HEAD

Chapter 2 THE HEAD


The head of the dog is often involved in trauma either from accidents or fighting. The position of the subcutaneous vessels is therefore important in these cases. Surgical repair of skin wounds is a common occurrence and damage to eyes, ears and mouth including the tongue is not uncommon. The tongue may also be involved in burns or electrocution. Teeth are also easily damaged by trauma, excessive chewing or foreign bodies. These foreign bodies may be trapped in the tongue, cheeks, soft palate or teeth. It is worth remembering that the oral and nasal orifices provide easy access for pathogens or excess antigens.


The mucous membranes of the mouth, eye, tongue and nose are valuable in the clinical assessment of the cardiovascular system. Paleness (pallor) may indicate anaemia, cyanosis (blue coloration) may be a result of poor oxygenation, and a yellow color indicates jaundice. There are a variety of causes some of which may originate in the liver including toxic, neoplastic and metabolic diseases. Hemorrhage (small or large) may also be seen from any of the vessels and within the mucous membranes. These may be associated with rat poisons in particular. The pulse can be obtained from the linguofacial artery and also the deep artery of the tongue (under the tip).


Most of the large blood vessels of the head and the nerves are protected by deep fascia. However, the cranial nerves V and VII supply the head. The extensive motor distribution of the facial nerve (VII) to the muscles of the head is contrasted with the less apparent distribution of sensory nerves from cranial nerve V which supply the cutaneous innervation of the skin of the head. Cranial nerve VII is easily damaged over the surface of the masseter muscle and therefore facial paralysis is not uncommon. This does not affect the upper eyelid which is supplied by branches of cranial nerve III.


The eyes are valuable in clinical diagnosis giving an impression of alertness and brightness. They are a major indicator of the state of health as retinal examination is possible. The presence of the orbital fat pad is also important. This readily dehydrates, raises the third eyelid and therefore gives a ‘hooded’ appearance to the eye. In cases of inanition when the orbital fat pad is reduced even further, then more of the third eyelid will be exposed. The eye is further protected laterally and caudally by the orbital ligament so the eye is retained in position. In some exophthalmic breeds, such as the Pekinese, the eye may ‘pop out’ and can be ‘popped back’ or enucleated (removed). Removal of the eyelid requires tying off of nerves and blood vessels and removal of the globe. The optic artery attaching to the back of the eye is important and in removal of the globe care should be taken not to pull too strongly or the optic chiasma may be damaged. A variety of clinical operations may be carried out on the eye including superficial keratectomy which is the removal of anterior corneal stroma. Grid keratotomy and debridement is fairly commonly carried out. Other examples of ocular surgery include entropion, where upper and lower eyelids may turn in onto the eye producing irritation. Effectively, tissue is removed to turn the eyelid out. The opposite condition, ectropion, also occurs and is corrected by shortening the lower lid and supporting with a skin flap. The condition of districhiasis (extra hairs irritating the cornea) and ectopic cilia, can be corrected by partial tarsal plate removal; a strip of eyelid is essentially removed. In cases where the cornea is damaged or ulcerated, it is possible to use conjunctival flaps to cover the cornea to promote healing or to use contact lenses.


Where the eye becomes very dry (keratitis sicca), it is possible to transplant the parotid duct. This condition may be associated with autoimmune disease and can be treated medically (Optimmune) in many cases. It opens at the level of the carnassial tooth (4th upper premolar) on a prominent papilla. The opening of the zygomatic salivary gland is slightly posterior and nearer to the gum margin. The duct is dissected out and transplanted into the upper lateral angle of the eye, or onto the lower conjunctival sac.


In connection with the salivary glands, sometimes these ducts become blocked (mucocele) and the glands become cystic. The sub-linguinal/submandibular gland complex can then be removed intact ‘in toto’ as they are difficult to separate. Care has to be taken to avoid the superficial maxillary vein dorsally and the linguofacial vein ventrally. Radio-opaque dyes injected into the caruncle can be used to discover patency. The mandibular salivary gland is an important structure, palpable in the angle of the jaw and easily confused with the mandibular lymph nodes.


