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Ok. Um Hello everyone. Welcome to another session. Uh Today's session is gonna be on head and neck anatomy. Um It's gonna be given by Mr Campbell who is a registrar um of uh ent um ready. So ma ma ma sorry, my mistakes, Max Fox. Um So please do Jonas and tune in. And then for next week, we will have another session on abdomen as well. At the end of the session today, we'll have uh feedback form sent out to you. Please do fill them in to get your certificate of attendance. Uh, recordings from the session will be also be available to you about 12 hours after the session, right? I'll hand it over to him if that's ok. Sure. Hi guys. Um I would say nice to see you or I can't see you, but I did a teaching session on the lower limb. So if you came to that one, then I guess you might um remember me and thanks for introduction. Yeah, so I'm a max fax trainee. I'm working in Kent at the moment, which is just south of London. Um, and um, I'm gonna talk to you today about some head and neck anatomy this evening. Um, and I think Jo's gonna kindly do the slides, uh, neck slide, please. Um, I think you can write stuff in the chat, which I can see on my screen as well. So if you want to ask something that's, that's totally fine, just ask away and, um, I'll answer it if I can. Um, so hopefully at the end of this hour, you'll have a better understanding of, um, head and neck anatomy. Um, seeing how the time goes, we might do a bit of a break, but these are the things that I'll try and cover. So we'll go through the neck muscles to begin with and then the neck triangles, um, a bit about the external carotid, um, thyroid gland, the larynx, er, and then facial nerve i anatomy and a tiny, tiny bit of dental stuff. Um, next slide, please. Um, he head and neck is, is a pretty mammoth topic. Um, I think that it's, I mean, people do whole years of study on, you know, lifetimes of study on it on, on subsections of the head and neck. Um, so, um I'm not gonna do neuroanatomy or the skull and sort of the blood supply, um, which is something that you'll need to know about, I guess from uh med med school. So I think the majority of you are medical students. Um, it's people in my experience with anatomy, people find um, different things that they like Um, so I like head and neck anatomy. I think it's very interesting, um, place to work and operate and to know about. Um, but other stuff is just, feels very foreign to me. Like I've never really understood the pelvis, but some people love it and they'll know much more about it. Um, um, so, you know, I hope you enjoy this evening, but I'm, I'm not gonna do anything on your anatomy and stuff, but it's worth knowing those things. I just put facial muscles at the bottom there. Um I don't think that's something that most medical schools would really expect you to know in great depth. It's not something that the MRC S which is the post graduate surgical exams, expect um, people to know. Um It's obviously interesting and you, and you can look at it, but that's just why I put it at the bottom there. A slide, please. Dr um So I had this type before. Um, anatomy is difficult. It's, it's, um, it can be, it can be really overwhelming and it's just repetition and that's why you see these um, older surgeons and anatomists that know everything and that's cos they've been doing it for 4050 years. Um And they've been revisiting stuff and medicine is so mammoth and so vast um, that, you know, experience counts for so much. Um because you just see things and you see small things more regularly and you remember it. Um, and anatomy is the same. Uh, and just you, you'll go over something and you understand it and then you look at it next week and it's gone and it's just repeating stuff. Um, pro sections and dissections are great. Um, using different ways of learning. Um, if you've got, uh, that available, um, simply because anatomy is very much a 3d thing. Um, again, if you're interested in surgery, it's about how things relate to each other. Um Which, which is 3D, which, you know, you don't get from looking at a textbook as a two D image um orientating yourself when you start. So the big structures, um you might remember one or two things from the area and if you can pick those out and remember where smaller nerves and muscles are in relation to that really helps. Um I've just written check your medical schools textbooks. Um It's not something I did but um so a lot of the London schools like Gray's and Gray's Anatomy, um Not that there's anything wrong with, with Netters or something like that. I've got Netters, which I think is really good, but sometimes there's some slight differentiations between what textbooks say about stuff even in something like anatomy. So I would just uh check what they say rather than learning the wrong sub branches of stuff. Um And I've thrown in a clinical clinical application of stuff, something you might see and how anatomy applies to that or how anatomy affects that is, is useful as well. Slide, please. Uh just different planes. So we had this at the start before um much more applicable now than it was in days gone by um due to CT scanning and MRI scanning. Um And again, knowing if you're in a sort of a coronal plane or um you know, a transverse plane allows you to again orientate yourself and work out where you are. Um Thank you slightly. OK. So we're just gonna dive in, I think and go straight to um some of the neck muscles. Um So I was in a big ent max joint case today. Um And we were sort of working in the neck and they call that a safari and tiger country apparently is the old school term for it. Um So there's a group of muscles known as the