Diseases and Injuries to the Head, Face and Neck : A Guide to Diagnosis and Management

Contents 1: Embryology of the Head and Neck: An Aid to Understanding Our Complex Anatomy and Some Interesting Anomalies 1.1 Introduction 1.1.1 Germinal Stage 1.1.2 Blastulation 1.1.3 Gastrulation 1.1.4 The Notochord 1.1.5 Neurulation 1.2 Development of the Brain 1.2.1 Flexures and Ventricles 1.2.2 Cerebrospinal Fluid Production and Function 1.2.3 Further Growth and Myelination 1.3 Embryonic Folding 1.3.1 The Pituitary Gland (Hypophysis Cerebri) 1.4 The Spinal Cord 1.5 The Neural Crest 1.6 Ectodermal Placodes 1.7 Development of the Face and Neck 1.7.1 Pharyngeal Clefts 1.7.2 Pharyngeal Arches 1.7.2.1 The First Arch 1.7.2.2 The Second Arch 1.7.2.3 The Third Arch 1.7.2.4 The Fourth Arch 1.7.2.5 The Sixth Arch 1.7.3 Pharyngeal Pouches 1.7.4 Pharyngeal Membranes 1.7.5 Cervical Sinus 1.7.6 Development of the Face 1.7.7 The Paranasal Sinuses 1.8 Muscles of Head and Neck 1.8.1 Myotomes 1.8.2 Dermatomes 1.8.3 The Skull 1.9 Arterial Development 1.10 Understanding Congenital Anomalies 1.10.1 Teratogenic Agents 1.10.2 Classification of Congenital Malformation of Brain 1.10.3 Craniofacial Deformations 1.10.4 Congenital Lumps 2: Initial Assessment of the “Head and Neck” Patient 2.1 Taking a ‘Focused’ History 2.1.1 The History 2.1.1.1 The Presenting Complaint Assaults/Injuries (See also Chapter on the Injured Patient) Possessing Pain Bleeding (Non-traumatic) Lumps and Swellings Disturbances in Sensation or Weakness Assessing Infections Rashes and Ulcers Trismus 2.1.1.2 Other Important Information 2.1.2 Practical Application of Information from the Medical, Drug and Social History 2.1.2.1 Age 2.1.2.2 Pregnancy 2.1.2.3 Ischaemic Heart Disease 2.1.2.4 Hypertension 2.1.2.5 Pulmonary System 2.1.2.6 Diabetes 2.1.2.7 Anti-coagulation 2.1.2.8 Bleeding Disorders 2.1.2.9 Deep vein Thrombosis (DVT) 2.1.2.10 Steroids in Surgery and “Steroid Cover” 2.1.2.11 Stress Ulceration 2.1.2.12 Hepatitis and HIV 2.1.2.13 Epilepsy 2.1.2.14 Previous Injuries 2.1.2.15 Tetanus Status 2.1.2.16 Drug Interactions 2.1.2.17 Bisphophonates 2.1.2.18 Alcohol Intake 2.1.2.19 Home Circumstances 2.1.2.20 Occupational History 2.2 Examining the Head, Neck, Face and Teeth 2.2.1 External Examination of the Head and Face 2.2.1.1 Specific Sites Forehead Eyes Nose Nasoethmoid Fractures Ears Temporomandibular Joints and Mandible Le Fort Fractures 2.2.2 Examination of the Mouth, Teeth and Throat 2.2.2.1 Tongue 2.2.2.2 Teeth Permanent (“Adult”) Teeth Deciduous (“Baby”) Teeth 2.2.2.3 Gingivae (Gums) and Oral Mucosa 2.2.2.4 Pharynx & Larynx 2.2.2.5 Salivary Glands/Salivary Flow 2.2.3 Examination of the Front of the Neck 2.2.3.1 Examination of Neck Lumps and Cervical Lymph Nodes 2.2.3.2 Examination of the Thyroid Gland 2.3 Radiographic Investigations Commonly Used in Head and Neck Conditions 2.3.1 Plain Films 2.3.1.1 Orthopantogram (OPG) and Posterior Anterior (PA) Mandible 2.3.1.2 Occipitomental Views (OM Views) 2.3.1.3 Lateral Soft Tissue Cervical Views 2.3.1.4 Cervical Spine Imaging 2.3.1.5 Computed Tomography (CT) 2.3.1.6 Cone Beam CT (CBCT) 2.3.1.7 Magnetic Resonance Imaging (MRI) 2.3.1.8 Sialography 2.3.1.9 Ultrasound 2.3.1.10 Nuclear Medicine 2.4 Chronic Pain 2.4.1 Assessing Chronic Pain 2.4.2 Common Causes of Facial Pain Following Trauma 2.4.2.1 Dentoalveolar 2.4.2.2 Inflammatory Conditions 2.4.2.3 Musculoskeletal Causes 2.4.2.4 Vascular Conditions 2.4.2.5 Neuropathic 2.4.2.6 Neuroma 2.4.2.7 The Future 2.5 Some Eponymous Diseases, Clinical Signs and Special Tests 3: The Injured Patient 3.1 Initial Assessment of the Injured Patient 3.1.1 Life-Threatening Injuries to the Head, Neck