Dr.

Mujahid Khan
 The skin, the subcutaneous tissue, and the epicranial
aponeurosis are closely united to one another and are
separated from the periosteum by loose areolar tissue

 The skin of the scalp possesses numerous sebaceous

glands

 The ducts are prone to infection and damage by combs

 Therefore sebaceous cysts of the scalp are common

 The scalp has a profuse blood supply to nourish the hair follicles

 Even a small laceration of the scalp can cause severe blood loss

 It is difficult to stop the bleeding because the arterial walls are

attached to fibrous septa in the subcutaneous tissue

 Are unable to contract or retract to allow blood clotting to take

place

 Local pressure applied to the scalp is the only satisfactory method

to stop the bleeding
 All the superficial arteries supplying the scalp ascend
from the face and the neck

 In an emergency situation, encircle the head just above

the ears and eyebrows with a tie, shoelaces, or even a
piece of string and tie it tight

 Insert a pen, pencil, or stick into the loop and rotate it

so that the tourniquet exerts pressure on the arteries
 Infections of the scalp tend to remain localized

 Are usually painful because of the abundant fibrous tissue in the

subcutaneous layer

 Infection may spreads by the emissary veins, causing

osteomyelitis

 Infected blood may travel by the emissary veins into the venous
sinuses and produce venous sinus thrombosis

 Blood or pus may collect in the potential space beneath the

epicranial aponeurosis
 The facial skin receives its sensory nerve supply from
the trigeminal nerve

 Trigeminal neuralgia is a relatively common condition

 Patient experiences severe pain in the distribution of

the mandibular or maxillary division

 The ophthalmic division usually escaping

 The area of facial skin bounded by the nose, the eye, and
the upper lip is a potentially dangerous zone to have an
infection

 A boil in this region can cause thrombosis of the facial

vein

 Causing spread of organisms through the inferior

ophthalmic veins to the cavernous sinus

 Resulting cavernous sinus thrombosis may be fatal unless

adequately treated with antibiotics
 The facial muscles are innervated by the facial
nerve

 Damage to the facial nerve causes distortion of

the face, with drooping of the lower eyelid, and
the angle of the mouth will sag on the affected
side
 The temporomandibular joint lies immediately in front of
the external auditory meatus

 Temporomandibular ligament prevents the head of the

mandible from passing backward and fracturing the
tympanic plate when a severe blow falls on the chin

 The articular disc of the temporomandibular joint may

become partially detached from the capsule

 Its movement become noisy and producing an audible

click during movements at the joint
 Dislocation occurs when the mandible is depressed

 In bilateral cases the mouth is fixed in an open position

 Both heads of the mandible lie in front of the articular

tubercles

 Reduction of the dislocation is achieved by pressing the

gloved thumbs downward on the lower molar teeth
and pushing the jaw backward
 The parotid duct is a comparatively superficial
structure on the face

 May be damaged in injuries to the face or by

cut during surgical operations on the face
 It develops after penetrating wounds of the parotid gland

 If patient eats, beads of perspiration appear on the skin covering the

parotid

 Caused by damage to the auriculotemporal and great auricular nerves

 During the process of healing, the parasympathetic secretomotor fibers in

the auriculotemporal nerve grow out and join the distal end of the great
auricular nerve

 These fibers reach the sweat glands in the facial skin

 A stimulus intended for saliva production produces sweat secretion instead

 The submandibular gland is a common site of calculus
formation

 It is rare in the other salivary glands

 Examination of the floor of the mouth reveals absence

of ejection of saliva from the orifice of the duct of the
affected gland

 Stone can be palpated in the duct, which lies below the

mucous membrane of the floor of the mouth
 The sublingual salivary gland lies beneath the
sublingual fold of the floor of the mouth

 It opens into the mouth by numerous small

ducts

 Blockage of one of these ducts is believed to be

the cause of cysts under the tongue
 At the junction of the mouth with the oral part
of the pharynx, and the nose with the nasal
part of the pharynx, are collections of lymphoid
tissue of considerable clinical importance

 The palatine tonsils and the nasopharyngeal

tonsils are the most important
 The palatine tonsils reach their maximum normal size in early
childhood

