8- Head & Neck MSQs Only Flashcards
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Which of the following structures is not transmitted by the jugular foramen?
Hypoglossal nerve
Contents of the jugular foramen:
Anterior: inferior petrosal sinus
Intermediate: glossopharyngeal, vagus, and accessory nerves
Posterior: sigmoid sinus (becoming the internal jugular vein) and some meningeal branches from the occipital and ascending pharyngeal arteries
The jugular foramen may be divided into three compartments:
Anterior compartment transmits the inferior petrosal sinus
Middle compartment transmits cranial nerves IX, X and XI
Posterior compartment transmits the sigmoid sinus
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What is the correct embryological origin of the stapes?
Second pharyngeal arch
Embryological origin stapes = 2nd pharyngeal arch
The ectoderm covering the outer aspect of the second arch originates from a strip of ectoderm lateral to the metencephalic neural fold. The cartilaginous element to this, eponymously known as Reicherts cartilage extends from the otic capsule to the midline on each side. Its dorsal end separates and becomes enclosed in the tympanic cavity as the stapes.
The dorsal ends of the cartilages of the first and second pharyngeal arches articulate superior to the tubotympanic recess. These cartilages form the malleus, incus and stapes. At least part of the malleus is formed from the first arch and the stapes from the second arch. The incus is most likely to arise from the first arch.
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A 73 year old man presents with a tumour at the central aspect of the posterior third of the tongue. To which of the following lymph node groups is it most likely to metastasise?
Bilateral deep cervical nodes
Posterior third tumours of the tongue commonly metastasise to the bilateral deep cervical lymph nodes
Tumours of the posterior third of the tongue will typically metastasise early and bilateral nodal involvement is well recognised, this is most often true of centrally located tumours and those adjacent to the midline as the lymph vessels may cross the median plane at this location.
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A 21 year old man undergoes surgical removal of an impacted 3rd molar. Post operatively, he is noted to have anaesthesia on the anterolateral aspect of the tongue. What is the most likely explanation?
Injury to the lingual nerve
The lingual nerve is closely related to the third molar and up to 10% of patients undergoing surgical extraction of these teeth may subsequently develop a lingual neuropraxia. The result is anaesthesia of the ipsilateral anterior aspect of the tongue. The inferior alveolar nerve innervates the teeth themselves.
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A surgical resection specimen is analysed histologically. The pathologist comments that at the periphery of the resected specimen, oxyphil cells are identified. In which of the structures listed below are these cells typically found?
Parathyroid gland
Oxyphil cells are typically found in parathyroid glands
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A 34 year old lady suffers from hyperparathyroidism. The right inferior parathyroid is identified as having an adenoma and is scheduled for resection. From which of the following embryological structures is it derived?
Third pharyngeal pouch
The inferior parathyroid is a derivative of the third pharyngeal pouch. The superior parathyroid originates from the fourth pharyngeal pouch.
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A 56 year old man is undergoing a superficial parotidectomy for a pleomorphic adenoma. During the dissection of the parotid, which of the following structures will be encountered lying most superficially?
Facial nerve
Most superficial structure on the parotid gland = facial nerve
The facial nerve is the most superficial structure in the parotid gland. Slightly deeper to this lies the retromandibular vein, with the arterial layer lying most deeply.
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A 78 year old man is due to undergo an endarterectomy of the internal carotid artery. Which of the following nervous structures are most at risk during the dissection?
Hypoglossal nerve
Nerves at risk during a carotid endarterectomy:
. Hypoglossal nerve
. Greater auricular nerve
. Superior laryngeal nerve
During a carotid endarterectomy the sternocleidomastoid muscle is dissected, with ligation of the common facial vein and then the internal jugular is dissected exposing the common and the internal carotid arteries. The nerves at risk during the operation include:
. Hypoglossal nerve
. Greater auricular nerve
. Superior laryngeal nerve
The sympathetic chain lies posteriorly and is less prone to injury in this procedure.
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As regards the internal jugular vein, which of the following statements is untrue?
- The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein ( Right )
- It lies within the carotid sheath
- It is the continuation of the sigmoid sinus
- The hypoglossal nerve is closely related to it as it passes near the atlas
- The vagus nerve is closely related to it within the carotid sheath
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Which of the following cranial venous sinuses is unpaired?
Superior sagittal sinus
The superior sagittal sinus is unpaired
The superior sagittal sinus is unpaired. It begins at the crista galli, where it may communicate with the veins of the frontal sinus and sometimes with those of the nasal cavity. It arches backwards in the falx cerebri to terminate at the internal occipital protuberance (usually into the right transverse sinus). The parietal emissary veins link the superior sagittal sinus with the veins on the exterior of the cranium.
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Which of the following laryngeal tumours will not typically metastasise to the cervical lymph nodes?
Glottic
The vocal cords have no lymphatic drainage and therefore this region serves as a lymphatic watershed. The supraglottic part drains to the upper deep cervical nodes through vessels piercing the thyrohyoid membrane. The sub glottic part drains to the pre laryngeal, pre tracheal and inferior deep cervical nodes. The aryepiglottic and vestibular folds have a rich lymphatic drainage and will metastasise early.
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An 18 year old man is cutting some plants when a small piece of vegetable matter enters his eye. His eye becomes watery. Which of the following is responsible for relaying parasympathetic neuronal signals to the lacrimal apparatus?
Pterygopalatine ganglion
The parasympathetic fibres to the lacrimal apparatus transit via the pterygopalatine ganglion.
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A 43 year old lady is undergoing a total thyroidectomy for an extremely large goitre. The surgeons decide that access may be improved by division of the infra hyoid strap muscles. At which of the following sites should they be divided?
In their upper half
Should the strap muscles require division during surgery they should be divided in their upper half. This is because their nerve supply from the ansa cervicalis enters in their lower half.
