REVIEW OF CLINICAL EMBRYOLOGY OF HEAD AND NECK
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1 REVIEW OF CLINICAL EMBRYOLOGY OF HEAD AND NECK OUTLINE - EMBRYOLOGY UNDERLYING CLINICAL CONDITIONS I. EARLY DEVELOPMENT OF FACE: CLEFT LIP, CLEFT PALATE, OBSTRUCTED NASOLACRIMAL DUCT II. BRANCHIAL ARCHES - STRUCTURES FORMED AND ANOMALIES: BRANCHIAL CYSTS AND FISTULI III. THYROID DEVELOPMENT - ECTOPIC THYROID, THYROGLOSSAL DUCT CYSTS
2 I. EARLY DEVELOPMENT - FEW STRUCTURES IN THE HEAD ARE DERIVED FROM SOMITES Many structures in the body are derived from somites; however, only two groups of muscles in the head are derived from somites. Preotic Somites Occipital Eye 6 weeks 8 weeks Tongue 1) Preotic myotomes (somitomeres) form extrinsic muscles of eye: III - Oculomotor, IV - Trochlear, VI - Abducens. 2) Occipital myotomes form muscles of tongue - XII - Hypoglossal N. Note: this is GSE innervation
3 MANY STRUCTURES ARE FROM BRANCHIAL ARCHES ~4 weeks ~11 weeks 1. BRANCHIAL ARCHES- Structures which develop in foregut (pharynx) and are similar to gills of fish - Gill = Branchial - Gills of fish are composed of cartilage and have muscles, nerves, arteries FISH GILLS
4 EARLY DEVELOPMENT: HEAD END ENLARGES HEAD END OF TRILAMINAR EMBRYO FRONTONASAL PROCESS = Central swelling NEURAL CREST CELLS Trilaminar embryo folds and head end enlarges Neural crest cells invade head and neck lateral to rostral part of foregut to develop branchial arches
5 DEVELOPMENT OF FACE First arch develops Maxillary and Mandibular process; Maxillary processes (bilateral) form part of upper lip and palate Frontonasal Process - formed by mesenchyme below brain Nasal Placode Maxillary and Mandibular processes surround developing mouth (Stomodeum) Nasal Placode Maxillary Process Mandibular Process Nasal Placodes (thickenings) form in Frontonasal process at site of external nares (nostrils) Stomodeum = primitive mouth
6 DEVELOPMENT OF UPPER LIP Medial & Lateral Nasal Processes form at margins of nasal placodes Medial nasal processes and Maxillary Processes fuse at philtrum to form upper lip fusion eye Lateral nasal process Medial nasal process Medial nasal processes fuse Terminology: process = prominence Medial nasal process Maxillary process PHILTRUM OF UPPER LIP
7 PHILTRUM OF LIP = central region of upper lip Philtron - Greek to love, to kiss
8 CLEFT LIP CLEFT LIP (cheiloschisis) = Failure of fusion of Medial Nasal Process and Maxillary process - 1/1000 Births, can be unilateral or bilateral -At philtrum of lip Medial Nasal Maxillary CLEFT LIP CAN OCCUR IN COMBINATION WITH CLEFT PALATE
9 ANATOMY OF BONY PALATE INCISIVE FORAMEN - connects oral cavity and nasal cavity; contains Nasopalatine nerve (branch of V2), Sphenopalatine artery NOSE Maxillary Bones - anterior Palatine bones - posterior view of bones of hard palate from inside mouth looking superiorly
10 PALATE DEVELOPMENT a. Primary Palate Anterior to Incisive Foramen formed by union Medial Nasal Processes PRIMARY PALATE = FUSED MEDIAL NASAL PROCESSES MAX PROC. MAX PROC. SECONDARY PALATE b. Secondary Palate Posterior to Incisive Foramenformed by fusion of Maxillary process of each side