strap muscles um which are in the central, the central neck region. So, um these are uh below the hyoid bone. So the hyoid bone is that sort of is the, the, the bone in the middle of the neck below the mandible. Um That's sort of floating there and the muscles below that um are the infra infra hard muscles known as the strap muscles. Um And you've got two superficial ones, um hopefully, you can see the picture well on your screen, which is the sternohyoid and the omohyoid. And then you have two deeper muscles called the sternothyroid and the thyrohyoid. Um The names sound quite complex. But again, thinking about where those muscles are going to and from. Um So, you know, for example, you've got um um the sterno um hy, the omohyoid and the sternothyroid, they're gonna be traveling um between those structures. So, from the sternum to the hyoid, you know, this is gonna be the sternohyoid bone. Um And on the right of your screen, you've got um a dissection there. So um number 34 I think on, yeah, number 34 there. That's, that's um the omohyoid muscle and then 31 is the sterno sternohyoid. Um 32 is the sternothyroid and then 38 is the thyrohyoid. And um if you can, I think they're picked out on the, on the picture diagram. So again, comparing the sort of illustration with the um um the prosection there is helpful. Um they, they like asking about the nerve supply to these muscles. So this, they're all supplied by parts of the ansa cervicalis um which uh it comes off the um cervical from the cervical vertebrae from C one to C three, the thyrohyoid. So the thyrohyoid muscle, a slight exception to this um which comes off the cervical spinal nerve branch one. So it's not quite from the anus cervicalis. Um and these muscles again um below the hyal, so they depress the hyoid bone and the larynx, which is the voice box um during swallowing and speaking. Um and the, the ansa cervicalis, ans means cup and handle it. It's sort of Latin term. Um And it's a, it's a plexus of nerves coming from C one to C three. It's got sort of um a superior and an inferior roots. Um And these fibers come from the anterior rite of the cervical spinal nerves around the back of the neck. Um and they're usually found over the carotid sheath. So in sort of neck dissection operations for head and neck cancer, this is something that you'd want to identify and try and avoid damaging because obviously, if you damage that you're gonna affect the these muscles that um depress the hyoid during swallowing and speaking, um there's lots of muscles in the neck. Um The other ones I'm gonna mention um are above the hyoid bone. Um So I think number three, so you sort of on the um on the prosection towards the, towards the front, you see a number three muscle, um which is um the anterior belly of the digastric. Um And that means you're also gonna have a posterior belly. And again, these are marked out on the illustration as well. Um I mentioned those because they help divide up the different triangles in the neck. So that's why it's an important muscle, which I'll talk about in a second. Um And I also mentioned that muscle because um of the nerve supply which er differentiates a bit. So the anterior belly comes from the marginal mandibular nerve from V three. And then the posterior belly is the, is the facial nerve. Um, and again, they like to catch you out. So that's um something that's, that can be asked. Um I think, and then, er, number 23 is the um mylohyoid muscle, which is, I think on the illustration as well. So that sort of forms to the floor of the mouth. Um, the other big muscle in the neck is the sterno cle a mastoid muscle, which probably one that you've heard of if you've done a bit of head and neck anatomy, um which helps sort of turn the neck from side to side. Um That's labeled as uh it's number 30. So on the prosection, it's been cut. So if you look up towards the ear there, you see number 30 it's, it's been cut. Um But as well as helping to differentiate um different triangles in the neck, um You've also got a couple of important nerves. So, um on the prosection, um if you look at the nerve on top of it, number 13, so that's the great auricular nerve. So this is on top of the sternocleidomastoid um running over it and this, this nerve supplies the skin of the angle of the mandible and the lower part of the protid and lower part of the ear here as well. So again, if you're working in the neck, um this is a nerve that you want to try and protect and preserve and then underneath that, um, muscle underneath the sterno, the muscle, you have the spinal accessory nerve. So, cranial nerve number 11, um and it runs diagonally, sort of under surface marking would be um between the upper third of the cern in the mastoid to the, underneath the SE M to the upper third of the trapezius. Um And again, this muscle helps you shrug your shoulders and it is another nerve and um that nerve innervates the trapez in the SE M, which helps you shrug your shoulders and it's a nerve that you want to um protect when you're operating in the neck as well. And these are the big structures that you want to identify and find. Um cos they have a big impact on the patient's life. You know, if these are, are sort of cut and damaged, um If you click, please j I think another picture will come up. So thi thanks, this is um so this is just ii like this picture cos it was quite simple. So it shows the Sterno CCL a Mastoid muscle there in the trapezius muscle, big muscles in the neck. And then you've got the spinal accessory nerve um running underneath that and then the great auricular nerve going up there as well. And these are the bigger nerves that you can see and want to identify the neck. Um OK, so