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A 22 year old women has recently undergone a surgical excision of the submandibular gland. She presents to the follow up clinic with a complaint of tongue weakness on the ipsilateral side to her surgery. Which nerve has been damaged?
Hypoglossal nerve
Three cranial nerves may be injured during submandibular gland excision.
. Marginal mandibular branch of the facial nerve
. Lingual nerve
. Hypoglossal nerve
Hypoglossal nerve damage may result in paralysis of the ipsilateral aspect of the tongue. The nerve itself lies deep to the capsule surrounding the gland and should not be injured during an intracapsular dissection. The lingual nerve is probably at greater risk of injury. However, the effects of lingual nerve injury are sensory rather than motor.
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A 67 year old man undergoes a carotid endarterectomy and seems to recover well following surgery. When he is reviewed on the ward post operatively he complains that his voice is hoarse. What is the most likely cause?
Damage to the vagus
Many of these nerves are at risk of injury during carotid surgery. However, only damage to the vagus would account for a hoarse voice.
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Which of the following nerves is most commonly damaged during a superficial parotidectomy?
Greater auricular
The greater auricular nerve and in particular its lobular branch is commonly injured in parotid surgery and consent usually makes particular reference to this. In a superficial parotidectomy, the facial nerve should not be injured and this is less common than a greater auricular nerve injury.
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An 21 year old man undergoes an uncomplicated tonsillectomy for recurrent attacks of tonsillitis. Post operatively he complains of otalgia. Which nerve is responsible?
Glossopharyngeal
The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.
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Which of the nerves listed below provides sensory innervation to the skin overlying the lateral aspect of the nose?
Lateral nasal branches of the ethmoidal nerve
The lateral aspect of the external nose is innervated by lateral nasal branches of the anterior ethmoidal nerve. The ethmoidal nerve is a branch of the nasociliary nerve which is one of the divisions of the trigeminal.
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A 12 year old boy undergoes surgery for recurrent mastoid infections. Post operatively he complains of an altered taste sensation. Which of the following nerves has been injured?
Chorda tympani
The chorda tympani branch of the facial nerve passes forwards through itrs canaliculus into the middle ear, and crosses the medial aspect of the tympanic membrane. It then passes antero-inferiorly in the infratemporal fossa. It distributes taste fibres to the anterior two thirds of the tongue.
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Which of the following structures separates the subclavian artery and vein?
Anterior scalene muscle
The anterior scalene muscle is an important anatomical landmark and separates the subclavian vein (anterior) from the subclavian artery (posterior).
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Which of the structures listed below is not a content of the carotid sheath?
Recurrent laryngeal nerve
Contents of carotid sheath:
Common carotid artery
Internal carotid artery
Internal jugular vein
Vagus nerve
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Which of the following is not a content of the cavernous sinus?
Optic nerve
Mnemonic for contents of cavernous sinus:
O TOM CAT
Occulomotor nerve (III)
Trochlear nerve (IV)
Ophthalmic nerve (V1)
Maxillary nerve (V2)
Carotid artery
Abducent nerve (VI)
OTOM=lateral wall components
CA= components within sinus
The optic nerve lies above and outside the cavernous sinus.
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A 43 year old man is due to undergo an excision of the sub mandibular gland. Which of the following incisions is the most appropriate for this procedure?
A transversely orientated incision 3cm below the mandible
To access the sub mandibular gland a transverse incision 3cm below the mandible should be made. Incisions located higher than this may damage the marginal mandibular branch of the facial nerve.
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A 5 year old boy presents with recurrent headaches. As part of his assessment he undergoes an MRI scan of his brain. This demonstrates enlargement of the lateral and third ventricles. Where is the most likely site of obstruction?
Aqueduct of Sylvius
The CSF flows from the 3rd to the 4th ventricle via the Aqueduct of Sylvius.
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What is the nerve supply to the muscle indicated by an X on the prosection below?
CN XI
The muscle indicated is trapezius and it is innervated by the accessory nerve (CN XI)
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Which of the following structures does not pass through the foramen ovale?
Maxillary nerve
Mnemonic: OVALE
O tic ganglion
V3 (Mandibular nerve:3rd branch of trigeminal)
A ccessory meningeal artery
L esser petrosal nerve
E missary veins
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An elderly man develops a squamous cell carcinoma affecting the lobule of his ear. Do which lymph node is the lesion most likely to metastasize?
Superficial cervical nodes
The lobule drains to the superficial cervical nodes.
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Which of the cranial nerves listed below is least likely to carry parasympathetic fibres?
II
Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)
The parasympathetic functions served by the cranial nerves include:
III (oculomotor): Pupillary constriction and accommodation
VII (facial) : Lacrimal gland, submandibular and sublingual glands
IX (glossopharyngeal): Parotid
X (vagus): Heart and abdominal viscera
The optic nerve carries no parasympathetic fibres.
The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1, Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)
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At which of the following levels does the inferior thyroid artery enter the thyroid gland?
C6
It enters the gland at C6.
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An occlusion of the anterior cerebral artery may compromise the blood supply to the following structures except:
Medial inferior surface of the frontal lobe
Corpus callosum
Medial surface of the frontal lobe
Olfactory bulb
Brocas area ( Right)
Brocas area is usually supplied by branches from the middle cerebral artery.
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Parasympathetic fibres innervating the parotid gland originate from which of the following?
Otic ganglion
Secretion of saliva by the parotid gland is controlled by nerve fibres originating in the inferior salivatory nucleus; these leave the brain via the tympanic nerve (branch of glossopharyngeal nerve (CN IX), travel through the tympanic plexus (located in the middle ear), and then form the lesser petrosal nerve until reaching the otic ganglion. After synapsing in the Otic ganglion, the postganglionic (postsynaptic) fibres travel as part of the auriculotemporal nerve (a branch of the mandibular nerve (V3) to reach the parotid gland.
