Clinical correlations

“Blowout” fracture

Fracture to the floor of the orbit that results in prolapse of the orbital contents in the maxillary sinus

Floor of orbit is relatively thin

Le Fort Fractures 

Traumatic fractures that cause a separation of a portion of the midface from the basicranium 

• Typically involves the maxillae, sphenoid, nasals, zygomatics 

Le Fort Fractures 

Traumatic fractures that cause a separation of a portion of the midface from the basicranium 

Typically involves the maxillae, sphenoid, nasals, zygomatics 

Trans-sphenoidal Hypophysectomy

Surgical procedure for resecting tumors of the pituitary gland

Pterion Fracture

Pterion is a weak point in the skull

• Pterion overlies the middle meningeal artery

• Pterion fractures can rupture this vessel (or its branches) and cause epidural hematoma

Cranial Modification

Fontanelles (“Soft Spots”) are stretched from a baby laying on its back

Craniosynostosis

Fontanelles (“Soft Spots”) are stretched from a baby laying on its back

Eagle Syndrome

1. Calcification of the stylohyoid ligament

   • Elongation of the styloid process of the temporal bone

2. AKA styloid syndrome, stylohyoid syndrome, styloid-carotid syndrome

3. Can cause throat/neck or ear pain, dysphagia

   • Can compress the internal carotid artery

4. •~4% of population has an elongated styloid process~4% of those are symptomatic (overall incidence ~0.16%)

5. Tx -styloidectomy

TMJ Dislocation 

Extreme opening of mouth (yawning, eating, etc.), sideways impact to the chin 

1. Anterior dislocation much more common

2. Mandible will fracture before posterior dislocation due to strength of the lateral ligament 

3. Tx: manual reduction

Horner’s Syndrome

Damage to sympathetic structures in the upper thorax or neck T1-T2 spinal cord, ascending cervical sympathetic chain, cervical ganglia

1. Symptoms (unilateral)

   1. Partial ptosis (drooping eyelid)→ paralysis of the superior tarsal m.

2. Miosis (pupil constriction)→ paralysis of the dilator pupillae m.

3. Anhidrosis→ loss of stimulation to sweat glands

Trigeminal Neuralgia

Neuropathic pain to one side of the face

• May cover regions supplied by one or more of the main branches of the trigeminal nerve

• “Tic douloreux”

Typically caused by compression of the

trigeminal ganglion inside of the cranial

cavity

• Usually caused by an aberrant artery

• Causes demyelination of sensory axons

• Excruciating, episodic pain

• Can be set off by touching the face, brushing teeth, chewing

Gustatory Sweating (Frey’s Syndrome)

Localized hyperhidrosis (sweating) and

erythema (redness) in response to gustatory

stimuli

• Commonly caused by surgical damage to the auriculotemporal n.

• Parasympathetic stimulation of the parotid gland (production of saliva) improperly stimulates sweat glands (normally stimulated by sympathetic)

Retropharyngeal Abscesses

Infection w/in retropharyngeal space

• Infections in the true retropharyngeal space may result from spread of infections of the middle ear, nasopharynx, and posterior oral cavity

• Inferior boundary of the true retropharyngeal space is ~T4

• Infections in the danger/alar space may spread inferiorly to the mediastinum (central compartment of the thorax) and cause very dangerous infections

• Inferior boundary of the danger/alar space is the diaphragm and includes the area around the heart

Congenital torticollis

Fibrous tissue tumor in SCM, injury to SCM at birth

• Contraction/shortening of the SCM

• Causes head tilt & neck twist = head will tilt towards the affected side, chin points away from the affected side

Spasmodic torticollis (AKA cervical dystonia): usually begins in adulthood

•May involve any bilateral combination of neck muscles, especially SCM and trapezius

•Results in sustained turning, tilting, flexing, or extending of the neck

Swollen Glands

“Swollen glands” felt in the neck due to upper respiratory infections, strep throat, etc. are not actually glands

Usually swollen submandibular lymph nodes surrounding the gland

Thoracic Outlet Syndrome

Compression of the neurovascular structures at the superior thoracic outlet by:

• Scalene muscle spasms or tension

• Clavicle fracture or congenital defects

• Cervical ribs (long cervical transverse process)

• Apical lung tumor

• Repetitive strain injury

Symptoms:

• Numbness, pain (nerve compression)

• Discoloration, temperature abnormalities (vasculature compression)

Why are ear infections more common in children

•Pharyngotympanic tube is shorter and more horizontal in children

•Ear infections are more common in children

•Movement of air and fluid is more difficult

•When tubes become swollen from a cold, upper respiratory infection, or allergies, bacteria can become trapped

•Ear tubes – tiny, hollow cylinders placed in the tympanic membrane to allow air circulation between the outer and middle ear

Epistaxis

Epistaxis = nosebleed

Very rich blood supply to the nasal mucosa

Most commonly from trauma to the anterior third of the nose

Kiesselbach’s area –

Common nose bleed area: anastomotic plexus involve branches of the ophthalmic, maxillary, and facial arteries

Adenoidectomy

Surgical removal of pharyngeal tonsils due to impaired breathing through the nose, chronic infections, or recurrent earaches

Caused by tonsilitis

Tonsillectomy

Surgical removal of palatine tonsils due to recurrent tonsillitis, throat infections, or sleep apnea

Danger Triangle of the Face

Infections on the face can through the angular vein into the superior/inferior ophthalmic veins and into the cavernous sinus (w/in the cranial cavity)

•Often affects movements of the eye

CN III Palsy

Symptoms

• Affected eye is directed “down and out”

• Lateral rectus & superior oblique are unopposed

• Partial ptosis (eyelid drooping)

• Pupil is abnormally dilated

Mydriasis

CN IV Palsy

Symptoms

• Affected eye is directed “up and in”

• Loss of only the superior oblique m.

  • All other muscles unopposed

• Diplopia (double-vision)

• Often have a compensatory head tilt

CN VI Palsy

Symptoms

• Affected eye is directed medially

• Loss of lateral rectus

• Medial rectus is unopposed

• Affected eye cannot be abducted to look laterally

Shingles (Herpes Zoster)

Reactivation of the chickenpox virus

• After initial infection, virus stays dormant in sensory ganglia

Development of painful blisters along a

dermatome

• Trigeminal involvement ~10-20% of cases

• May involve one or multiple branches

• V1 involvement can severely impact the eye