SCALP
• The skin, subcutaneous tissue and
the aponeurosis are closely united
to each other, and can move
forward and backward as one unit.
• Common site of sebaceous cysts
• Highly vascular, even small
laceration may cause profuse
bleeding.
• Deep wounds involving the
aponeurosis gape widely because of
the pull of the frontal and occipital
bellies of the occipitofrontalis
muscle in opposite directions
• Superficial infections remain localized and are painful
• Deep infections may spread through emissary veins to the skull
bones causing ‘osteomyelitis’ and to the intracranial venous
sinuses causing ‘sinus thrombosis’.
• Subaponeurotic collection of blood or pus tends to spread over
the calvaria (limited by the attachment of the aponeurosis)
• Subperiosteal collection of blood or pus is limited to one bone
• The arteries of the scalp supply little blood to the calvaria,
which is supplied by the middle meningeal arteries. Therefore,
loss of the scalp does not produce necrosis of the calvarial
bones.
• An infection or fluid (e.g., pus or blood) can
enter the eyelids and the root of the nose
(because the frontalis inserts into the skin and
subcutaneous tissue and does not attach to
the bone & because of the loose nature of the
subcutaneous tissue within the eyelids)
causing the eyelids to swell.
• Blows to the periorbital region usually
produce soft tissue damage because the
tissues are crushed against the strong and
relatively sharp margin. Consequently, “black
eyes” (periorbital ecchymosis , or purple
patches) develop as a result of extravasation
of blood into the subcutaneous tissue and
skin of the eyelids and surrounding regions.
Face
• Damage to facial nerve results in
paralysis of facial muscles: Facial
palsy (Bell’s palsy);lower motor
neuron lesion (whole face
affected)/upper motor neuron lesion
(upper face normal).
 Face is distorted: drooping of lower
eyelid, sagging of the angle of the
mouth, dribbling of saliva, loss of
facial expressions, loss of chewing,
blowing, sucking, unable to show
teeth or close the eye on affected
side
 Test individual branch of facial nerve
• Sensory nerve supply of the face: From the three divisions of the
trigeminal nerve
• Skin over the angle of the mandible is supplied by the great
auricular nerve C2 &3.
• Trigeminal neuralgia is a common case with no obvious cause.
• The patient complains of severe excruciating pain in the
distribution of the mandibular or maxillary divisions, rarely the
ophthalmic division.
• Dangerous zone: Infection in this area
of the face are dangerous as it may
spread to the cavernous sinus and
result in thrombosis of the sinus
• Because of its superficial position,
damage to parotid duct can occur in
facial lacerations or in surgical
procedure on the face
• Feeling the pulsation of the:
• Facial artery: Lower margin of
mandible along the anterior border
of masseter
• Superficial temporal artery: As it
crosses the zygomatic arch in front
of the auricle
• Cleft upper lip may be
accompanied by cleft palate.
• Usually unilateral, but it
could be bilateral.
• Due to failure of fusion of
the maxillary process to the
medial nasal process.
Parotid Gland
• Parotid duct, being a superficial structure, is prone to
get damaged in injuries to the face, or during surgical
procedures on the face
• Parotid neoplasms (malignant) are very invasive and
quickly involve the facial nerve causing facial palsy
• Inflammation of parotid gland (e.g.mumps) results in
painful swelling. The swollen glenoid process gives pain
when opening the mouth
• Frey’s syndrome: when the patient eats, beads of sweat
appear on the skin over the parotid gland. It is due to a
communication between the auriculo-temporal &
greater auricular nerves which may develop after healing
from an injury to this region
Temporomandibular Joint
• The strong Lateral
temporomandibular
ligament prevents
posterior dislocation of the
head of the mandible.
• Detachment of the
articular disc from the
capsule leads to audible
click
• Anterior dislocation of TMJ
(most common)
Nose, Nasal Cavity & Paranasal Sinuses
• Inflammation of the nasal mucosa, Rhinitis, results in
nasal congestion and excessive production of mucus
leading to ‘postnasal drip’
• Infections of the nasal cavity can extend to the
paranasal sinuses and the nasolacrimal sac
• Inflammation of mucosa of the paranasal sinuses,
Sinusitis, causes excessive production of mucus
leading to obstruction of the drainage of sinuses.