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Which of the following does not pass through the superior orbital fissure?
Opthalmic artery
Mnemonic for the nerves passing through the supraorbital fissure:
Live Frankly To See Absolutely No Insult
Lacrimal
Frontal
Trochlear
Superior Division of Oculomotor
Abducens
Nasociliary
Inferior Division of Oculomotor nerve
The opthalmic artery arises from the internal carotid immediately after it has pierced the dura and arachnoid. It runs through the optic canal below the optic nerve and within its dural and arachnoid sheaths. It terminates as the supratrochlear and dorsal nasal arteries.
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A 44 year old man is undergoing a parotidectomy and the surgeon is carefully preserving the facial nerve. Unfortunately his trainee then proceeds to divide it. Which of the following will not be affected as a result?
Taste sensation from anterior two thirds of the tongue( Right)
Closing the ipsilateral eyelid
Raising the ipsilateral side of the lip
Ipsilateral corneal reflex
None of the above
The chorda tympani branches inside the facial canal and will therefore be unaffected by this most unfortunate event! The corneal reflex is mediated by the opthalmic branch of the trigeminal nerve sensing the stimulus on the cornea, lid or conjunctiva; the facial nerve initiates the motor response of the reflex.
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Which cranial nerve supplies general sensation to the posterior third of the tongue?
Glossopharyngeal
The glossopharyngeal nerve supplies general sensation to the posterior third of the tongue and contributes to the gag reflex.
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Which of the nerves listed below is responsible for providing innervation to the lower molar teeth?
Inferior alveolar nerve
The branches of the lower molar and premolar teeth are supplied by branches of the inferior alveolar nerve. Those of the canine and incisors by the incisive branch of the same nerve. The gingiva and supporting structures are innervated by the lingual nerve.
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An 18 year old man undergoes a tonsillectomy for attacks of recurrent acute tonsillitis. Whilst in recovery he develops a post operative haemorrhage. Which of the following vessels is the most likely culprit?
External palatine vein
The external palatine vein lies immediately lateral to the tonsil and if damaged may be a cause of reactionary haemorrhage following tonsillectomy.
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What is the arterial blood supply to the lacrimal apparatus?
Ophthalmic artery
The ophthalmic artery supplies the gland
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During a radical neck dissection, division of which of the following fascial layers will expose the ansa cervicalis?
Pretracheal fascia
The ansa cervicalis lies anterior to the carotid sheath. It may be exposed by division of the pretracheal fascia at the posterolateral aspect of the thyroid gland. The pre vertebral fascia lies more posteriorly and division of the investing layer of fascia will not expose this nerve.
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What is the sensory nerve supply to the angle of the jaw?
Greater auricular nerve (C2-C3)
The trigeminal nerve is the major sensory nerve to the face except over the angle of the jaw.
The angle of the jaw is innervated by the greater auricular nerve.
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Which of the following structures separates the subclavian artery from the subclavian vein?
Scalenus anterior
The artery and vein are separated by scalenus anterior. This muscle runs from the transverse processes of C3,4,5 and 6 to insert onto the scalene tubercle of the first rib.
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The vertebral artery traverses all of the following except?
Transverse process of C6
Transverse process of the axis
Vertebral canal
Foramen magnum
Intervertebral foramen ( Right)
The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra, it does not traverse the intervertebral foramen.
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A 60 year old female attends the preoperative hernia clinic. She reports some visual difficulty. On examination she is noted to have a homonymous hemianopia. Where is the lesion most likely to be?
Optic tract
Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion
Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion
Unfortunately we thought as surgeons we could forget about visual field defects! However the college seem to like them. Remember a homonymous hemianopia is indicative of an optic tract lesion. Parietal lobe lesions tend to cause inferior quadranopias and there is a bitemporal hemianopia with optic chiasm lesion or pituitary tumours.
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A 38 year old lady is due to undergo a parathyroidectomy for hyperparathyroidism. At operation the inferior parathyroid gland is identified as being enlarged. A vessel is located adjacent to the gland laterally. This vessel is most likely to be the:
Common carotid artery
The common carotid artery is a lateral relation of the inferior parathyroid.
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Following a carotid endarterectomy a man notices that he has a weakness of his tongue. Damage to which of the following nerves is the most likely explanation for this process?
Hypoglossal
The hypoglossal nerve innervates the tongue and is one of the structures more commonly at risk in carotid surgery.
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A motorcyclist is injured in a road traffic accident and is not wearing a helmet. He suffers a severe closed head injury and develops raised intracranial pressure. The first cranial nerve to be affected by this process is likely to be:
Abducens
The abducens nerve (CN VI) has a long intra cranial course and is thus susceptible to raised intra cranial pressure. It also passes over the petrous temporal bone and 6th nerve palsies are also seen in mastoiditis.
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A 43 year old lady underwent an attempted placement of a central line into the internal jugular vein. Unfortunately, the doctor damaged the carotid artery and this necessitated surgical exploration. As the surgeons incise the carotid sheath a nerve is identified lying between the internal jugular vein and the carotid artery. Which of the following is this nerve most likely to be?
Vagus
The vagus lies in the carotid sheath. The hypoglossal nerve crosses the sheath, but does not lie within it.
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Which of the following nerves is not contained within the posterior triangle of the neck?
Accessory nerve
Phrenic nerve
Greater auricular nerve
Ansa cervicalis( Right)
Lesser occiptal nerve
Ansa cervicalis is a content of the anterior triangle of the neck
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Which of the structures listed below lies posterior to the carotid sheath at the level of the 6th cervical vertebra?
Cervical sympathetic chain
The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis.
The vagus lies within it. The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.
