Head/Neck

Question 1

Salivary glands

Answer 1

Parotid gland
Sublingual
Submandibular

Question 2

Parotid gland: anatomic position

Answer 2

Lies in deep hallow: parotid region
Superior: zygomatic arch
Inferior: inferior border of mandible
Anterior: masseter
Posterior: external ear/sternocleidomastoid

Question 3

Parotid gland: structure

Answer 3

Bilobed: deep and superficial lobes
Secretions are transported to oral cavity via Stensen duct (transversing master muscle)
Opens into cavity near second upper molar

Question 4

Parotid gland: anatomical relationships

Answer 4

Facial nerve gives 5 terminal branches within parotid.
External carotid: ascends through parotid
Retromandibular vein: formed within gland by convergence of superficial temporal and maxillary veins

Question 5

Parotid gland: blood supply

Answer 5

Post auricular artery

Superficial temporal artery

Question 6

Parotid gland: venous drainage

Answer 6

Retromandibular vein

Question 7

Parotid gland: innervation

Answer 7

Sensory: auriculotemporal nerve (gland), great auricular nerve (fascia)

Parasympathetic: glossopharyngeal nerve (CNIX)

Question 8

Sublingual gland: structure & anatomical position

Answer 8

Small gland. Almond shaped. Joins other gland to form U-shape around lingual frenulum.
Situated beneath tongue in sublingual fossa
Lateral: mandible
Medial: genioglossus
Submandibular duct and lingual nerve travel medial to sublingual

Question 9

Sublingual gland: drainage

Answer 9

Drains into oral cavity by minor sublingual ducts (of Rivinus): 8-20 ducts per gland.
Anatomical variance: sublingual papillae (large single duct)

Question 10

Sublingual gland: blood supply

Answer 10

sublingual and submental arteries (branches from lingual and facial, from ECA)

Question 11

Sublingual gland: venous drainage

Answer 11

Sublingual and submittal veins

Question 12

Sublingual gland: innervation

Answer 12

Parasympathetic: CNVII –> chorda tympani
Sympathetic: superior cervical ganglion

Question 13

Submandibular gland: anatomic position

Answer 13

In submandibular triangle
Superior: inferior body of mandible
Anterior: anterior belly of digastric
Posterior: posterior belly of digastric

Question 14

Submandibular gland: Structure

Answer 14

Superficial arm and deep arm

Travel to oral cavity via submandibular duct (Wharton’s duct)

Question 15

Submandibular gland: anatomical relationships

Answer 15

Lingual nerve: start lateral, loops beneath duct, terminating as several medial branches
Hypoglossal nerve: lies deep to gland and runs superficial to hypoglossus
Facial nerve: MM branch curves inferior to gland

All can be damaged during excision of SM gland

Question 16

Submandibular gland: blood supply

Answer 16

Submental artery

Question 17

Submandibular gland: venous drainage

Answer 17

Facial vein

Sublingual vein

Question 18

Submandibular gland: innervation

Answer 18

Parasympathetic: CNVII –> chorda tympani
Symp: superior cervical ganglion

Question 19

Salivary gland tumours

Answer 19

Benign: pleomorphic adenoma, Warthin’s tumour
Malignant: Mucopeidoermoid carcinoma, Adenoid Cystic Carcinoma, acinic cell carcinoma, SCC, adenocarcinoma

Parotid: 80/20 benign/malignant
Submand: 50/50
Sublingual: 20/80

Question 20

Sialolithiasis

Answer 20

Calculi in salivary glands/ducts
Calcium phosphate or hydroxyapatite stones
RF: drugs (diuretics/anti-cholinergics), dehydration, gout smoking, hyperPTH
Sx: intermittent pain/swelling

Question 21

Sialadenitis

Answer 21

Inflammation of salivary gland

Causes: infective (viral: mumps), stones, malignancy, automimmune (sarcoid, Sjogren’s)

