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ENT and OMF Laven Anand University of Dundee Year 3Thanks to our partners!Learning Outcomes ● Recall the bony anatomy of the viscerocranium and the gross anatomy of the TMJ. ● Understand and describe the function and innervation of muscles of facial expression & muscles of mastication. ● Understand pathology and surgeries that can damage these muscles and the clinical signs and complications this can result in. ● Trace the course of important neurovascular structures of the face: facial nerve (CNVII), trigeminal nerve (CNV), external carotid artery & retromandibular vein. ● Explain the gross anatomy of the oral cavity and tonsils ● Understand the referral criteria, surgical management and complications of tonsillitis ● Appreciate the anatomy of the retropharyngeal space as well as red flags and management of retropharyngeal abscess ● Grossly be able to identify red flags in ENT presentationsViscerocranium and TMJ articular tubercle of the temporal bone Mandibular fossa head of the mandible (mandibular condyle)Muscles of facial expression Muscles of facial expression are- Occipitofrontalis, Orbicularis oculi (palpebral and orbital), Orbicularis oris Buccinator, Mentalis Platysma Function- open and close jaw, lips and eyes, help in facial expression Innervated by CN VII Buccal fat pad Muscles of Mastication Masseter: elevates (close) Temporalis: elevates and retracts the mandible(close) Medial pterygoid: elevates (close) Lateral pterygoid: protracts mandible and depresses chin (open) Function- speech and chew Innervated by CN V3 Facial Palsy There are a few instances where it can be damaged. Potential areas of harm: - Damage to temporal bone (trauma) - Parotid surgeries Bell’s Palsy- idiopathic syndrome that causes damage to the facial nerve. Px- Unilateral lower motor neurone facial nerve palsy Mx- Prednisolone( within 72 hours off symptoms) , eye drops Ramsay Hunt syndrome- herpes zoster affecting the facial nerve. Caused by Varicella zoster virus Px- Unilateral lower motor neurone facial nerve palsy + painful and tender vesicular rash in the or around the ear Mx- Acyclovir + prednisolone, eyedrops Note – Forehead sparing = UMN lesion (stroke), No forehead sparing= LMN lesionHouse-Brackmann facial paralysis scaleCranial Neve VII (Facial Nerve) CN VII originates from the posterior border of the pons and runs through the internal acoustic meatus. CnVII exits through the stylomastoid foramen . It has five terminal motor branches: temporal, zygomatic, buccal, marginal mandibular, cervical (To Zanzibar By Motor Car) CNVII also gives off the chorda tympaniTrigeminal Nerve CN V originates from the pons The trigeminal ganglion present inside a dural recess (trigeminal cave) in the temporal bone. The ganglion gives rise to three branches ophthalmic nerve (CN V1)- superior orbital fissure maxillary nerve (CN V2)- foramen rotundum mandibular nerve (CN V3)- foramen ovaleExternal Carotid artery External carotid artery arises from the common carotid artery It gives off 6 arteries- • Superior thyroid artery • Lingual artery • Facial artery • Ascending pharyngeal artery • Occipital artery • Posterior auricular artery After giving off these arteries, it divides to form two terminal branches- Maxillary artery and superficial temporal artery Mnemonic: Some Anatomists Like Freaking Out Poor Medical StudentsRetromandibular Vein Retromandibular vein = superficial temporal and maxillary veins It runs deep to the parotid gland. It gives off anterior and posterior branches Anterior branch - Anterior branch+ facial vein = common facial vein (empties into the internal jugular vein) Posterior branch -posterior branch+ posterior auricular vein = external jugular vein (drains into the subclavian vein)Oral Cavity Oral cavity is divided into two parts by the upper and lower dental arches(formed by the teeth and their bony scaffolding)- Vestibule- the space between teeth and gingivae (gums) and the lips and cheeks. Mouth cavity proper- It is bordered by a roof(hard and soft palette) , a floor, and the cheeks. The tongue fills a large proportion of the cavity of the mouth proper. Oral cavity and tongue Innervation Oral cavity is innervated by the trigeminal nerve - The roof of the mouth = CNV2 - The floor of the mouth and cheeks =CNV3 Tongue sensory innervation- Tongue motor innervation- all by CN XII (hypoglossal nerve) EXCEPT palatoglossus (innervated by CNX) All muscles of the the soft palate are innervated by the vagus nerve, except