nerve and internal laryngeal branch if lodged in the piriform
recess. Also nerves may be injured if the instrument used sto
remove accidentally pierces the mucous membrane =>
anesthesia of laryngeal mucous membrane as far inferiorly as
vocal folds.
Usually removed via visualization through a pharyngoscope.
Zone 1: root of neck from clavicles and manubrium to cricoid
cartilage. Cervical pleurae, apices of lungs, thyroid/parathyroid
glands, trachea, esophagus, common carotids, jugulars, cervical
region of vertebral column endangered
Zone 2: cricoid cartilage to angles of mandible. Apices of thyroid
gland, thyroid and cricoid cartilages, larynx, laryngopharynx,
carotids, jugulars, esophagus and cervical region of vertebral
 column endangered.
Zone 3: superior to angles of mandible. Salivary glands, facial
nerve, oral/nasal cavities, oropharynx and nasopharynx
endangered.

Zones 1/3 injuries obstruct airway so highest risk of morbidity

and mortality because injured structures are difficult to visualize
and repair and vascular damage difficult to control.
Zone 2 injuries are most common but morbidity and mortality
lower because easier to visualize and repair and control vascular
damage by direct pressure.

Region Condition Description

Cranium Fractures of calvaria Rupture ant branch of middle meningeal artery - Pterion overlies
ant branches of middle meningeal vessels which lie in grooves of
int aspect of lateral wall of calvaria => blow to side of head will
fracture pterion and therefore vessels
(untreated => hemorrhage causing extradural collection of blood
compressing cerebral cortex => death)

Depressed fractures – fragment of bone depressed inwards

Comminuted fractures – bone broken into several pieces
Linear fractures – at point of impact usually with fracture lines
radiating away from it in two or more directions
Contrecoup fracture – opposite side of cranium than point of
impact

