CORRELATIVE ANATOMY

NASAL CAVITY

PARANASAL SINUSES

Sphenoidal sinus

Ethmoidal sinus

Further divided to:

 Anterior
 Middle
 Posterior

Frontal sinus

Maxillary sinus

***nasal sinus

Functions:

- Resonance of sound
- To make the head lighter (ex. Sinusitis-makes you feel your head is heavier and different resonance of sound

***Sinus from netter

 What sinuses are present at the time of birth?

- Ethmoid and maxillary sinuses

- Mnemonics M.E. (I’m present at time of birth)

MAXILLARY SINUS

- Largest paranasal sinus

- First sinus to develop
- Remember MAXILLARY sounds like MAXIMUM or
MAXIMUS

Lifted from nelson’s pediatrics

- Ethmoidal and maxillary sinuses are present at BIRTH

- Sphenoidal sinus @ 5 y.o. - mnemonic: “5 looks like S”
- Frontal sinus@ 7-8 y.o. – last to develop

Infection of sinuses particulalrly frontal sinus – can also be a

source of entry of bacteria to the brain.

Sinusitis can lead to brain abscess

Superior concha

Middle concha

Inferior concha

DRAINAGE

Sphenoethmoidal recess

Drain into the Sphenoidal sinus

Superior meatus

Posterior ethmoidal sinus

Middle meatus
 Frontal sinus

Anterior ethmoidal sinus

Middle ethmoidal sinus

Maxillary sinus

Inferior meatus

Nasolacrimal duct

Nasolacrimal duct

Inferior nasal concha

The blood supply of the nasal cavity:

a. superior nasal artery

b. superior labial artery

c. lateral nasal artery

d. sphenopalatine artery

**tears will drain from nasolacrimal duct to inferior nasal concha

MNEMONIC

Kick Lazy Guys Ass

KIESSELBACH’S PLEXUS

LITTLE’S AREA

GREATER PALATINE ARTERY

ANTERIOR ETHMOIDAL ARTERY

SPHENOPALATINE ARTERY

SUPERIOR LABIAL ARTERY

- MAJOR BLOOD VESSELS AND PLEXUS SEEN IN NASAL CAVITY

MOST COMMON CAUSE OF EPISTAXIS: trauma/ nose picking

MEMORIZE BY HEART: KIESSELBACH’S PLEXUS – blood vessel that would most rupture during trauma

BLOOD SUPPLY:

Kiesselbach’s plexus (GASS)- found in anterior Nasal cavity

Great palatine artery

 Anterior Ethmoidal artery

Sphenopalatine artery

Superior labial artery

Woodruff’s plexus (post.nasal cavity)

- Ascending pharyngeal art.

- Sphenopalatine art.
- Post. Nasal art.

What is the difference between anterior Epistaxis and posterior Epistaxis? –

Ant. – source of bleeding from anterior Nasal cavity – major plexus is kiesselbach’s – can be managed by nasal packing –
some place epinephrine and nss to add vasoconstriction –people who take coccaine have erosions

Post – post. Nasal cavity – major plexus is woodruff’s – more difficult to manage

SALIVARY GLANDS

MUCOUS

- Round/elongated
- Flattened nucleus at base
- Pale staining mucin droplets
- Lubricant (major fxn) – to fascilitate mastication

PAROTID GLAND

- Largest (side) of all of the salivary gland

- Secretion: serous (only purely serous secreting salivary gland)
- Duct: stensen’s duct – opens into the oral vestibule, opposite the upper 2nd molar tooth
- SSSS
- Insert picture of parotid gland with muscles
- Infxn with parotid gland present with mumps or parotitis

What is the nerve supply to the parotid gland?

a. facial nerve
b. occulomotor nerve

c. glossopharyngeal nerve cn9

d. vagus nerve
P=9

PAROTID GLAND

Pacial nerve divides the gland into: 1. Superficial lobe 2. Deep lobe **insert picture of parotid gland with nerve

FREY SYNDROME

- Post gustatory sweating due to damage to auricotemporal and great auricular nerve (trauma/surgery (AGA)
- Innervate a sweat gland
- A stimulus intended for saliva prod’n results to sweat secretion instead

SUBMANDIBULAR GLAND

- Lies at the floor of the mouth

- Secretion mixed, serous> mucous
- Duct: wharton’s duct

SUBLINGUAL GLAND

- Smallest
- Secretion: mixed mucous> serous
- Ducts: rivinu’s duct, bartholin’s duct
BENIGN EPITHELIAL AND NON EPITHELIAL TUMORS

Epithelial tumors

- Pleomorphic adenoma (80%) – most common benign salivary tumor

- Monomorphic adenoma
- Warthin’s tumor
- Oncocytoma

Non epithelial tumors

- Hemangioma
- Neural sheath tumor
- Lipoma

Do not memorize everything!! Memorize the epithelial tumors

SALIVARY GLAND TUMORS

Pleomorphic adenoma

- Most common benign salivary tumor

- Parotid gland

Warthin’s tumor

- Second most common benign salivary tumor

- 95% occuring in parotid, 3% bilaterally found

MALIGNANT TUMOR

Mucoepidermoid CA

- Most common
- Low grade
- High grade

SALIVARY GLAND TUMORS (MALIGNANT)

