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
15.1.1.5 Eye Movement: The Extra Ocular Muscles
15.1.2 Connective Tissue System
15.1.3 Nerves Within the Orbit
15.1.4 Vascular Supply
15.1.5 The Lacrimal Gland
15.1.6 Orbital Emphysema
15.2 Diplopia
15.2.1 Horror Fusionis (“Fear of Fusion”)
15.2.2 Cranial Neuropathies and Ophthalmoplegia
15.2.2.1 Differential Diagnosis of Painful Ophthalmoplegia
15.2.3 The Oculocardiac Reflex
15.2.4 Cerebrospinal Fluid Oculorrhea and Orbitocele
15.2.5 Orbital Congestion
15.3 Important Considerations When Taking a History
15.3.1 Examining the Cheek and Orbit and Associated Structures
15.3.2 Assessment of Proptosis in the Unconscious Patient
15.3.3 Investigating Symptoms and Signs
15.3.3.1 Laboratory Tests
15.3.3.2 Plain Films
15.3.3.3 CT/MRI
15.3.3.4 Angiography
15.3.3.5 Ultrasound
16: The Cheek and Orbit: Part II
16.1 Proptosis and Exophthalmos: The Bulging Eye
16.1.1 Orbito-Masticatory Syndrome
16.1.2 Trauma Related Proptosis
16.2 Orbital Pseudotumor
16.2.1 IgG4-Related Disease
16.2.2 Tolosa-Hunt Syndrome (Painful Ophthalmoplegia)
16.2.3 Orbital Myositis
16.3 Sarcoidosis
16.4 Orbital Tuberculosis
16.5 The Vasculitides
16.6 Other Vascular and Similar Lesions
16.6.1 Capillary Haemangioma (Benign Haemangioendothelioma)
16.6.2 Cavernous Haemangioma
16.6.3 Orbital Varices
16.6.4 Hemangiopericytomas
16.6.5 Lymphangiomas
16.6.6 Carotid-Cavernous Fistula and Dural Arteriovenous Fistula
16.7 Non-vascular Lesions
16.7.1 Hydatid Cyst
16.7.2 Amyloidosis
16.7.3 Frontal Mucocele
16.7.4 Miscellaneous Lesions
16.8 Orbital Infections
16.8.1 Preseptal Cellulitis
16.8.2 Orbital Cellulitis
16.8.3 Orbital Abscess
16.8.4 Mycotic Infections: Mucormycosis (Zygomycosis)
16.9 Thyroid Eye Disease
16.10 Miscellaneous Space Occupying Lesions
16.10.1 Orbital Tumours, Cysts and Bony Growths
16.10.1.1 Tumours of the Lacrimal Gland
16.10.1.2 Orbital Lymphoma (and Other Plasma Cell Tumours)
16.10.1.3 Orbital Leukaemia
16.10.1.4 Sarcomas and Other Rare Tumours
16.11 Bony Dysplasias and Cysts
16.12 Lacrimal Conditions
16.12.1 Miscellaneous Lesions of the Lacrimal Gland
16.13 Ocular Motility Disorders
16.13.1 Brown’s Superior Oblique Tendon Sheath Syndrome
16.13.2 Gradenigo’s Syndrome (Abducens Nerve)
16.13.3 Ocular Myasthenia Gravis
16.13.4 Oculopharyngeal Muscular Dystrophy
16.13.5 Congenital Cranial Dysinnervation Disorders and Congenital Fibrosis of Extraocular Muscles
16.13.6 Mitochondrial Myopathies
17: The Cheek and Orbit: Part III
17.1 Injuries to the Cheek and Orbit
17.1.1 Cheek Fractures
17.2 Orbital Fractures (Isolated)
17.2.1 WEBOF Fractures
17.2.2 “Blow-In” Fractures
17.2.3 Orbital Haematomas and Haematic Cysts
17.2.4 Orbital Roof Fractures
17.2.5 Lateral Orbital Wall Fractures
17.2.6 Penetrating (Transorbital) Roof Injuries
17.3 Retrobulbar Haemorrhage and Orbital Compartment Syndrome (OCS)
17.3.1 Lateral Canthotomy and Cantholysis
17.4 Orbital Apex Injuries and Orbital Apex Syndrome
17.5 Injuries to the Lacrimal Gland
17.6 Traumatic Globe Subluxation
18: The Upper Jaw (“Midface”) and Sinuses: Part I
18.1 Applied Anatomy and Physiology
18.1.1 The Upper Jaw
18.1.1.1 Development of Paranasal Air Sinuses
18.1.2 The Soft Tissues
18.1.3 Blood Supply
18.1.3.1 Aseptic Necrosis of the Maxilla
18.2 Nerve Supply
18.2.1 The Trigeminal, Maxillary and Infraorbital Nerves
18.3 Anatomy and Physiology of Facial Pain
18.3.1 The Role of the Midface in Airway Maintenance, Speech and Swallowing
18.4 Important Considerations When Taking a History
18.5 Examining the Midface and Associated Structures
18.5.1 Examination of the Midface Following Trauma
18.6 Investigating Symptoms and Signs
18.6.1 Laboratory Tests
18.6.2 Plain Films
18.6.3 CT/MRI
18.6.4 Ultrasound
19: The Upper Jaw (“Midface”) and Sinuses: Part II
19.1 Swellings and Lumps Around the Midface
19.1.1 Dental Infections
19.1.1.1 Buccal Space
19.1.1.2 Canine Fossa
19.1.1.3 Masticator Space
19.1.1.4 Parotid Space
19.1.1.5 Upper Lip
19.1.2 Spread of Infections
19.1.3 Maxillary Sinusitis
19.1.4 Osteomyelitis of the Upper Jaw
19.1.4.1 Actinomycotic Osteomyelitis
19.1.4.2 Infantile Osteomyelitis
19.1.5 Odontogenic Cysts and Other Tumours of the Midface
19.1.6 Maxillary Tumours
19.1.6.1 Osteomas of the Upper Jaw
19.1.6.2 Reparative Giant Cell Granuloma of the Maxilla
19.1.7 Extramedullary Haematopoiesis (EH)
19.1.8 Osteoradionecrosis (ORN)
19.1.9 Medication Related Osteonecrosis of the Jaw (MRONJ)
19.1.10 Paget’s Disease (Osteitis Deformans)
19.1.11 Fibrous Dysplasia (FD)
19.2 Facial Pain and Numbness
19.2.1 Facial Pain Syndromes
19.2.1.1 Atypical Facial Pain (AFP)
19.2.1.2 Atypical Odontalgia
19.2.1.3 Complex Regional Pain Syndrome (CRPS)
19.2.2 Identifiable Causes of Facial Pain
19.2.2.1 Herpes Zoster (Shingles) (See Also the Chapters on the Eye and Lower Jaw)
19.2.2.2 Trigeminal Neuralgia (‘tic douloureux’)
19.2.2.3 Anaesthesia Dolorosa/Post Traumatic Trigeminal Neuropathy
19.2.2.4 Facial Migraine
19.2.2.5 Granulomatosis with Polyangiitis
19.2.2.6 Osteopetrosis
19.2.3 Facial Numbness and Trigeminal Neuropathy
20: The Upper Jaw (“Midface”) and Sinuses: Part III