the tensor veli palatini which is innervated by the mandibular nerve. Tonsils Tonsils are masses of lymphoid tissue found in the pharynx. They are- 1. Pharyngeal 2. Tubal tonsils (2) 3. Palatine tonsils (2) 4. Lingual tonsil. They form a ring shaped structure known as Waldeyer’s ring. The tonsils are classified as mucosa-associated lymphoid tissue(MALT. Function- fighting infection. Tonsilitis Tonsillitis - form of pharyngitis characterized by acute inflammation of the tonsils. Viral or bacterial cause. Px- sore throat Fever >38ºC Dysphagia Nasal congestion, headache, earache, cough On examination- inflamed tonsils, cervical lymphadenopathy, purulent tonsils Note- absence of cough and presence of pustulent tonsils indicate bacterial cause Scoring system- Centor criteria and FeverPAIN criteria Management - reassurance, fluids, paracetamol or ibuprofen - Antibiotics may be given if high enough Centor or FeverPAIN. Differentials- Glandular fever (severe fatigue, splenomegaly, check abdominal pain) , Deep neck space infectionTonsillectomy Tonsillectomy is the removal of the palatine tonsils. According to NICE, patients meeting all the criteria listed below should Complications of tonsillectomy- be considered for tonsillectomy • Sore throats are due to tonsillitis (i.e. not recurrent upper -Primary (< 24 hours): haemorrhage in respiratory tract infections) 2-3% of patients (cause- inadequate • The person has haemostasis commonly), pain seven or more episodes of sore throat per year five or more such episodes in each of the preceding two years or three or more such episodes in each of the preceding three years -Secondary (24 hours to 10 days): haemorrhage (cause- infection • Symptoms have been occurring for at least a year commonly ), pain • The episodes of sore throat are disabling and prevent normal functioning Manage bleeding through ABCDE method, hydrogen peroxide gargle, other established indications include: • Recurrent febrile convulsions secondary to episodes of tonsillitis antibiotics • Obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils • Peritonsillar abscess (quinsy) if unresponsive to standard treatmentComplications of tonsilitis 1. Peritonsillar Abscess (Quinsy): •severe throat pain, which lateralises to one side •difficulty swallowing and speaking- hot potato voice •deviation of the uvula to the unaffected side •trismus (difficulty opening the mouth) •reduced neck mobility •systemic features: fever and chills, malaise -Treatment - antibiotics and drainage 2. Deep neck infections -Parapharyngeal abscess- infection in parapharyngeal space -retropharyngeal abscess (next few slides)Retropharyngeal Space Location= between the visceral part of the prevertebral layer of deep cervical fascia and the buccopharyngeal fascia surrounding the pharynx superficially. Divided into - true retropharyngeal space and the danger space The true retropharyngeal space ends at the upper thoracic spine The danger space runs all the way to the posterior mediastinum until the level of the diaphragm (extends to posterior mediastinum) Infection in this space causes retropharyngeal abscessRetropharyngeal abscess RED FLAGS- Sore throat in the absence of an abnormal oropharyngeal examination Severe neck pain or stiffness Any signs of airway compromise, such as stridor, dyspnoea, drooling, dysphonia Torticollis Chest pain – infection can extend into mediastinum causing mediastinitis (50%mortality) Inability to tolerate oral secretions Trismus (lock jaw) Ix- CT scan with contrast Mx- surgical drainage as the first line and then antibiotics ( ceftriaxone, metronidazole) Dental Infection Spread Ludwig's angina is a type of progressive cellulitis that invades the floor of the mouth and spreads to the soft tissues of the neck. (into the sublingual and submandibular space) It can then travel to the parapharyngeal and retropharyngeal spaces, encircling the airway-> airway compromise Occurs as a complication of dental infection(cavities) , immunocompromised more at riskRed Flags ENT EAR •Persistent unilateral hearing loss/tinnitus •Sudden onset hearing loss •discharging ears [espec in immunocompromised =malignant otitis externa] •Pain (including referred otalgia) •Facial nerve palsy •NOSE: •Blood stained mucous •Facial pain [esp unilateral,persistent, getting worse] •Orbital symptoms [epiphoria] •Sinusitus in immunocompromised ??fungal •CSF leak •THROAT •Dysphonia (hoarseness) •Dysphagia •Odynophagia •Pain [can radiate to ear] •Any persistent growing lump@supta_uk @SUPTAUK www.supta.uk