11 MALFORMATIONS: CLEFT PALATE 1) Anterior Cleft Palate - Not fuse Medial Nasal Process and Maxillary Process (Primary and Secondary Palate) 1:1000 Births INCISIVE FORAME 2) Posterior Cleft Palate - Maxillary Processes from each side (Secondary Palate) 1:2500 births Note: Ant. Cleft Palate is same as Cleft Lip
12 SUMMARY OF CLEFT LIP, CLEFT PALATE CLEFT LIP Medial Nasal Maxillary CLEFT PALATE 1) CLEFT LIP AND ANTERIOR CLEFT PALATE (PRIMARY PALATE) failure of fusion of Medial Nasal Process and Maxillary process 1:1000 births Maxillary Maxillary 2) POSTERIOR CLEFT PALATE (SECONDARY PALATE) failure of fusion of Maxillary process of each side 1:2500 births INCISIVE FORAMEN is landmark
13 ANATOMY OF LACRIMAL APPARATUS LACRIMAL GLAND - LOCATED IN SUPEROLATERAL ORBIT - OPENS BY DUCTS (~12) THROUGH CONJUNCTIVA TO SUPERIOR FORNIX -TEARS CONSTANTLY PRODUCED LACRIMAL GLAND SUPERIOR CONJUNCTIVAL FORNIX UPPER EYELID LACRIMAL GLAND IS INNERVATED BY VII- FACIAL NERVE (PARASYMPATHETICS)
14 DRAINAGE OF TEARS Lacrimal gland Ducts Nasolacrimal Duct TEARS FLOW Inferior Meatus Lacrimal puncta Canaliculi Sac Inferior Concha - TEARS FLOW ACROSS EYE TO LACRIMAL PUNCTA ON MEDIAL END OF EYELIDS (eyelids meet at MEDIAL CANTHUS); - TEARS THEN PASS THROUGH LACRIMAL CANALICULI TO LACRIMAL SAC; - SAC CONNECTS TO NASOLACRIMAL DUCT WHICH DRAINS TO INFERIOR MEATUS OF NASAL CAVITY LACRIMAL GLAND IS INNERVATED BY VII - FACIAL NERVE
15 OBSTRUCTED NASOLACRIMAL DUCT Frontonasal process NASOLACRIMAL DUCT - extends from Medial Canthus of eye to Inferior Meatus of nasal cavity - Develops as a fold between maxillary process and frontonasal process - then forms a solid cord that becomes canalized. Obstructed Duct - failure of duct to canalize; tears drain over lower eyelid to face; opened surgically for tears to drain to nasal cavity Maxillary process
16 II. BRANCHIAL ARCH DERIVATIVES - EACH ARCH HAS A NERVE, MUSCLES AND CARTILAGES I. MANDIBULAR ARCH - TRIGEMINAL NERVE (V) has Maxillary and Mandibular Processes II. HYOID ARCH - FACIAL NERVE (VII) III. THIRD ARCH- GLOSSO- PHARYNGEAL NERVE (IX) IV. FOURTH ARCH - VAGUS NERVE (X) VI. SIXTH ARCH - ACCESSORY NERVE (XI)
17 TERMINOLOGY: ARCHES, GROOVES, POUCHES, MEMBRANES VIEW OF EXTERIOR OF EMBRYO 2. Branchial Grooves (Clefts) - ectodermal clefts between adjacent arches VIEW OF EMBRYO BISECTED IN SAGITTAL PLANE 1. Branchial Arches = LUMPS 3. Branchial Pouch - endodermal out pocketing from rostral foregut - between adjacent arches
18 BRANCHIAL APPARATUS - 4 elements MEMBRANE 1. Branchial Arch = LUMP covered by: Ectoderm - externally Endoderm - lined internally (Mesenchyme-core); arch form skeletal elements, muscles, arteries; Each nerve innervates structures derived from its associated arch POUCH endoderm GROOVE (CLEFT) ectoderm 2. Branchial Groove (Cleft) - ectodermal cleft between adjacent arches 3. Branchial Pouch - endodermal outpocketing between adjacent arches (from rostral foregut) 4. Branchial Membrane - site of contact of Groove (ectoderm)
19 STRUCTURES DERIVED FROM BRANCHIAL ARCHES