The parotid lymph node is not normally palpable in its position close to the cartilaginous ear canal, but it may be damaged during ear surgery. The mandibular lymph nodes are larger, more important and can be identified in infectious or neoplastic disease. They are palpable just caudal to the ventral border and angle of the mandible. The linguofacial trunk and the parotid duct lie just lateral to these nodes.


The temporomandibular joint may be the seat of pain in some dogs and it can be palpated in front of the base of the ear. It can be felt when the mouth is opened and closed carefully. Dislocation may require replacement under anesthesia. Other conditions affecting the mandible include fracture of the symphysis (requires wiring together) and occasionally fracture of the ramus of the mandible may require surgical correction. This may be iatrogenic in young dogs when removing temporary teeth or lower canines. There is also the specific condition of cranial mandibular osteodystrophy.


Teeth can be vital in helping to estimate the age of dogs, as the pulp cavities narrow with increasing age. It can be more usual to rely upon the degree of tartar formation wear and general health of the gingiva. Teeth are obviously closely associated with mandible and maxillae. A malar abscess may occur around the root of the 4th (carnassial) upper premolar. It may cause swelling of the face below the eye and will eventually fistulate to the skin. It requires removal to allow drainage. It may be necessary to remove persistent temporary teeth usually the canines. Adult canine teeth have a wide root, greater than the alveolus, and require elevators or removal of lateral wall of alveolus to be able to remove a tooth. The upper and lower canine teeth have extensive roots which reach caudally beneath the roots of the first two pre-molars. The upper carnassial has three roots, is more difficult to remove and is easily damaged by chewing bones etc. It can easily become affected by a root granuloma or a fistula. Prosthetic dentistry is also carried out in show dogs or police dogs. The tonsil may become infected. It is usually obscured by the overlying mucosa of the crypt, but if infected, bulges from the crypt.


Tonsillectomy (removal) may then be required. The palate may be subject to two major problems. There may be the congenital abnormality of a cleft palate. Extra flaps are made by incisions and the palate is then joined to the tonsillar crypts. The soft palate does not normally extend beyond the caudal limit of the tonsillar crypts and should just contact the epiglottis which lies dorsal to the soft palate during normal breathing.


In brachycephalic breeds, the soft palate may be too long and needs to be cut back in size to fit. If cut and left long, the dog will have difficulty breathing (dyspnea) and noisy breathing will result, but if cut too short, food drips into the nasal cavity during swallowing. The endotracheal tube can be placed from oral cavity into larynx and trachea requires the soft palate to be elevated dorsally to expose the epiglottis and then the tube enters the aditus laryngis.


Ears can be the cause of many clinical problems; bitten, trapped and haematomas. Infection of the external ear (otitis externa) is the most common of all ear complaints. Infection of the inner ear can produce facial paralysis. In canines, otitis media can affect sympathetic fibers that run through the middle ear. Aural hematomas require removal of the blood and stitching flat to a matrix. There are some methods that include mattress sutures and drain placements but in many of these cases the problem recurs. A considerable amount of veterinary activity focuses on blocked auditory canals (too much hair, too much wax, foreign bodies). The problem is that there is a vertical canal which fills up, provides an excellent breeding place for pathogens, and does not self-clean easily. This is worse in flap-eared breeds with long hair such as spaniels. It has to be de-haired and cleaned by auroscope. Occasionally, this is not sufficient and has to be extended to an aural resection. In this the ventral part of the external auditory canal is ablated and this leads to increased aeration and drainage with horizontal canal opening directly to the skin. It can only be used when the horizontal canal is in good clinical condition.


The tympanic bulla is located medial to the muscular process of the mandible and great cornu of the hyoid bone. The bullae can be opened ventrally for drainage. Great care has to be taken to avoid damaging the surrounding structures including the hypoglossal nerve, internal carotid artery and internal maxillary vessels. Debris is removed and the secretory tissue as well as any inflamed tissue, and the site cleaned. It can be removed by lateral or ventral bullar osteotomy.