20.1 Injuries to the Midface
20.1.1 Dentoalveolar Fractures
20.1.2 Midface (Le Fort) Fractures
20.1.2.1 Le Fort I (“Low Level”)
20.1.2.2 Le Fort II (“Pyramidal”)
20.1.2.3 Le Fort III (“High Transverse” or “Craniofacial Dysjunction”)
20.1.3 Split Palate
20.1.4 Extended Fractures
20.1.4.1 First Aid Measures
20.1.5 Controlling Midface Bleeding
20.1.5.1 Supraselective Embolisation
20.1.6 Management of Midface Fractures
21: The Lower Jaw (Mandible) and Associated Structures: Part I
21.1 Applied Anatomy and Physiology
21.1.1 Osteology
21.1.2 Muscle Attachments
21.1.3 Dentition
21.1.4 Age-Related Changes
21.1.5 Blood Supply
21.1.6 Nerve Supply
21.2 The Temporomandibular Joint (TMJ)
21.2.1 Restricted Mouth Opening
21.2.1.1 Trismus
21.2.1.2 Mechanical Causes of Restricted Mouth Opening
21.2.2 Temporomandibular Joint Ankylosis
21.2.3 The Jaw Jerk (Masseteric) Reflex
21.3 Important Considerations When Taking a History
21.4 Examining the Mandible Associated Structures
21.4.1 Neurosensory Testing
21.5 Investigating Symptoms and Signs
21.5.1 Laboratory Tests
21.5.2 Plain Films
21.5.3 Sialography
21.5.4 CT/MRI
21.5.5 Ultrasound
21.5.6 Nuclear Medicine
22: The Lower Jaw (Mandible) and Associated Structures: Part II
22.1 Swellings and Infections of the Lower Jaw
22.1.1 Fascial Spaces Related to the Mandible
22.1.1.1 Mental Space
22.1.1.2 Submental Space
22.1.1.3 Submandibular Space
22.1.1.4 Buccal Space
22.1.1.5 Parotid Space
22.1.1.6 Masticator Space
22.1.1.7 Submasseteric Space
22.1.1.8 Sublingual Space
22.1.2 The Spread of Infection Beyond the Mandible
22.2 Life-Threatening Infections Related to the Lower Jaw
22.2.1 Ludwig’s Angina
22.2.2 Necrotising Fasciitis
22.2.3 Descending Necrotising Mediastinitis (DNM)
22.3 Determining the Severity of Infection
22.4 Other Soft Tissue Infections Related to the Lower Jaw
22.4.1 Cellulitis
22.5 Infections Within the Mandible
22.5.1 Pericoronitis
22.5.2 Periapical Infections
22.5.3 Chronic Dentoalveolar Abscess
22.5.4 Infected Fractures
22.5.5 Osteomyelitis
22.5.6 Infections in Mandibular Osteoradionecrosis
22.5.7 Primary Chronic Osteomyelitis (PCO)
22.5.8 Actinomycosis
22.5.9 Syphilis
22.6 Infections Related to the Salivary Glands
22.6.1 Viral Infections
22.6.1.1 Mumps (Epidemic Parotitis)
22.6.2 Acute Submandibular Gland Sialadenitis
22.6.3 Acute Bacterial Parotid Sialadenitis
22.6.3.1 Juvenile Recurrent Parotitis (Recurrent Parotitis of Childhood)
22.6.4 Chronic Bacterial Sialadenitis
22.6.5 Fungal and Parasite Infections
22.6.6 Granulomatous Infections
22.6.7 Pneumoparotitis
22.7 Non-infective Swellings of the Lower Jaw and Associated Lumps
22.7.1 Salivary Gland Pathology
22.7.2 Cystic Lesions and Tumour-Like Growths of the Mandible
22.7.2.1 Odontogenic Keratocysts (OKC)
22.7.2.2 Odontogenic Myxoma
22.8 Tumours and Other Growths of the Mandible
22.8.1 Ameloblastoma
22.8.2 Chondrosarcoma
22.8.3 Osteosarcoma
22.8.4 Ewing’s Sarcoma/Peripheral Primitive Neuroectodermal Tumour
22.8.5 Malignant Odontogenic Tumours
22.8.6 Metastatic Tumours
22.9 Osteoblastoma and Osteoid Osteoma
22.9.1 Mandibular Tori
22.9.2 Chondroma
22.9.3 Synovial Chondromatosis and Osteochondroma
22.9.4 Aggressive Mesenchymal Tumours of Childhood
22.9.5 Central Giant Cell Granuloma
22.9.6 Giant Cell Tumour
22.10 Conditions Causing Progressive Asymmetry of the Lower Face
22.10.1 Parry-Rhomberg Syndrome
22.10.2 Condylar Hyperplasia
22.11 Benign Fibro-Osseous Diseases
22.11.1 Fibrous Dysplasia
22.11.2 Cemento-Osseous Dysplasia
22.11.3 Periapical Cemento-Osseous Dysplasia
22.11.4 Focal Cemento-Osseous Dysplasia
22.11.5 Florid Cemento-Osseous Dysplasia
22.11.6 Familial Gigantiform Cementoma
22.11.7 Ossifying Fibroma
22.11.8 Juvenile Aggressive Ossifying Fibroma
22.11.9 Cherubism
22.11.10 Paget’s Disease (Osteitis Deformans)
22.12 Myositis Ossificans (Ossifying Pseudotumour)
22.12.1 Aneurysmal Bone Cyst
22.12.2 Vascular Malformations
22.12.2.1 Haemangiomas
22.12.3 Traumatic Bone Cyst
22.12.4 Stafne’s Bone Defect
22.13 Sinuses and Fistulae Arising from the Lower Jaw
22.13.1 Osteoradionecrosis (ORN)
22.13.2 Medicine Related Osteonecrosis of the Jaws
22.14 Pain and Numbness in and Around the Mandible
22.14.1 Toothache: See the Chapter on the Mouth
22.14.1.1 Herpes Zoster (Shingles)
22.14.1.2 Trigeminal Neuralgia (‘Tic Douloureux’) (See Also the Chapter on the Upper Jaw)
22.14.1.3 Acute Sickle Cell Crisis
22.14.2 Referred Pain
22.14.3 Numbness of the Lower Lip
22.15 Temporomandibular Dysfunction (Facial Arthromyalgia)
22.15.1 Pathophysiology
22.15.2 Assessment and Management
23: The Lower Jaw (Mandible) and Associated Structures: Part III Injuries to the Lower Jaw
23.1 Common Fracture Patterns
23.1.1 Anterior Fractures at the Symphysis and Parasymphysis
23.1.2 Posterior Angle Fractures
23.1.3 Ramus Fractures
23.1.4 Condylar Fractures
23.1.5 Imaging and Management
23.1.6 Paediatric Fractures
23.1.7 Edentulous Fractures
23.1.8 Pathological Fractures
23.1.9 Infected Fractures
23.1.10 Complications of Mandibular Fractures
23.2 Condylar Fractures
23.2.1 Traumatic Arthritis