Question 22

Tonsils

Answer 22

Pharyngeal tonsil
tubal tonsils (x2)
Palatine tonsils (x2)
Lingual tonsil

Mucosa associated lymphoid tissue: MALT

Question 23

Lingual tonsil

Answer 23

Location: submucosa of posterior 1/3 tongue
Blood supply: lingual artery
Nerve: glossophyaryngeal (CNIX)
Lymph: jugulodiagastric/deep cervical

Question 24

Pharyngeal tonsil

Answer 24

Roof of nasopharynx
Covered by ciliated pseudostratified epithelium
Blood supply: ascending palatine. ascending pharyngeal, Pterygoid canal. tonsillar branch of facial
Venous: pharyngeal plexus
Lymph: retropharyngeal nodes

Question 25

Tubal tonsils

Answer 25

Around opening of Eustachian tube in lateral wall of nasopharynx Blood: ascending pharyngeal Venous: pharyngeal plexus Nerve: maxillary, glossopharyngeal nerves Lymph: retropharyngeal/deep cervical

Question 26

Palatine tonsils

Answer 26

Location: Tonsil bed of lateral oropharynx between palatoglossal arch (anterior) and palatopharyngeal arch (posterior) Covered by stratified non-keratinised squamous epithelium Blood: tonsils branch of facial Venous: external palatine vein Nerve: maxillary, glossopharyngeal Lymph: jugulodigastric/deep cervical

Question 27

Post tonsillectomy bleeding

Answer 27

5% Primary: <24hrs. Loosened sutures Secondary: >24hrs. Infection, collection

Question 28

Parts of the ear

Answer 28

External ear Middle ear Inner ear

Question 29

Parts of external ear

Answer 29

Auricle External acoustic meatus Tympanic membrane

Question 30

Parts of the auricle

Answer 30

``` Helix: outer curvature Antihelix Superior crus Inferior crus Concha: middle hollow depression Tragus: elevation immediate anterior to EAM Antitragus Lobule ```

Question 31

External acoustic meatus

Answer 31

Sigmoid shaped tube: S shaped curve Extends from deep part of concha to tympanic membrane External 1/3: cartilage walls Inner 2/3: temporal bone forms walls

Question 32

Tympanic membrane

Answer 32

``` Connect tissue with skin on outside. Membranous inside. Parts: Lateral process Handle of malleus Umbo Pars tensa ```

Question 33

Blood supply to external ear

Answer 33

``` Branches of external carotid: Post. auricular Superficial temporal Occipital Maxillary ```

Question 34

Innervation to external ear

Answer 34

Sensory: Greater & lesser auricular nerves (from C-plexus): skin of auricle Auriculotemporal n. (CNV3) skin of auricle and external auditory meatus Branches of vagus and facial also innervate deeper aspects of auricle and external auditory meatus

Question 35

Parts of the middle ear

Answer 35

Tympanic cavity | Epitymanic recess

Question 36

Borders of middle ear

Answer 36

``` Roof: petrous part of temporal Floor: jugular wall Lateral: tympanic membrane Medial: lateral wall of inner ear Anterior: thin bony plate w. 2 openings (auditory tube and tensor tympani) Posterior: Mastoid wall ```

Question 37

Bones of the middle ear

Answer 37

"Auditory ossicles" Malleus Incus Stapes

Question 38

Mastoid air cells

Answer 38

Located posterior to epitympanic recess Collection of air filled spaces in mastoid process of temporal bone Acts as "buffer" releasing air into tympanic cavity when pressure it too low