and Face 3.1.2 Secretions and Bleeding Compromising the Airway 3.1.3 Oedema 3.1.4 Other Causes of Blockage of the Airway 3.1.5 Cervical Spine Injuries 3.1.6 Haemorrhage 3.1.7 Head Injuries (Brain Injuries) 3.2 Understanding the (Rapid) Primary Survey 3.2.1 Providing Oxygen 3.2.2 Airway Patency 3.2.3 Breathing (Ventilation) 3.2.4 Circulation (Haemorrhage Control) 3.2.5 Disability 3.2.6 Critical Steps in the ABCDE Algorithm 3.2.7 History Taking in Trauma: The “Ample” History 3.2.7.1 Allergies 3.2.7.2 Medications 3.2.7.3 Past Medical History 3.2.7.4 Last Meal 3.2.7.5 Events 3.3 Airway Management 3.3.1 The ‘Difficult Airway’ in Facial Trauma 3.3.2 The Front of the Neck 3.3.3 Clearing the Cervical Spine 3.3.4 Airway Procedures 3.3.4.1 Simple Manoeuvres and Adjuncts 3.3.4.2 Definitive Airways 3.3.4.3 Surgical Airways 3.3.5 Breathing and Ventilation 3.3.6 Circulation and the Control of Bleeding 3.3.6.1 Damage Control 3.3.7 Blood Loss Following Head, Neck and Facial Trauma 3.3.7.1 Midface Bleeding 3.3.7.2 Epistaxis 3.3.7.3 Oral Bleeding 3.3.8 Urgent Surgical/Radiological Intervention in Bleeding 3.3.9 Disability 3.3.10 Exposure, Environment (And the Eye) 3.3.10.1 Vision Threatening Injuries in Trauma 3.3.11 Reassessment and the “Secondary Survey” 3.3.12 Facial Injuries: Triage and an Overview of Treatment 3.3.12.1 Triaging Facial Injuries: A Simple Approach 3.4 The ‘Walking Wounded’ 3.4.1 “Soft tissue” Injuries 3.4.2 Assessment and Classification of Soft Tissue Injuries 3.4.2.1 Management of Soft Tissue Injuries 3.4.2.2 Scalp Injuries 3.4.2.3 Scalp Avulsion 3.4.2.4 Eyelid Injuries 3.4.2.5 Eyebrow Injuries 3.4.2.6 Ear Injuries 3.4.2.7 Nasal Injuries 3.4.2.8 Cheek Injuries 3.4.2.9 Lip Injuries 3.4.2.10 Intraoral Injuries 3.4.2.11 Devitalised Tissue and Foreign Bodies 3.4.2.12 Bites and Scratches 3.4.2.13 Suturing 3.4.2.14 Referring Soft Tissue Wounds: Which to Refer 3.4.3 Facial Fractures: An Overview 3.4.3.1 Applied Anatomy 3.4.4 Forehead Injuries 3.4.4.1 Skull Fractures 3.4.5 Midface Injuries 3.4.6 Lower Third Injuries 3.5 Examination of the Injured Face 3.5.1 Extraoral Examination 3.5.2 Palpation of the Bones 3.5.3 Examination of the Eyes 3.5.4 Examination of the Ears 3.5.5 Examination of the Nose 3.5.6 Sensory and Motor Nerve Examination 3.5.7 Intraoral Examination 3.5.8 Abnormal Mobility of the Midface 3.6 Useful Signs and Their Significance 3.6.1 General Inspection 3.6.2 The Face 3.6.3 Within the Mouth 3.6.4 The Eyes 3.6.5 The Ears 4: Anaesthetic Considerations 4.1 The Injured Patient 4.1.1 Initial Considerations in the Injured Patient 4.1.2 Airway Considerations 4.1.2.1 Traumatic Brain Injury 4.1.2.2 Nasal Trauma 4.1.2.3 Ocular Trauma 4.1.2.4 Mandibular Fractures 4.1.2.5 Injuries to the Front of the Neck 4.1.2.6 Injuries to the Back of the Neck 4.1.3 ‘Can I Sit Up?’ 4.1.4 Vomiting in Supine Patients 4.1.5 Haemorrhage 4.1.6 Burns 4.1.7 The Anticipated Difficult Airway in Head and Neck Trauma 4.1.8 Fibre-Optic Intubation 4.1.8.1 Assessment of Mouth Opening 4.2 Infections in the Head and Neck 4.3 Hypotensive Anaesthesia for Head and Neck Surgery 5: Nutritional Consideration in Some Head and Neck Diseases 5.1 Nutritional Requirements in Head and Neck Cancer 5.1.1 Pre treatment 5.1.2 Postoperative Feeding 5.2 Enteral Nutrition 5.2.1 Gastrostomy Feeding 5.2.2 Care and Use of Gastrostomy Tubes 5.2.3 Providing Medications via a Gastrostomy Tube 5.2.4 Cleaning the Stoma Site 5.2.5 Feeding via the Gastrostomy Tube 5.2.6 Constipation or Diarrhoea 5.2.7 Nausea 5.3 Common Problems with Gastrostomy Tubes 5.3.1 Tube Blockage 5.3.2 Tube Breakage 5.3.3 Tube Falls Out 5.4 Nasogastric Tube Feeding (NGT) 5.4.1 Care and Use of