23.2.2 Ankylosis of Temporomandibular Joint
23.3 Dislocation of the Jaw (TMJ)
23.3.1 Reducing a Dislocated TMJ
24: The Lips, Mouth, Tongue and Teeth: Part I
24.1 Applied Anatomy and Physiology
24.1.1 The Tongue and Floor of the Mouth
24.1.1.1 The Tongue
Lingual Artery Aneurysms
24.1.1.2 The Floor of the Mouth
24.1.2 The Lips and Cheeks
24.1.3 The Gingivae (Gums)
24.1.4 The Teeth
24.1.5 The Retromolar Trigone (RMT)
24.1.6 The Palate
24.1.7 The Sublingual and Minor Salivary Glands
24.1.7.1 Saliva
24.1.8 Nerves
24.1.8.1 Hypoglossal Nerve Lesion (Motor Weakness)
24.1.9 Anatomical Variants
24.1.9.1 Lip Pits
24.1.9.2 Racial Pigmentation
24.1.9.3 Foliate Papillae, Lymphoid Aggregates and the Lingual Tonsil
24.1.9.4 Fordyce Spots
24.1.9.5 Varicosities
24.1.9.6 Fissured Tongue
24.1.9.7 Scalloped (Crenated) Tongue
24.1.9.8 Exostoses
24.1.9.9 Prominent Genial Tubercle
24.1.10 Abnormalities of the Teeth
24.2 Abnormalities of the Tongue
24.2.1 Depapillation/Atrophic Glossitis
24.2.2 Hairy Tongue (Lingua Villosa)
24.2.3 Fissured Tongue (Scrotal Tongue, Lingua Plicata)
24.2.4 Median Rhomboid Glossitis
24.2.5 White Sponge Nevus
24.2.6 Haemangiomas and Lymphangiomas
24.2.7 Tongue Tie
24.3 Halitosis (Fetor Oris, Bad Breath)
24.3.1 Oral Galvanism
24.3.2 Hypersalivation
24.3.3 Excessive Production
24.3.4 Decreased Clearance (Impaired Swallowing)
24.4 Important Considerations When Taking a History
24.4.1 Peri-Oral Tingling of Hypocalcaemia
24.5 Examining the Oral Cavity and Its Associated Structures
24.5.1 The Lips and Cheeks
24.5.2 The Tongue and Floor of the Mouth
24.5.3 The Palate and Oropharynx
24.5.4 The Teeth and Gums
24.6 Investigating Symptoms and Signs
24.6.1 Laboratory Tests
24.6.2 Plain Films
24.6.3 CT and MRI
24.6.4 Ultrasound
25: The Lips, Mouth, Tongue and Teeth: Part II
25.1 Swellings and Lumps in and Around the Mouth
25.1.1 Normal Anatomical ‘Lumps’
25.1.2 Infections/Abscesses
25.1.3 Surgical Emphysema
25.1.4 Anaphylaxis
25.1.5 Angioedema
25.1.6 Swelling Secondary to Injury
25.1.6.1 Sublingual Haematoma
25.1.7 Mucocele (Mucus Retention Cyst)
25.1.8 Ranula
25.1.9 Haemangioma and Varices
25.1.10 Orofacial Granulomatosis
25.1.11 Amyloidosis
25.1.12 Dermal Fillers
25.1.13 Fibrous Dysplasia
25.1.14 Paget’s Disease
25.1.15 Dermoid Cyst
25.1.16 Calculi (Stones)
25.1.17 Submucosal Fibroma/Lipoma
25.1.18 Papilloma
25.1.19 Epulis
25.1.19.1 Pyogenic Granuloma
25.1.19.2 Pregnancy Epulis
25.1.19.3 Fibrous Epulis
25.1.19.4 Ossifying Fibroid Epulis
25.1.19.5 Giant Cell Epulis
25.1.19.6 Congenital Epulis
25.1.20 Gingival Hyperplasia
25.1.21 Salivary Gland Tumours
25.1.22 Unerupted Teeth
25.2 Bleeding from the Mouth
25.2.1 Gingivitis/Periodontitis
25.2.2 Desquamative Gingivitis
25.2.2.1 Lichen Planus
25.2.2.2 Immune-Mediated Blistering Diseases (Vesiculobullous Disorders)
25.2.3 Infections
25.2.4 Oral Cancer
25.2.5 Antiplatelet and Anticoagulant Medication
25.2.6 Haematological Disorders
25.2.7 Management of Oral Bleeding
25.3 Dental Caries, Toothache and Dental Abscesses
25.3.1 Draining Sinus
25.3.2 Progression of Infection
25.3.3 Dental Pain
25.3.3.1 Pulpitis
25.3.3.2 Periodontal/Periapical Abscess
25.3.3.3 Recent Dental Treatment
25.3.3.4 Dentine Hypersensitivity
25.3.3.5 Cracked Tooth
25.3.3.6 Referred Pain
25.3.4 The Wisdom Teeth and Pericoronitis
25.4 Ulceration and Blistering of the Mouth and Lips
25.4.1 Traumatic Ulcers and Burns
25.4.2 Acute Necrotising Ulcerative Gingivitis (Trenchmouth)
25.4.3 Herpes Infection (Primary Herpetic Stomatitis, Cold Sores)
25.4.3.1 Primary HSV (Herpes Simplex Virus)
25.4.3.2 Secondary HSV (Recurrent Herpes Labialis, or Cold Sores)
25.4.4 Hand, Foot and Mouth Disease
25.4.5 Herpangina
25.4.6 Stevens-Johnson Syndrome (SJS)
25.4.7 Behcet’s Disease
25.4.8 Pemphigus and Mucous Membrane Pemphigoid
25.4.9 Aphthous Ulceration
25.4.10 Angina Bullosa Haemorrhagica
25.4.11 Wegener’s Granulomatosis
25.5 Malignancies of the Mouth and Lips
25.5.1 Squamous Cell Carcinoma
25.5.1.1 Oral Submucous Fibrosis
25.5.2 Mucosal Malignant Melanoma
25.5.3 Lymphomas
25.5.4 Kaposi’s Sarcoma
25.5.5 Necrotising Sialometaplasia
25.5.6 Melanotic Neuroectodermal Tumour of Infancy
25.5.7 Lip Cancer
25.5.8 Erythroplakia
25.6 White and Red Lesions in the Lips, Tongue and Mouth
25.6.1 Physiological White Patches
25.6.2 Leukoplakia
25.6.3 Actinic Keratosis
25.6.4 Nicotine Stomatitis of the Palate
25.6.5 Oral Lichen Planus (OLP)
25.6.6 Lichenoid Reaction
25.6.7 Frictional Keratosis
25.6.8 Candidiasis
25.6.9 Hairy Tongue of HIV
25.6.10 Anaemia
25.6.11 Red Patches in the Mouth
25.6.12 Erythema Multiforme
25.6.13 Lupus Erythematosus
25.6.14 Erythroleukoplakia (Speckled Leukoplakia)
25.7 Pigmented and Discoloured Lesions
25.7.1 Racial Pigmentation and Pigmentation in Pregnancy
25.7.2 Oral Melanotic Macules and Nevi
25.7.3 Extrinsic Staining: Drugs, Food, Betel, Nicotine
25.7.4 Diffuse Pigmentation
25.7.5 Malignant Melanoma
25.7.6 Haemangioma/Arteriovenous Malformation (AVM)
25.7.7 Discoloured Teeth
25.8 Exposed Bone in the Mouth
25.8.1 Dry Socket (Alveolar Osteitis)
25.8.2 Osteomyelitis
25.8.3 Radiation: Osteoradionecrosis (ORN)