if that hasn't put you off and you're still there, can we have the next slide, please? OK. So neck triangles, um there's, there, there are lots of sub, sub triangles in the neck, which I'll talk about a little bit. But the main ones are the anterior triangle and the posterior triangle. So we'll just try and keep it simple to begin with. Um So the, so the anterior triangle of the neck, so you've on that pitch, you've got the posterior triangle and the yellow color, anterior triangle is gonna be in front of that. OK. So the boundaries of the anterior triangle, so you've got the midline of the neck, this is the anterior boundary and then the posterior. So going towards about the posterior boundary is gonna be the anterior border of the stern occluder mastoid to the front of that muscle. Um And then the top of the superior boundary is gonna be the lower border of the mandible. So those are your boundaries. So that's the anterior triangle of the neck. Um And on the right is a list of the things within the anterior triangle of the neck. Um So you've got the big submandibular gland, the nodes, you've got facial vessels, hypoglossal nerves, that's gonna big nerve that's gonna innervate the muscles of the tongue. Um And then again, just thinking about the anterior triangle of the neck that can be further subdivided as well. So if you look at the green part of the picture, um this can be divided up into the um the, you've got a submandibular triangle, which I think is labeled there for you. Um And you see that there's or you can see the hyoid bone and then you've got the digastric muscle that we mentioned earlier. So that's why I wanted to tell you about that. Cos that helps you work out the submandibular triangle, um which will contain the, you know, the sub mandibular gland. Um Then you've got the carotid triangle, OK. So then you're going below the posterior belly of the digastric. Um But above this omohyoid muscle, um which we didn't point out on the prosection, but that's another muscle that helps to find out the triangle. So again, in that carotid triangle, you're gonna have the carotid artery and sheath that's gonna be sitting in there and then the triangle at the front is the muscular triangle. OK. So that's where the, the strap muscles sit that we, we talked about um in the previous slide. Um I think knowing the boundaries of the anterior triangle is important, knowing the subdivisions, I think you'd be doing extremely well. Um Even MRC S is it would be, you know, it would be good to know that. But med school level would be impressive, but definitely, you know, the boundaries and the contents of the anterior triangle I think is important. Uh Next slide, please. So posterior triangle. So again, keeping it nice and simple, this is the yellowy area on the picture. Um and um thinking about the boundaries now, so you've got the apex, the top is gonna be the se m of the trapezius muscle where they meet. OK, the anterior boundary of the posterior triangle. So the front boundary is gonna be the posterior border, the back border, the sterno, the mastoid muscle. Um the post, um the posterior border is gonna be the anterior border of the trapezius and the base is gonna be the middle of the clavicle there at the bottom. Um You can subdivide it up a little bit by the omohyoid muscle, which is that string of muscle that runs through the posterior triangle. Um But um knowing the boundaries of the posterior triangle, I think is important a and as you might have, you might know, you know that the boundaries are sort of shared with the anterior triangle in front of it. Um Contents is listed there, I think on your screen. Um Again, knowing that you've got the accessory nerve, um the phrenic nerve trunks of the brachial plexus. Um I think George talked to you about the, the, the brachial plexus which is divided up into sections um in the roots, the trunks divisions, um cords and branches. Um and the um the trunks are found in the posterior triangle of the neck. So, so this is where if you're working towards the bottom here, you'd be worried about the trunks of the brachial plexus. Um You've got the external jugular vein, um muscles and lymph nodes as well. And if you click, I think another picture would come up to your own, please. Um So this is just the, the the vessels that are written to be included as content. So you've got the external jug there. You can see that's lying over the SE M and you know, in sort of skinny people, you can, you can often see that. Um And then if you click again, please, Jerome. Thank you. Um And then you've got the um some nerves that are mentioned that we talked about there. Um and the accessory nerve um running forward and the great auricular nerve there and then some transverse focal branches as well. But the great auricular in the uh accessory nerve I think are the important ones. OK. Uh slide, please. So I just put this here um because you might hear about or be taught about neck levels and we've ta so the neck can be divided up into these triangles that we've talked about which um are sort of anatomical triangles um um divided up by above and below muscles that we've mentioned. But the, the er surgeon's radiologist, this is just a different way of dividing the neck up into different areas. Um So for example, six here, this, this is level six, this is the, the muscular triangle really. Um But I think um just ii don't think this is something you need to know, the anatomical divisions you get into, you know, consultant surgeon, sort of level um really. But um it's just to, to give you an idea of where they, where of where they are. So, so s so level one is um at the top page, you've got the submental and submandibular