Mucoepidermoid ca

- Most common malignant salivary gland tumor

- Most common parotid malignancy

Adenoid cystic ca

- 2nd most common in adults

- Propensity for neural spread
- Indolent growth but hight propensity for distant mets
- Most common submandibular and minor salivary gland malignancy
- 2nd most common parotid malignancy
- Perineural invasion
- 2nd most common malignant tumor

The only virtually restricted to the parotid gland? Warthin’s tumor (papillary cystadenoma lymphomatosum)

What is the fossa of rossenmuller/ posterolateral recess (other name)?

Most common site of nasopharyngeal ca

Memorize that there is a virus assoc. with nasopharyngeal ca: EBV also assoc. with burkitt’s lymphoma.

RIMA GLOTTIDIS - opening between the true vocal cords and the arytenoid
FOREIGN BODY INGESTION

PYRIFORM SINUS – most common site for the lodging of ingested sharp foreign bodies (fishbones)

RETROPHARYNGEAL SPACE

“danger space” of the neck/ behind the pharynx

Retropharyngeal abscess  airway compression

Tracking to thorax and mediastinum

A deep neck infxn may extend down to mediastinum through?

Substernal space of burns
Memorize the hyoid bone – because muscle of the floor of rthe mouth are attached

EXTRINSIC MUSCLES OF THE TONGUE

Genioglossus

- Protrudes, depresses

Hyoglossus

- Depresses, retracts

Styloglossus

- Retracts, elevates

Palatoglossus

- Elevates

Intrinsic muscles of the tongue

- Longitudinal
 - Transverse
- Vertical

Zone 1 – inferior aspect of cricoid cartilage to the thoracic

outlet

Zone 2 cricoid to angle of mandible

Zone 3 – angle of mandible to the base of the skull

Penetrating injuries to the neck, landmark is platysma

(penetrating wound if goes thru platysma)

83% zone 2

15% zone 1

What is the blood vessel of choice for central line? (memorize by heart)

Right internal jugular is straight to right atrium

Why internal jugular vein?

- IJV has a direct course to right atrium

- Anatomically closer to right atrium
- Has no valves
STRAP MUSCLES

Infrahyoid muscles

- Thyrohyoid
- Omohyoid
o - superior belly
o - inferior belly
- Sternohyoid
- Sternothyroid
- TOSS

Nerve supply: ansa cervicalis except thyrohyoid c1 and

c2

EXTERNAL CAROTID ARTERY

Superior thyroid artery

Lingual artery

Facial artery
Ascending pharyngeal artery

Occipital artery

Posterior auricular

Superficial temporal artery

Internal Maxillary artery

“Stephani lies flat as oscars penis sets in”

LARYNX

Muscles:

Thyropiglottic

- Controls laryngeal inlet (widens the larynx)

Cricothyroid

- Control mov’t of vocal cords (tensor/ tense vocal cords)

Sustained tension of the vocal cords is best achieved thru the action of what intrinsic muscle of the larynx? –
cricothyroid muscle

Thyroarytenoid

- Controls movt of vocal folds (relaxor)

Recurrent laryngeal nerve –

Nerve supply :

Superior laryngeal nerve

- Sensory and motor fxn to larynx\

- External branch innervates cricothyroid
- Injury: unable to reach high pitched notes, increased voice fatigability

All external muscles of larynx are innervated by the recurrent laryngeal nerve except cricothyroid

Recurrent laryngeal nerve

- Motor fxn to most intrinsic laryngeal muscles

- Injury paralyzes laryngeal abductors
o Unilateral – hoarseness
o Bilateral – airway obstruction
- The thyroid gland buds off the foregut diverticulum at the base of the tongue in the region of the future
foramen cecum at 3 weeks of embryonic life.
Thyroid gland

- Base at level of 5th and 6th tracheal ring

- Isthmus is at level of 2nd or 3rd tracheal ring
- Lies posterior to the strap muscles
- Weighs 20g
- Lobes connected by isthmus
- Pyramidal lobe in 50%

Arterial blood supply

- Superior thyroid artery < -- external carotid artery

- Inferior thyroid artery  thyrocervical trunk
- Thyrodea ima artery  brachiocephalic trunk

Venous drainage

- Sup. Thyroid vein. And middle thyroid vein  internal jugular

vein
- Inferior Thyroid vein  brachiocephalic vein

Thyroid hormoes

- Thyroxine t4
- Triiodothyronine t3
- Peptide calcitonin – decreases thyroid hormone – produced by
parafollicular cells

Pyramidal lobe usually attached at superior border of left side

In thyroidectomy, the nerve that maybe injured during ligation of superior thyroid artery : SUPERIOR LARYNGEAL
NERVE
 Inferior thyroid artery is very close to recurrent laryngeal nerve