25.8.4 Medication Related Osteonecrosis of the Jaws (MRONJ)
25.8.5 Malignant Invasion
25.9 Generalised Pain and Alteration of Sensation Within the Mouth
25.9.1 Xerostomia (Dry Mouth)
25.9.1.1 Radiation Induced Xerostomia
25.9.2 Mucositis
25.9.3 Trigeminal Neuralgia (See Also the Lower Jaw)
25.9.4 Burning Mouth Syndrome
25.9.5 Reflux Oesophagitis
25.9.6 Tumours
25.9.7 Iatrogenic Injury to the Inferior Alveolar and Lingual Nerve
25.10 Some Denture and Orthodontic Related Problems
25.10.1 Denture Related Problems
25.10.1.1 Loose or Broken Dentures
25.10.1.2 Denture Stomatitis
25.10.1.3 Soft Tissue Changes: Denture Hyperplasia, Flabby Ridge, Denture Fibroma
25.10.1.4 Dentures Too Tight
25.10.2 Orthodontic Appliances
25.10.3 Restorative Dentistry Related Issues
25.11 Miscellaneous Infections of Oral Mucosa
25.11.1 Syphilis
25.11.2 Gonorrhea
25.11.3 Measles
25.11.4 Rubella
25.11.5 HIV
25.12 Recreational Drug Use and the Oral Cavity
26: The Lips, Mouth, Tongue and Teeth: Part III
26.1 Injuries
26.1.1 Lip Lacerations
26.1.1.1 Repair of Lacerations
26.1.2 Intraoral Lacerations (Mucosa and Tongue)
26.1.3 Penetrating Intraoral Wounds
26.1.4 The Loose Tooth
26.1.5 The Injured Tooth
26.1.5.1 Intrusion
26.1.5.2 Extrusion
26.1.5.3 The Avulsed Tooth
26.1.5.4 Re-implanting a Tooth
26.1.5.5 Splinting a Replaced Tooth
26.1.5.6 Initial Management of Isolated Tooth Avulsion at the Time of Injury (Telephone Advice)
26.1.5.7 Initial Assessment in the Emergency Department
26.1.5.8 Contraindications to Replanting an Avulsed Tooth
26.1.6 Fractured Teeth
26.1.6.1 Crown Fractures
26.1.6.2 Root Fractures
26.1.7 Alveolar Fractures
26.1.8 Injuries to the Gingiva and Alveolar Mucosa
26.1.9 Tooth Damage During General Anaesthesia
26.1.10 Bleeding Extraction Sockets
26.1.10.1 Management of a Bleeding Socket
27: The Eye (Globe), Eyelids and Associated Structures: Part I
27.1 Applied Anatomy and Physiology
27.1.1 The Eye (Globe)
27.1.1.1 The Anterior Chamber (Iridocorneal) Angle
27.1.1.2 Aqueous Humor (AH)
27.1.1.3 Vitreous Body
27.1.1.4 The Conjunctiva
27.1.2 The Orbit
27.1.2.1 Orbital (Retrobulbar) Contents
27.1.3 The Eyelids
27.1.4 The Lacrimal System
27.1.5 Ocular Blood Supply
27.1.6 The Third, Fourth and Sixth Cranial Nerves
27.2 Ocular Related Functions
27.2.1 The Tear Film
27.2.2 The Cornea
27.2.2.1 Corneal Dystrophies
27.3 The Aqueous Humor
27.3.1 The Ciliary Body and Iris
27.3.2 The Lens
27.3.3 The Sclera, Choroid and Retina
27.3.4 The Optic Nerve
27.3.5 The Vitreous
27.3.6 Overview of the Visual Pathway
27.4 Diplopia (Double Vision)
27.4.1 Causes of Monocular Diplopia
27.4.1.1 Third Nerve Palsy
27.4.2 Fourth Nerve Palsy
27.4.2.1 Sixth Nerve Palsy
27.5 Photophobia
27.5.1 Ocular Conditions
27.5.2 Central Nervous System Causes
27.6 Important Considerations When Taking a History
27.6.1 Visual Disturbances
27.6.2 Pain
27.6.3 Injuries
27.6.4 Additional Symptoms and Changes
27.6.5 Double Vision
27.6.6 Systemic Symptoms
27.6.7 Past Ocular and Medical History
27.6.8 Family History
27.6.9 Social History
27.6.10 Triaging Ocular Symptoms and Signs
27.7 Examining the Eye, Eyelids and Associated Structures
27.7.1 External Examination
27.7.2 Examination of the Eyelids
27.7.3 Visual Acuity
27.7.3.1 Visual Field Determination
27.7.3.2 Pupillary Assessment
27.7.3.3 Assessing Eye Movements
Examination of the Fundus
Leukocoria
27.7.3.4 Slit-Lamp Examination
27.7.4 Examining Children
27.8 Investigating Symptoms and Signs
27.8.1 Laboratory Tests
27.8.2 Seidel Test
27.8.3 Van Herick Test
27.8.4 Smith Test
27.8.5 Gonioscopy
27.8.6 Schirmer’s Test
27.8.7 Tear Breakup Time (TBUT) Test
27.8.8 Visual Evoked Potential (VEP)
27.8.9 Optical Coherence Tomography (OCT) Scanning
27.8.10 Miscellaneous Tests
27.8.11 Measuring Intraocular Pressure (IOP)
27.9 Imaging of the Eye
27.9.1 Plain Xrays
27.9.2 CT/MRI Scanning
27.9.3 Ultrasound (US)
27.10 Tools to Study Ocular Blood Flow
28: The Eye (Globe), Eyelids and Associated Structures: Part II
28.1 The Red Eye
28.2 The Painless Red Eye
28.3 The Painful Red Eye
28.4 The Red Eye that Does Not Get Better
28.5 Orbital Problems
28.6 Eyelid Problems
28.7 Conjunctival Problems
28.8 Corneal Problems
28.9 Viral Infections
28.10 Uveitis
28.11 Scleral Problems
28.12 Anterior Chamber Problems
28.13 Infections and Inflammation of the Eye
28.13.1 Keratitis and Corneal Ulceration
28.14 Corneal Ulceration
28.15 Conjunctivitis
28.15.1 Toxic Conjunctivitis
28.16 Infective Conjunctivitis
28.17 Ocular Myiasis
28.18 Allergic and Irritant Conjunctivitis
28.19 Inflamed Pterygium and Pingueculum
28.20 Orbital Cellulitis
28.21 Endophthalmitis
28.21.1 Panophthalmitis
28.21.2 Toxic Anterior Segment Syndrome (TASS)
28.22 Iritis, Iridocyclitis, Anterior Uveitis, and Panuveitis
28.23 Scleritis and Episcleritis
28.24 Glaucoma
28.24.1 Causes and Classification of Glaucoma
28.25 Primary Open Angle Glaucoma
28.26 Acute Angle Closure Glaucoma (AACG)
28.27 Other Types of Glaucoma
28.28 Congenital Glaucoma
28.29 Normal-Tension (Low-Tension) Glaucoma
28.29.1 Drug-Induced Glaucoma
28.29.2 End Stage Glaucoma
28.30 Loss of Vision