triangles, uh that's the same place. And then you, as you go sort of 234, you're sort of working down the internal jugular vein. It's also known as the deep cervical nodes. Um And then level five, there is the posterior triangle. Um and level six is the the muscular triangle, the central component. So it was just to let you know that this is an alternative way of dividing up the neck as well. Um Slide, please. OK. Right, external carotid artery. Um So this is a continuation of the common carotid artery. Um I think knowing where it starts is important, which is at the upper border of the thyroid cartilage. OK. Which I think you can see sort of labeled um on, you can see the picture on the illustrations. It starts the upper border of thyroid cartilage, which is at level C four. which I think is important to know where it starts. They like knowing different levels again. So you can work out where you are. So if you know your cervical vertebrae, number four, this is where the um external carotid start and it splits, giving you obviously the internal carotid and the external carotid, the internal carotid goes um on to supply the um to supply the brain. Um and the external carotid um supplies a lot of the neck. Um it will terminate um behind the neck of the mandible, the jaw bone inside the protid gland. And here it divides into the two terminal branches which are the superficial temporal branch, which you can sometimes see pulsating on someone's forehead. Um and the maxillary artery branches. Um So onscreen is just a pneumonic uh weight. There's lots of pneumonics in medicine which are great. I think they, they, they help you remember things and learn things. Um um So those are the branches um of the external carotid. I think it's reasonable to try and learn those. Um But again, if you think about anatomy being um 3d, um the external quater will have um three branches that come up towards the front, which is the superior thyroid, the lingual and the facial er two go backwards, go posteriorly which are the occipital and posterior. And then the deeper branch goes is the ascending pharyngeal. So the pneumonic is the order that they come out in, but remember they'll be sort of shooting off in um in different directions as well. Um Slide, please. Um So I'm not going to talk about this too much, but um this is more of a physiology type thing, but I think it's important to know where this is as we were talking about the external carotid. So the picture shows um the um common carotid bifurcating. Um And at this point again, um C four that we said you'll find the carotid body. So the carotid body is sensitive um to blood ph um and it sounds sort of just behind the bifurcation of the common carotid artery and it's labeled on the picture. And then you also find there um is the carotid sinus um which is a dilated area at the base of the internal carotid artery um is just above the bifurcation. Um And this has barrow um receptors um which help to measure uh BP. So, uh this is a big important, an anatomical structure that is gonna have a big effect on the body if it's um damaged as well. Um OK. Next slide, please. OK. So thyroid gland, um What can we say about that? Um It's an endocrine gland. Um uh So this means that it, it makes hormones that are released into the bloodstream as opposed to an exocrine gland that makes substances um that are released through uh an orifice or a, or a duct um like a sweat gland or something like that. Um It's found in the neck at the front of the neck um from levels about levels C five to T one. Um And I think on the picture you've, it's, it has a, it's got a right lobe. OK. And a left lobe and the er, and the, the gland is connected by a central isthmus and it gives it that sort of butterfly shape um at the top of your screen. Um it, it is a picture given a cross section of the um of the neck to give you an idea. You've got the trachea with the esophagus behind it, the vertebra bodies behind that and then the blood vessels on either side. Um and the, the thyroid gland is found in the pretracheal fascia. Um And fascia is quite important in, in terms of dividing things up and, and which fascial layers, different things are in. Um And the thyroid gland is sign of the pretracheal fascia. It releases thyroid ht three and T four and also calcitonin, which plays a role in um calcium homeostasis. So, again, anatomically, surgically, it's an important gland damage unit is going to do bad things um to the rest of the body blood supply. Um So you've got the superior thyroid artery, um which is as was, you might remember the first branch of the external carotid. Um You've got the inferior thyroid artery which comes off the thyroid, so I called trunk lower down. Um And this is from the first um branch of the subclavian artery. Ok. And some people have um about 10% of people have the thyroid I ma branch coming off the brachiocephalic artery as well. Venous drainage of the gland. It's a plexus of three veins um you've got a superior and middle, a thyroid vein that drain into the internal, internal jug and then a inferior thyroid vein going to the um brachiocephalic vein and then the lymph drainage, um it goes all over the place really pre laryngeal, pretracheal, paratracheal, upper and lower deep cervicals, um brachial phallic lymph nodes to it. So it does sort of go all over the place. Um anatomically, they, they are, they, they quite like you knowing about um the embryology. Um and the thyroid gland develops um from something called the Framan cecum, which is found at the sort of at the base of the tongue about two thirds along it um towards the back of the tongue. Um So, embryologically this um moves forward and it