Nasogastric Feeding Tubes 5.5 Tracheo-oesophageous Puncture Feeding Tube (TOFT) 5.6 Post Enteral Feeding (Weaning) 5.6.1 Texture Modified Diet and Food Fortification 5.6.2 Fluids 5.7 Referral to Dietitian 6: The Skull, Brain and Associated Structures: Part I Applied Anatomy and Physiology 6.1 The Scalp 6.2 The Skull 6.3 Hyperostosis Frontalis Interna (HFI) 6.4 Paget’s Disease (Osteitis Deformans) 6.5 The Meninges 6.5.1 Arachnoid Cysts 6.5.2 Cavernous Sinus Syndrome (CSS) 6.6 Cerebral Blood Supply 6.7 The Blood-Brain Barrier (BBB) 6.8 Arteriovenous Malformations (AVMs) 6.9 The Brain 6.9.1 Localisation of Cortical Functions 6.9.2 The Cerebellum 6.9.3 The Brainstem 6.9.4 The Ventricular System 6.10 CSF and Cerebral Perfusion Pressure 6.11 Intracranial Pressure (ICP) 6.12 Brain Swelling 6.12.1 Cytotoxic Oedema 6.12.2 Vasogenic Oedema 6.12.3 Osmotic Oedema 6.12.4 Hydrocephalic-Interstitial Brain Oedema 6.12.5 Hydrostatic Oedema 6.13 Brain Swelling Following Head Injury 6.14 Trigeminocardiac Reflex (TCR) 6.15 Bulbar Palsy and Pseudobulbar Palsy 6.16 Important Considerations When Taking a History 6.17 Sudden Loss of Consciousness 6.17.1 Lethargy 6.17.2 Headache 6.18 Head Injuries 6.19 Examining the Head and Associated Structures 6.19.1 Conscious Level: The Glasgow Coma Scale 6.19.2 Components of the Glasgow Coma Scale (Corresponding Score in Brackets) 6.19.3 Paediatric Variation of the Glasgow Coma Scale 6.19.4 Assessing Higher Mental Function 6.19.5 Cranial Nerve Examination 6.19.5.1 Olfactory Nerve 6.19.5.2 Optic Nerve 6.19.5.3 Oculomotor, Abducent and Trochlear Nerves 6.19.5.4 Trigeminal Nerve 6.19.5.5 Facial Nerve 6.19.5.6 Vestibulocochlear Nerve 6.19.5.7 Glossopharyngeal and Vagus Nerves 6.19.5.8 Accessory Nerve 6.19.5.9 Hypoglossal Nerve 6.19.6 Peripheral Neurological Examination 6.19.7 Brainstem Reflexes 6.19.8 External Examination 6.19.9 Examination in the Unconscious Patient 6.19.10 Some Useful Clinical Signs 6.19.10.1 Facial Nerve Palsy 6.19.10.2 Intercanthal Distance 6.19.10.3 Anosmia 6.19.10.4 Racoon (Panda) Eyes 6.19.10.5 Third Nerve Palsy 6.19.10.6 Superior Orbital Fissure Syndrome (SOFS) 6.19.10.7 Orbital Apex Syndrome 6.19.10.8 Haemotympanum 6.19.10.9 Battles Sign (Mastoid Ecchymosis) 6.19.10.10 CSF Rhinorrhoea/Otorrhoea 6.20 Investigating Symptoms and Signs 6.20.1 Laboratory Tests 6.20.1.1 Emerging Tests 6.20.2 The Role of Imaging 6.20.2.1 Plain Films 6.20.2.2 CT/MRI Scanning 6.20.3 Cerebral Angiography 6.20.4 PET/SPECT 6.20.5 Ultrasound 6.21 Intracranial Pressure Monitoring: External Ventricular Drain 7: The Skull, Brain and Associated Structures: Part II The Patient with a Headache 7.1 Classification of Headaches: Separating Benign from Serious Causes 7.1.1 Primary Headaches 7.1.2 Secondary Headaches 7.2 Assessing a Patient with a Headache 7.2.1 Date of Onset, Age at Onset, and Frequency of Symptoms 7.2.2 Location 7.2.3 Duration 7.2.4 Predisposing Factors 7.2.5 Preceding Symptoms 7.2.6 Quality and Severity of Pain 7.3 Other Associated Factors 7.4 Associated Symptoms 7.4.1 Worrying Features of a Headache 7.4.2 Ictal Headaches 7.5 Primary Headaches 7.5.1 Migraine 7.5.2 Cluster Headaches 7.5.3 Tension Headache 7.5.4 Hemicrania Continua (Paroxysmal Hemicrania) 7.5.5 Thunderclap Headache 7.5.6 Reversible Cerebral Vasoconstriction Syndrome (RCVS) 7.6 Extracranial Causes of Headache 7.6.1 Temporal Arteritis (Giant-Cell Arteritis) 7.6.2 Polymyalgia Rheumatica (PMR) 7.6.3 Glaucoma 7.6.4 Frontal/Ethmoidal Sinusitis 7.6.5 Drug (Medication) Induced Headache 7.6.6 Ice Cream Headache 7.6.7 Primary Sexual Headache (Coital Cephalalgia) 7.6.8 Ice-Pick Headaches (Jabs and Jolts Syndrome) 7.7 Spontaneous Intracranial