28.31 Painless Loss of Vision
28.31.1 Sudden Onset
28.31.2 Amaurosis Fugax
28.32 Retinal Arterial Ischaemic Disorders
28.32.1 Cotton Wool Spots (CWSs)
28.32.2 Venous Occlusion
28.32.3 Retinal Detachment
28.32.4 Posterior Vitreous Detachment
28.32.5 Vitreous Haemorrhage
28.32.6 Macular Degeneration
28.32.7 Retinitis Pigmentosa
28.32.8 Refractive Errors
28.32.9 Corneal Diseases and Fuchs’ Endothelial Dystrophy
28.32.10 Cataract
28.32.11 Primary Open Angle Glaucoma
28.33 Painful Loss of Vision
28.33.1 Optic or Retrobulbar Neuritis
28.34 Blurred and Distorted Vision
28.35 Eyelid Related Problems
28.35.1 Eyelid Lumps and Deformities
28.36 Swelling of the Eyelids
28.36.1 Blepharitis
28.36.2 Preseptal Cellulitis
28.36.3 Allergic Angioedema
28.36.4 Herpes Zoster Ophthalmicus (HZO) and Herpes Simplex
28.37 Sore, Itchy and Watery Eyes
28.38 Watery Eyes
28.39 Crocodile Tear Syndrome (CTS)
28.40 Nasolacrimal Mucocele and Obstruction
28.41 Dry Eyes
28.42 Sjögren’s Syndrome
28.43 Proptosis
28.44 Proptosis Following Trauma and Orbital Compartment Syndrome
28.45 Orbital Inflammatory Disease
28.45.1 Thyroid Eye Disease and Pseudotumour
28.46 Neoplastic Lesion in the Orbit
28.47 Carotico-Cavernous Fistula
29: The Eye (Globe), Eyelids and Associated Structures: Part III
29.1 Injuries to the Eye and Eyelids
29.2 Blunt Injuries
29.3 Ruptured Globe
29.4 Penetrating/Perforating Globe Injuries
29.5 Intraocular Foreign Bodies (IOFBs) and Metallosis
29.5.1 Secondary Infection (Endophthalmitis)
29.6 Traumatic Optic Neuropathy (TON)
29.7 Corneal Abrasion
29.8 Recurrent Erosions
29.9 Traumatic Lens Subluxation and Dislocation
29.10 Traumatic Globe Subluxation
29.11 Optic Nerve Avulsion (ONA)
29.12 Hyphaema
29.13 Commotio Retinae
29.14 Choroidal Rupture
29.15 Macular Haemorrhage and Traumatic Macular Hole
29.16 Chorioretinitis Sclopetaria (CRS)
29.17 Retinal Tears and Detachment
29.18 Traumatic Choroidopathy
29.19 Eyelid Lacerations
29.20 Lacerations Not Involving the Lid Margin
29.21 Lacerations Involving the Lid Margin
29.22 Ocular Surface Foreign Bodies
29.23 Rust Rings
29.24 Arc Eye
29.25 Chemical and Thermal Injuries
29.25.1 Superglue in the Eye
29.25.2 Thermal Injuries
29.26 Contact Lens Related Problems
29.27 Superior Epithelial Arcuate Lesion
29.28 Abrasions and Corneal Oedema
29.29 Contact Lens Intolerance
29.30 Contact Lens Allergy
29.30.1 Lens Deposits
29.30.2 Lost Contact Lens
29.30.3 Infections
29.30.4 Corneal Warpage
29.30.5 Corneal Neovascularisation
30: The Throat: Part I
30.1 Applied Anatomy
30.1.1 Overview
30.1.2 Oropharynx
30.1.2.1 Peritonsillar Space
30.1.3 Nasopharynx
30.1.4 Hypopharynx
30.1.4.1 Zenker’s Diverticulum
30.1.5 Waldeyer’s Ring
30.1.5.1 Reactive Lymphoid Hyperplasia
30.1.5.2 Tangier Disease
30.1.5.3 Accessory Tonsillar Tissue
30.1.5.4 Tonsilloliths
30.1.6 Retromolar Trigone (RMT)
30.1.7 Parapharyngeal Space
30.1.8 Retropharyngeal Space
30.1.9 Nerve Supply
30.1.9.1 The Glossopharyngeal Nerve (CN IX)
30.1.9.2 Glossopharyngeal Neuralgia
30.1.9.3 Vagus Nerve
30.1.10 Gag Reflex
30.1.11 Swallowing (Deglutition)
30.2 Important Considerations When Taking a History
30.3 Examining the Throat and Associated Structures
30.4 Investigating Symptoms and Signs
30.4.1 Laboratory Tests
30.4.2 Plain Films
30.4.3 CT/MRI/PET
30.4.4 Video-Flouroscopy and Assessment of Swallowing
30.4.5 Laryngoscopy and Oesophagoscopy
31: The Throat: Part II - Inflammation, Infections and the Acutely Painful Throat
31.1 Pharyngitis and Pharyngeal Infections
31.1.1 Acute Pharyngitis
31.1.1.1 Adenovirus and Upper Respiratory Viruses
31.1.1.2 Coxsackie Virus and ECHO
31.1.1.3 Infectious Mononucleosis (Glandular Fever)
31.1.1.4 Cytomegalovirus
31.1.1.5 Measles
31.1.1.6 Herpes Simplex Virus
31.1.1.7 Human Immunodeficiency Virus
31.1.1.8 Streptococcal Pharyngitis
31.2 Tonsillitis (Adenotonsil Infections)
31.2.1 Acute Tonsillitis
31.2.2 Recurrent Acute and Chronic Tonsillitis
31.3 Complications of Acute Pharyngeal/Tonsil Infections
31.3.1 Scarlet Fever
31.3.2 Acute Rheumatic Fever
31.3.3 Post Streptococcal Glomerulonephritis
31.3.4 Central Nervous System Complications
31.3.5 Peritonsillar Abscess (Quinsy)
31.3.6 Retropharyngeal Abscess
31.3.7 Deep Neck Infections (See also the Front of the Neck)
31.4 Other Serious Infections
31.4.1 Diphtheria
31.4.2 Whooping Cough
31.4.3 Sexually Transmitted Diseases (STD)
31.4.4 Mycobacterium
31.4.5 Epiglottitis (Supraglottitis)
31.5 Fungal Infections
31.5.1 Candidiasis
31.5.2 Other Invasive Fungi
31.6 Chronic Inflammation of the Pharynx
31.6.1 Chronic Pharyngitis and Adenoiditis
31.6.2 Chronic Adenotonsillar Hypertrophy and Obstructive Sleep Apnea (OAS)
31.7 Non-infective Causes of Pharyngitis
31.7.1 Inflammatory/Autoimmune Pharyngitis
31.7.1.1 Pemphigus
31.7.1.2 Bullous Pemphigoid
31.7.2 Cicatricial Pemphigoid (CP), Stevens–Johnson Syndrome (SJS), and Epidermolysis Bullosa (EB)
31.7.3 Wegener’s Granulomatosis
31.7.4 Sarcoidosis
31.7.5 Crohn’s Disease
31.7.6 Behçet’s Disease
31.7.7 Gastroesophageal Reflux Disease
31.7.8 Radiation
31.7.9 Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis (PFAPA)