sort of loops around the hyoid bone um beneath it. And if this doesn't happen properly and there is um incomplete descent, you can get these pyramidal lobes. And if you look on the illustration there, that's, that's illustrated, that's what it looks like. And you can see how it's sort of joined up towards the hyoid bone. Um So that's a pyramidal lobe, which is an anatomical variation. Um And if this pathway doesn't close, you can get something called a, a thyro thyroglossal cyst. Um And this is, yeah, so this is a persistent um uh thoraco duct track and it, it seen as an irregular lump in the neck that and the way to differentiate it is to ask the patient to swallow and the, and it will move up cos it's attached to the hyoid bone. So it will go up and down with it. Um And also because it's in that pretracheal fascia where the gland is and that pretracheal fascia is attached to the thyroid cartilage in the hyoid bone. And when those muscles contract during swallowing, um it, it pulls the hyoid bone up and all the pretracheal fascius, it all goes up with it. Um And if you um click your own, if you don't mind, I think there's a, so this is a picture of a young man with a lump in the midline of his neck, um which is a thyroglossal duct cyst and the way to test it would be to get him to drink a glass of water and see if it goes up and down. Um These can get infected and you have these sort of big procedures to do a cyst trunk procedure where they dissect out the middle portion of the hyoid bone and the remnants of the track. And uh if you click again, please, Jerome, this is just a picture I found of a lady with a goiter which you might um hear about on the medical lectures and stuff, which is a problem with the thyroid gland not working properly. Um We can get it with iodine deficiency lots of different things. Um But, but that, that would be a differential for that big neck lump and that's a, a goiter, thyroid goiter that that lady's got. Um, ok, next slide, please. Ok. So I know this is heavy work. I'm gonna try and talk about the thyroid nerves. Um, thyroid surgery is, you know, the guys do it. It is common. Um, you get a lot of problems with the thyroid. Lots of people who have had thyroid surgery, it's safe but there are things that can be um injured and the consequences of that, of those things can be fairly serious. Um, so there's a couple of nerves that are commonly injured. Um, you've got the external laryngeal nerve, um which I think is in er labeled on the diagram. So this nerve, um it, so they like, you know, and it's, it's relation. So the external laryngeal nerve is close OK to the superior thyroid artery. So there might be like a question of superior thyroid arteries, ligated or damaged, which nerve might be injured. It's gonna be external laryngeal nerve. External la nerve is a branch, it's a vagus nerve, the 10th cranial nerve. Um um coming from the brain stem known as the a wandering nerve goes all the way down to the gut. Um, so the external angio nerve, this nerve supplies the um, the cricothyroid muscle. So again, this is something to remember. The external laryngeal nerve supplies the cryo thyroid muscle and this is the um the only intrinsic larynx muscles. So the larynx being the voice box that's not supplied by the recurrent laryngeal nerve. So all the other muscles in the larynx, um, speaking muscles, um, which I've got a slide on. Um, those are all supplied by the recurrently laryngeal nerve, other in the cricothyroid muscle. Um, it gives off the internal angio nerve, um, which supplies mucosal sensation to the portion, slot, portion and the epiglottis. Um, and the reason why I'm going on about this nerve is because damage to it can um affect the uh pitch of voice and, and, and singing. Um So that's the external ge nerve and then the recurrent laryngeal nerve. OK. So this is the nerve that runs uh that supplies the rest of the laryngeal muscle. Um um other than the cricothyroid. Um So I think it is on the picture. Um So this, so, so it, it's got a difference in its pathway. OK? On the right and the left hand side, um So on the right hand side, which is if you look at the picture on the left of your screen, it's labeled in bold. You got the right uh recurrent laryngeal nerve. Um So on the right hand side, it goes anteriorly over the subclavian artery and then in an inferior and it loops, it goes backwards and loops posteriorly under the um to go um back up the neck uh between the trachea and the esophagus er to the larynx. Whereas the left side, um you can see it goes all the way down. Um And then it goes under the aortic arch and then comes back up. Um um, and knowing the um difference in the side is important, so they often can label those on a specimen because the right side is different to the left side in terms of its course. Um So I think that's something you definitely need to be aware of and knowing the, um again, the external nerve supplying the cricothyroid muscle um in the larynx. So as I said, people will have the thyroid glands removed and operated on um and removing the thyroid gland is gonna give you hypothyroidism. Ok. So the patient will need to be started on thyroid medication on thyroxine. Um but they also at risk of low calcium levels or hypocalcemia. So, on the picture, you can see um that little dots on the back of the thyroid gland. So this is the back of you um of the um parathyroids. So these are at risk of damage, either physical damage or removal or their blood supply being hit, even if you're operating on the thyroid. Um the surgeon will try and preserve the parathyroid glands but they can still be damaged. So we always check someone's calcium levels afterwards because those