Anatomy of the head – the essentials for surgical practice

1. Anatomy of the head – the essentials for surgical practice

2. The skull

3. Neurocranium – anatomic landmarks • Glabella –frontal proeminences • Bregma – coronal suture • Lambda – crossing between the sagital and lambdoid sutures

4. Facial bones – anatomic landmarks • Nasion • Alveolar depression • Mentonier point • Gonion • Malar point • Dacryon

5. Projection of viscus and bones

6. The eyes: what is apparent and what should we see?

7. Anatomy of the eye

8. The pupilary reflex

9. Near sight reflex

10. The ear:Testing the vestibulary apparatus an hearing

11. Test for normal hearing

12. Test for balance • Walk on s narrow pathway • Romberg test for balance

13. Nasal cavity and paranasal sinuses

14. Nasal cavity and paranasal sinuses

15. Oral Cavity

16. Clincal signs in cranio-cerebral trauma

17. Why do we discuss in conjunction skull and cerebral lesions?

18. Direct impact • ACCELERATION: traumatic agent is moving while the head is immobile. • Produces an area of depression of the skull • Decreases the kinetic energy of the traumatic agent – energy transfer • Limited extra space – impact on the brain which does not have an escape route

20. Direct impact • DECELERATION: the head in move stops abruptly when hitting an immobile strong surface. • Kinetic energy transmits to the skull and cerebrum • Cerebrum continues to move after the skull stops. Secondary trauma to the brain while hitting the bony irregularities: back of orbit and sphenoidal bones (ridge)

22. Direct trauma • BILATERAL COMPRESION: sudden compression with reduction of normal convexity

23. Direct trauma • ROTATIONAL ACCELERATION – complex mechanism where a combination of acceleration and deceleration prdoduces a rotational movement

24. Indirect trauma • Physical force does not action on the head but produces lesions from a distant impact. • Although produced by different type of impact, pathogenic mechanisms are similar with those presented for acceleration and deceleration.

25. Indirect trauma • Sudden flexion or extension = produces movements of the skull and cerebrum with different speeds the brain is pushed against the hard skull and is injured. • Landing on feet or ischiatic protuberances typical mechanism is that of counter-hit

28. Clinical examination • History: thorough evaluation of the mental status and neurological effects as traumatic effects may determine primary consequences (neurological disturbances, dilacerations) , secondary (accumulation of fluids) or late effects (cerebral edema). Time schedule can be very important in judging severity. Evaluation of conscience – a superior form of reflection of the objective world – 90% of head trauma present an impairment of consciousness.

29. Clinical examination • Impairment of consciencesness : • Agitation: motor/ psychological - motor • Stupor: no tendency to move spontaneously and indifference – conscience status appears to be suspended • Obnubilation (difficulties in responding to questions, as if in superficial sleep • Mute and akinetic • Lack of initiative and less impressed about people around him • Confused • Coma – partial or total loss of conscience and other function that relate a human being with the environment, chenges in vegetative functions

30. Definitions are to complex + a lot of subjectivism = confusion in terms GLASGOW Coma Scale International accepted grading for the conscience status 0-8 9-12 13-15

31. 0-8 9-12 13-15

32. Evaluation of vegetative function • Respiration • Circulation • Thermal homeostasis

33. Clinical examination • Muscular tonus • Back of the head • Limbs • Ability to sustain the forearm or ankle (integrity of the pyramidal pathway) • Rigidity by lack of cerebral function(extension of limbs) • Rigidity by lack of functional cortex (flexion of limbs) • Testing sensibility • Evaluation functionality of cranial nerves – in particular for lesions with fracture lines in the base of the skull.

34. Cranial nerves

35. Olfactiv N. (I) • Fracture lines involve the fine perforated bonny structure of the etmoid bone, through which the nerve fibers pass inside the skull. • The patient if conscientious acuses anosmia impossibility to sense any odor), usually it is unilateral !!!

36. Optic N (II) • Lesions in the middle fossa, between the optic chiasm and the eye – blindness (different areas according to lesion) • Concussions may be reversible • Section of the nerve is always followed by atrophy and definitive blindness.

37. Motor nerves of the eye (oculomotor III) • Motility disorders with the consequent double vision • Ptosis of the eye lid (unilateral) • Divergent strabismum • Midriasis (unilateral)

38. Motor nerves of the eye (abducens IV) • Palsy of the great oblique muscle with impossibility to look below and outward • Double vision depending on the position of the view

39. Decrease sensibility or anesthesia in the respective cutaneous sensitive areas Motor branch – difficulties in mastication and lateral deviation of the mandible Ophthalmic branch – lack of corneal reflex Trigeminal (V)

40. Extern oculomotor (VI) • Convergent strabismus, with deviation opposite in direction to the normal movement of the nerve

41. Facial asymmetry Deviation of the mouth towards the normal side Labial corner lowered on the affected side Eye-bulb on the affected side appears larger Acoustic/vestibular syndrome may be associated when the fracture involves the base of the skull Facial nerve (VII)

42. Acustico-vestibular nerve (VIII) • Audition: • Abnormal sounds • Auditory deficit • Vestibular: • Only in cases with unaltered conscience the patient may suffer from dizziness or vertigo

43. Glosopharingeal nerve (IX) • Mixt composition motor and sensitive compoents • Deglutition problem (palsy of the superior constrictor of the pharynx) • Absent pharingeal reflex • Hipoestesia or anestesia of the pharynx and posterior third of the tongue

44. Vagus nerve (X) • Palsy of the soft palate • Palsy of the recurrent nerve with voice characterized by bitonality • Changes in respiration and cardiovascular activity

45. Spinal (XI) • Palsy of sterno-cleido-mastoidian nerve and trapesius. • Shoulder is abnormally low and the patient can not move the scapula away from the midline • The sterno-cleido-mastoidian on the affected side does not contract when the head is moving.

46. Hipoglosal nerve (XII) • Atrophy of half of the tongue • Deviation of the tongue towards the affected side

47. Cranio-cerebral concussions There is significant difference in terms from soft tissues concussions: in head injuries it is possible the skin to be continuous, but a fracture to produce endocranian infection

48. 1. Concussions of the scalp • Particularities: deep fascia slides over the skull (periostum) and as such it is very mobile • The scalp is a complex structure that behaves as an entity. It has numerous fibrous structures that produces honey-comb spaces that comprise blood vessels.

49. 1. Concussions of the scalp • Haematoma of the skull – may appear during delivery in the skull of babies in the area of presentation of the head. • It is a cutaneous bloody suffusion • It has a tumor-like appearance which can be deformed while pressing it and will be reabsorbed in days.

50. 1. Concussions of the scalp • Subcutaneous hematoma: • Direct impact • Painful swelling (spontaneous or after manipulation0 • Relatively soft (deformable) but may be hard (in tension) • If large enough can present a softer area in the middle which can produce “thumb-printing” • Specific sound – crepitating – similar when crushing snow in your hand) – poses a risk of confusion with the sound of moving bony fragments • It develops under the deep fascia and can migrate in adjacent area