Parotid and Temporal Region 20-3-2012 (1)
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Qfrom the previous lecture What is the treatment for hydrocephaly?Hydrocephaly causes:
there is increased production of CSF
there is no drainage for CSF
or when the foramina of luschka is closed or occluded (it is a foramen in the
roof of the 4th ventricle where the CSF moves from the ventricles into the
subarachnoid space)
in the foramina of luschka is closure the solvent is to make a foramen between
the brain and the subarachnoid space that's achieved by a procedure called
THIRD VENTRICULOSTOMY ,, tongue twisting :P,, which means partial cut in the
3rd ventricle cuz it's the easiest place and closest space to reach the endoscopeinto it.
firstly open a bare hole in the skull anterior to the coronal suture of the skull ,
then insert the endoscope inside then u can see the following: inter ventricular
foramen (the foramen between the lateral ventricles and the third ventricle),
corroid plexus (the part that produces CSF), the floor of the third ventricle, fluid
movement in the 3rd ventricle, the basilar artery (formed by the joining of the 2
vertebral arteries)
when we reach the floor of the 3rd ventricle we burn it by the very hot tip of the
endoscope to penetrate it to make an opening to the subarachnoid space, then
we noticed the movement of the CSF from inside the ventricles to the outside.
to watch the video -->http://www.youtube.com/watch?v=bjGVXYH9mZg
In case there is increase production or no drainage of CFS without closure of the
foramina of luschka so the fluid go easily from ventricles and the subarachnoid
space this time we have to do a shunt " " we call it THE CSF SHUNT.
everything is explained here -->
http://www.youtube.com/watch?v=Qmym2iFVNw8
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http://www.youtube.com/watch?v=bjGVXYH9mZghttp://www.youtube.com/watch?v=bjGVXYH9mZghttp://www.youtube.com/watch?v=bjGVXYH9mZghttp://www.youtube.com/watch?v=Qmym2iFVNw8http://www.youtube.com/watch?v=Qmym2iFVNw8http://www.youtube.com/watch?v=Qmym2iFVNw8http://www.youtube.com/watch?v=bjGVXYH9mZg8/2/2019 Parotid and Temporal Region 20-3-2012 (1)
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Parotid and temporal regions
as u know when we study any region we have to study the borders and the
contents (5 things ; organs, veins, arteries, nerves and lymph nodes) .
the parotid region
location :
extends between the ramous of the mandible anteriorly and the mastoid process
posteriorly ,placing your index in the mandible and the thumb on the mastoid
process it is the area in between and below the auricle , we call it by the parotid
region because it contains the parotid gland (the largest slivery gland)
Contains:
Parotid Gland&Structures Inside it or within the gland tissue VAN (facial n.,
ECA, retro mandibular vein)
We will classify them from lateral to medial or superficial to deep :
1. Superficial:
The most superficial is the Facial n. terminates there to provide five
branches to the muscles of facial expressiontemporal, zygomatic, buccal,mandibular and cervical branches you can see them within the parotid tissue.
2. Middle:
Deep to the nerve you will find theRetromandibular V. the vein behind the
mandible and the terminal branches of the vein forming it superficial temporal
vein and maxillary vein; the terminal part of superficial temporal and maxillary
veins enters the parotid gland and within the parotid tissue they unite to form
retromandibular v.
3. Deep:
the deepest structure always is the artery you will find theECA (external
carotid artery) with its terminations it terminates there within the parotid tissue
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behind the neck of themandible into two main arteries maxillary a. and
superficial temporal a., the beginning part of them located within the parotid
tissue.
4. Parotid L.N.:
Distributed within& on the gland, drain into DCLN deep cervical lymph
nodes all of the lymph nodes in the facial area in the head drain into the DCLN
which unite with IJV within the carotid sheet.