parathyroids again are involved in that calcium homeostasis axis. Um So knowing where those are is important, um I think the other er helpful bit is they like occasionally to ask you about the embryology of the parathyroids. So it's kind of sort of flipped. So the inferior parathyroid um comes from the third branchial arch. Um whereas the superior one comes from the fourth branchial arch, sometimes they um have that as an M CQ question. Um And the blood supply is um from the inferior thyroid artery. So for the um parathyroid glands, OK. Slide, please. OK. So it will just take a couple of minutes break for me more than anything. Um, so it is 739. So if you come back at just do three minutes, come back at um, 742. If that's all right, bye. Ok. If you're there, I'm happy to keep going. Yeah, thanks. Ok. Right. The larynx. So, um, it's, it's, it's complex. It's, it's a difficult anatomy. So I hope this is helping, um, try the pharynx itself. Larynx is the voice box down here. Pharynx is further up. The pharynx can be split into three, which is showed by the, the colors on the right hand side. You've got the nasal cavity. Ok. So, um, you can see that the, the nasal cavity has got a straight floor. Ok. So it's, it's got a straight floor like this. It doesn't, it doesn't go up there into the nose. So if you want to get into someone's nose, you go, you go straight along here, um, rather than sort of up sort of base of a pyramid type thing. And you've got the nasopharynx. So you're getting towards the back, going back of the back of the nose now into the, into the oropharynx as well. Um And then in the, the larynx itself, you've got hypopharynx, which is the sort of bottom part of the pharynx. Um, um, just above it, that, that helps make up the larynx before you go down into the trachea. Um So he just said, um, just to remind you go over it again, you said that all the muscles of the larynx, the little muscles are supplied by the recurrent laryngeal nerve. Apart from the cricothyroid muscle, which is the external laryngeal nerve, which is of the superior laryngeal branch of the vagus nerve. So that's just the one thing to just try and drill into your brains cos you may well get asked about it. Um And also does sensory, as I said, above, the vocal cord is the internal laryngeal nerve, which comes off the superior laryngeal nerve. And then below the vocal cord is the recurrent laryngeal nerve in terms of sensation. Um No, we're gonna do some bits of cartilage. Um If you click, please, Jerome, I think another picture should come up. Ok. So, um before we do that, I just threw this in here. So you might, if you're on placement and stuff, you'll see people do some scopes. Ok? So you go along the base of the nose there with it with a thin camera and this is the view you're gonna get. Um you're gonna have, you'll be able to see the vocal cords and the epilosa top of the picture um and down into the trachea. So this isn't uh a fine nasal endoscope or an F ne um which you want to do to check. Um You can see if the vocal cords are moving to see if you've damaged a nerve or if you want to see if there's any sort of tumors basically in a place that you can't examine, you can do this with the patient awake. It's a really useful um tool to be able to do and have um, if you click again, please. Um And once more. Ok. So these are some pictures of the um cartilages. So you've got in the, in the larynx, it's made up of cartilage. You've got unpaired cartilages, impaired cartilages. So, the unpaired cartilages of the thyroid cartilage, ok. This is the biggest cartilage and I've given you different um sections cos again, you've got at the top is a sort of um, a view from the top and bottom like a cross section. Whereas um this is a view from the side at the bottom of your screen. Um And as you can see quite different, again, thinking about anatomy is 3D. So thyroid cartilage is the biggest, it makes up the um, Adam's Apple, which is the laryngeal prominence, you know, more common in uh bigger in men. Um the posterior border of the thyroid cartilage has the superior and inferior horns called the cornu. The cricoid cartilage is the ring of cartilage. OK. It goes all the way round. Um um And that is at C six. So that's the level to remember. Um It's at C six and this articulates with the um Anoides cartilages posteriorly. Um And it's the only complete ring of cartilage. So you, you, you can do a maneuver which is called um Cellex maneuver where you press it because it's a ring of cartilage. It will occlude um the um esophagus behind it. So, if someone was um being sick, you could prevent them, sort of regurgitating any content um of the stomach celex maneuver. Um The epiglottis is a unpaired cartilage. Um And this covers the larynx when you swallow prevents aspiration. It's kind of that leaf shaped object and you've got paired cartilages, um which I'm just gonna run through, which is the Anoides corniculate, which tiny little things, a cni form. Um And I was gonna talk about the muscles, but um I'm just gonna, I think skip on because um it's so minute and we're getting into real detail here, I think. Um And, you know, I don't know all of these really well. Um um But remembering the injury to the, the nerves that we talked about the thyroid are gonna, are gonna damage um these, these muscles of the larynx. Um, ok. So, um which can affect um swallowing and, and, and pitch of voice and, and, and distance and um hoarseness as well. So, um these are all been innervated by the um the, the nerves that we talked about. Um So, um, you know, that's the side effects or risks of, of, of thyroid surgeries that the patient will be told about. Ok. Slide, please. Ok. Um So it's