Bleeding 7.7.1 Subarachnoid Haemorrhage (SAH) 7.8 Complications of SAH 7.8.1 Spontaneous Intracerebral haemorrhage (ICH): Cerebrovascular Accident, or Stroke 7.8.2 Ischaemic Stroke 7.8.3 Cerebral Haemorrhage 7.8.4 Intraventricular Haemorrhage 7.8.5 Transient Ischaemic Attack (TIA) 7.8.6 Locked-in Syndrome (LIS) 7.8.7 Pituitary Apoplexy 7.9 Intracranial and Related Infections 7.9.1 Diffuse Infections in the CSF: Meningitis 7.9.2 Tuberculous Meningitis (TBM) 7.9.3 Non-infectious Meningitis 7.10 Encephalitis and Meningoencephalitis 7.11 Focal Infections with the Potential for ‘Mass Effect’ 7.11.1 Brain Abscess 7.11.2 Subdural Empyema 7.11.3 Other Focal Infections 7.11.3.1 Neurosyphilis 7.12 Raised Intracranial Pressure (Intracranial Hypertension) 7.12.1 Hydrocephalus 7.12.2 Communicating 7.12.3 Non-communicating 7.12.4 Common Causes of Hydrocephalus (Figs. 7.18, 7.19 and 7.20) 7.12.4.1 Hydrocephalus Is Most Often Treated by Surgically Inserting a Shunt 7.12.5 Shunt Assessment 7.12.6 Shunt Infection 7.12.7 Shunt Overdrainage 7.13 Idiopathic (Benign) Intracranial Hypertension (IIH) 7.13.1 Management Aims to Prevent Visual Loss and Symptom Control. Measures Include 7.14 Intracranial Thrombosis 7.14.1 Dural Venous Sinus Thrombosis 7.14.2 Cavernous Sinus Thrombosis 7.15 Intracranial Tumours 7.15.1 Primary Tumour Types 7.15.2 Meningiomas 7.15.3 Astrocytoma (glioma) 7.15.4 Pituitary Adenoma 7.16 Sudden Disturbance in Cerebral Function 7.16.1 Epilepsy 7.16.2 Vertigo 7.16.3 Central Vertigo 7.16.4 Multiple Sclerosis (MS) 8: The Skull, Brain and Associated Structures: Part III 8.1 Head Injuries 8.1.1 Terminology in Head Injuries: Traumatic Brain Injury (TBI) 8.1.2 Primary Injuries to the Brain 8.1.2.1 Cortical Lacerations (Burst Lobe) 8.1.2.2 Cerebral Contusions/Haematoma 8.1.2.3 Diffuse Axonal Injury 8.1.2.4 Concussion 8.2 Secondary Injuries to the Brain 8.2.1 Pathophysiology 8.2.1.1 The Effects of Intracranial Swelling and Bleeding 8.2.1.2 Neuro-endocrine Changes 8.3 Assessing Traumatic Brain Injuries (Head Injuries) 8.4 History 8.4.1 Providing Telephone Advice 8.5 Examination of the Injured Head 8.6 Further Evaluation: The Role of Imaging 8.6.1 Indications for Head CT: New Orleans Criteria (2000) 8.6.2 Indications for Head CT: Nexus II 8.6.3 Indications for Head CT: CT in Head Injury Patients (CHIP) 8.6.4 CT Scanning in Children 8.6.4.1 History 8.6.4.2 Examination 8.6.4.3 Mechanism 8.7 Classification and Common Types of Head (Brain) Injuries 8.7.1 Head Injury Severity Score 8.8 Concussion (Mild Traumatic Brain Injury: MTBI) 8.8.1 Second-Impact Syndrome 8.9 Skull Fractures 8.10 Linear Fractures 8.10.1 Growing Skull Fracture 8.10.2 Depressed Fractures 8.10.3 Depressed Fractures Over Dural Sinuses 8.10.4 Basal Skull Fractures 8.10.5 Tension Pneumocephalus 8.10.6 Orbital Roof Fractures 8.10.7 Frontal Sinus Fractures 8.11 Intracranial Haematomas 8.12 Cerebral Contusions 8.13 Extradural Haematomas (EDH) 8.14 Subdural Haematomas 8.14.1 Acute Subdural Haematoma 8.14.2 Chronic Subdural Haematomas 8.14.3 Traumatic Subarachnoid Haemorrhage 8.14.4 Subdural Hygroma 8.15 Brain Herniation 8.16 Penetrating Head Injuries 8.17 High Energy Penetrating Injuries 8.18 Low Energy Penetrating Injuries 8.18.1 Penetrating Orbital Roof Injuries 8.19 Blast Injuries to the Brain 8.20 Pituitary Necrosis 8.21 Post traumatic Intracranial Aneurysm and Caroticocavernous Sinus Fistula (CCF) 8.22 Shaken Baby Syndrome (Abusive Head Trauma/Non Accidental Head Injury) 8.23 Management Principles of Head Injuries 8.23.1 Prehospital Care of Head Injuries 8.23.2 Emergency Department Care 8.23.3 Scalp Lacerations 8.23.4 Potentially Significant Head Injuries 