31.7.10 Neoplasms
31.7.11 Kawasaki’s Disease
31.7.12 Angina Bullosa Haemorrhagica
31.8 Stridor and Airway Obstruction
31.8.1 Causes of Stridor
31.8.1.1 Acute Stridor
31.8.2 Chronic Stridor
31.8.2.1 Retropharyngeal Haematoma
31.8.2.2 Retropharyngeal and Mediastinal Emphysema
31.9 Foreign Bodies and Caustic Ingestion
31.9.1 Inhaled Foreign Bodies
31.9.1.1 Fish Bones in the Throat
31.9.2 Ingestion of Caustic Substances
31.10 Hypopharyngeal Problems
31.10.1 Candidiasis
31.10.2 Plummer-Vinson Syndrome (Patterson-Kelly Syndrome)
31.10.3 Primary Oesophageal Motility Disorders: Diffuse Oesophageal Spasm
31.10.4 Oesophagitis and Gastroesophageal Reflux Disease (GORD)
31.10.5 Oesophageal Perforation and Rupture
31.10.6 Globus
31.11 Cancer of the Throat
31.11.1 Field Change and Second Primary Tumours
31.11.2 Tonsil Tumours
31.11.3 Oropharyngeal Tumours
31.11.4 Hypopharyngeal and Upper Oesophageal Tumours
31.11.5 Oesophageal Neoplasms
31.11.5.1 Benign Tumours and Cysts
31.11.5.2 Malignant Tumors
31.12 Miscellaneous Conditions Involving the Throat
31.12.1 Aphthous Ulcers
31.12.2 Swollen Uvula (Quincke’s Disease or Sign)
31.12.3 Eagle Syndrome
31.12.4 Leukoplakia and Erythroplakia
31.12.5 Sleep-Disordered Breathing: Snoring, Upper Airway Resistance Syndrome and Obstructive Sleep Apnea
31.13 Dysphagia and Aspiration
31.13.1 Main Steps in Swallowing
31.13.2 Odynophagia
31.13.3 Surgical Management
31.13.4 Signs of Aspiration
31.13.4.1 Acute
31.13.4.2 Chronic
31.13.5 Silent Aspiration
32: The Throat: Part III
32.1 Injuries
32.1.1 Hypopharyngeal Perforation
32.1.2 Penetrating Injuries
33: The Nose and Associated Structures: Part I
33.1 Applied Anatomy and Physiology
33.1.1 Choanal Atresia
33.1.2 Congenital Nasal Pyriform Aperture Stenosis (CNAPS)
33.1.3 Concha Bullosa
33.2 Blood Supply
33.3 Nerve Supply
33.3.1 The Olfactory Nerve
33.3.2 Sensory Innervation
33.4 The Nasopharynx
33.5 Nasal Function
33.6 Normal Commensal Flora of the Upper Respiratory Tract
33.7 Sneezing
33.8 Mucociliary Clearance and the Nasal Cycle
33.9 Nasal Congestion
33.9.1 Nasal Irrigation
33.10 The ‘Runny Nose’: Rhinorrhoea
33.10.1 CSF Rhinorrhoea
33.11 Post Nasal Drip
33.12 Disturbances in Smell: Anosmia and Dysosmia
33.13 Important Considerations When Taking a History
33.14 Examining the Nose and Associated Structures
33.15 Investigating Symptoms and Signs
33.15.1 Laboratory Tests
33.15.2 Clinical Tests
33.15.3 Saccharine Transit Time
33.15.4 Imaging
34: The Nose and Associated Structures: Part II
34.1 Nasal Congestion and Obstruction
34.2 Rhinitis
34.2.1 The Common Cold
34.2.2 Acute Rhinosinusitis
34.3 Chronic Rhinosinusitis (CRS)
34.3.1 Klebsiella Rhinoscleromatis
34.3.2 Mycobacterium Leprae
34.3.3 Allergic Rhinitis
34.3.4 Vasomotor Rhinitis
34.3.5 Rhinitis Medicamentosa (RM)
34.3.6 Atrophic Rhinitis
34.3.7 Rare Causes of Rhinitis
34.3.8 Surgical Management
34.4 Sinusitis
34.5 Nasal Polyps
34.6 Foreign Bodies
34.6.1 Infestations
34.7 Empty Nose Syndrome
34.8 The Septum: Deformity and Destructive Conditions
34.8.1 Septal Perforation
34.8.2 Septal Deviation
34.9 Relapsing Polychondritis
34.10 Wegener’s Granulomatosis
34.11 Syphilis
34.12 Nose Bleeds (Epistaxis)
34.13 Tumours of the Nose and Nasal Cavity
34.13.1 Juvenile Nasopharyngeal Angiofibroma (JNA)
34.14 Nasopharyngeal Carcinoma
34.15 Squamous Cell Carcinoma
34.16 Adenocarcinoma
34.17 Adenoid Cystic Carcinoma
34.18 Mucosal Melanoma
34.19 Olfactory Neuroblastoma (Esthesioneuroblastoma)
34.20 Undifferentiated and Rare Tumours
34.20.1 Nasal Glioma
34.21 Sinonasal Papilloma (Schneiderian Papilloma)
34.22 Haemangioma
34.23 Osteoma
34.24 Dermoid
34.25 Nasoalveolar Cyst
34.26 Vestibulitis
34.27 Rhinophyma
34.28 Sarcoid
35: The Nose and Associated Structures: Part III
35.1 Injuries
35.1.1 Nasal Fractures
35.2 Classification of Fractures
35.2.1 Frontal Impact Injuries
35.2.2 Side Impact Injuries
35.3 Imaging and Management
35.4 Septal Haematoma
35.5 Nasoethmoid (Naso-Orbital-Ethmoid, NOE) Fractures
35.6 Classification and Mangement
36: The Ear and Associated Structures: Part I
36.1 Applied Anatomy and Physiology
36.1.1 External Ear
36.1.2 Congenital Anomalies of External Ear
36.1.3 Preauricular Sinuses (Congenital Auricular Fistula, or a Geswein Hole)
36.1.4 Middle Ear (Tympanic Cavity)
36.1.5 Congenital Anomalies of Middle Ear
36.1.6 Inner Ear
36.1.7 Congenital Anomalies of Inner Ear
36.1.8 The Internal Acoustic Canal
36.1.9 Nerve Supply to the Ear
36.1.10 The Facial Nerve
36.1.11 The Vestibulocochlear Nerve
36.2 Pathophysiological Mechanisms
36.2.1 Cerumen
36.2.2 Normal Hearing
36.2.3 Hearing and Voice Production
36.2.4 Motion Sickness
36.2.5 Tympanic Membrane Perforation
36.2.6 Aural Fullness
36.2.7 Ear Itching
36.2.8 Perilymphatic Fistula
36.2.9 Gout
36.3 Important Considerations When Taking a History
36.4 Examining the Ear and Associated Structures
36.4.1 Battle’s Sign (Mastoid Ecchymosis)
36.4.2 Facial Nerve Function
36.4.3 Vestibulocochlear Nerve Function
36.4.4 Pneumatic Otoscopy and the Fistula Test
36.4.5 Tuning Fork Tests: Weber’s Test
36.4.6 Tuning Fork Tests: Rinne Test
36.4.7 Dix-Hallpike Manoeuvre
36.4.8 Head-Shake Nystagmus
36.4.9 Caloric Reflex Test
36.5 Investigating Symptoms and Signs
36.5.1 Laboratory Tests
36.5.2 Plain Films
36.5.3 CT/MRI of Temporal Bones
36.5.4 Nuclear Medicine
36.5.5 Audiometric Tests
37: The Ear and Associated Structures: Part II
37.1 Otalgia (“Earache”)
37.1.1 Chondrodermatitis Nodularis Helicis