gonna briefly talk about the facial nerve. So it's um it's a long, it's a long nerve. I just chose this nerve. Cos I think it's, it's it's a really important one and um I think knowing the branches is something you definitely need to know at med school. So on the left of the screen. So the facial nerve um it's um it does the motor supply, so it does all the muscles um of the face. So all the muscles are facial expression all supplied by the facial nerve. OK. Um It's got five branches um and those are colored on, on, on your, on your screen. They're temporal zygomatic buccal marginal mandibular cervical. Er the pneumonic is uh I remember it's slightly rude which is the er temporal Z zebra. Um B is buccal bal bugged my cat and marginal mandibular cervical. So the zebra bugged my cat and there's your five branches. Um lots of other ones out there that you can you can use. Um So it starts um it originates between the pons and medulla of the brain stem OK. And it travels through the internal acoustic meatus um through the facial canal in, in, in the prus part of the temporal bone and exits through the stylomastoid foramen. On the right of your screen is a brain stem. Ok. Um, that is something you'll cover during the neuro anatomy stuff. But just to give you an idea of where the facial nerve starts is between pons and er the medulla. Um, it's a big nerve and that's where it begins and it travels with the vestibular cochlea nerve, the hearing nerve through the um internal acoustic meatus, it gives off a few branches. In addition to the um motor branches of the face, you can see those there by the ear in the protid gland. Um So we mentioned that it supplies the, the posterior digastric branch. Uh it gives off a posterior auricular branch and then a little nerve to a hearing muscle called stapedius as well. Um But knowing the, the motor branches is important and if you click, please do. Um this is a picture. Um OK. Yeah. So this is a picture as the facial nerve exits through the stylo muscle framing, which is one of the framing in the base of the skull where the nerves come out. Um You can sit giving enough branch of the digastric muscle, um um shooting a nerve branch back, the posterior auricular, so behind, posterior to the aicar nerve. Um and you can't see the little nerve to the stapedius which is inside the canal. Um But those are the few branches it gives off before it goes on to give off the um those motor motor branches as well. And you can see how that's close to the external acoustic meatus, which is the um your, your ear, your hearing canal. Ok. Uh Slide, please. Ok. So, um I just thought I'd mention um the structures that are going through the protid gland briefly as well. That's something that would be worth knowing about. So, we've talked about the facial nerve and those five branches that are going through the protid gland. In addition to that, you're gonna have the external carotid artery that we talked about. You're gonna have the retromandibular vein. Um You're gonna have the auriculotemporal um nerve. Um whi which is a branch of the, one of the branches of the trigeminal nerve, the V three and some deep protid lymph nodes. Um So I'll just say that again. So you've got the five motor branches of the facial nerve, external carotid artery, retromandibular vein, um thot temporal nerve and some deep carotid lymph nodes, knowing those structures in the carotid gland again, is something they can ask, why are they asking that people get tumors in the carotid um benign ones, malignant ones. It's fairly common surgery to have done and knowing that those things are at risk um when you're working in that region um is important. Um the protid duct opens. So it, it has a, it has an an orifice which is um called Stenson's duct. And that is found inside the mouth opposite the second maxillary molar tooth. And if you go in the mirror tonight and pull your cheek back and you'll be able to see it. What you probably think is a tag of skin, tag of tissue on the inside of your mouth. That is uh the top tooth, maxillary tooth, second molar at the back that is stent and duct, which is where the protid will release its secretions. Um And then this slide on the, the picture on the right hand side um is just to um help you differentiate between an upper and motor um neurone sort of lesion. So, um again, clinically like super relevant. So um if someone's had um a lower motor nerve nerve, um facial palsy, um um the whole face is gonna be affected. So, um they were basically, they're not gonna be able to raise their eyebrow whereas um if someone can raise their eyebrow, but they've got a facial droop and they're quite likely to be having a stroke and it's an upper motor neurone lesion. Whereas a lower motor neurone, you know, if you, if you knocked off this um the facial nerve, then the patient won't be able to raise their eyebrow. Whereas if they had a stroke or something on the opposite side of the brain due to cross innervation but they're gonna, um, be able to raise their eyebrows. So that's just, uh, I think an important take away and point and some relevant anatomy. Um. Ok. Slide, please. Ok. Ici don't know why I chose this. This is so difficult but, um, I'll hopefully try and help you understand. I just gonna go with some air boundaries. Ok. So the ear is, um, you got to think of it a bit like a box. So it's really important to try and get your sort of 3D heading gear. Um And it's, I think it's relevant because er when you've got a hole to the outside and it's a 3D box, basically you can get infections spreading to, to various places. Um the, the, so the picture on the left of your screen, you've got the green er the external ear, the middle