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A 45 year old man presents with a lipoma located posterior to the posterior border of the sternocleidomastoid muscle, approximately 4cm superior to the middle third of the clavicle. During surgical excision of the lesion troublesome bleeding is encountered. Which of the following is the most likely source?
External jugular vein
The external jugular vein runs obliquely in the superficial fascia of the posterior triangle. It drains into the subclavian vein. During surgical exploration of this area the external jugular vein may be injured and troublesome bleeding may result. The internal jugular vein and carotid arteries are located in the anterior triangle. The third, and not the second, part of the subclavian artery is also a content of the posterior triangle
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A 45 year old man sustains a significant head injury and a craniotomy is performed. The sigmoid sinus is bleeding profusely, into which of the following structures does it drain?
Internal jugular vein
The sigmoid sinus is joined by the inferior petrosal sinus to drain into the internal jugular vein.
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A 44 year old lady is recovering following a transphenoidal hypophysectomy. Unfortunately there is a post operative haemorrhage. Which of the following features is most likely to occur initially?
Bi-temporal hemianopia
The pituitary is covered by a sheath of dura and an expanding haematoma at this site may compress the optic chiasm in the same manner as an expanding pituitary tumour.
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Which of the following cranial foramina pairings are incorrect?
Carotid canal and internal carotid artery.
Optic canal and ophthalmic artery.
Foramen ovale and mandibular nerve.
Optic canal and ophthalmic nerve.( Right)
Foramen rotundum and maxillary nerve.
Question derived from 2010 and 2011 exams
The optic canal transmits the optic nerve. The ophthalmic nerve traverses the superior orbital fissure.
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A 63 year old man is admitted with severe headache, nausea and recent epileptic fit. Fundoscopy shows papilloedema. He is also noted to have diplopia. Which of the cranial nerves listed accounts for the latter?
Abducens
The long intracranial course of this nerve makes it susceptible to damage early in the course of raised ICP.
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Which of the following is not a content of the anterior triangle of the neck?
Vagus nerve
Submandibular gland
Phrenic nerve ( Right)
Internal jugular vein
Hypoglossal nerve
The phrenic nerve is a content of the posterior triangle. The anterior triangle contains the carotid sheath and its contents.
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A 22 year old man is undergoing an endotracheal intubation. Which of the following vertebral levels is consistent with the origin of the trachea?
C6
The trachea commences at C6. It terminates at the level of T5 (or T6 in tall subjects in deep inspiration).
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A young child undergoes a difficult craniotomy for fulminant mastoiditis and associated abscess. During the procedure the trigeminal nerve is severely damaged within Meckels cave. Which deficit is least likely to be present?
Anaesthesia over the entire ipsilateral side of the face
The angle of the jaw is not innervated by sensory fibres of the trigeminal nerve and is spared in this type of injury.
Remember the trigeminal nerve provides motor innervation to the muscles of mastication. The close proximity of the site of injury to the motor fibres is likely to result in at least some
compromise of motor muscle function.
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Which of the following is not a branch of the external carotid artery?
Mandibular artery
External carotid artery branches mnemonic:
‘Some Angry Lady Figured Out PMS’
Superior thyroid (superior laryngeal artery branch)
Ascending pharyngeal
Lingual
Facial (tonsillar and labial artery)
Occipital
Posterior auricular
Maxillary (inferior alveolar artery, middle meningeal artery)
Superficial temporal
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Which of the following statements relating to the basilar artery and its branches is false?
The superior cerebellar artery may be decompressed to treat trigeminal neuralgia
Occlusion of the posterior cerebral artery causes contralateral loss of the visual field
The oculomotor nerve lies between the superior cerebellar and posterior cerebral arteries
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the basilar artery ( Right)
The labyrinthine branch is accompanied by the facial nerve
…………………………………….
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the vertebral artery. The labyrinthine artery is long and slender and may arise from the lower part of the basilar artery. It accompanies the facial and vestibulocochlear nerves into the internal auditory meatus. The posterior cerebral artery is often larger than the superior cerebellar artery and it is separated from the vessel, near it’s origin, by the oculomotor nerve. Arterial decompression is a well established therapy for trigeminal neuralgia.
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Which of the following structures is not closely related to the carotid sheath?
Sternothyroid muscle
Sternohyoid muscle
Hypoglossal nerve
Superior belly of omohyoid muscle
Anterior belly of digastric muscle ( Right)
At its lower end the carotid sheath is related to sternohyoid and sternothyroid. Opposite the cricoid cartilage the sheath is crossed by the superior belly of omohyoid. Above this level the sheath is covered by the sternocleidomastoid muscle. Above the level of the hyoid the vessels pass deep to the posterior belly of digastric and stylohyoid. Opposite the hyoid bone the sheath is crossed obliquely by the hypoglossal nerve.
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A 22 year old man is involved in a fight and sustains a skull fracture with an injury to the middle meningeal artery. A craniotomy is performed, and with considerable difficulty the haemorrhage from the middle meningeal artery is controlled by ligating it close to its origin. What is the most likely sensory impairment that the patient may notice post operatively?
Parasthesia of the ipsilateral external ear
The auriculotemporal nerve is closely related to the middle meningeal artery and may be damaged in this scenario. The nerve supplied sensation to the external ear and outermost part of the tympanic membrane. The angle of the jaw is innervated by C2,3 roots and would not be affected. The posterior third of the tongue is supplied by the glossopharyngeal nerve.
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A 21 year old develops tonsillitis. He is in considerable pain. Which of the following nerves is responsible for the sensory innervation of the tonsillar fossa?
Glossopharyngeal nerve
The glossopharyngeal nerve is the main sensory nerve for the tonsillar fossa. A lesser contribution is made by the lesser palatine nerve. Because of this otalgia may occur following tonsillectomy.
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Where is the vomiting centre located?