Convexity avoids fractures

Thick calvaria => bend without fracturing
Face Facial injuries No distinct layer of deep fascia, and subcutaneous tissue is loose
between attachments of muscles => injury or infection causes
marked swelling
Bruising – casues by accumulation of large amounts of tissue fluid
and blood due to looseness of subcutaneous tissue
Facial lacerations – gape, so skin should be sutured to avoid
scarring
Trigeminal neuralgia Sensory disorder of CN V characterized by sudden attacks of
excrutiating ligtening-like jabs of pain
Paroxysm – sudden sharp pain – lasts for 15 mins or more
Usually involves maxillary nerve, then mandibular and least
frequently ophthalmic
Pain initiated by trigger points on skin
Cause unknown but could be anomalous blood vessel that
compresses sensory root of CN V. (sometimes necessary to
section the sensory root for relief of trigeminal neuralgia)
Lesions of trigeminal Cause widespread anesthesia involving:
nerve -Corr. Ant half of scalp
-Face except for area around angle of mandible
-Cornea and conjunctiva
-Mucous membranes of nose and paranasal sinuses, mouth, ant
part of tongue
-Paralysis of muscles of mastication
Bell Palsy Most common nontraumatic cause of facial palsy due to
inflammation of facial nerve near stylomastoid foamen causing
edema and compression of nerve in facial canal
- Loss of tonus of orbicularis oculi => lower lid everts => cornea
on that side not hydrated and vulnerable to laceration
- Cannot whistle, blow wind instrument due to weakening of
buccinator and orbicularis oris. Food stuck in teeth after chewing
- Displacement of mouth due to unopposed contralateral facial
muscle contraction and drooping of corner of mouth by
unopposed pull of gravity => food and saliva dribbles out
Pulses of facial Palpated when artery winds around inf border of mandible
arteries Compression of lacerated facial artery does not stop bleeding due
 to numerous anastomoses between branches of facial and other
arteries
Facial wounds bleed freely but heal quickly
Pulse of sup temporal artery palpated as artery passes anterior to
ear and cross zygomatic arch to supply scalp
Carcinoma of Lip Usually lower lip
Overexposure to sunlight and smoking usually cause
Cancer spreads: central lip -> submental lymph nodes
Lateral lip -> submandibular lymph nodes
Parotid gland Injury to facial nerve Facial nerve and branches pass through parotid so in jeopardy
during surgery
Identification, dissection, isolation and preservation of nerve
important in parotidectomy
Infections of parotid Infected through blood stream as with mumps
gland Causes parotiditis and swelling of gland.
Pain due to parotid sheath limiting swelling, worse when chewing
because compressed against mastoid process of temporal bone
when mouth is opened.
Mumps – inflammation of parotid causing redness of parotid
papilla.
Pain confused with toothache, so parotid papilla swelling is early
sign of glandular disease.
Often causes pain in auricle, external acoustic meatus, temporal
region, and TMJ because the auriculotemporal nerve also supplies
sensory to skin over temporal fossa and auricle.
Scalp Scalp injuries and Scalp arteries protected by DCT and anastomoste freely =>
infections partially detached scalp replaced with reasonable chance of
healing as long as one of the vessels intact.
Attached craniotomy – removal of segment of calvaria with soft
tissue scalp flap to expose cranial cavity, incisions made convex