ear and the internal ear. So those are the three major bits of the ear, so to speak. Um So if you were just thinking about the middle layer, first of all, so the axon layer is just your ear canal, ok. Um And the middle ear, so majorly um of of, of the middle ear is, is, is gonna be um um so sorry, so laterally it is gonna be the um tympanic membrane or the eardrum. So medial to the middle ear, um it is the, you've got those or medial going working inwards, you've got the three small ear bones, the malleus incus and stapes which transmit the sound vibrations, OK? Um And then if you look at the picture on the um the right is sort of com complicated picture. Um If you look at it's a box, if you look at the roof of the box or the top of the screen, you've got the, this is the roof of the middle layer, OK? And this is the Tegmen, Tegmen Tympani. So this is bone separating um the mid lip from the medial cranial fossa. So you go, you go through that, you're going into the brain, which is why you know, people can die from, from sort of ear infections, from middle ear infections. Ok? And get meningitis. Um The other way it can go is through the back wall. OK? Um So this is into the, into the mastoid air cell. So if you the sort of top left of that picture, the additus to the mastoid antrum, um um additus means means opening um it can go forward so it can go anteriorly, you've got a thin piece of bone close to that is the internal carotid artery. Um This is where the opening is for the Eustachian tube. Um And you've got the tins and timpani muscle here. So this is a muscle that when you pop your ears or you, you swallow the tins and timpani pulls, it contracts um which is a muscle in the soft palate, um innervated by the, the mandibular nerve and um and that helps pop your ears. Ok? When you, when you put on that and it equalizes the pressure in your ear. Um and you can get, um you can get fluid because it's got that tube that connects to the back of your throat. You can get fluid build up in there. So you can get a Titus media middle ear infection with a fusion and this is essentially flu air. Um and you get persistent dysfunction of that. Um You can get negative pressure in the middle ear, which is a high risk of infection common in kids because their eustachian tube is shorter than adults. And this is when they might go on to have a grommet placed um which helps equalize the pressure, which is a little bit plastic within the tympanic membrane, helps stop the build up quick come an operation, the floor of the box um going back to the picture is the jugular wall. Um So you got a thin piece of bone, separate the tympanic cavity from the superior bulb of the internal jugular vein and then the medial wall um is towards the internal ear. So the orange part of that, that picture um with the three colors um with the vestibular apparatus. Um and this is the part where you get the conversion of the mechanical signals from the middle ear um and the bones into electrical signals which are then transmitted um to the brain. Um with the vestibular cochlear nerve and it also helps um maintain balance and motion and you get these little crystals and stuff that can get out of whack um within the internal ear. Um The two, the, the, the inner ear sort of split up into um a bony labyrinth, um which has the cochlear vestibule and the semicircular canals um in it. And then the membranous labyrinth, those are the two parts. Um And then going back to the box, you've got the lateral wall, which is where you have the tympanic membrane, as I said, and the lateral wall, the epi tympanic recess, which is a kind of a bit of a space above this. But um um again, we're getting quite detailed. I hope you uh made sense of that a bit. Um If you click, please. Um Jerome, this is just a picture. OK. So this is a baby. They've got mastoiditis. So they've got redness behind the ear. They've got a middle ear infection. It's spread um through the, the back wall into the mastoid air cells. The mastoid is bony prominence here. It's got air cells in it. Um And people can get really sick with this cos it can spread into the brain and stuff. So, um if you saw a baby like this, you know, they don't just have a sort of run of the mill ear infection. It's gone to mastoiditis, the air will be pushing forward, it's gonna be red, they're gonna be, you know, really unwell and they're gonna definitely need um um a admission and intravenous antibiotics and stuff like that. Ok. Slide, please. Ok. We are pretty much done. I just threw this in because um this is more of my dental background. So this is an O PG, this is a dental X ray, ok? Um it's more for your dental colleagues but um I'll just briefly run through it with you. So you've got um you've got all your teeth in there. So this is your jaw, OK. Top jaw, bottom jaw at the top and the bottom, um dentists like to split things up into four. So you have a top, right, top left, lower, right, lower left quadrants. Um This is a fairly straightforward, straightforward, there's not nothing too wrong with it, although the teeth at the bottom, there are sort of side ways. Those are the, those are the wisdom teeth. Um But um you know, you're not going to be expected to interpret it, this, interpret this X ray. Um But you may when you start working, um be asked to order them. Um and if they want a X ray of the teeth in the hospital, generally they go for an orthopantogram, which is um which is an PG, uh it's a bit hard to talk you through the anatomy without a pointer. But um um that's just more for um your information and interest than anything else. And I think that's it, Joan. Thank you. Um Anyone have any questions for Mister Campbell here.