37.2 The Discharging Ear (Otorrhoea)
37.2.1 Purulent Otorrhoea
37.3 Infections and Inflammation: Otitis
37.3.1 Infections of the EAM and Pinna
37.3.1.1 Acute Localised Otitis Externa (Furuncle)
37.3.1.2 Acute Diffuse Otitis Externa (“Swimmer’s Ear”).
37.3.2 Malignant Otitis Externa (MOE)
37.3.3 Chronic and Eczematous Otitis Externa
37.3.4 Perichondritis
37.3.5 Bullous Myringitis
37.3.6 Granular Myringitis
37.4 Infections of the Middle Ear
37.4.1 Otitis Media
37.4.2 Acute Otitis Media (AOM)
37.4.3 Otitis Media with Effusion (OME): “Glue Ear”
37.4.4 Chronic Suppurative Otitis Media (CSOM)
37.4.5 Herpes Zoster Oticus (Ramsay Hunt Syndrome)
37.4.6 Tuberculous Otitis Media
37.5 Extension of Infection into the Surrounding Bones
37.5.1 Mastoiditis
37.5.2 Petrous Apex Mucosal Disease (Petrous Apicitis)
37.5.3 Osteomyelitis of the Skull Base (Necrotising or Malignant Otitis Externa)
37.6 Disturbances in Hear: Loss of Hearing (Deafness)
37.6.1 Hearing Loss in Children
37.6.2 Hearing Loss in Adults
37.6.3 Diagnosing Hearing Loss
37.6.4 Conductive Hearing Loss (CHL)
37.6.5 Sensorineural Hearing Loss (SNHL)
37.6.6 Mixed Hearing Loss
37.6.7 External Ear Causes of Hearing Loss
37.6.8 Middle Ear Causes of Hearing Loss
37.6.9 Inner Ear Causes of Hearing Loss
37.6.10 Presbycusis
37.6.11 Sudden vs. Gradual Onset of Sensorineural Hearing Loss
37.6.12 Management of Hearing Loss
37.6.13 Auditory Processing Disorder
37.6.14 Hyperacusis
37.7 Disturbances in Hearing: Abnormal Sounds (Tinnitus)
37.7.1 Hyperacusis
37.7.2 Tinnitus
37.7.3 Subjective Tinnitus
37.7.4 Objective Tinnitus
37.7.5 Assessment and Management of Tinnitus
37.7.6 Pulsatile Tinnitus (Pulse Synchronous Tinnitus)
37.7.7 Cerumen (Wax) Impaction
37.7.8 Foreign Bodies/Insects
37.8 Disturbances in Balance: Dizziness and Vertigo
37.8.1 Benign Paroxysmal Positional Vertigo (BPPV)
37.8.2 Epley’s Manoeuvre (Modifications Exist)
37.8.3 Brandt-Daroff Exercises
37.8.4 Labyrinthitis and Vestibular Neuritis
37.8.5 Ménière’s Disease (Endolymphatic Hydrops)
37.8.6 Recurrent Acute Vertigo
37.8.7 Vestibular Migraine
37.8.8 Cerebellopontine Angle Syndrome
37.9 Superior Semicircular Canal Dehiscence
37.10 Otosclerosis
37.11 Cholesteatoma
37.12 Eustachian Tube Problems
37.12.1 Eustachian Tube Dysfunction (ETD)
37.12.2 Patulous Eustachian Tube (PET)
37.12.3 Palatal Myoclonus
37.13 Tumours and Tumour-Like Conditions of the Ear
37.13.1 Glomus Jugulare Tumours
37.13.2 Acoustic Schwannoma
37.13.3 Tumours of the External Ear
37.13.4 Keloids
37.13.5 Other Tumours of the Middle/Inner Ear
37.14 Benign Lesions of Bone
37.14.1 Exostoses and Osteomas
37.14.2 Fibrous Dysplasia
37.15 Facial Palsy and the Ear
37.15.1 Nerve Injury
37.15.2 Congenital Causes
37.15.2.1 Möbius’ Syndrome (Congenital Facial Diplegia)
37.15.2.2 Hemifacial Microsomia
37.15.2.3 Osteopetrosis
37.15.3 Acquired Causes
37.15.3.1 Trauma
37.15.3.2 Cerebrovascular Accidents
37.15.3.3 Infection
37.15.3.4 Tumours
37.15.3.5 Hemifacial Spasm
37.15.3.6 Miscellaneous Disorders
37.15.4 Bell’s Palsy
37.15.4.1 Bell’s Palsy in Children
38: The Ear and Associated Structures: Part III
38.1 Injuries
38.2 Auricular (Pinna) Haematoma and Seroma
38.3 Traumatic Perichondritis
38.4 Frostbite
38.5 Burns
38.6 Lacerations and Tears of the Pinna and External Auditory Meatus
38.7 Avulsion of the Pinna
38.8 Tympanic Membrane Perforation
38.9 Temporal Bone Fractures
38.9.1 Longitudinal Fractures
38.9.2 Transverse Fractures
38.10 Traumatic Dislocation of the Mandibular Condyle into the Middle Cranial Fossa
38.11 Facial Nerve Injury (Intracranial)
38.12 Perinatal Facial Palsy
38.13 Vestibulochochlear Nerve Injury
38.14 Ossicular Injuries
38.15 Post Traumatic Cholesteatoma and External Auditory Canal Stenosis
38.16 Vertigo Following Trauma
38.17 Perilymphatic Fistula (PLF)
38.18 Pressure Induced Disorders: Barotitis and Barotrauma
38.19 Otic Barotrauma
38.20 Noise and Blast Induced Hearing Loss
39: The Skin (Integument): PART I
39.1 Applied Anatomy and Physiology
39.1.1 Epidermis
39.1.1.1 Keratinocytes
39.1.1.2 Basal Layer
39.1.1.3 Squamous Cell Layer
39.1.1.4 Granular Layer
39.1.1.5 Lucidum layer
39.1.1.6 Cornified Layer
39.1.1.7 Regulation of Proliferation and Differentiation
39.1.1.8 Melanocytes
39.1.1.9 Merkel Cells
39.1.1.10 Langerhans Cells
39.1.2 The Dermal-epidermal Junction
39.1.3 Epidermal Appendages (Adnexa)
39.1.3.1 Eccrine Sweat Glands
39.1.3.2 Apocrine Sweat Glands
39.1.3.3 Hair Follicles
39.1.3.4 Sebaceous Glands
39.1.4 Dermis
39.1.5 Subcutaneous Fat (Panniculus Adiposus)
39.2 Nomenclature in Dermatoses
39.2.1 Primary Lesion
39.2.1.1 Flat Lesions
39.2.1.2 Solid Raised (Palpable) Lesions
39.2.1.3 Fluid Filled Lesions
39.2.1.4 Depressed Lesions
39.2.2 Secondary Features
39.3 The Dermatological Diagnostic Approach
39.3.1 Important Considerations When Taking a History
39.3.2 Examining the Skin and Associated Structures
39.3.2.1 Inspection
39.3.2.2 Palpation
39.4 Investigating Symptoms and Signs
39.4.1 Laboratory Tests
39.4.2 Histology
39.4.3 Other Investigations
40: The Skin (Integument): PART II—Dermatological Diseases Commonly Seen in the Head and Neck
40.1 The Lesion
40.1.1 Non-pigmented Lesions
40.1.2 Non-pigmented “Premalignant” (Potentially Malignant) Lesions
40.1.2.1 Actinic Keratosis (Solar Keratosis)
40.1.2.2 Bowen’s Disease (Squamous Cell Carcinoma in situ)
40.1.3 Non-pigmented Malignant Lesions
40.1.3.1 Basal Cell Carcinoma (Rodent Ulcer)
40.1.3.2 Squamous Cell Carcinoma
40.1.3.3 Keratoacanthoma