The last of the major clinical areas is the nostril and nasal cavity. The nasal cavity may become infected or may be the seat of trapping of foreign bodies. This is rarely done but occasionally for the treatment of conditions such as nasal aspergillosis. The nasal cavity can be examined by rhinoscopy for signs of obstruction and the nasolacrimal duct can also be checked for patency. In cases of persistent purulent nasal discharge or the occurrence of polyps, it is possible to carry out rhinectomy (removal of the conchal bones) with a midline incision from the frontal sinus to the rostral end of the nasal bones. Parallel incisions remove the central bone and the conchal bones are then removed, hemostasis applied and the skin incision stitched without the underlying bone fragment.



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Fig. 2.1 Surface features of the head: left lateral view. The major bony features that are readily palpable and/or visible on the surface of the head are indicated in this figure. These ‘points’ correspond to those colored green on the bones illustrated in Fig. 2.2. Additional palpable features include the thyroid cartilage, the orbital ligament, the temporal and masseter muscles, and the mandibular lymph nodes. The position of the temporomandibular joint rostral to the base of the auricular cartilage is also readily palpable when the mouth is opened and closed carefully. Figs 2.55, 2.59 and 2.125 show the surface of the head from dorsal and ventral views and should be compared with this figure.




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Fig. 2.2 Skeleton of the head: left lateral view. The palpable bony features shown in Fig. 2.1 are colored green on this skull and first three cervical vertebrae. Absent from this skeletal preparation are the hyoid apparatus (the component parts and topographical position are shown in dissections of the pharyngeal region – from lateral view in Figs 2.782.83; from medial view in Figs 2.93 and 2.94; and from ventral view in Figs 2.1292.133), the nasal cartilages (shown in Figs 2.992.106), and the auricular cartilages (shown in Figs 2.32 and 2.33, and Figs 2.612.67). In addition to distinct palpable ‘points’, large areas of bone can also be felt through the overlying musculature, particularly in the facial region.








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Fig. 2.6 Radiograph of the head: ventrodorsal view. Only the major features are pointed out here, as in fig 2.4. Of particular note is the transverse orientation of the temporomandibular joints and the somewhat narrower lower jaw and lower dental arcade. With jaw action being hinge-like the teeth of the lower dental arcade, especially the first lower molar tooth, show a shearing bite against the lingual surfaces of the teeth of the upper arcade.




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Fig. 2.8 Surface features of the head with mouth open: rostral view. When the mouth is closed the tongue practically fills the oral cavity (see also Fig. 2.143 of the head in transverse section): an open mouth displays mucous membrane covering the tongue and palate and lining the inside of the cheeks. The length of the soft palate should be noted (see also Fig. 2.87) since in brachycephalic breeds it may interfere with air flow through the larynx.






Fig. 2.11 Radiograph of the jaws and permanent teeth: lateral view. Superimposition of upper and lower jaws in a lateral view creates a confusing image of the dental arcades (see fig. 2.4). For this reason a sagittally sectioned head has been radiographed and the permanent dentition on only one side of each jaw is shown. The sectorial (carnassial) teeth – upper fourth premolar and lower first molar – have been labelled in the drawing. The permanent dental formula is:



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Fig. 2.17 Surface features of the eye: left lateral view (1). The eye is shown with eyelids open. The palpable bony orbital margin is completed laterally by an orbital ligament linking the supraorbital process with the zygomatic arch (cf. Fig. 2.39). A dog has quite a wide field of view, in the order of 240°, and there is some measure of overlap between the fields of left and right eyes when it is looking straight ahead.





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Fig. 2.20 Skeletal basis of variation in conformation of the head: dorsal and lateral views. The shape of the head is determined in large measure by the skull, and in particular the facial region. Within the spectrum of skull construction, three broad categories are generally recognized – brachycephalic, mesaticephalic and dolichocephalic. The montage of skulls in the accompanying illustration shows all three categories; e.g. bulldog (brachycephalic), basset hound (mesaticephalic), and rough collie (dolichocephalic). It is the facial part of the skull that is shortened/widened in brachycephalics, but lengthened/narrowed in dolichocephalics. These categories refer specifically to head type and say nothing about the rest of the body. This fact is demonstrated by the three lateral views at the foot of the page – brachycephalic (Pekinese), mesaticephalic (dachshund), and dolichocephalic (Sealyham terrier). The lateral views also show the difference in level between the dorsal contours of the cranium and face. Although in approximately parallel planes, the marked step down from cranial to facial level produces the nasofrontal angle or ‘stop’. In brachycephalic breeds the shortened broadened face is coupled with a deepened stop and eyes that are directed more forwards. Selective breeding has also produced a discrepancy in length between upper and lower jaws – a short face is generally prognathic with an undershot lower jaw: a long face is often accompanied by a brachygnathic, receding lower jaw. The montage also demonstrates the enormous intraspecific size range, especially well displayed by the juxtaposed Chihuahua and Great Dane skulls at the top of the page. The head of a brachycephalic breed (boxer) is also displayed at the top of the page.