Medulla oblongata
ABC’s of Non- GI causes of vomiting
Acute renal failure
Brain (Increased ICP)
Cardiac (Inferior MI)
DKA
Ears (labyrinthitis)
Foreign substances (Tylenol, theo, etc)
Glaucoma
Hyperemesis Gravidarum
Infections (pyelonephritis, meningitis)
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Which of the following nerves conveys sensory information from the laryngeal mucosa?
Laryngeal branches of the vagus
The laryngeal branches of the vagus supply sensory information from the larynx.
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A 25 year old man sustains a severe middle cranial fossa basal skull fracture. Once he has recovered it is noticed that he has impaired tear secretion. This is most likely to be the result of damage to which of the following?
Greater petrosal nerve
The greater petrosal nerve may be injured and carries fibres for lacrimation .
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Which of the following pairings of foramina and their contents is not correct?
- Superior orbital fissure and the oculomotor nerve
- Foramina rotundum and the maxillary nerve
- Jugular foramen and the hypoglossal nerve ( Right)
- Foramina spinosum and the middle meningeal artery
- Carotid canal and the internal carotid artery
The hypoglossal nerve passes through the hypoglossal canal.
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A 55 year old man with carcinoma of the larynx is undergoing a difficult laryngectomy. The surgeons divide the thyrocervical trunk, from which of the following vessels does this structure most commonly originate?
Subclavian artery
The thyrocervical trunk is a branch of the subclavian artery. It arises from the first part between the subclavian artery and the inner border of scalenus anterior. It branches off the subclavian distal to the vertebral artery.
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A man develops an infection in his external ear. The infection is extremely painful. Which of the following nerves conveys sensation from this region?
Auriculotemporal nerve
Tensor tympania and stapedius are the only two muscles of the middle ear. Contraction of tensor tympani will tend to dampen the vibrations produced by loud sounds, it is innervated by a branch of the trigeminal nerve. The stapedius dampens movements of the ossicles in response to loud sounds and is innervated by a branch of the facial nerve.
The auriculotemporal nerve, which is derived from the mandibular branch of the trigeminal nerve supplies this area.
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What is the most useful test to clinically distinguish between an upper and lower motor neurone lesion of the facial nerve?
Raise eyebrow
Upper motor neurone lesions of the facial nerve- Paralysis of the lower half of face.
Lower motor neurone lesion- Paralysis of the entire ipsilateral face.
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Which of the following does not pass through the superior orbital fissure?
- Oculomotor nerve
- Abducens nerve
- Ophthalmic artery ( Right)
- Ophthalmic division of the trigeminal nerve
- Ophthalmic veins
The ophthalmic artery, a branch of the internal carotid enters the orbit with the optic nerve in the canal.
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Which of these muscles is innervated by the cervical branch of the facial nerve?
Platysma
The cervical branch of the facial nerve innervates platysma.
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During a thyroidectomy the surgeons ligate the inferior thyroid artery. From which vessel does this structure usually originate?
Thyrocervical trunk
The inferior thyroid artery originates from the thyrocervical trunk. This is a branch of the subclavian artery.
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Which of the following statements relating to the Cavernous Sinus is false?
- The pituitary gland lies medially
- The internal carotid artery passes through it
- The temporal lobe of the brain is a lateral relation
- The mandibular branch of the trigeminal and optic nerve lie on the lateral wall ( Right)
- The ophthalmic veins drain into the anterior aspect of the sinus
The veins that drain into the sinus are important as sepsis can cause cavernous sinus thrombosis. The maxillary branch of the trigeminal and not the mandibular branches pass through the sinus
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Which of the following is not a branch of the subclavian artery?
Superior thyroid artery
Mnemonic for the branches of the subclavian artery: VIT C & D
V ertebral artery
I nternal thoracic
T hyrocervical trunk
C ostalcervical trunk
D orsal scapular
Superior thyroid artery is a branch of the external carotid artery.
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Which of the following muscles is supplied by the external laryngeal nerve?
Transverse arytenoid
Cricothyroid ( Right)
Thyro-arytenoid
Posterior crico-arytenoid
Oblique arytenoid
The others are all supplied by the recurrent laryngeal nerve.
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During a carotid endarterectomy the internal carotid artery is cross clamped. Assuming that no shunt is inserted, which of the following vessels will not have diminished or absent flow as a result?
Maxillary artery
Mnemonic for branches of the cerebral portion of the internal carotid artery ‘Only Press Carotid Arteries Momentarily’
Only = Opthalmic
Press = Posterior communicating
Carotid = Choroidal
Arteries = Anterior cerebral
Momentarily = Middle cerebral
The maxillary artery is a branch of the external carotid artery.
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A 21 year old man is hit with a hammer and sustains a depressed skull fracture at the vertex. Which of the following sinuses is at risk in this injury?
Superior sagittal sinus
The superior sagittal sinus is at greatest risk in this pattern of injury. This sinus begins at the front of the crista galli and courses backwards along the falx cerebri. It becomes continuous with the right transverse sinus near the internal occipital protuberance.
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A 22 year old man undergoes a superficial parotidectomy for a pleomorphic adenoma. The operation does not proceed well and a diathermy malfunction results in division of the buccal branch of the facial nerve. Which of the following muscles will not demonstrate impaired function as a result?
Zygomaticus minor
Mentalis( Right)
Buccinator
Levator anguli oris
Risorius
Buccal branch supplies:
Zygomaticus minor: Elevates upper lip
Risorius: Aids smile
Buccinator: Pulls corner of mouth backward and compresses cheek
Levator anguli oris: Pulls angles of mouth upward and toward midline
Orbicularis: Closes and tightens lips together
Nasalis: Flares nostrils and compresses nostrils
218 of 368
At which of the following vertebral body levels does the common carotid artery typically bifurcate into the external and internal carotid arteries?
C4
It terminates at the upper border of the thyroid cartilage, Which is usually located at C4.