upward and sup temporal artery included. Surgical flaps made to
remain attached inferiorly to preserve vessels and nerves and
promote good healing.
Craniotomy – scalp proper, first three layers, remain together, as
well as in accidents when torn off. Nerves and vessels enter
inferiorly and ascend through second CT layer of scalp to skin.
Loose CT = dangerous area of scalp because pus and blood
spreads easily. Infection passes into cranial cavity via emissary
veins, but not posteriorly into neck because of the occipital belly
of occipitofrontalis attaches to occipital and mastoid process of
temporal. Cannot spread laterally to zygomatic because epicranial
aponeurosis is continuous with temporal fascia of temporalis
muscle.
Black eye – due to spread of infection or fluid into eyelids and root
of nose because of the frontal belly of the occipitofrontalis
inserting into skin and DCT and not to bone. Mostly upper eyelid.
Scalp lacerations – bleed profusely because of anastomoses, stay
open due to DCT so need to be controlled (by sutures, GER makes
a point of saying that sutures however will occlude these vessels
and therefore bleeding must be controlled by other means).
Meninges Thrombophlebitis Connections between facial veins and cavernous sinus via the sup
ophthalmic veins. Blood from medial angle of eye, nose and lips
draining into facial which has no valves => blood passes sup to
sup ophthalmic vein and enter cavernous sinus.
Thrombus due to thrombophlebitis of facial may spread to
cavernous sinus.
Infection of facial veins spreading to dural venous sinus = due to
squeezing pustules of face on nose and upper lip.
Metastasis of tumor Basilar and occipital sinuses communicate via foramen magnum
cells with int vertebral venous plexus.
Valveless => compression of thorax/abdomen/pelvis will cause
venous blood from these regions into int vertebral venous plexus
and then into dural venous sinuses => pus spread to vertebrae
and brain via these interconnections.
 Fractures of cranial May tear IC within cavernous sinus producing arteriovenous fistula
base esp into sup ophthalmic veins which connect with the sinus.
Results:
Exophthalmos – protrusion of eye, pulsates in synchrony with
radial pulse => pulsating exophthalmos
Chemosis – conjunctiva engorged
CN III, IV, V1 V2, VI lie close to lateral wall of sinus => may be
affected also

Blow to head and can detach dura from calvaria without fracturing
bone also because of attachment of periosteal layer of dura being
firmer to floor of cranium than to calvaria.
=> basal fracture usually tears dura and results in leakage of CSF
into the neck.
Dural origin of Dura sensitive to pain esp where related to dural venous sinuses
headaches and meningeal arteries => pulling on arteries at base or veins
near vertex where they pierce dura causes pain.
Distention of scalp/meningeal vessels usually a cause.
Headache after lumbar puncture = dural origin due to stimulation
of sensory nerve endings in dura because when CSF removed,
brain sags slightly pulling on dura
Lying in Trendelenburg (head lower htan trunk) position prevents.
Head injuries Extradural and epidural hemorrhage between endosteal layer of
dura and calvaria follow blow to head
=> brief concussion and lucid interval of some hours and then
drowsiness and coma.
Bleeding from meningeal arteries = exradural/epidural hematoma
=> compression of brain and occlusion of bleeding vessels.