20 SKELETAL DERIVATIVES OF BRANCHIAL ARCHES I. MANDIBULAR ARCH - forms a) BONES OF MIDDLE EAR (malleus, incus, also ant. lig. of malleus); b) STRUCTURES ASSOCIATED WITH MANDIBLE sphenomandibular lig., (Meckel's cartilage, framework of mandible) note: FIRST ARCH SYNDROME (TREACHER COLLINS) - genetic disorder; Neural crest cells do not migrate into Arch 1: - mandibular hypoplasia - conductive hearing loss - facial malformation TREACHER COLLINS SYNDROME II. HYOID ARCH - a) ONE BONE OF MIDDLE EAR (stapes); also b) STYLOID PROCESS and stylohyoid lig. c) part of HYOID BONE (upper half of body of hyoid bone) III. THIRD ARCH- REST OF HYOID BONE - lower half of body of hyoid IV. FOURTH ARCH - cartilages of larynx
21 BRANCHIAL POUCHES, GROOVES (CLEFTS), MEMBRANE PLANE OF CUT MEMBRANE POUCH endoderm GROOVE (CLEFT) ectoderm 1. Branchial Groove (Pharyngeal Cleft) - ectodermal cleft between adjacent arches 2. Branchial Pouch - endodermal outpocketing from rostral foregut -between adjacent arches 3. Branchial Membrane - site of contact of Groove (ectoderm) Pouch (endoderm)
22 BRANCHIAL POUCH DERIVATIVES Branchial Pouch A. Pouch 1 - forms Tubotympanic recess - Auditory Tube, Tympanic cavity B. Pouch 2 - lining (crypts) of Palatine Tonsils C. Pouch 3- Inferior Parathyroid Glands & Thymus D. Pouch 4 - Superior Parathyroid Glands & C-Cells (Calcitonin) Note: Pouch 3 derivatives migrate caudal to pouch 4
23 OUTER AND MIDDLE EAR DEVELOP FROM FIRST BRANCHIAL, CLEFT, MEMBRANE AND POUCH : SIMILAR TO ADULT ANATOMY First Membrane Tympanic Membrane First Pouch - Auditory Tube TYMPANIC MEMBRANE = first branchial membrane First Cleft - Ext. Aud. Meatus External Auditory Meatus - derived from first branchial cleft - ectoderm Middle Ear and Auditory Tubeextends from Nasopharynx to middle ear; derived from first branchial pouch - endoderm
24 BRANCHIAL 'CLEFT' CYSTS - PERSISTENT CERVICAL SINUS NORMALLY - OTHER GROOVES (CLEFTS) OBLITERATED Branchial Sinus = Blind pouch from Pharynx cleft 1 pouches clefts 2-4 Branchial cleft cysts - persist anywhere along path between pouch and cleft FORM CERVICAL SINUS THAT NORMALLY DISAPPEARS Confusion: Clinically can be called Branchial cleft cysts and refer to embryological pouches or clefts
25 BRANCHIAL CLEFT CYSTS, FISTULI Branchial Fistula = Channel, often connecting Pharynx to skin of neck; usually passes Anterior to Sternocleidomastoid Muscle Branchial Fistula = Channel Branchial Fistula = Channel Anterior to Sternocleidomastoid
26 BRANCHIAL CLEFT 'CYSTS' (FISTULAE) - often have tracts that extend from site of embryological origin
27 BRANCHIAL 'CLEFT' CYSTS (FISTULAE) First Branchial 'Cleft' Cyst - external auditory meatus/ auditory tube Second Branchial 'Cleft' Cyst - tract to palatine tonsils MOST COMMON NOTE: OPENING ANTERIOR TO STERNO- CLEIDOMASTOID MUSCLE Third Branchial 'Cleft' Cyst - tract to piriform recess, Thyrohyoid membrane
28 BRANCHIAL 'CLEFT' CYSTS 1st Branchial Cleft Cystopens on face or near ear Type 1 - tract to external auditory meatus Type 2- tract to auditory tube OPENING
29 BRANCHIAL 'CLEFT' CYSTS 1st Branchial Cleft Cystopens on face or near ear Type 1 - tract to external auditory meatus Type 2- tract to auditory tube
30 BRANCHIAL 'CLEFT' CYSTS 2nd Branchial Cleft Cyst- MOST COMMON - opens on neck ANTERIOR TO STERNOCLEIDO- MASTOID MUSCLE - tract to PALATINE TONSIL OPENING - clinical sign - mucous secretion; can increase when have respiratory infection.