220 of 368
An 18 year old man is stabbed in the neck and has to undergo repair of a laceration to the internal carotid artery. Post operatively he is noted to have a Horners syndrome. Which of the following will not be present?
Apparent enopthalmos
Loss of sweating on the entire ipsilateral side of the face ( Right)
Normal sympathetic activity in the torso
Constricted pupil
Mild ptosis
…………………………………….
The anhidrosis will be mild as this is a distal lesion and at worst only a very limited area of the ipsilateral face will be anhidrotic.
229 of 368
A 23 year old lady with sialolithiasis of the submandibular gland is undergoing excision of the gland. Which of the following nerves is at risk as the duct is mobilised?
Lingual nerve
The lingual nerve wraps around Whartons duct. The lingual nerve provides sensory supply to the anterior 2/3 of the tongue.
235 of 368
Which of the following nerve roots contribute nerve fibres to the ansa cervicalis?
C1, C2 and C3
Ansa cervicalis muscles:
GHost THought SOmeone Stupid Shot Irene
GenioHyoid
ThyroidHyoid
Superior Omohyoid
SternoThyroid
SternoHyoid
Inferior Omohyoid
The ansa cervicalis is composed of a superior and inferior root, derived from C1, C2 and C3.
The superior root arises where the nerve crosses the internal carotid artery. It descends anterior to the carotid sheath in the anterior triangle. It is joined in the region of the mid neck by the inferior root. The inferior root may pass either superficially or deep to the internal jugular vein.
236 of 368
Considering the pituitary gland, which of the following is false?
The anterior pituitary secretes thyroid stimulating hormone
The anterior pituitary develops from Rathkes pouch ( Right)
Patients with craniopharyngioma may develop bi temporal hemianopia
The pituitary is in direct contact with the optic chiasm
The posterior pituitary secretes oxytocin via a positive feedback loop
…………………………………………………..
Although the optic chiasm is closely related to the pituitary, and craniopharyngiomas may compress this structure leading to bitemporal hemianopia, it is separated from the chiasm itself by a dural fold.
237 of 368
A 24 year old man is involved in a fight and his face is cut with a knife. The wound lies immediately anterior to the tragus of the ear and extends anteriorly. The wound is surgically explored and the laceration is found to be mainly superficial. It extends slightly more deeply immediately inferior to the main trunk of the facial nerve. Bleeding is observed, from which of the following is it most likely to originate?
Retromandibular vein
The retromandibular vein lies slightly more deeply than the facial nerve in the parotid gland.
It is formed from the maxillary and superficial temporal vein.
238 of 368
An ENT surgeon is performing a radical neck dissection. She wishes to fully expose the external carotid artery. To do so she inserts a self retaining retractor close to its origin. Which of the following structures lies posterolaterally to the external carotid at this point?
Internal carotid artery
The internal carotid artery lies posterolaterally to the external carotid artery at it’s origin from the common carotid. The superior thyroid, lingual and facial arteries all arise from its anterior
240 of 368
A 28 year old man has a pleomorphic adenoma and the decision is made to resect this surgically. Which of the following structures is least likely to be encountered during surgical resection of the parotid gland?
Mandibular nerve
Structures passing through the parotid gland:
. Facial nerve and branches
. External carotid artery (and its branches; the maxillary and superficial temporal)
· Retromandibular vein
. Auriculotemporal nerve
The mandibular nerve is well separated from the parotid gland.
The maxillary vein joins to the superficial temporal vein and they form the retromandibular vein which then runs through the parotid gland.
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating (Freys Syndrome).
The facial nerve branch is the marginal mandibular branch and this is related to the gland.
242 of 368
A 56 year old man is undergoing a carotid endarterectomy. The internal carotid artery is mobilised. How many branches does this vessel give off in the neck?
0
The internal carotid does not have any branches in the neck.
244 of 368
From which of these foraminae does the opthalmic branch of the trigeminal nerve exit the skull?
Superior orbital fissure
Mnemonic:
Standing Room Only -Exit of branches of trigeminal nerve from the skull
V1 -Superior orbital fissure
V2 -foramen Rotundum
V3 -foramen Ovale
The opthalmic branch of the trigeminal nerve exits the skull through the superior orbital fissure.
Question 245 of 368
Which of the following nerves is responsible for the motor innervation of the sternocleidomastoid muscle?
Accessory nerve
The motor supply to the sternocleidomastoid is from the accessory nerve. The ansa cervicalis supplies sensory information from the muscle.
249 of 368
A 45 year old man is undergoing a lymph node biopsy from the posterior triangle of his neck.
Which structure forms the posterior border of this region?
Trapezius muscle
The borders are described below.
252 of 368
Which cranial nerve supplies the motor fibres of styloglossus?
Hypoglossal
The hypoglossal nerve supplies motor innervation to all extrinsic and intrinsic muscles of the tongue. The only possible exception to this is palatoglossus, which is jointly innervated by the vagus and accessory nerves.
254 of 368
Which of the following statements relating to the posterior cerebral artery is false?
It supplies the visual cortex
It is closely related to the 3rd cranial nerve
It is a branch of the basilar artery
It is connected to the circle of Willis via the superior cerebellar artery ( Right)
When occluded may result in contralateral loss of field of vision
The posterior cerebral arteries are formed by the bifurcation of the basilar artery and is connected to the circle of Willis via the posterior communicating artery.
The posterior cerebral arteries supply the occipital lobe and part of the temporal lobe.
263 of 368
Where does Stensens duct primarily open?
Opposite the second molar tooth
Stensens duct conveys secretions from the parotid gland and these enter the oral cavity at the level of the second molar tooth.
264 of 368
Which of the following nerves is responsible for the innervation of the posterior belly of the digastric muscle?