Dural border hematoma – usually venous in origin and commonly

results from tearing of cerebral vein as it enters sup sagittal sinus.
No naturally occurring space at dura-arachnoid junction but
epidural hemorrhaging makes a real space.
Usually follows blow to head that jerks brain and injures it, usually
greatest trauma in elderly where shrinkage of brain has occurred.

Suarachnoid hemorrhage – extravasation of blood into

subarachnoid space, usually due to rupture of saccular aneurysm,
also associated with head trauma involving cranial fractures and
cerebral lacerations.
Bleeding causes meningeal irritation => severe headache, stiff
neck, loss of consciousness.
Brain Cerebral injuries Cerebral concussion – abrupt brief loss in consciousness
immediately after blow to head, contusion results from trauma.
Pia stripped from injured area and may be torn allowing blood
entry into subarachnoid space. Bruising due to moving brain
impact against stationary cranium or from cranium against brain.
Contusion may result in extended loss of consciousness.
Cerebral lacerations – tearing of neural tissue associated with
depressed cranial fractures or gunshot wounds. Rupture of blood
vessels and bleeding into brain and subarachnoid space =>
intracranial pressure/cerebral compression.
Compression caused by:
Intracranial collections of blood
Obstruction of CSF circulation or absorption of CSF
Intracranial tumors/abcesses
Edema of brain, eg. Swelling due to head injury
Cisternal puncture CSF obtained from post cerebromedullary cistern = cisternal
puncture
Subarachnoid space/ ventricular system entry to measure/monitor
CSF pressure, inject antibiotics, administer contrast media for
radiography.
Hydrocephalus Overproduction of CSF, obstruction of flow, interference with
absorption results in excess of CSF in ventricles nad enlargement
 of head.
May occur in adult also. Excess CSF dilates ventricles, thins brain,
separates cranial bones.
Leakage of CSF CSF otorrhea - fractures in floor of middle cranial fossa result in
leakage of CSF from ear if meninges sup to middle ear are torn
and tympanic membrane ruptured
CSF rhinorrhea – fractures in floor of ant cranial fossa involving
cribriform plate of ethmoid => leakage of CSF through nose
Both present risk of meninges due to possibility of infection
spreading from ear or nasal cavities to meninges.
Vascular strokes Cerebral arterial circle = collateral circulation in event of one of
the arteries being obstructed
Anastomoses inadequate in elderly person and therefore when for
eg. Large artery such as IC occluded => stroke
Most common causes: cerebrovascular accidents eg. Cerebral
thrombosisl, cerebral hemorrhage, cerebral embolism,
subarachnoid hemorrhage
Hemorrhagic stroke = due to rupture of artery or aneurysm
Most common aneurysm = berry aneurysm occurring in vessels of
or near circle of willis and medium sized arteries at base of brian.
Hypertension => weak part of arterial wall expands and ruptures
=> blood enters subarachnoid space.
Transient ischemic Neurological attacks resulting from ischemia of brain. Symptoms:
attacks staggering, dizziness, light-headedness, fainting, par-esthesia.
Mostly shortlived.
Orbit Fracture of orbit Ant blow to eye may fracture thin medial and inf walls of orbit.
Indirct traumatic injury that displaces orbital walls – blowout
fracture
Fratures of medial wall – usually involve ethmoidal and sphenoidal
sinuses
Fratures in inf wall – maxillary sinus
Sharp object may pass through relatively thicker superior wall of
orbit to pass into frontal lobe of brain
Exophthalmos Tumors of the orbit produce protrusion of the eyeball or
exophthalmos
Easiest entrance of tumor in middle cranial fossa into orbital
cavity is through sup orbital fissure
Hyperthyroidism may cause also due to expansion of orbital
musculature and fat
Injury to facial nerve Paralysis of orbicularis oculi muscle preventing eyelids from
supporting eyelids closing fully
Protective rapid blinking lost. Lower lid everts and falls away =>
drying of cornea
Irritation of eyeball causes excessive but inefficient lacrimation
Inflammation of Sty or painful red suppurative swelling develops on eyelids if
Palpebral glands obstruction of palpebral glands occurs from either infection or
obstruction of ducts
Chalazia – cysts of ciliary glands – also form
Ophthalmoscopy Observation of the fundus of the eye with retinal vessels and veins
radiating from optic disc
Increase in CSF pressure slows venous return from retina – edema
of the retina
Viewed by opththalmoscopy because normaly disc is flat and does
not form papilla but papilladema results from increased
intracranial pressure which increases CSF pressure in extension of
subarachnoid space around optic nerve.
Continued pressure => blindness
Detachment of In embryo, layer of retina separated by intraretinal space, but
Retina embryonic layers fuse obliterating the space during early fetal
development
Pigmented layer firmly attached to choroids but not to neural
layer => may detach resulting in seepage of fluid between the
layers with complaints of flashes of light.
Laser treatment may help
 Corneal abrasions Abrasions due to foreign objects that cause sudden stabbing eye
and lacerations pain and excess lacrimal fluid
Lacerations by sharp objects eg. Fingernails
Corneal ulcers and Cornea injured easily by foreign particles when sensory
transplants innervation impaired causing corneal ulcers
Corneal transplants given to those with scarred or opaque corneas
– usually small prescription plastic lens
Presbyopia and Lenses become harder and more flattened as you get older =>
Cataracts presbyopia, reduced focusing power
Also cataracts – loss of transparency due to areas of opaqueness
as you get older
Replace with plastic lens
Glaucoma Pressure buildup in chambers of eye due to reduced drainage of
aqueous humor => compression of neural retina
Danger usually primarily due to slow gradual process without
presenting symptoms – if untreated irreversible blindness results.
Oculomotor and Oculomotor - CN III affects most of the ocular muscles, levator
abducent nerve palpebrae superioris and sphincter pupillae. Sup eyelid droops
palsy (ptosis) and cannot be raised voluntary due to action of orbicularis
oris supplied by facial nerve

