Trigeminal Neuralgia: intermittent shooting pain in the face along the trigeminal nerve

- usually one sided & affects V3

- Pain triggered by touching sensitive area (Trigeminal ganglion)
- Pressure on the Trigeminal Nerve
- Needle inserted formen rotundum

Peripheral Facial Nerve Palsy: lower motor neuron lesion in facial nerve, mostly in the stylomastoid
foramen

Bells Palsy: paralysis of the face

- function usually recovers; viral infection can cause
- Sagging of face of the affected side
- paralysis of buccinator & orbicularis oris
- Speech affected
- Below stylomastoid foramen

Facial Nerve Lesions

Below stylomastoid foramen Bells Palsy

Facial canal Symptoms above

- loss of taste (anterior 2/3 tongue)

- Decreased salivation

- Hyperacusis
Geniculate Ganglion Symptoms above

- numbness of ear canal

- Dry eye & nose

Facial Nerve Lesions

Intracranial/Internal auditory meatus Symptoms above

- deafness
Danger Area of the Face: region of the face where infection can spread from facial or opthalmic
(lacerations, blemishes, etc.) veins to the cavernous sinus
- can cause meningitis & abscesses
- cavernous sinus thrombosis if blood clot travels from facial vein to cavernous sinus

Cavernous Sinus Thrombosis: infection leading to blood clot caused by complication of an infection
in the paranasal or central face sinuses
- fatigue, seizures, vomiting, impaired vision, face boil, eyelid droop, fever, sinusitis, pain, numbness,
eye infection/irritation

Injury in Scalp
-extensive bleeding; vessels can not constrict normally
-blood prevented from passing into the neck or sub-
temporal regions
-Gravity causes blood to descend into orbits = bilateral
orbital hematomas (orbital branch of infraorbital artery)
Scalp Layer 4: Subaponeurotic Tissue: danger area of the scalp; potential space beneath the
epicranius muscle & its aponeurosis
Clinical:
1. Black eye formation —> accumulation of blood in this layer due to injury to emissary veins
2. Caput Succedaneum —> in newborns; temporary swollen edematous portion of scalp
3. Passage through birth canal —> veins are compressed; interference with venous return

Scalp Layer 5: Pericranium:

- outer periosteum of the skull
- Collection of uid beneath produces localized swellings

Route of Infection into the Calvarium: communication between extra/intra cranial structures
meninges & dural sinuses
- pus from an infection collects in loose CT; may transfer to skull, meninges & brain via emissary
veins
- Results in meningitis or
encephalitis

Mumps: viral infection of the parotid gland

- prevented by MMR vaccine
fl
Frey’s or Auriculotemporal Syndrome
- Occurs after surgery on the parotid gland
- Auriculotemporal nerve
- Otic ganglion take over superior cervical ganglion
- Sympathetic & Parasympathetic innervation are disrupted & start to regrow
—> Parasympathetic Fibers grow rst; inappropriately innervate the blood vessels & sweat glands;
when eating salivary discharge causes sweating & ushing of skin

Maxillary Nerve (CNV2) Block:

- may be required for extensive dental surgery
- Maxillary nerve is in the pterygopalatine fossa and is often approached intraorally via the greater
palatine canal
Approaches:
1. Skin —> posterior to coronoid process
2. Intraorally —> soft palate OR oral vestibule
fi
fl
Temporomandibular Joint Dislocation:
- mandible can dislocate medially, laterally, anteriorly
or posteriorly
- May accompany fractures of mandible
- May damage facial nerve & auriculotemporal nerve
(joint instability)
- Posterior dislocations are rare; prevented by the
lateral ligament
- Anterior dislocation is MOST COMMON; occurs
when the mandible is shifted forwards as the mouth
is excessively opened

Temporomandibular Joint Fractures:

A. Coronoid process fractures
- uncommon; usually singular
B. Fractures of the neck of the condylar process
- associated with temporomandibular joint dislocation
C. Fracture of the angle of the mandible
- usually oblique; may involve alveolus of the 3rd molar tooth
D. Fracture of the body of the mandible
- usually passes through the socket of the canine tooth
Excessive Anterior Displacement/Protrusion (Lock Jaw) Treatment:
- conscious sedation with versed & morphine
- Protect physician
thumbs with bit guard
- Stabilize skull then
forceful downward
traction of mandible;
muscles will pull
condylar process back
into socket