8.23.5 Transferring Head Injured Patients 8.23.6 Monitoring Should Include 8.23.7 Investigations Undertaken Prior to Transfer Should Include 8.23.8 Head Injuries in Children 8.23.9 Growing Skull Fracture 8.24 Other Issues 8.24.1 Post-Concussion Headache 8.24.2 Post-Traumatic Amnesia (PTA) 8.24.3 Driving 8.24.4 Chronic Traumatic Encephalopathy (CTE) 8.24.5 Heterotopic Ossification (Neurogenic Myositis Ossificans) 8.25 Head Injury Instructions 8.26 Screening Tests for Concussion 8.27 Advanced Head Injury Management 8.28 Critical Care Management 8.28.1 Analgesia, Sedation and Paralysis 8.28.2 Mechanical Ventilation 8.28.3 Haemodynamic Support 8.28.4 Hyperosmolar Therapy 8.28.5 Temperature Modulation 8.28.6 Seizure Prophylaxis 8.28.7 Deep Vein Thrombosis Prophylaxis 8.28.8 Stress Ulcer Prophylaxis 8.28.9 Nutritional Support 8.28.10 Glycemic Control 8.28.11 Fluids and Electrolytes 8.28.12 General Intensive Care 8.28.13 Cerebral Vasospasm 8.29 ICP Management 8.29.1 Intracranial Pressure Monitoring 8.30 Decompressive Craniectomy and Hemicraniectomy 8.31 CSF Leaks 8.31.1 Other Causes of CSF Leaks 8.31.2 Diagnosing and Treating CSF Leaks 8.31.3 Orbital CSF Fistula (CSF Oculorrhea) 8.32 Spontaneous Cerebrospinal Fluid Leaks 8.33 Syndrome of the Trephined 8.34 Brain Death 8.34.1 Assessment of Brainstem Reflexes 8.34.2 Vegetative State 9: The Vertebral Column, Spine and Associated Structures: Part I 9.1 Applied Anatomy and Physiology 9.1.1 The Cervical Spine 9.1.2 Cervical Vertebrae 9.1.3 The Intervertebral Joints and Ligaments 9.1.4 Spinal Stability 9.2 The Spinal Cord 9.2.1 Spinal Topography 9.2.2 Syringomyelia 9.3 Diastematomyelia 9.4 Spinal Meninges 9.5 Muscles of the Posterior Neck 9.6 Congenital Muscular Torticollis 9.7 The Posterior Triangle 9.8 The Brachial Plexus 9.9 Blood Supply 9.9.1 The Vertebral Artery 9.10 Spinal and Neurogenic Shock 9.11 Important Considerations When Taking a History 9.12 Examination of the Non-Injured Neck and Associated Structures 9.12.1 Look 9.12.2 Feel 9.12.3 Move 9.13 Peripheral Neurological Examination 9.13.1 Inspection 9.13.2 Tone 9.13.3 Power 9.13.4 Reflexes 9.13.5 Sensation 9.13.6 Co-ordination 9.13.7 Provocative Tests 9.14 1 Spurling (cervical compression) test 9.15 2 Hoffman’s Test 9.16 3 Lhermitte sign 9.17 Investigating Symptoms and Signs 9.18 Laboratory Tests 9.19 Imaging 9.19.1 Plain Radiography 9.19.2 CT and CT Myelography 9.19.3 Magnetic Resonance Imaging 10: The Vertebral Column, Spine and Associated Structures: Part II 10.1 Lumps and Swellings in the Back of the Neck 10.2 Assessing the Injured Neck 10.2.1 Initial Protection of the Cervical Spine 10.2.1.1 Canadian c-Spine Rules 10.2.1.2 Immobilising the Spine 10.2.2 Log Rolling 10.2.3 Neurological Assessment 10.2.4 When to Image the Cervical Spine 10.2.4.1 Other Guidelines 10.2.5 Imaging the Cervical Spine in Trauma 10.2.6 Plain Films 10.2.7 Interpreting the Lateral View 10.2.7.1 Alignment 10.2.7.2 Line of Swischuk (Spinolaminal Line) 10.2.7.3 Bones 10.2.7.4 Cavities 10.2.7.5 Discs 10.2.7.6 Soft Tissue Spaces 10.2.7.7 Some Useful Guidelines 10.2.7.8 Checklist for Lateral Xray Assessment 10.2.8 Interpreting the AP View 10.2.9 Interpreting the Peg (‘Open Mouth’) View 10.2.10 ‘Swimmer’s’ View 10.2.11 Anatomical Variants 10.2.12 CT and MRI 10.2.13 Clearing the Neck 10.2.13.1 Clearance in the Awake Patient 10.2.13.2 Clearance in the Obtunded Patient 10.2.13.3 Prolonged Use of Cervical Immobilisation 10.3 Specific Injuries of the Neck 10.3.1 Neck Sprain: ‘Whiplash’ 10.3.2 Acute Torticollis 10.3.3 Hanging/Strangulation 10.3.4 Fractures of the Cervical Spine 10.3.4.1 Occipital Condyle Fractures 10.3.4.2 C1 Burst Fractures (Jefferson