Diseases and Injuries to the Head, Face and Neck: A Guide to Diagnosis and Management

Description

This book provides a practically applicable guide to injuries, diseases, and disorders affecting the head, neck, and dental region seen within accident and emergency departments. These regions contain a number of specialized structures each with individual neural, muscular and vascular elements, meaning that the study of these anatomical areas is complicated and often quite daunting. Chapters in this work aim to break the treatment of such injuries and diseases into an easy-to-digest format via chapters featuring a symptom-based approach. Therefore, enabling the reader to quickly access the information they require when treating patients with a variety of disorders in the emergency room. Diseases and Injuries to the Head, Face and Neck: A Guide to Diagnosis and Management is a concise overview of how to deal with head, neck, and dental emergencies and is an important up-to-date resource for all medical professionals and trainees who encounter these patients. 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