Facial nerve
The posterior belly of digastric is innervated by the facial nerve and the anterior belly by the mylohoid nerve.
274 of 368
A 49 year old man undergoes a low anterior resection for cancer. He is assessed in the outpatient clinic post operatively. His wounds are well healed. However, he complains of impotence. Which of the following best explains this problem?
Damage to the nervi erigentes
The penis takes autonomic nerves from the nervi erigentes that lie near the seminal vesicles.
These may be compromised by direct surgical trauma (such as use of diathermy in this area) and also by radiotherapy that is used in these patients pre operatively. The result is that up to 50% of patients may develop impotence following rectal cancer surgery.
275 of 368
A 43 year old lady develops a cerebello-pontine angle lesion. Which of the nerves listed below is likely to be affected first?
CN V
The most likely lesion to occur in the cerebello-pontine angle is an acoustic neuroma.
The trigeminal nerve has a broad base and involvement of at least part of this nerve is the most likely initial finding. The defect may be subtle such as loss of the ipsilateral corneal reflex. Ipsilateral hearing loss will also occur. Untreated, progressive lesions, may ultimately affect cranial nerve roots in this region.
279 of 368
Which cranial nerve provides general sensation to the anterior two thirds of the tongue?
Trigeminal
Taste to the anterior two thirds of the tongue is supplied by the facial nerve, the trigeminal supplies general sensation, this is mediated by the mandibular branch of the trigeminal nerve (via the lingual nerve).
281 of 368
Which of the following statements relating to the tympanic membrane is false?
The umbo marks the point of attachment of the handle of the malleus to the tympanic membrane
The lateral aspect of the tympanic membrane is lined by stratified squamous epithelium
The chorda tympani nerve runs medial to the pars tensa (Right)
The medial aspect of the tympanic membrane is lined by mucous membrane
The tympanic membrane is approximately 1cm in diameter
………………………………………………
The chorda tympani runs medially to the pars flaccida. The relationship is shown from the medial aspect in the dissection below.
287 of 368
An 18 year old male presents to casualty with a depressed skull fracture. This is managed surgically. Over the next few days he complains of double vision on walking down stairs and reading. On testing ocular convergence, the left eye faces downwards and medially, but the right side does not do so. Which of the nerves listed below is most likely to be responsible?
Trochlear
The trochlear nerve has a relatively long intracranial course and this makes it vulnerable to injury in head trauma. Head trauma is the commonest cause of an acute fourth nerve palsy.
A 4th nerve palsy is the commonest cause of a vertical diplopia. The diplopia is at its worst when the eye looks medially which it usually does as part of the accommodation reflex when walking down stairs.
288 of 368
What is the level of the hyoid bone?
C3
289 of 368
The following muscles are supplied by the recurrent laryngeal nerve except:
Transverse arytenoid
Posterior crico-arytenoid
Cricothyroid ( Right)
Oblique arytenoid
Thyroarytenoid
Innervates: all intrinsic larynx muscles (excluding cricothyroid)
The external branch of the superior laryngeal nerve innervates the cricothyroid muscle.
291 of 368
A 16 year old boy is hit by a car and sustains a blow to the right side of his head. He is initially conscious but on arrival in the emergency department is comatose. On examination his right pupil is fixed and dilated. The neurosurgeons plan immediate surgery. What type of initial approach should be made?
Right parieto-temporal craniotomy
A unilateral dilated pupil is a classic sign of transtentorial herniation. The medial aspect of the temporal lobe (uncus) herniates across the tentorium and causes pressure on the ipsilateral oculomotor nerve, interrupting parasympathetic input to the eye and resulting in a dilated pupil. In addition the brainstem is compressed. As the ipsilateral oculomotor nerve is being compressed, craniotomy (rather than Burr Holes) should be made on the ipsilateral side.
296 of 368
A man is undergoing excision of a sub mandibular gland. As the gland is mobilised, a vessel is injured lying between the gland and the mandible. Which of the following is this vessel most likely to be?
Facial artery
…………………………………………………………
The high salivary viscosity of submandibular gland secretions favors stone formation. Most stones are radio-opaque.
The marginal mandibular nerve is the most superficial structure.
The facial artery lies between the gland and mandible and is often ligated during excision of the gland. The lingual artery may be encountered but this is usually later in the operative process as Whartons duct is mobilised.
298 of 368
A 22 year old man sustains a blow to the side of his head with a baseball bat during a fight. He is initially conscious. However, he subsequently loses consciousness and then dies. Post mortem examination shows an extradural haematoma. The most likely culprit vessel is a branch of which of the following?
Maxillary artery
The middle meningeal artery is the most likely source of the extradural haematoma in this setting. It is a branch of the maxillary artery. The middle cerebral artery does not give rise to the middle meningeal artery. Note that the question is asking for the vessel which gives rise to the middle meningeal artery (“the likely culprit vessel is a branch of which of the following”)
302 of 368
Which statement is false about the foramina of the skull?
The hypoglossal canal transmits the hypoglossal nerve
The foramen spinosum is at the base of the medial pterygoid plate. (Right)
The jugular foramen transmits the accessory nerve
The foramen lacerum is located in the sphenoid bone
The stylomastoid foramen transmits the facial nerve
306 of 368
A 73 year old man presents with a tumour at the tip of his tongue. To which of the following regions will the tumour initially metastasise?
Sub mental nodes
308 of 368
Which of the following is not a content of the posterior triangle of the neck?
Spinal accessory nerve
Phrenic nerve
External jugular vein
Occipital lymph nodes
Internal jugular vein( Right)
The IJV does not lie in the posterior triangle. However, the terminal branches of the external jugular vein do.
309 of 368
Which nerve is at risk during submandibular gland excision?
Marginal mandibular nerve
The marginal mandibular nerve lies deep to platysma. It supplies the depressor anguli oris and the depressor labii inferioris. If injured it may lead to facial asymmetry and dribbling.