40.1.4 Non-pigmented Benign Lesions
40.1.4.1 Seborrhoeic Keratosis (Seborrhoeic Wart/Basal Cell Papilloma)
40.1.4.2 Skin Tag (Achrochordon, Fibroepithelial Polyp)
40.1.4.3 Sebaceous Gland Hyperplasia
40.1.4.4 Keloid Scar
40.1.4.5 Epidermal Naevus
40.1.4.6 Sebaceous Naevus
40.1.4.7 Chondrodermatitis Nodularis Helicis
40.2 Vascular Lesions
40.2.1 Cherry Angioma (Campbell de Morgan Spots)
40.2.2 Spider Naevus (Naevus Araneus, Spider Angioma)
40.2.3 Venous Lake
40.2.4 Pyogenic Granuloma
40.2.5 Haemangioma (Strawberry Haemangioma)
40.3 Lipid Deposition Lesions and Cysts
40.3.1 Xanthelasma
40.3.2 Epidermoid Cyst (Sebaceous Cyst)
40.3.3 Trichilemmal Cyst (Pilar Cyst)
40.3.4 Milium (Plural- Milia)
40.4 Adnexal Lesions
40.4.1 Pilomatrixoma/Pilomatricoma (Benign Calcifying Epithelioma of Malherbe)
40.4.2 Trichoepithelioma
40.4.3 Syringoma
40.4.4 Cylindroma (Turban Tumour)
40.5 Fibrohistiocytic Lesions
40.5.1 Dermatofibroma
40.5.2 Juvenile xanthogranuloma
40.5.3 Cutaneous Angiofibroma
40.6 Pigmented Lesions
40.6.1 Pigmented Lesions: Malignant and Pre-malignant
40.6.1.1 Malignant Melanoma
40.6.1.2 Types of Melanoma
40.6.1.3 Melanoma Subtypes
40.6.1.4 Lentigo Maligna (Melanoma in-situ: MIS)
40.6.1.5 Pigmented BCC
40.7 Pigmented Lesions: Benign
40.7.1 Freckles (Ephelides)
40.7.2 Solar Lentigo (Plural- lentigines)
40.7.3 Ink-spot Lentigo
40.7.4 Oral Melanotic Macules (Labial Melanotic Macule)
40.7.5 Naevi (Moles)
40.7.5.1 Junctional Naevus
40.7.5.2 Compound Naevus
40.7.5.3 Dermal Naevus
40.7.5.4 Congenital Melanocytic Naevi
40.7.5.5 Atypical Naevi (Dysplastic Nevus)
40.7.5.6 Spitz Naevus
40.7.5.7 Blue Naevus
40.7.5.8 Melasma/cholasma
40.8 Infections
40.8.1 Bacterial
40.8.1.1 Impetigo
40.8.1.2 Cellulitis and Erysipelas
40.8.1.3 Necrotising Fasciitis
40.8.1.4 Boils (Furuncle) and Carbuncles
40.8.2 Viral
40.8.2.1 Warts
40.8.2.2 Molluscum Contagiosum
40.8.3 Herpes Viral Infections
40.8.3.1 Herpes Simplex Virus (HSV) Infections
40.8.3.2 Varicella-Zoster Virus
40.8.3.3 Hand, Foot and Mouth
40.8.4 Fungal
40.8.4.1 Tinea Faciei
40.8.4.2 Fungal Infections of the Scalp (Tinea Capitis and Kerion)
40.9 Rashes
40.9.1 Acne
40.9.2 Rosacea
40.9.3 Periorificial Dermatitis
40.9.4 Psoriasis
40.9.4.1 Seborrhoeic Eczema
40.9.4.2 Irritant/Contact Allergic Eczema
40.9.4.3 Angioedema and Urticaria
40.9.5 Sunburn and Photosensitivity
40.9.5.1 Sunburn
40.9.5.2 Photosensitivity
40.10 Blistering Conditions of the Face
40.10.1 Common Causes
40.10.1.1 Friction Blisters
40.10.1.2 Insect Bites and Stings
40.10.1.3 Burns (see Burns Chapter)
40.10.1.4 Contact Dermatitis
40.10.1.5 Allergic Contact Eczema
40.10.1.6 Drug-Induced Blistering
40.10.1.7 Fixed Drug Eruptions (FDE)
40.10.1.8 Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
40.10.1.9 Drug Induced Bullous Pemphigoid
40.10.1.10 Drug-Induced Pemphigus Vulgaris
40.10.1.11 Drug-Induced Phototoxicity
40.10.1.12 Erysipelas
40.10.2 Uncommon Causes
40.10.2.1 Porphyria Cutanea Tarda (PCT)
40.10.2.2 Pseudoporphyria
40.10.2.3 Bullous Pemphigoid
40.10.2.4 Pemphigus Vulgaris
40.10.2.5 Dermatitis Herpetiformis
40.10.2.6 Linear IgA
40.10.2.7 Epidermolysis Bullosa
40.11 Hair Loss (Alopecia)
40.11.1 History
40.11.2 Common Causes of Alopecia
40.11.2.1 Androgenic Alopecia: (Male/Female Pattern Hair Loss)
40.11.2.2 Alopecia Areata
40.11.2.3 Telogen Effluvium
40.11.2.4 Anagen Effluvium
40.11.2.5 Trichotillomania
40.11.2.6 Traction Alopecia
40.11.2.7 Lichen Planopilaris
40.11.2.8 Frontal Fibrosing Alopecia
40.11.2.9 Central Centrifugal Cicatricial Alopecia
40.11.2.10 Discoid Lupus Erythematosus
40.11.2.11 Acne Keloidalis
40.11.2.12 Dissecting Cellulitis of the Scalp
40.12 Some Useful Algorithms to Aid Lesion Diagnosis
41: Burns to the Head, Face and Neck: PART I
41.1 Applied Anatomy
41.1.1 Epidermis
41.1.2 Dermis
41.1.3 Subcutaneous Tissue
41.2 Pathophysiology
41.3 Principles of Management for all Burns
41.3.1 Stop the Burning Process as Soon as Possible
41.3.2 Cool the Burn
41.3.3 Calculate the Depth and Area of Burn
41.3.4 Analgesia
41.3.5 Prevention of Infection
41.3.6 Nutritional Support
41.3.7 Dressings
41.3.8 Other Measures
41.4 Burn Primary Survey
41.4.1 Airway Considerations
41.4.2 Breathing Considerations
41.4.3 Circulatory Considerations
41.4.4 Neurological Considerations
41.4.5 Exposure with Environmental Control
41.4.6 Fluids
41.4.7 The Secondary Survey
41.5 Assessing a Burn
41.5.1 Assessment of Burn Area
41.5.1.1 Lund and Browder Charts
41.5.1.2 Burn Zones
41.5.2 Depth of Burn
41.5.2.1 Superficial
41.5.2.2 Superficial Dermal
41.5.2.3 Deep Dermal
41.5.2.4 Full Thickness
41.5.3 Burns Involving Key Structures
41.5.3.1 Burns to the Ears and Nose
41.5.3.2 Burns to the Eyes
41.5.3.3 Burns to the Mouth
41.5.3.4 Burns to the Scalp
41.5.4 Fluid Resuscitation and Requirements
41.5.4.1 Parkland Formula
41.6 Management of Minor Burns
41.6.1 Electrical Burns
42: Burns to the Head, Face and Neck: PART II
42.1 Surgical Management of Burns
42.2 Escharotomy
42.3 Early/Intermediate Surgery
42.4 Reconstruction
42.4.1 No Deficiency of Tissue
42.4.2 Deficiency of Tissue
42.4.2.1 Skin Graft
42.4.2.2 Dermal Regeneration Template
42.4.2.3 Tissue Expansion
42.4.2.4 Local Flap
42.4.2.5 Free Flap
42.4.2.6 Face Transplant
42.4.3 Specific Anatomic Sites
42.4.3.1 Eyelid
42.4.3.2 Lip and Chin Region
42.4.3.3 Neck
42.4.3.4 Cheek
42.4.3.5 Upper Lip
42.4.3.6 Nose
42.4.3.7 Forehead
42.4.3.8 Ear
42.5 Child Abuse and Immersion Scald Burns
42.6 Psychiatric Considerations