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Fig. 2.26 Superficial structures of the temporal, auricular, parotid and masseteric regions after removal of the platysma muscle: left lateral view. This is a closer view of part of the dissection shown in Fig. 2.25. Some limited cleaning of superficial fascia from around the concha of the auricular cartilage exposes the parotid salivary gland and the proximal part of its duct. Cutaneous innervation of the head is through the trigeminal nerve (V), some of the branches being displayed in this dissection (see also Fig. 2.58). However, many of its terminal ramifications have been unavoidably removed along with the skin and platysma muscle so that at best only the proximal stumps of such nerves are preserved intact.





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Fig. 2.28 Superficial structures of the temporal, auricular, parotid and masseteric regions after removal of the platysma and sphincter colli profundus muscles: left lateral view. This is a closer view of a part of the dissection shown in Fig. 2.27. Removal of the intermediate part of the sphincter colli profundus has exposed the mandibular lymph nodes (see also Fig. 2.127). These nodes are of considerable size when compared to the very small parotid lymph node exposed in Fig. 2.30. Lymph nodes are generally few in number and small in size (relative to body size) in the dog and lymphatic tissue is generally poorly displayed. Lymphatic vessels (apart from the thoracic duct – see Chapter 5) are not demonstrated.





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Fig. 2.30 Superficial nerves and blood vessels of the temporal, auricular, parotid and masseteric regions after removal of the facial muscles and parotid salivary glands: left lateral view. This is a closer view of a part of the dissection shown in Fig. 2.29 but with the parotid salivary gland removed, including the proximal part of its duct, and that component of the superficial temporal vein which lay embedded in parotid gland tissue also removed. The cut ends of the vein are visible as it leaves the temporal fascia dorsal to the zygomatic arch, and just before it enters the maxillary vein caudoventral to the concha of the auricular cartilage. The small parotid lymph node, now uncovered, partially obscures the communicating ramus linking the auriculotemporal branch of the trigeminal nerve (V) with the dorsal buccal branch of the facial nerve (VII).











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Fig. 2.36 Mandibular ramus and temporal muscle after removal of the masseter muscle and temporal fascia: left lateral view (2). This is a closer view of the temporal and masseteric regions of the dissection shown in Fig. 2.35. It displays the deep facial vein leaving the pterygopalatine fossa and embedded to some extent in the zygomatic salivary gland. The buccal nerve from the mandibular branch of the trigeminal nerve (V) appears in the cheek immediately rostral to the coronoid process of the mandibular ramus. Caudal to the external acoustic meatus the remains of the caudal auricular vessels and nerve have been displaced caudally after removal of the auricular cartilage. They are spread out on the aponeurosis of the cleidocervical and sterno-occipital muscles in the region of the atlas wing.



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Fig. 2.37 Temporal fossa and mandibular ramus after removal of the temporal and masseter muscles: left lateral view. ‘Piecemeal’ removal of the temporal muscle has left its nerve and blood supply intact and visible through the mandibular notch (see also Figs 2.69 and 2.70). In the process of temporal muscle removal the isolation of orbital structures within the periorbita was clearly apparent: temporal fascia fuses with the orbital ligament whereas the temporal muscle itself merely butts onto but does not attach to the periorbita (see also Fig. 2.70). Likewise, separation of the temporal muscle from the maxillary nerve and blood vessels and buccal nerve in the pterygopalatine fossa ventral to it was readily accomplished (see also Fig. 2.72). The hole in the cranium at the point labelled ‘X’ was made to allow the insertion of a hook to support the head following embalming of the cadaver.







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Jul 8, 2016 | Posted by in SUGERY, ORTHOPEDICS & ANESTHESIA | Comments Off on HEAD

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