Question 39

Muscles of middle ear

Answer 39

``` Tensor tympani (tesnor tympani nerve, CNV3) Stapedius (nerve to stapedius, CNVII) ``` Function: protection of middle ear Contract in response to loud noise, inhibiting vibrations of malleus, incus and stapes. reducing sound transmission to inner ear.

Question 40

Auditory tube

Answer 40

"Eustachian tube" Cartilaginous and bony tube that connects middle ear to nasopharynx Equalise pressure

Question 41

Parts of inner ear

Answer 41

Bony labyrinth | Membranous labyrinth

Question 42

Bony labyrinth

Answer 42

Series of bony cavities within petrous part of temporal bone Cochlea Vestibule 3 semi-circular canals

Question 43

Membranous labyrinth

Answer 43

Continuous duct system filled with endolymph Cochlear duct Saccule & Utricle Semi-circular ducts

Question 44

Blood supply to inner ear

Answer 44

Bony: Anterior tympanic branch (maxillary artery) Petrosal branch (middle meningeal, from Maxillary) Stylomastoid branch (from posterior auricular) Membranous: Labyrinthine artery

Question 45

Innervation to inner ear

Answer 45

Vestibulocochlear nerve

Question 46

Rinne's test

Answer 46

1. Place tuning fork (512Hz) on mastoid. Tests bone conduction. 2. Pt confirms they can hear it and says when its stops. 3. When cannot hear it move to external auditory meatus. Tests air conduction. 4. Ask if they can still hear (If yes: normal) Air conduction > bone (Rinne's positive): normal/sensorineural Bone > air (Rinne's negative): conductive deafness

Question 47

Weber's test

Answer 47

1. 512Hz tuning fork placed in midline of forehead 2. Ask where patients hears sound Normal: equal in both ears Sensorineural: louder on intact Conductive: louder on affected

Question 48

Conductive hearing loss

Answer 48

``` Impacted earwax Foreign body Tympanic membrane perforation Infection: otitis externa/media Cholesteatoma Middle ear effusion Otosclerosis Neoplasm (SCC of external ear) Exostoses ```

Question 49

Sensorineural hearing loss

Answer 49

``` Age-related hearing loss NIHL Meniere's Ototoxic substances (amino glycoside substances), loop diuretics, anti-malarial, cytotoxic (cisplatin, bleomycin) Labyrinthitis Vestibular schwannoma (acoustic neuroma) Neuro: MS/stroke Malignancy Autoimmune: RA, SLE, sarcoid Hereditary: Alport's ```

Question 50

Acute otitis externa

Answer 50

Infection of external ear RF: water exposure (swimming), trauma to canal, blockage Sx: red, swollen, tender canal Cause: Pseudomonas (40%), Staph epidermis/aureus. Can be fungal. Brighton Grading System I-IV Rx: topic Abx

Question 51

Acute Otitis media

Answer 51

Bacterial infection of middle ear resulting from nasopharyngeal organisms migrating via Eustachian tube Cause: Strep pneumoniae (most common), H influenza, M catarrhalis RF: age (6-15mths), M>F, parental smoking, bottle feeding Sx: pain, malaise, fever, coryzal TM redness and bulging Complications: CNVII involvement, intracranial complications, mastoiditis Rx: conservative if uncomplicated. Abx for unwell, RFs. Mastoiditis: IV abx +/- mastoidectomy

Question 52

Otitis media with effusion

Answer 52

"Glue ear" Build up of viscous inflammatory fluid in middle ear Sx: conductive hearing impairement TM appears dull +/- bubble seen Rx: 50% resolve in 3 months Surgical: myringotomy + grommet insertion Non-surg: hearing aid insertion

Question 53

Cholesteatoma

Answer 53

Abnormal sac of keratinising squamous epithelium and accumulation of keratin in middle ear. Sx: persistent, recurrent ear discharge Complications: local destruction of ossicles (conductive HL), semicircular canals (vertigo), cochlea (sensorineural HL), facial canal (CNVII palsy)

Question 54

Acoustic neuroma (vestibular schwannomas)

Answer 54

Benign tumours from Schwann cells surrounding vestibulocochlear n. (CNVIII). Slow growing. Vestibular portion most commonly affected (80%). 80% at cerebellopontine angle. RFs: NF2 (bilateral) Sx: triad of: unilateral SNHL, tinnitus, vertigo. Sx of raised ICP: headache, seizures. Rx: MRI monitoring. Stereotactic radio surgery. Surgical resection.

Question 55

Vertigo

Answer 55

``` Central: MS Posterior stroke Migraine SOL Otological: BPPV Meniere's Vestibular neuronitis ```