If we have a cross section of the parotid tissue and flip it to look from above we
will have the following view : 1-muscles of the wall of the pharynxget into the
pharyngeal area and oral cavity 2- the skin 3- mastoid process 4- cross section of
the ramous of the mandible so between 3 and 4 we have the parotid region 5-
fibrous capsule (facial capsule) very strong fibrous sheet covers the whole parotid
gland originating from investing layer of deep cervical facia 6- facial n. the most
superficial structure passing within the gland 7- retromandibular v. after the n. 8-
ECA the most deepest one not the common nor the internal cuz both are within
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the carotid sheet 9- Carotid sheet with contents ICA 10- Parotid lymph nodes
groups of lymph nodes
distributed within and on the surface of the gland
The parotid gland :
it is the largest slivery gland wedge (triangular ) shape gland anatomically
speaking , its base pureriorly inferior to the zygomatic arch while the apex is
located inferiorly behind the neck of the mandible.
The parotid gland usually secrets a pure serous saliva,, we have two types of
saliva: mucous and serous ; serous is more watery and the mucous is more
viscous (). It is covered by a connective tissue called parotid capsule which
comes from the investing layer of deep cervical facia.
Homework : what is the difference in function between mucous and serous
saliva?
Processes of the parotid gland :
Process is an elevation or extension, the parotid region is between the ramousand the mastoid process and below the auricle ( the external auditory meatus)
until the angle of the mandible ,, but if there is any part if the parotid gland tissue
that extend over this region we will refer to it as a process of the parotid gland so
its part of the gland tissue but not located in its region ( ) crossing the
border of this region.
The process: an extension from the parotid gland tissue into certain regions
outside of the parotid region.
there are three processes glenoid process, pterygoid process and facial process;each one indicating to each way they go:
1- Glenoid Process:
An extension of the parotid tissue into the Glenoid cavity (or the glenoid fossa it is
the same as the mandibular fossa in the skull when u look to the skull in the
So till now we spoke about all the contents except the parotid gland those are : facial n., retromandibular
v., ECA and parotid lymph nodes.
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temporal bone there is a depression for the TM joint we call it the mandibular
fossa) so behind the TM joint in the posterior part of the mandibular fossa
(glenoid fossa) u will see part of the parotid gland which is the glenoid process.
So its the process that extends upward into the posterior part of themandibular fossa.
2- Pterygoid Process:
It will go forward and deep to the mandible between the ramous of the mandible
and the medial pterygoid muscle.
Now we have to speak about medial and lateral pterygoid
muscles >> you remember we have four muscles of mastication
those are the temporalis and masseter from outside of the
mandible and from onside of the mandible we have another two
we call them the lateral and medial pterygoid muscles; the
horizontal one is the lateral and the vertical one is the medial
pterygoid, we call them medial and lateral cuz both of them
originates from the lateral pterygoid plate one from the lateral
surface of the lateral pterygoid plate into the neck of the
mandible which is the lateral pterygoid muscle but from themedial surface of the lateral pterygoid plate to the angle of the
mandible medially this one is the medial pterygoid muscle.
There is another muscle of mastication insert on the lateral aspect (outside) of the
neck of the mandible it is the masseter, As a result the ramous of the mandible is
sandwiched between two muscles of mastication from outside is the masseter
from inside the medial pterygoid muscle, Behind the ramous more superficial
should be the parotid gland because it located the posterior border of the ramous
and the mastoid process.
Part of the glands tissue will extends into two different ways the first pat go
deeply into the space between the ramous and the medial pterygoid which is the
Summury:
So both originate from
the lateral pterygoidplate, no one of them
from the medial plate;
but the one from the
lateral surface of the
lateral pterygoid plate is
the lateral pterygoid
and the one from the
medial surface of the
lateral pterygoid plate is
called medial pterigoid,cuz where they originate
fom.
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pterygoid process, and the second part go outside or superficially too sleep over
the masseter muscle which is the facial process.
3- Facial Process:
extends forward superficially from the parotid gland over the
masseter muscle Sleeps anterior to the masseter muscle from
outside.
@@ sometimes part of the facial process get to separate completely from the
parotid tissue as a small piece by itself which is the accessory part if the parotid
gland, it is not always present in all individuals put if its present its a small
branch of the facial process that get separate completely.