Fontanelle Indications:
1. Sunken
- indicates dehydration
2. Bulging
- increased intracranial pressure

Craniosynostosis: Bones of the skull fuse prematurely before the brain has grown fully formed
- The resulting growth pattern provides space for the brain to grow
- Results in an abnormal head shape and facial features
- Can cause increased intracranial pressure
 Basilar Skull Fractures
- occur anywhere along the base of the skull
- Break occurs in at least one of the following bones:
1. Temporal
2. Occipital
3. Sphenoid
4. Frontal
5. Ethmoid
Otorrhea: Draining of CSF from ear
Rhinorrhea: Draining of CSF from nose
Periorbital Ecchymosis: bruising around both eyes; racoon eyes
Postauricular Ecchymosis: bruising over the mastoid process; battle sign

Le Fort Fractures:
Type I: horizontal fracture superior to maxillary alveolar process crossing the nasal bony septum
- May affect pterygoid plates
- Results in “ oating” separated palate
Type II: fracture of maxillary sinuses through the infraorbital foramina lacrimal or ethmoid bones to
the nasion
- central part of face is separated from the cranium
- Results in “ oating” separated maxilla
Type III: horizontal fracture through the superior orbital ssures, ethmoid and nasal bones; laterally
through greater wings of sphenoid, frontozygomatic sutures & zygomatic arches
- Viscerocranium separates from the neurocranium
fl
fl
fi
Fratures at the Pterion (thin/weak region where temporal, sphenoid, parietal & frontal bones
meet):
- Deep to the Pterion is the Middle meningeal artery which can be ruptures by an injury to this region
- Middle meningeal artery rupture = epidural hemotoma; blood trapped between skull & dura

Alzheimer’s Disease: massive cell loss

Parkinson’s Disease: Dopaminergic neuron destroyed causing defects in movement & muscle control
- reciprocal connections between the basal ganglia & cerebellum
- Diminished substantia nigra
Cerebellum Lesion: the cerebellum plays a role in motor control so lesion results in a “drunken
sailor” gait

Cerebral Artery Strokes

Intracranial (Berry) Aneurysms:
- circle of willis
- Blood in CSF

Cavernous Sinus Infection in The Dangerous Triangle of The Face:

- infection may produce thrombophlebitis of the facial (angular) vein that can spread to the cavernous
sinus via the ophthalmic veins
- Second root of infection can spread from the upper molars via pterygoid venous plexus through the
inferior ophthalmic vein to the cavernous sinus
- Septicaemia leads to meningitis and cavernous sinus thrombosis
 Subarachnoid Hemorrhage: extravasation of blood into the subarachnoid space
- most cases result from the rupture of an aneurysm
- Results in meningeal irritation, headache & loss of consciousness

Extra-Axial Hemorrhages:
1. Subdural
- Blood between dura &
arachnoid
- Usually cerebral veins
2. Epidural
- Blood between skull & outer
dura
- Middle meningeal artery
3. Subarachnoid
- Blood ows in space of CSF
- Rapid distribution
fl
Hydrocephalus: congenital; increase in intracranial pressure, mental retardation & motor dysfunction
(including cranial nerves) due to the dilation of ventricles secondary to…
1. Excessive production of CSF
2. Blockage of CSF while production continues
3. Reduced reabsorption of CSF
Types:
1. Communicating: CSF ow into venous sinuses is impeded in subarachnoid space or by
obstruction at the level of arachnoid vili
2. Non-communicating: CSF ow obstructed ANYWHERE within ventricles or between the
ventricles and subarachnoid space

Spinal Tap: used to sample CSF

- level of L3/L4 in adults
- Level of L4/L5 in children
fl
fl
Meningitis:
infection of the
meninges caused
by bacterial, viral
or fungal infection
- WORST case is
bacterial; treated
with antibiotics

Extraocular Eye Muscle Disruption

1. Oculomotor Nerve (CNIII) Damage:
- ONLY superior oblique & lateral rectus are active
- Pull eye laterally & down

2. Trochlear Nerve (CNIV) Damage:

- superior oblique NOT functional
- Eye can’t move down & out; trouble walking down stairs