Ligament of berry – identify the recurrent laryngeal nerve before transecting the posterior thyroid ligament

Thyroglossal duct cyst

- The descent of the thyroid is intimately connected with the dev’t of hyoid bone
- Residual thyroid tissue left behind in the migration may persist and subsequently present in the midline of the
neck as a thyroglossal duct cyst.
- Insert picture of thyroglossal duct cyst
- Symptoms: small soft round mass in the center of the neck, difficulty in breathing or swallowing

Clinical Manifestation

- Presents as intrathyroidal mass and usually asymptomatic

- Cyst is encountered in the midline at or beloew the level of the hyoid bomne
- Moves up and down with swallowing and protrusion of the tongue

Diagnosis

- P.E. – mass moves upward when the tongue is extended and with swallowing since the thyroglossal duct often
connects at the base of the tongue.

Complications

- Infxn – most common

- Local growth and invasion
- Carcinoma 1 -2 % of px
- Thyroid ectopia

Sistrunk procedure

- Resection of the cyst in continuity of the central portion of the hyoid bone and the tract connection to the
pharynx
- Ligation at the foramen cecum
- Resecting the body of the hyoid bone
Must know thyroid d.o

THYROIDITIS

- Inflammtory d/o of thyroid gland

- Hashimoto’s dse – chronic
- Acute suppurative thyroiditis
- Subacute (de quervain’s) thyroiditis
- Riedel’s struma

Hashimoto’s

- Chronic
- Destruction of thyrocytes by cytotoxic t cells and from autoab
- Female 30-50 yrs
- Presence of thyroid autoab confirm the dx
- Lymphocytic infiltrates
- Insert picture
- Clinical mani
o Affects women
o Most frequent complaint – enlargement of the neck w/ pain and tenderness in the region of the neck

Granulomatous thyroiditis

- Subacute thyroiditis
- Dequervain’s thyroiditis – post viral
- Presence of giant cells characterized the lesion

Riedel’s

- Riedel’s struma or invasive fibrous thyroiditis

- Replacement of all or part of the thyroid parenchyma by fibrous tissue
- Hardy, woody thyroid gland with fixation to surrounding tissues
- Tx:
o Thyroid hormone therapy
o Sx relied of tracheoesophageal obstruction

Papillary ca

- Most common type of thryoid ca and seen in both adult and children
- Childhood cases with hx of previous head and neck irradiation
- Histo: psamomma bodies (calcific deposits with distinct concentric lamination)

Orphan annie nuclei – clear cell nuclei

Surgeon’s perspective

- Pre op to decrease vascularity of thyroid

- Lugol’s iodine sol’n to decrease size and vascularity (also known as sski saturated sol’n of potassium iodide) of
the thyroid gland

Do not ligate the inferior thyroid artery – very close to recurrent laryngeal nerve
In thyroidectmy, the nerve that maybe injured during ligation of superior thyroid artery: superior laryngeal nerve

Most common site of ectopic thyroid tissue: base of tongue/ sublingual

Hypocalcemia

- Neuromuscular excitability
- Early manifestations – numbness and tingling sensation in the circumoral area, fingers and toes
- PE
o Chvostek’s sign
o Trousseau sign
- ECG

Chvostek’s sign

- Tapping on the face at a pinpoint just anterior to the ear and just below the zygomatic bone
- Response: twitching of the ipsilateral facial ms suggestive of neuromuscular excitability caused by hypocalcemia

Trousseau sign

- Maneuver
o Inflating a sphygmo cuff above systolic blood pressure for several minutes
o Response: muscular contraction including flexion of the wrist and metacarpophalangeal joints,
hyperextension of the fingers, and flexion of the thumb on the palm, suggestive of neuromuscular
excitability caused by hypocalcemia
o Trousseau’s sign – carpopedal spasm

PARATHYROID GLAND

4 SEPARATE GLANDS

Secretes parathyroid hormone (fxn)/counter regular hormone of calcitonin

Blood supply

- Superior thyroid artery

- Inf. Thyroid artery
 P-pataasng calcium

Embryology

Superior parathyroids from 4th branchial pouch

Inferior parathyroid from 3rd branchial pouch

Anatomy

Weighs 40-50mg each

Blood supply generally from inferior thyroid artery

Chief cells produce PTH ( increase calcium)

**Parafollicular cells – calcitonin

Thymus: most common location of supernumerary glands

Paraesophageal: most common location of ectopic parathyroids

Sx perspective

If a px has parathyroid CA: 3.5 parathyroid can be removed

Complications of thyroid sx

1. wound hemorrhage

- most common

- manifested by dyspnea

- p.e. anterior cervical swelling

- tx: immediate opening of the incision

2. recurrent laryngeal nerve injury

- unilateral: hoarseness

- bilateral: dyspnea

3. hypoparathyroidism

4.Thyroid storm