Relations To Parotid Gland
Superficial (lat.):Firstly the parotid gland is covered by skin then the superficial facia then the deep
facia (investing layer make the parotid capsule) within the superficial facia there is
an important nerve the great auricular nerve (C2,C3) if u remember it gives
Summery :
there are three process from the parotid
gland :
1- Glenoid : upward into the mandibular
fossa
2- pterygoid : forward between the
ramous and medial pterygoid muscle
3- facial: forward too but superficial
over the masseter muscle
** we can find accessory part
sometimes from the parotid gland, its
usually extension from the facial
process.
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sensation to the skin over the angle of the mandible the parotid region and the
lower part of the auricle (lobule).
Superior:Superiorly there are the external auditory meatus (EAM) and the TM joint.
Deep Relations (Medial):Deep relations means the medial aspect or where the parotid is resting we refer
to these relation as the parotid bed cuz they representing where the parotid
tissue is resting and because its pyramidal shape there will be anterior and
posterior medial there is nothing exactly medial:
Antero-medial:
We can see the masseter muscle and part of the ramous and part of the TM joint
(specially the lower part of the capsule)
Postero-medial:
We can see the carotid sheath and its contents, the styloid process and related
muscles (styloglossus, stylohyoid ,stylopharyngous) an d the mastoid process with
muscles related (from outside the SCM & from inside the posterior belly ofdigastric).
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Parotid Duct (Stensen's duct)
They named it according to the person who described it Stensens duct the
submandibular duct we call itwhartons duct extends from the facial process of
the parotid and go superiorly then horizontally superficial to the masseter muscleand inferior to the zygomatic arch, at the anterior border of the masseter it turns
medially passing throw the cheek penetrating the buccinator muscle to open into
the oral cavity opposite to the upper second molar in most individuals so
sometimes you can find it opening opposite to the upper second premolar! Or
upper first molar but most commonly speaking upper second molar.
There is an accessory duct sometimes if you have an accessory part the part
that originate from the facial process so cuz its independent it has its own small
duct which drain into the main duct (Stensens duct) so we call it accessory
parotid duct.
For Blood Supply, Innervation & Lymph Drainage of Parotid Gland :
The external carotid artery (ECA) will provide blood supply to the parotid tissue,
the vein is the retromandibular vein so it will provide the drainage to it , the
sensation over the parotid gland come from the great auricular nerve and it takes
from the glossopharyngeal nerve (IX) for secretion which isthe lesser petrosalnervewe will talk about it.
Clinical: Mumps
It is an acute viral infection to the parotid gland that cause swilling and pain, so if
there is an inflammation there is edema and fluid accumulation and the parotid is
covered by a strong capsule (parotid capsule) so what happening is this fluid
accumulation enlarged an the but the swilling is limited by the capsule which
leads to severe pressure and stretch on the parotid capsule itself will produce thepain feeling and also this will press on the nerve inside the parotid capsule the
facial nerve leading to a paresthesia (partial paralysis) in the muscles of facial
expirations So the pain because of the swilling of the tight parotid facia.
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The pain is getting worst during chewing because when you open your mouth the
ramous of the mandible go posteriorly to make the space of the parotid gland
smaller than it is so this will increase the pressure by compressing it between the
ramous of the mandible and the mastoid process, so its very hard to chew in this
case.
the viral infection may reach to the parotid duct through the parotid tissue if so
you will see it more reddish in color and swilling.
Parotidectomy
It is a common procedure in Oral and maxillofacial surgery mainly it is a surgical
removal of the parotid gland its most common cause is the cancer because 80% ofthe tumors of the salivary gland affect the parotid gland cuz its the largest one.
The most and first important step for any surgeon oral surgeon or maxillofacial
surgeon once he removes the parotid is to preserve the vital structures within the
parotid tissue those are the facial nerve, ECA and the retromandibular vein its
Unacceptable to get injury to any of those if you cut part of the facial nerve the
patient will have facial palsy bells palsy , and the ECA will lead to severe
bleeding cuz its very large artery and the same for the retromandibular vein. Sothe first step you have to identify those structures by cutting the tissue to find
them, secondly; you have to isolate () them, thirdly; you have to preserve
) them after that you can start removing the tissue of that gland,, so its )
step by step not just cutting the parotid simply!!Thats totally Huge mistake!
The Temporal Region
the temporal region its the region that sets on the side of the head over the
temporal bone or the temple.