31 BRANCHIAL 'CLEFT' CYSTS 2nd Branchial Cleft Cyst- MOST COMMON - opens on neck ANTERIOR TO STERNOCLEIDO- MASTOID MUSCLE - TRACT TO PALATINE TONSIL 3rd Branchial Cleft Cyst- more inferior on neck; also ANTERIOR TO STERNOCLEIDOMASTOID MUSCLE - tract opens to piriform recess or thyrohyoid membrane
32 BRANCHIAL 'CLEFT' CYSTS - can also become apparent in adult - lateral neck mass - slow growing - anterior to Sternocleidomastoid muscle
33 DEVELOPMENT OF ORAL CAVITY - Stomodeum formed by Ectoderm; forms Oral Cavity & Nasal Cavity - Contacts Endoderm at Oropharyngeal Membrane - Pharynx rostral foregut - formed by Endoderm Pharynx Stomodeum Oropharyngeal Membrane
34 SAY AAHH! PALATOGLOSSAL ARCH PALATOGLOSSAL ARCH = SITE OF OROPHARYNGEAL MEMBRANE = BOUNDARY, BETWEEN ORAL CAVITY AND PHARYNX
35 ANATOMY OF TONGUE - HAS ORAL AND PHARYNGEAL PARTS ORAL PART OF TONGUE = ant.2/3 SENSORY INNERVATION 1) TASTE - VII Facial N. 2) TOUCH - V Trigeminal N. PHARYNGEAL PART OF TONGUE = post. 1/3 SENSORY INNERVATION FORAMEN CECUM - pit in midline of sulcus terminalis PHARYNGEAL PART TASTE AND TOUCH - most CN IX CN X (small part anterior to epiglottis) ORAL PART SULCUS TERMINALIS -marks boundary ALL MUSCLES OF TONGUE - XII HYPOGLOSSAL N.
36 DEVELOPMENT OF THYROID TONGUE THYROGLOSSAL DUCT 1) Thyroid start as Median endodermal thickening on floor of pharynx at future junction of ant 2/3 & post 1/3 of tongue (marked by foramen cecum) 2) Elongates to form Thyroid Diverticulum; descends ant. to hyoid bone & larynx 3) Thyroglossal duct connects Diverticulum to Foramen cecum
37 NORMAL ANATOMY OF THYROID GLAND A. THYROID GLAND Right lateral lobe Isthmus- links lateral lobes below cricoid cartilage Left lateral lobe Pyramidal lobe Lateral Lobe Lateral Lobe Two Lateral Lobes - below & on sides cricoid cartilage Pyramidal Lobe - 50% of people; attached to hyoid by fibrous strand; no clinical problems
38 THYROID MALFORMATIONS FORAMEN CECUM OF TONGUE HYOID BONE CYSTS Thyroglossal Duct Remnants - can have thyroid tissue or form Thyroglossal Duct cysts anywhere along path Symptom - Midline neck mass, anterior to hyoid bone, larynx
39 Thyroglossal Duct Cyst - Midline of Neck
40 Thyroglossal Duct Cyst - Anterior to Hyoid Bone
41 PARATHYROID GLANDS - 4 small bodies (2 on each side) located posterior to or within Thyroid gland Superior parathyroid gland Inferior parathyroid gland Location variable due to migration after embryological origin from Branchial Pouches 3 and 4; Inferior parathyroid glands from 3, Superior parathyroid gland from 4 Abnormal location - Normally no symptoms Clinical consequence Surgical removal of thyroid - calcium imbalance
42 GOOD LUCK!
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