3. Abducens Nerve (CNVI) Damage:

- eye would be adducted by the unopposed pull of medial rectus
- if ONLY medial rectus is NOT functioning then eye would be abducted laterally by unopposed pull
of lateral rectus
 Orbital Floor Blowout: fracture of the thin bones on the oor of the orbit (roof of maxillary sinus)
causes the eye to drop either entirely into the maxillary sinus
- Trapdoor fracture: when the
muscles at the bottom of the eye
(inferior rectus & inferior oblique)
can be trapped in the fractured bone
so the eye can not elevate (look up)
- Infraorbital nerve damage

Other Key Quiz Information:

Tumor @ hypoglossal canal will affect Genioglossus muscle

In ammation of Parotid gland pain or pain to TMJ = auriculotemporal nerve

Inability to close eye = Zygomatic branch of Facial Nerve

Hyperacusis is a result of injury to the facial nerve

Parotid gland tumor removal = risk of developing same side facial muscle paralysis

Loss of general sense & taste sensation from anterior 2/3 of tongue = injury of lingual nerve

Fractured pterion & epidural hematoma = Injury of middle meningeal artery

Dif culty with mandibular depression due to pain; movement elicits an audible clicking sound;
tightness/muscle spasm along left mandibular ramus = Masseter

Important in jaw protrusion & depressing Mandible = Lateral pterygoid

Anterior TMJ displacement = Lateral pterygoid

Intact taste & salivation but no general sensation to anterior tongue = injury to Lingual nerve prox. To
junction with Chorda tympani (near foramen ovale)

Pure elevator of the jaw = Medial pterygoid

Blood in CSF = ruptured berry aneurysm

Arachnoid villi allow CSF between subarachnoid space & superior sagittal sinus

Ciliary body bers from superior cervical ganglion

fl
fi
fi
fl
Middle Ear Infections: infections in the oropharynx or nasopharynx can travel to the middle ear
Otitis Media: Route for bacteria to enter the middle ear

Tonsillitis: In ammation of the tonsils

- commonly caused by viral strains that cause the common cold but can be bacterial (strep throat)
- High fever, sore throat, ear/headaches, swollen lymph nodes

Tonsillectomy: removal of palatine tonsils (most common)

recommended for:
- enlarged (hypertrophic) tonsils
- Several infections in one year or the past few years
At risk:
Tonsilar branch of Glossopharyngeal nerve (CNIX) (because the
wall is thin on the lateral wall of the pharynx)
Internal Carotid Artery (variants & aneurysms increase incidence
of accidental lesion)
fl
 Piriform Recesses: objects can become lodged here; if objects are sharp
it can pierce the mucosal membrane & damage the recurrent laryngeal
nerve

Retropharyngeal Space:
- weak fascial plane
- Infection spread
- Compromise airway & laryngeal nerves

Epiglottis: a bacterial infection may obstruct the airway; requires wide-spectrum antibiotics

Gag Re ex: touching the posterior part of the pharynx rests in muscular contraction of each side of the
pharynx
- Afferent Limb = CNIX
- Efferent Limb = CNX
- Injury to the Glossopharyngeal nerve (CNIX) will result in negative gag re ex

- Injury to one Vagus nerve results in

paralysis of the pharyngeal & uvula on the
affected side; opposite side will still
contract & uvula will move toward the
undamaged side —> Gag Re ex
Disruption

Hypoglossal Nerve Lesion: tongue deviated to paralyzed side during protrusion

because of the action of the unaffected genioglossus muscle on the other side
- unilateral trauma results in paralysis and atrophy of one side of the tongue
- Tongue deviates to paralyzed side during protrusion because of the action of
the unaffected
genioglossus muscle on the
other side; deviates
toward side of the lesion
fl
fl
fl
 Inferior Alveolar Nerve Block
- Most common type of nerve block used for dental procedures; involves
anaesthetization of the inferior alveolar nerve (CN V3)
- Injection site is around mandibular foramen (passage for the alveolar
neurovasuculature to enter mandible canal)
- This process will also anaesthetize the lower lip, labial alveolar mucosa,
half of the chin, and the gingivae
- Problems can occur with “misses” into the parotid gland, facial nerve, or
medial pterygoid muscle

Oral Cavity Drug Administration

- Used when rapid absorption of drug is required where they are absorbed by simple
diffusion
- Drugs enter the sublingual vessels and or mucosa
- The absorption of potential or oral mucosa is in uenced by the lipid solubility and
therefore the permeability of the solution (osmosis)
- Sublingual drug administration is applied in the eld of cardiovascular drugs,
steroids, some barbiturates and enzymes