Boundaries:
Superiorly and posteriorly the superior temporal line ; there are two linear
elevation at the side of the skull we refer to them as the superior temporal line
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and the inferior temporal line, when we have an elevation that means there is an
attachment of a muscle, ligament or facia .. so what attaching to the inferior one
is the temporalis muscle (the largest muscle of mastication), and the superior line
attachment is a homework ???
so superiorly demarcating of the temporal region is the superior temporal line.
Anteriorly it demarcating by the frontal process of zygomatic bone, and inferiorly
by the zygomatic arch.
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Contents of Temporal Region:
1- Tmporalis muscle:its the largest muscle of mastication, originates from the
whole floor of the temporal region area of the temporal fossa then it diverge all
the way to insert by a small tendon into the coronoid process of the mandible andthe anterior border of the ramous.
The muscles fibers of the anterior half are vertical so when they contract they
elevate the mandible to close the mouth, but the posterior half fibers are more
horizontal so when the contract they retrode (moving backward) the mandible
retraction. So it has two function elevation (the anterior part of it) and
retraction (the posterior part of it)
2- Deep temporal arteries and nerves:
The innervation: any muscle of mastication innervated by the mandibular of
trigeminal so the innervation of this muscle come from the mandibular of
trigeminal and because it is a very alrge muscle and has two parts each one has a
different function its got innervation by two nerves we name them the temporal
nerves coming from the anterior division of the mandibular nerve if you still
remember the story of mandibular nerve and they pass deep to the temporalis
muscle between temporalis and the bone,so we have two nerves: the anteriordeep temporal nerve to the anterior half and the posterior deep temporal nerve
to the posterior half.
The arteries : the same as the nerves cuz its too large it has two deep temporal
arteries, the external carotid artery terminate by the superficial temporal a. and
the maxillary a. as the maxillary passing it gives a branch to the posterior and a
branch to the anterior which are the anterior and posterior deep temporal
arteries so their origin from the maxillary a.
3- Temporal facia :
is the deep facia covering the muscle its usually attached as continuation of the
epicranial aponeurosis lateraly.
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4- superficial temporal artery and vein:
They are the artery and vein over the temporal region superficially where you feel
the bulls, both of them pass posterior to the TM joint.
5- Auriculotemporal nerve:
It passes posterior to the superficial temporal artery and vein, originating from
the posterior division of mandibular nerve the posterior division of mandibular
has three branches sensory (lingual, inferior alveolar and auriculotemporal) and
one is motor (nerve to mylohyoid) , so it gives sensation over the temporal
region.
AND THATS ALL -.-"
*****
This is a true real Question from the US MLE , thats howthey ask you they give a clinical condition and give anatomical and physiological
questions, they dont ask like what we examine you just a question and whats
the answer!! So you have to read the scenario then you can answer the
questions whether they related or notCLINICAL CASE
A 44-year-old female with swelling over the parotid gland on the right side
not bilateral visited you in the clinic. She stated that she first noticed the
swelling 3 months previously so its not painful,and since that time it had rapidly
increase in size. Recently, she noticed that her right side of her face felt weak
and she could no longer whistle for her cat.
On examination, a hard swelling its not edematous so its not inflammation, theridged swelling is more dangerous refer to a tumordeeply attached to the parotid
gland was identified. On testing the facial muscles, it was found that the
muscles on right side were weaker than those on left side. Before starting any
further management, answer the following questions?
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Q1. What is (are) the cutaneous innervation of the skin over the parotid region?
Great auricular nerve; Cutaneous means skin and sensory.
Q2. What muscles control her whistling?
Buccinator & orbicularis oris , those are the two main ones.
Q3. What is the connection between the right side facial weakness & the
parotid swelling?
The swelling is pressuring over the facial nerve.
Q4. What is the diagnosis?
Parotid tumor, because its ridged and painless.
Q5. What is the treatment?
Parotidectomy, removal of the parotid gland.
Q6. What is (are) the structure(s) that may be endangered of such kind of
treatment?
Facial nerve, ECA and retromandibular vein.
THE HAPPY END
Baraa'h Al-Salamat
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