Paralysis of CN VII prevents folding of eyelids but does not cause

ptosis. Pupil fully dilated and nonreactive due to unopposed
dilator pupillae, also pupil fully abducted and depressed due to
unopposed lateral rectus and superior oblique muscles.

Lesion of abducent nerve results in loss of lateral gaze to

ipsilateral side because of paralysis of lateral recuts, eye diverted
medially on forward gaze because of lack of normal resting tone in
lateral rectus => diplopia (double vision)
Horner syndrome Interruption of cervical sympathetic trunk resulting in paralysis of
sup tarsal muscle (supplied by SNS) => ptosis
Also constricted pupil, sinking, redness and dryness of the eye
and increased temp of face on affected side
Paralysis of By brainstem injury of one or more extraocular muscles =>
extraocular muscles diplopia. Limitation of eye movement in field of action of muscle
nad production of two images when one attempts to use the
muscle.
Blockage of central Thrombi or emboli in central arteries can result in instant
retinal artery blindness because they end in end arteries, extent of blindness
determined by area normally supplied by blockage
Blockage of central Central vein enters cavernous sinus, so thrombophlebitis of this
retinal vein sinus => passage of thrombi to central retinal vein and produce
clotting in small retinal veins
Usually slow loss of vision results
Temporal region Mandibular nerve Anesthetic injected adj to mandibular nerve where it enters
block infratemporal fossa, usually anesthetizing auriculotemporal, inf
alveolar, lingual and buccal branches of mandibular nerve.
Inferior alveolar Usually when repairing mandibular teeth, anesthetizes inf alveolar
nerve block nerve CN V3 branch.
Injected around mandibular foramen (opening of mandibular
canal) which gives passage to the nerve, artery and vein.
When successful, all mandibular teeth anesthetized to median
plane. Skin/mucous membrane of lower lip, labial alveolar
mucosa, gingival and skin of chin also anesthetized due to supply
by mental branch of this nerve.
Temperomandibular Dislocation of TMJ During yawning and taking large bites, causing excessive
joint (TMJ) contraction of lateral pterygoids => heads of mandible dislocate
anteriorly => unable to close mouth.
Usually due to sideways blow to face.
Fractures accompanied by dislocation of TMJ
Close relationship of facial and auriculotemporal to TMJ => care
taken during surgical procedures to preserve both branches of
facial nerve and articular branches of auriculotemporal nerve that
 enter post part of joint.
Injury to articular branches due to traumatic dislocation and
rupture of articular capsule and lateral ligament => laxity and
instability of TMJ.
Teeth Pulpitis and Invasion of pulp of tooth by carious lesion results in infection and
Toothache irritation of tissues in pulp cavity, causing an inflammatory
process (pulpitis)
Swollen pulpal tissues cause pain because the cavity is a closed
space
Gingivitis and Inflammation of gingivae caused by improper dental hygiene
Periodontitis resulting in food deposits in tooth and gingival crevices
May spread to supporting structures such as alveolar bone =>
periodontitis => inflammation of gingivae and result in absorption
of alveolar bone and gingival recession exposes sensitive cement
of teeth
Palate Nasopalatine nerve By injecting anesthetic into mouth of incisive fossa in hard palate.
block Needle iserted post to incisive papilla – a slight elevation of
mucosa that covers incisive fossa
Affected tissues are palatal mucosa, lingual gingivae, alveolar
bone of six ant maxillary teeth and hard palate
Greater palatine Injecting anesthetic into greater palatine foramen, nerve emerges
nerve block between 2nd and 3rd molar teeth. Anesthetizes all palatal mucosa
and lingual gingivae post to maxillary canine teeth and underlying
bone of palate on side concerned
Tongue Gag reflex When pharyngeal part of tongue is touched. Muscular contraction
on each side controlled by CN IX and X. Glossopharyngeal
branches CN IX provide afferent limb of reflex
Paralysis of Tongue mass shifts posteriorly when genioglossus is paralyzed.
genioglossus Total relaxation occurs during general anesthesia and therefore
airway inserted to prevent tongue from relapsing and suffocating
patient
Injury to hypoglossal Due to trauma such as fractured mandible resulting in paralysis
nerve and eventual atrophy of one side of tongue, tongue deviates to
paralyzed side during protrusion because of anchoring effect on
inactive side
Sublingual Thin mucosa allows absorbed drug to enter deep lingual veins in
absorption of drugs less than a minute as with nitroglycerin used as vasodilator in
angina pectoris (chest pain)
Lingual carcinoma Malignant tumors on post part -> sup deep cervical nodes on both
sides
Apex and anterolateral – do not metastasize to inf deep cervical
nodes until late in disease
Deep nodes closely related to IJVs, so carcinoma from tongue
spreads to submental and submandibular regions and long IJVs
into neck
Excision of Due to calculus in its duct or tumor in gland, risk of severing
submandibular gland mandibular branch of facial nerve avoided by making skin incision