Fracture) 10.3.4.3 Fracture of the Posterior arch of C1 Fracture (Posterior Neural Arch Fracture) 10.3.4.4 Craniocervical Dissociation 10.3.4.5 Dens Fractures (C2) 10.3.4.6 Rupture of Transverse and Alar Ligaments 10.3.4.7 Hangman’s Fracture 10.3.4.8 Wedge Compression Fractures 10.3.4.9 Burst Fractures 10.3.4.10 Flexion Tear Drop Fractures 10.3.4.11 Extension Tear Drop Fracture 10.3.4.12 Facet Joint Injuries 10.3.4.13 Cervical Lateral Mass Fracture Separation 10.3.4.14 Clay Shoveler’s Fracture 10.3.5 Stability of Fractures 10.3.6 Spinal Cord Injury Without Radiological Abnormality (SCIWORA) 10.3.7 Penetrating Neck Injuries (See also the Front of the Neck) 10.4 Conditions Affecting the Spinal Cord 10.4.1 Spinal Cord Injuries 10.4.1.1 Pathophysiology 10.4.2 Clinical Features 10.4.2.1 Central Cord Syndrome (CCS) 10.4.2.2 Anterior Cord Syndrome (ACS or Beck’s Syndrome) 10.4.2.3 Posterior Cord Syndrome (Posterior Spinal Artery Syndrome) 10.4.2.4 Brown-Sequard Syndrome 10.4.3 Management of Spinal Cord Injuries 10.4.3.1 Neurogenic Shock (Not Spinal Shock) 10.4.3.2 Bowel and Bladder Management 10.4.3.3 Venous Thrombosis Prophylaxis 10.4.3.4 Corticosteroids 10.4.3.5 Traction 10.4.3.6 Surgical Management 10.4.3.7 Nonsurgical Management of Instability 10.4.3.8 Therapeutic Hypothermia 10.4.4 Can the Damaged Spinal-Cord Heal? 10.4.5 Pharmacological Treatments 10.4.6 Biological Treatments 10.4.6.1 Stem Cells 10.4.7 Oscillating Field Stimulation 10.4.8 Hypothermia 10.4.9 Complications of Spinal Cord Injury 10.4.10 Spinal Cord Compression 10.4.11 Causes of Compression 10.4.11.1 Trauma 10.4.11.2 Haematomas 10.4.11.3 Prolapsed Intervertebral Disc 10.4.11.4 Osteomyelitis and Discitis 10.4.11.5 Extradural Abscess 10.4.11.6 Subdural Empyema 10.4.11.7 Spinal Cord Abscess 10.4.11.8 TB and Rare Infections 10.4.11.9 Rheumatoid Arthritis 10.4.11.10 Spinal Stenosis/Cervical Spondylotic 10.4.11.11 Tumours 10.4.11.12 Vertebral Haemangiomas 10.4.11.13 Chordomas 11: The Vertebral Column, Spine and Associated Structures: Part III 11.1 Other Causes of Neck Pain or Neurology 11.1.1 Retropharyngeal Abscess (See also the Chapter on the Throat) 11.1.2 Tuberculosis 11.1.3 Tabes Dorsalis 11.1.4 Cervical Osteoarthritis or Cervical Spondylosis 11.1.5 Radiculopathy 11.1.6 Brachial Plexus Injury 11.1.7 Idiopathic Spinal Cord Herniation (ISCH) 11.2 Multiple Sclerosis 11.3 Vascular Related Conditions 11.3.1 Vertebral Haemangioma 11.3.2 Retropharyngeal Haematoma 11.3.3 Vertebrobasilar Insufficiency (Beauty Parlour Syndrome (BPS)) 11.3.4 Vertebral Dissection 12: The Viscera and Glands of the Neck: Part I 12.1 Applied Anatomy and Physiology 12.1.1 Superficial Cervical Fascia 12.1.2 Deep Cervical Fascia 12.1.2.1 Investing Layer 12.1.2.2 Pretracheal Layer 12.1.2.3 Prevertebral Layer 12.1.2.4 Carotid Sheath 12.1.3 Fascial Spaces 12.1.4 Muscles 12.1.4.1 The Sternocleidomastoid 12.1.4.2 Omohyoid 12.1.4.3 Other Muscles 12.1.5 Major Blood Vessels 12.1.5.1 Carotid Artery 12.1.5.2 Eagle Syndrome (Styloid–Carotid Artery Syndrome) 12.1.5.3 Subclavian Artery 12.1.5.4 Venous Drainage 12.1.6 Major Nerves 12.1.6.1 Spinal Accessory Nerve (CN XI) 12.1.6.2 Hypoglossal Nerve (CN XII) 12.1.6.3 Branches of the Glossopharyngeal (CN IX) and Vagus (CN X) Nerves 12.1.6.4 The Roots of the Brachial Plexus (Anterior Rami of C5–C8 and T1) 12.1.6.5 The Cervical Plexus 12.2 The Anterior Cervical Region (Anterior Triangle) 12.2.1 The Larynx, Hyoid, Trachea and Thyroid 12.2.1.1 The Larynx Age Related Changes in Larynx The Valsalva Manoeuvre 12.2.1.2 The Hyoid Bone 12.2.1.3 The Trachea 12.2.1.4 The Thyroid Gland 12.2.2 The Salivary Glands 12.2.3 The Parotid Gland 12.2.4 The Submandibular