 Gradually atrophy after puberty

 Palatine tonsils are a common site of infection

 Producing the characteristic sore throat and pyrexia

 The deep cervical lymph node is usually enlarged and tender

 Recurrent attacks of tonsillitis are best treated by tonsillectomy

 A peritonsillar abscess is caused by spread of
infection from the palatine tonsil to the loose
connective tissue outside the capsule

 This is called quinsy

 Excessive hypertrophy of pharyngeal tonsils are referred
to as adenoids

 Marked hypertrophy blocks the posterior nasal openings

and causes the patient to snore loudly at night and to
breathe through the open mouth

 It may be the cause of deafness and recurrent otitis media

 Adenoidectomy is the treatment of choice for

hypertrophied adenoids with infection
 The piriform fossa is a recess of mucous membrane
situated on either side of the entrance of the larynx

 It is bounded medially by the aryepiglottic folds and

laterally by the thyroid cartilage

 It is a common site for the lodging of sharp ingested

bodies such as fish bones. The presence of such a
foreign body immediately causes the patient to gag
violently
 Palpation of the fontanelles enables to know the progress of
growth in surrounding bones

 The degree of hydration of the baby

 The state of intracranial pressure

 Samples of cerebrospinal fluid can be obtained by passing a long

needle obliquely through the anterior fontanelle into the
subarachnoid space or even into the lateral ventricle

 It is usually not possible to palpate the anterior fontanelle after 18

months
 At birth, the tympanic membrane faces more
downward and less laterally than in maturity

 If examined with the otoscope it lies more

obliquely in the infant than in the adult
 Mastoid process is not developed in the
newborn infant

 The facial nerve emerges from the stylomastoid

foramen and is close to the surface

 It can be damaged by forceps in a difficult

delivery
 In these fractures the cribriform plate of the ethmoid bone may be
damaged

 This usually results in tearing of the overlying meninges and

underlying mucoperiosteum

 Patient bleeds from the nose (epistaxis) and leakage of cerebrospinal

fluid into the nose (cerebrospinal rhinorrhea)

 Fractures involving the orbital plate of the frontal bone result in

hemorrhage beneath the conjunctiva and into the orbital cavity, causing
exophthalmos

 The frontal air sinus may be involved, with hemorrhage into the nose
 These fractures are common, because this is the weakest part of the
base of the skull

 This weakness is caused by the presence of numerous foramina and

canals in this region

 Cavities of the middle ear and the sphenoidal air sinuses are
particularly vulnerable

 Leakage of CSF and blood from the external auditory meatus is

common

 Blood and cerebrospinal fluid may leak into the sphenoidal air
sinuses and then into the nose
 In these fractures blood may escape into the
nape

 Later, it tracks between the muscles and

appears in the posterior triangle, close to the
mastoid process

 The mucous membrane of the roof of the

nasopharynx may be torn, and blood may
escape there
 Nasal Fractures

 Maxillofacial Fractures

 Blowout Fractures of the Maxilla

 Fractures of the Zygoma or Zygomatic Arch

 Extradural hemorrhage results from injuries to the meningeal
arteries or veins

 Subdural hemorrhage results from tearing of the superior cerebral

veins at their point of entrance into the superior sagittal sinus

 Subarachnoid hemorrhage results from leakage or rupture of a

congenital aneurysm on the circle of Willis or, less commonly, from
an angioma

 Cerebral hemorrhage is generally caused by rupture of the thin-

walled lenticulostriate artery, a branch of the middle cerebral
artery
 Otoscopic examination of the tympanic
membrane is done by first straightening the
external auditory meatus by gently pulling the
auricle upward and backward in the adult, and
straight backward or backward and downward
in the infant

 Normally, the tympanic membrane is pearly

gray and concave
 Pathogenic organisms can reach the middle ear
by ascending through the auditory tube from
the nasal part of the pharynx

 Acute infection of the middle ear called otitis

media

 It produces bulging and redness of the

tympanic membrane
 If not treatment otitis media can result in the spread of the
infection into the mastoid antrum and the mastoid air cells
called acute mastoiditis