at least 2.5 cm inf to angle of mandible
Sialography Radiographic observation of parotid and submandibular glands.
Demonstrates salivary ducts and some secretory units
Cannot usually inject contrast medium into sublingual ducts due
to their small size
Nose Nasal fractures Deformity of external nose usually present with fracture esp with
lateral force
Direct blow => ethmoid bone may fracture resulting in CSF
rhinorrhea
Epistaxis Nose bleeds, due to rich blood supply to nasal mucosa. In most
cases bleeding located in ant third of nose (Kiesselbach’s area)
supplied by anastomosing branches of five different arterial
sources (sphenopalatine, ant/post ethmoidal, greater palatine, sup
labial, lateral nasal branches of facial artery).
Also due to infections and hypertension
CSF Rhinorrhea Nasal discharge after head injury may be CSF due to frature of
cribriform plate tearing the meninges and causing leakage of CSF
 from nose
Rhinitis Nasal mucosa becoming red and inflamed during upper
respiratory infections and allergic reactions
Swelling due to vascularity and abundancy of mucosal glands
Infections spread to:
- ant cranial fossa via cribriform plate
- Nasopharynx and retropharyngeal soft tissues
- Middle ear through auditory tube
- Paranasal sinuses
- Lacrimal apparatus and conjunctiva
Paranasal sinuses Infection of Infections of ethmoidal cells break through fragile medial wall of
ethmoidal cells orbit and severe infections cause blindness because some post
ethmoidal cells lie close to optic canal which gives passage to
optic nerve and ophthalmic artery => cause optic neuritis by
affecting dural sheath of eye
Infection of Maxillary Most commonly affected because ostia located high on
sinuses superomedial walls, poor location for drainage
Ostia often obstructed when mucous membrane is inflamed
Proximity of molar teeth to floor of sinus => piece of root may be
driven superiorly up into maxillary sinus creating fistula between
oral cavity and maxillary sinus, but can be drained via cannulation
(from nostril to maxillary ostium)
Middle ear Otoscopy Examination begins by aligning cartilaginous and bony parts of
meatus
Helix of auricle is grasped and pulled posterosuperiorly in adults
to straighten the meatus
In infants external acoustic meatus is relatively short so extra care
should be taken to prevent damage to tympanic membrane
Otitis media Indicated by bulging red tympanic membrane. Usually secondary
to upper respiratory infections.
Inflammation and swelling of mucous membrane cause partial or
complete blockage of pharyngotympanic tube and tympanic
membrane becomes red and bulges => ear popping
If untreated may lead to scarring of ossicles and impaired hearing
due to decreased response to sound
Perforation of Resulting from otitis media or foreign bodies in external acoustic
tympanic membrane meatus
Sup half more vascular than inf half => incisions made
posteroinferiorly through membrane to also avoid injury to chorda
tympani and auditory ossicles
Bleeding from a ruptured tympanic membrane due to severe blow
to head
Fratures of floor of middle cranial fossa => tearing of meninges
=> CSF otorrhea due to leakage through ruptured membrane
Mastoiditis Infections of mastoid anruma nd mastoid cells resulting from
middle ear infections causing inflammation of mastoid process
May spread superiorly into middle cranial fossa or petrosquamous
fissure or cause osteomyelitis of tegmen tympani
Course of facial nerve important to know to avoid injury
One point of access to tympanic cavity via mastoid antrum
Children thin plate of bone, adults 15 mm or more
Most mastoidectomies are endaural at present (i.e. performed
through post wall of external acoustic meatus)
Auditory ossicles Paralysis of Dampen large vibrations of tympanic membrane resulting from
Stapedius loud noises normally
Paralysis of stapedius muscle associated with excessive acuteness
of hearing – hyperacusis/ hyperacusia => uninhibited movements
of stapes
Blockage of Route for infections to pass from nasopharynx into tympanic
pharyngotympanic cavity
tube Blocked easily by inflammation of mucous membrane because
walls of cartilaginous part normally already in apposition
When occluded residual air of tympanic cavity usually absorbed in
mucosal blood vessels => lower pressure in tympanic cavity,
 retraction of tympanic membrane and interference with free
movement => hearing affected
More sudden usually temporary pressure changes resulting from
air flight equalized by swallowing or yawning opening up
phayrngotympanic tubes
Inner Ear Motion sickness Maculae of membranous labyrinth have otoliths embedded among
hair cells and under influence of gravity cause bending of hair
cells stimulating vestibular nerve and providing awareness of
position of head in space => respond to quick tilting movements
and linear acceleration and deceleration, motion sickness mainly
from fluctuating stimulation of maculae
High tone deafness Degenerative changes in spiral organ due to persistent exposure
to excessively loud sounds
Otic Barotrauma Injury caused by implaance in pressure between ambient air and
air in middle ear, usually in fliers and divers