Gland 12.2.5 The Lymph Nodes of the Neck 12.2.6 The Cervical Sympathetic Trunk 12.2.6.1 Horner (or Horner’s) Syndrome 12.3 The Root of the Neck 12.3.1 Chylous Fistula 12.4 The Pharynx and Oesophagus 12.5 Airway Obstruction: Difficulty Breathing and Noisy Breathing 12.6 Important Considerations When Taking a History 12.7 Examining the Neck and Associated Structures 12.7.1 Useful Landmarks 12.7.2 Inspection 12.7.3 Palpation 12.7.4 Additional Techniques 12.7.4.1 Carotid Bruits 12.7.4.2 Cervical Venous Hum 12.7.5 Assessment of Upper Airway Obstruction 12.7.6 Clinical Assessment of a Neck Lump 12.7.6.1 Describing the Position of a Lymph Node 12.8 Directly Visualising Important Structures 12.9 Investigating Symptoms and Signs 12.9.1 Laboratory Tests 12.9.2 Plain Films 12.9.3 CT/MRI 12.9.4 Angiography 12.9.5 Ultrasound 12.9.6 Nuclear Medicine 12.9.7 Fine-Needle Aspirate (FNA) and Core-Biopsies 12.9.8 Non Urgent Investigations 13: The Viscera and Glands of the Neck: Part II 13.1 Swellings and Lumps in the Neck 13.1.1 The Swollen Neck 13.1.2 Commonly Infected Fascial Spaces in the Neck 13.2 Deep Neck Space Infections 13.2.1 Submandibular Space 13.2.2 Submental Space 13.2.3 Ludwig’s Angina 13.2.4 Carotid Sheath Infections 13.2.5 Mediastinitis 13.2.6 Necrotising Fasciitis 13.2.7 Acute Bacterial Submandibular Sialadenitis 13.2.8 Surgical (Subcutaneous) Emphysema 13.3 Branchial Cysts and Associated Problems 13.3.1 Branchial (Lateral Cervical) Cysts 13.3.2 Cystic Hygroma (Lymphangioma) 13.4 Lump(s) in the Neck 13.4.1 Differential Diagnosis of a Neck Lump 13.4.2 The Anterior Triangle of Neck 13.4.3 The Posterior Triangle 13.4.4 The Lymphatic Drainage of the Neck 13.4.5 Assessing a Neck Lump 13.4.6 Taking a Relevant History 13.4.6.1 Age 13.4.6.2 Onset 13.4.6.3 How Long Has the Lump Been Present? 13.4.6.4 Is It Painful? 13.4.6.5 Has the Lump Changed, or Does It Vary in Size? 13.4.6.6 Does Eating Affect the Lump? 13.4.6.7 Is There Pain on Swallowing? 13.4.6.8 Is There Any Effect on the Voice? 13.4.6.9 Does the Patient Have Bad Breath (Halitosis) or an Offensive Taste in Their Mouth? 13.4.6.10 Any Symptoms of Recent Infection Involving Associated Structures (Cough, Cold, Sore Throat, Earache, Toothache, Skin Problems, Head Lice, Bites) 13.4.6.11 Unilateral Hearing Loss or Earache 13.4.6.12 Other Symptoms of Systemic Upset 13.4.6.13 Recent Travel Overseas 13.4.6.14 Any Past History of Cancer or Other Features of Malignant Disease 13.4.6.15 Social and Family History 13.4.6.16 Any Features of Thyroid Disease 13.4.6.17 Any Red Flag Symptoms of Systemic Illness 13.4.7 Examination 13.4.8 Investigations 13.5 Common and Other Causes of Neck Lumps 13.5.1 Lymphadenopathy 13.5.1.1 Local Causes 13.5.1.2 Generalised Causes 13.5.2 Infections Causing Lymphadenopathy 13.5.2.1 Glandular Fever (Infectious Mononucleosis) 13.5.2.2 Bacterial Cervical Lymphadenitis 13.5.2.3 Atypical Mycobacteria 13.5.2.4 Nonspecific Lymphadenitis 13.5.2.5 Cervical Adenopathy in the HIV Patient 13.5.2.6 Unilateral Persistent Cervicofacial Lymphadenopathy 13.5.2.7 Cat-Scratch Disease 13.5.2.8 Toxoplasmosis 13.5.2.9 Tularemia (Hare Fever) 13.5.2.10 Parasites/Protozoa 13.5.2.11 Fungi 13.5.3 Tumours Causing Lymphadenopathy 13.5.3.1 Primary: Hodgkin’s Disease and Non-Hodgkin’s Lymphomas 13.5.3.2 Secondary: Metastatic Disease 13.5.4 Immunologic Conditions Causing Lymphadenopathy 13.5.4.1 Sarcoidosis 13.5.4.2 Common Variable Immunodeficiency 13.5.4.3 Miscellaneous Causes 13.5.5 Metabolic Conditions Causing Lymphadenopathy 13.5.6 Hypersensitivity Conditions Causing Lymphadenopathy 13.5.6.1 Serum Sickness 13.6 Thyroid Lumps and Swelling, the Parathyroid, Thyroglossal