This results in headache and change in the voice
• Infection of frontal & anterior ethmoidal sinus can
easily spread to maxillary sinus because of the
location of their openings
• Infection of upper teeth can lead to inflammation of
the maxillary sinus
• Extraction of an infected upper tooth may result in a
fistula.
Orbit
• Eye tauma: no protection from front. Small objects may
cause severe damage to eye ball. It is least protected
from lateral side
• Fractures of the orbital floor:
• The orbital fat moves inferiorly into the maxillary sinus
resulting in displacement of the eyeball with resulting
symptoms of diplopia.
• It may injure the infraorbital nerve, producing loss of
sensation of the skin of cheek and gum on that side
• Entrapment of inferior rectus muscle may limit upward gaze
• Concomitant strabismus: imbalance in the action of
opposing muscles, common in infancy
Dural venous Sinuses
• Venous sinus
thrombosis
• Suerior sagittal sinus
thrombosis
• Cavernous sinus
thrombosis
Glossopharyngeal Nerve Lesion
 Difficulty in swallowing
 Loss of general sensation over
the posterior one-third of the
tongue, palate, and pharynx
 Loss of taste sensation over
the posterior one-third of the
tongue and palate
 Dysfunction of the parotid
gland
 Loss of the gag reflex
Vagus Nerve Lesion
• Clinical manifestations range from mild symptoms of
hoarseness of voice, loss of gag reflex and loss of effective
cough mechanism, to dysphagia and choking when drinking
fluids, to life-threatening airway obstruction from bilateral
recurrent laryngeal nerve injury
• Failure of soft palate elevation
• Deviation of uvula away from
the side
of lesion
• Abnormalities of esophageal motility, gastric acid secretion,
gallbladder emptying, and heart rate; and other autonomic
dysfunction.
Accessory Nerve (Spinal Part) Lesion
• Injury to the spinal accessory nerve
results in paralysis of the
sternocleidomastoid and the
trapezius muscles.
• Patients exhibit signs of lower
motor neuron disease, such as
paralysis, fasciculation, and wasting
of the affected muscles.
• Because of its superficial position in
the posterior triangle of the neck, it
can be injured in penetrating
wounds. The trapezius muscle gets
paralyzed, and shows wasting.
• Paralysis of the
sternocleidomastoid muscle
results in an asymmetric
neckline
• Paralysis of the trapezius
muscle results in:
 Drooping of shoulder
 Winging of scapula
 Difficulty in elevating the arm
above the head, having
abducted it to a right angle by
using the deltoid muscle.
 The patient is unable to shrug
the shoulders.
Hypoglossal Nerve Lesion
• If the patient is asked to protrude
the tongue, it will deviate toward
the paralyzed side .
• As the genioglossus muscle is
paralyzed on the affected side, the
normal genioglossus muscle pulls
the unaffected side of the tongue
forward, leaving the paralyzed side
of the tongue stationary. The result
is the tip of the tongue deviates
toward the paralyzed side.
• The paralyzed muscles show
wasting, and the tongue becomes
wrinkled on that side.
Palate
• Cleft palate:
– Unilateral
– Bilateral
– Median
• Paralysis of the soft palate
– The pharyngeal isthmus
can not be closed during
swallowing and speech
Pharyngeal
isthmus
pharynx
• Enlarged pharyngeal tonsils
(Adenoides) &
adenoidectomy
• Otitis media, secondary to
infection of nasopharynx
• Tonsillitis & Tonsillectomy
• Peritonsillar abcess (quinsy)
• Piriform fossa…a common
site for the lodging of foreign
bodies
• Pharyngeal pouch, leading to
dysphagia (difficulty in
swallowing)
Larynx
•
•
•
•
Laryngitis
Edema of laryngeal mucosa
Laryngeal nerve lesions:
External laryngeal nerve
A. Unilateral
B. Bilateral
• Recurrent laryngeal nerve
C. Unilateral complete (of
right nerve)
D. Bilateral complete
E. Unilateral partial (of right
nerve)
F. Bilateral partial
The position of vocal
cords
Ear
• The otoscopic exam is performed
by gently pulling the auricle
upward and backward. In
children, the auricle should be
pulled downward and backward.
This process will move the
acoustic meatus in line with the
canal.
• Too much cerumen can block
sound transmission.
• This ear-throat connection makes
the ear susceptible to infection
(otitis media).
• Infection of mastoid air cells
Thank You & Good
Luck