Sialolithiasis Or “Salivary Stones”

A condition where a calci ed mass (sialolith) forms within a salivary gland.
-most commonly in the duct of the submandibular gland
-In ammation or infection in gland may occur
-Sialolithiasis may also occur because of existing chronic infection of the
gland, dehydration, or increased local levels of calcium
-In most cases, cause is unknown
-Pain & swelling of affected gland that gets worse when salivary production is
stimulated (chewing/smelling food)
fl
fi
fl
fi
 Nasal Mucosa
- mucosa over concha is highly vascularized;
they swell up in cold weather to bring more
blood into the conchae in order to warm &
humidify the air
- The nasal mucosa and mucosa membranes of
the sinuses can be commonly infected/
in amed resulting in a stuffy, runny nose &
discomfort.
- When infected the mucosa may swell and
block the nasal passage

Nasal Polyps
Overgrowth of mucosa in the nasal cavity that obstruct both air ow & the opening of paranasal sinuses
- Surgically removed but may regrow

Epistaxis (Nosebleed)
Associated with injury/trauma, infection, hypertension & medication
- anastomoses of several arteries in anterior septum; called kiesselbach’s
plexus
- Anterior bleeds = 90% of the time and are mainly from dryness from
inspired air & nose picking
- Posterior bleeds = usually require medical attention as bleeding is more
profuse & harder to stop because arteries are so far back

Nasal Packing: placement of strips

of gauze into the nasal cavity to
create pressure on the bleeding site.
Other materials that promote clotting
may be used.
fl
fl
 Septal Deviation
- Can be congenital or due to trauma
- Corrected by septoplasty surgery
- Extreme lateral deviation of septum may result in
obstruction of the nasal passages & reduced air ow
- Dif culty breathing.
- Nosebleeds
- Sleep apnea
- Mild to severe loss of smell

Nasal Fractures
- most common facial fracture
- Can result in nose deformation

CSF Rhinorrhea
- if nasal fracture is severe, it may cause fracture of the
cribriform plate of the ethmoid bone
- Provides a pathway for CSF to drain from the
subarachnoid space into the nose
- May lead to meningitis

Brachial Cleft Cysts

-Manifest as a painless, rm neck mass lateral to the midline

Thyroglossal Cysts
- Midline mass/swelling
- non-tender,
- often near hyoid bone in the thyroglossal duct; may rupture
spontaneously & present as a draining sinus (thyroglossal stula)

Retinal Detachment
neural retina is separated from its blood supply; results in death of neural retina unless reattached by
“spot welds” from laser
- potential site at intraretinal space between epithelial layers
- Head trauma expands intraretinal space
fi
fi
fl
fi
Cleft Lip
- Often due to failure in the formation of the rst pharyngeal arch

Jefferson OR Burst Fracture of C1 (atlas)

Vertical forces compress the lateral masses between the occipital condyles & the axis drive them apart,
fracturing one or both of the anterior or
posterior arches
causes:
- compression from above
- Jump out of 4th oor window
- Head on football injury

Does NOT necessarily result in spinal cord injury but it is more likely
if transverse ligament of atlas is ruptured

Traumatic Spondylolysis of C2 (axis) OR Hangman’s

Fracture
Fracture usually occurs in the bony column formed by the
superior & inferior articular processes of the axis (pars inter-
articularis)
- result of hyperextension of the head/neck with or w/out
dislocation of the axis
- Injury of the spinal cord and/or brainstem is likely to occur
fl
fi
Fractures of the Dens
- make up 40% of axis fractures
- Type II is Most common: fracture of dens at its junction with the body of the axis
- These fractures are unstable because the transverse ligament of the axis becomes interposed
between fragments & because the separated dens fragments no longer have blood supply resulting
in avascular necrosis

Cervical Vertebrae Dislocation

Intracranial Bleeding Types
1. Epidural
2. Subdural

Epidural Hematoma
Presents with LOC followed by a lucid interval followed by rapid
deterioration
- Blood collects between skull & dura
- Biconvex CT
- Usually associated with a skull fracture that lacerates a dural artery
or venous sinus
- Middle meningeal artery

Subdural Hematoma
- Tearing of bridging veins
-Blood collects between arachnoid & dura
-Crescent shaped CT