Cysts and the Thymus 13.6.1 Thyroid Development and some Anomalies 13.6.2 Enlargement of the Thyroid Gland 13.6.3 Goitres 13.6.3.1 Graves Disease 13.6.3.2 Hashimoto’s Thyroiditis 13.6.3.3 Subacute Thyroiditis (De Quervain’s Thyroiditis) 13.6.3.4 Riedel Thyroiditis 13.6.4 Thyroid Lumps and Cancers 13.6.5 Parathyroid Tumours 13.6.6 Thyroglossal Duct Cyst 13.6.7 Thymic Cysts 13.7 Neurogenic, Vascular and Lipomatous Tumours 13.7.1 Haemangioma 13.7.2 Hemangiopericytoma 13.7.3 Paragangliomas (Chemodectomas) 13.7.3.1 Carotid Body Tumour (Chemodectomas) 13.7.3.2 Glomus Jugulare 13.7.3.3 Glomus Vagale 13.7.4 Neural Tumours 13.7.4.1 Schwannoma 13.7.4.2 Neurofibroma 13.7.5 Lipomatous Tumours 13.7.6 Cervical Rib 13.7.7 Subclavian and Internal Carotid Aneurysm 13.7.8 Dermoid Cysts and Teratomas 13.8 The Salivary Glands 13.8.1 Obstruction 13.8.1.1 Calculi 13.8.1.2 Salivary Duct Stricture (Duct Stenosis) 13.8.1.3 Plunging Ranula 13.8.2 Salivary Gland Infections 13.8.2.1 Mumps 13.8.2.2 Suppurative Sialadenitis 13.8.3 Chronic Submandibular Sialadenitis (Kuttner’s Tumour) 13.8.4 Salivary Gland Tumours 13.8.5 Salivary Gland Dysfunction 13.8.5.1 Sjögren’s Syndrome 13.8.5.2 Chronic Non-specific Sialadenitis 13.8.5.3 Sialadenosis (Sialosis) 13.8.5.4 Sarcoidosis 13.9 Carotid Artery Disease 13.9.1 Carotid Artery Stenosis 13.9.2 Carotid Artery Dissection 13.10 The Vocal Apparatus 13.10.1 Dysphonia and Related Problems 13.10.1.1 Sound Generation 13.10.2 Assessment of Dysphonia 13.10.3 Vocal Cord Palsy and Related Conditions 13.10.4 Laryngitis 13.10.5 Croup (Laryngotracheobronchitis) 13.10.6 Epiglottitis (Supraglottitis) 13.10.7 Laryngeal Papillomatosis 13.10.8 Subglottic Stenosis (SGS) 13.10.9 Reinke’s Oedema and Chorditis 13.10.10 Vocal Cord Nodules 13.10.11 Vocal Cord Polyps 13.10.12 Vocal Fold Granulomas 13.10.13 Muscle-Tension Disorders (Functional Voice Disorders) 13.10.14 Chronic/Severe Coughing 13.10.14.1 Postnasal Drip 13.10.14.2 Gastroesophageal Reflux Disease 13.10.14.3 Haemoptysis 13.10.15 Laryngeal Cancer 13.10.16 Miscellaneous Masses and Conditions in the Aerodigestive Tract 13.11 Oesophageal Related Problems 13.11.1 Pharyngeal Pouch 13.11.2 Tracheo-Oesophageal Fistula 13.11.3 Oesophageal Cancer 13.12 Mediastinal Masses 14: The Viscera and Glands of Neck: Part III (Trauma and Injuries to the Neck) 14.1 Injuries to the Front of the Neck 14.1.1 Initial Considerations 14.1.2 Injuries to the Larynx 14.1.2.1 Assessment and Initial Management 14.1.2.2 Imaging 14.1.2.3 Classification of Laryngeal Trauma and Management 14.1.2.4 Paediatric External Laryngeal Trauma 14.1.2.5 Iatrogenic Injury 14.1.2.6 Chemical and Thermal Injury 14.1.3 Tracheal Injuries 14.1.4 Hyoid Bone Fracture (Garrotter’s Throat) 14.2 Oesophageal Injuries 14.2.1 Blunt Injuries 14.2.2 Hanging and Strangulation 14.3 Penetrating Neck Injuries 14.3.1 The Zones of the Neck 14.3.2 Key Points to Remember 14.3.3 Tracheostomy 14.3.4 Surgical Technique 14.3.5 Types of Tracheostomy 14.3.6 Tracheostomy Care 14.3.7 Decannulation 14.3.8 Types of Tracheostomy Tubes 14.3.8.1 Cuffed Tubes 14.3.8.2 Non-cuffed Tubes 14.3.8.3 Fenestrated Tubes 14.3.9 Non-cuffed, Fenestrated Tube 14.3.9.1 Non-cuffed Tube, Non-fenestrated 14.3.9.2 Single Lumen Tubes 14.3.9.3 Double Lumen Tubes 14.3.9.4 Adjustable Flange Tubes 14.3.9.5 Mini Tracheostomy 14.3.9.6 Speaking Valves 14.3.10 Complications of a Tracheostomy 14.3.10.1 Blocked Tracheostomy Tube 14.3.10.2 Displaced Tracheostomy Tube 14.3.11 Paediatric Tracheostomy 15: The Cheek and Orbit: Part I 15.1 Applied Anatomy and Physiology 15.1.1 The Cheek 15.1.1.1 The Malar Fat Pad 15.1.1.2 The Buccal Fat Pad 15.1.1.3 Lipomatosis 15.1.1.4 The Orbit 1