 It may be followed by the further spread of the organisms

beyond the confines of the middle ear

 Meninges and the temporal lobe of the brain lie superiorly

 Spread of the infection in this direction could produce a

meningitis and a cerebral abscess in the temporal lobe
 Beyond the medial wall of the middle ear lie the facial
nerve and the internal ear

 A spread of the infection in this direction can cause a

facial nerve palsy and labyrinthitis with vertigo

 Posterior wall of the mastoid antrum is related to the

sigmoid venous sinus

 If the infection spreads in this direction, a thrombosis in

the sigmoid sinus may well take place
 A physician must be able to recognize all the structures visible in
the mouth and be familiar with the normal variations in the color
of the mucous membrane covering underlying structures

 The sensory nerve supply and lymph drainage of the mouth cavity
should be known

 The close relation of the lingual nerve to the lower third molar
tooth should be remembered

 The close relation of the submandibular duct to the floor of the

mouth may enable one to palpate a calculus in cases of periodic
swelling of the submandibular salivary gland
 A wound of the tongue is often caused by the teeth
following a blow on the chin while the tongue is partly
protruded from the mouth

 It can also occur when a patient accidentally bites the

tongue while eating, during recovery from an
anesthetic, or during an epileptic attack

 Bleeding is halted by grasping the tongue between the

finger and thumb posterior to the laceration, thus
occluding the branches of the lingual artery
 It may be carried out by inserting a speculum
through the external nares or by means of a
mirror in the pharynx

 In the latter case, the choanae and the posterior

border of the septum can be visualized

 A severely deviated septum may interfere with

drainage of the nose and the paranasal sinuses
 Fractures involving the nasal bones are
common

 Blows directed from the front may cause one or

both nasal bones to be displaced downward
and inward

 Lateral fractures also occur in which one nasal

bone is driven inward and the other outward;
the nasal septum is usually involved
 Infection of the nasal cavity can spread in many of
directions

 Paranasal sinuses are especially prone to infection

 Organisms may spread via the nasal part of the pharynx

and the auditory tube to the middle ear

 It is possible for organisms to ascend to the meninges of

the anterior cranial fossa, along the sheaths of the
olfactory nerves through the cribriform plate, and produce
meningitis
 Foreign bodies in the nose are common in
children

 Presence of the nasal septum and conchae

make impaction and retention of balloons,
peas, and small toys
 Epistaxis, or bleeding from the nose, is a frequent
condition

 Most common cause is nose picking

 Bleeding may be arterial or venous

 Most episodes occur on the anteroinferior portion of

the septum and involve the septal branches of the
sphenopalatine and facial vessels
 Infection of the paranasal sinuses is a common complication of
nasal infections

 Rarely, the cause of maxillary sinusitis is extension from an apical

dental abscess

 The frontal, ethmoidal, and maxillary sinuses can be palpated

clinically for areas of tenderness

 The frontal sinus can be examined by pressing the finger upward

beneath the medial end of the superior orbital margin

 Here the floor of the frontal sinus is closest to the surface

 The ethmoidal sinuses can be palpated by pressing the
finger medially against the medial wall of the orbit

 The maxillary sinus can be examined for tenderness by

pressing the finger against the anterior wall of the
maxilla below the inferior orbital margin

 Directing the beam of a flashlight either through the roof

of the mouth or through the cheek in a darkened room
often enable a physician to determine whether the
maxillary sinus is full of inflammatory fluid rather than
air
 Radiologic examination of the sinuses is
helpful in diagnosis. One should always
compare the clinical findings of each sinus on
the two sides of the body

 The maxillary sinus is innervated by the

infraorbital nerve and, in this case, pain is
referred to the upper jaw, including the teeth
 Recurrent laryngeal nerves are vulnerable during
operations on the thyroid gland

 Left recurrent laryngeal nerve may be involved in a

bronchial or esophageal carcinoma or in secondary
metastatic deposits in the mediastinal lymph nodes

 The right and left recurrent laryngeal nerves may

be damaged by malignant involvement of the deep
cervical lymph nodes