311 of 368
Which of these openings transmits the facial nerve into the temporal bone?
Internal acoustic meatus
It enters the temporal bone through the internal acoustic meatus and exits through the stylomastoid foramen.
321 of 368
A 34 year old man with a submandibular gland stone is undergoing excision of the submandibular gland. The incision is sited transversely approximately 4cm below the mandible. After incising the skin, platysma and deep fascia which of the following structures is most likely to be encountered.
Facial vein
When approaching the submandibular gland the facial vein and submandibular lymph nodes are the most superficially encountered structures. Each sub mandibular gland has a superficial and deep part, separated by the mylohyoid muscle. The facial artery passes in a groove on the superficial aspect of the gland. It then emerges onto the surface of the face by passing between the gland and the mandible. The facial vein is encountered first in this surgical approach because the incision is made 4cm below the mandible (to avoid injury to the marginal mandibular nerve).
322 of 368
You are working as an anatomy demonstrator and the medical students decide to test your knowledge on the Circle of Willis. Which of the following comments is false?
The anterior communicating artery links the right and left sides
Asymmetry of the circle of willis is a risk factor for the development of intracraniale aneurysms
Majority of blood passing through the vessels mix together(Right)
Includes the anterior communicating artery
The circle surrounds the stalk of the pituitary gland
…………………………………………
There is minimum mixing of blood passing through the vessels.
324 of 368
Which of the following is not a direct branch of the facial nerve?
Greater petrosal nerve
Nerve to stapedius
Auriculotemporal ( Right)
Chorda tympani
Buccal
………………………………….
The auriculotemporal nerve is a direct branch of the mandibular nerve.
Other branches of the mandibular nerve include:
Lingual
Inferior alveolar
Nerve to the mylohyoid
Mental
326 of 368
Which of the following is not a content of the anterior triangle of the neck?
Ansa cervicalis
Vagus nerve
Anterior jugular vein
Transverse cervical nerve( Right)
Hypoglossal nerve
………………………………….
The transverse cervical nerve lies within the posterior triangle. The anterior jugular vein is formed in the submental region and descends in the superficial fascia near the median ether plane. It passes inferior to enter the suprasternal space, it is linked to the contralateral anterior jugular vein by the jugular venous arch.
328 of 368
Which of these statements relating to the external carotid is false?
It ends by bifurcating into the superficial temporal and ascending pharyngeal artery( Right)
Its first branch is the superior thyroid artery
The superior thyroid, lingual and facial arteries all arise from its anterior surface
The ascending pharyngeal artery is a medial branch
Initially it lies anteromedial to the internal carotid
………………………………………
It terminates by dividing into the superficial temporal and maxillary branches. The external carotid has eight branches, 3 from its anterior surface ; thyroid, lingual and facial. The pharyngeal artery is a medial branch. The posterior auricular and occipital are posterior branches.
329 of 368
The recurrent laryngeal is connected to which of the following nerves?
Vagus
331 of 368
Into which of the following veins does the middle thyroid vein drain?
Internal jugular
It drains to the internal jugular vein. Which is one of the reasons why it bleeds so copiously if a ligature slips.
334 of 368
Which muscle is not innervated by the trigeminal nerve?
Medial pterygoid
Mylohyoid
Stylohyoid ( Right)
Masseter
Temporalis
………………………………………
Stylohyoid is innervated by the facial nerve.
339 of 368
Which of the following muscles is not innervated by the ansa cervicalis?
Sternohyoid
Mylohyoid( Right)
Omohyoid
Sternothyroid
None of the above
………………………………………
Ansa cervicalis muscles:
GHost THought SOmeone Stupid Shot Irene
GenioHyoid
ThyroidHyoid
Superior Omohyoid
SternoThyroid
SternoHyoid
Inferior Omohyoid
Mylohyoid is innervated by the mylohyoid branch of the inferior alveolar nerve.
343 of 368
In relation to the middle cranial fossa, which of the following statements relating to the foramina is incorrect?
The foramen rotundum transmits the maxillary nerve
The foramen lacerum is closely related to the internal carotid artery
The foramen spinosum lies posterolateral to the foramen ovale
The foramen ovale transmits the middle meningeal artery( Right)
The foramen rotundum lies anteromedial to the foramen ovale
………………………………………….
The foramen spinosum transmits the middle meningeal artery. The foramen ovale transmits the mandibular nerve. As the foramina weaken the bone, a fracture at this site is not uncommon.
350 of 368
The space between the vocal cords is referred to as which of the following?
Rima glottidis
The rima glottidis is the narrowest part of the laryngeal cavity.
354 of 368
Which of the following is a recognised tributary of the retromandibular vein?
Maxillary vein
The retromandibular vein is formed from the union of the maxillary and superficial temporal veins.
363 of 368
Which of the following muscles is penetrated by the parotid duct?
Buccinator
The duct crosses the masseter muscle and buccal fat pad and then penetrates the buccinator muscle to enter the oral cavity opposite the second upper molar tooth.
359 of 368
The motor nucleus of cranial nerve V supplies all except which of the following muscles?
Masseter
Posterior belly of digastric ( Right)
Temporalis
Tensor tympani
Tensor veli palatini
……………………………………….
The posterior belly of digastric is supplied by the branchial motor component of the facial nerve. All of the other muscles are supplied by axons from the motor nucleus of cranial nerve V.
367 of 368
Which of the following statements relating to sternocleidomastoid is untrue?
The external jugular vein lies posteromedially.( Right)
It is supplied by the accessory nerve.
It has two heads of origin
It inserts into the lateral aspect of the mastoid
It marks the anterior border of the posterior triangle.
…………………………………
The external jugular vein lies lateral (i.e. superficial) to the sternocleidomastoid.
