8- Revision Head & Neck MSQs Only Flashcards
1- 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.
2- 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.
3- When performing minor surgery in the scalp, which of the following regions is considered a danger area as regards spread of infection into the CNS?
Loose areolar tissue
This area is most dangerous as infections can spread easily. The emissary veins that drain this area may allow sepsis to spread to the cranial cavity.
4- 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.
5- 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.
6- A 32 year old lady is admitted with weakness, visual disturbance and peri orbital pain. On examination, she is noted to have mydriasis and diminished direct response to light shone into the affected eye. The consensual response is preserved when light is shone into the unaffected eye. Which of the cranial nerves listed below is responsible for the diminished direct response?
Optic
This describes a relative afferent pupillary defect (RAPD). RAPD is a defect in the direct response to light. It is due to damage in optic nerve or severe retinal disease. If an optic nerve lesion is present the affected pupil will not constrict to light when light is shone in the that pupil during the swinging flashlight test. However, it will constrict if light is shone in the other eye (consensual response).
The most likely cause for this is an optic neuritis (not really surgical!). Other causes include ischemic optic disease or retinal disease, severe glaucoma causing trauma to optic nerve and direct optic nerve damage (trauma, radiation, tumor).
7- 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.
8- 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.
9- 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 process.
It marks the anterior border of the posterior triangle.
………………………
The external jugular vein lies lateral (i.e. superficial) to the sternocleidomastoid.
10- 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.
11- Which of the following most commonly arises from the brachiocephalic artery?
Thyroidea ima artery
Other occasional branches include the thymic and bronchial branch.
14- Into which of these 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.
12- 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.
13- Which muscle is not innervated by the trigeminal nerve?
Medial pterygoid
Mylohyoid
Stylohyoid( Right)
Masseter
Temporalis
……………………………………..
Stylohyoid is innervated by the facial nerve.
15- The recurrent laryngeal is connected to which of the following nerves?
Vagus
16- 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.
17- 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 plane. It passes inferior to enter the suprasternal space, it is linked to the contralateral anterior jugular vein by the jugular venous arch.
18- Which of the following is not a direct branch of the facial nerve?
Greater petrosal nerve
Nerve to stapedius
Auriculotemporal ( Right)
Chorda tympani
Buccal branch of facial nerve
…………………………
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
19- 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 intracranial
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
20- 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).
21- A 35 year old man is admitted to hospital with vomiting, nausea and severe headaches. An MRI scan reveals a tumour of the cerebellopontine angle. Which one of the following pairs of cranial nerves is most likely to be compressed by this tumour?
Facial and vestibulocochlear
The cerebellopontine angle is located between the superior and inferior limbs of the angular cerebellopontine fissure formed by the petrosal cerebellar surface folding around the pons and middle cerebellar peduncle. The cerebellopontine fissure opens medially and has superior and inferior limbs that meet at a lateral apex. The fourth through the eleventh cranial nerves are located near or within the angular space between the two limbs commonly referred to as the cerebellopontine angle. The commonest lesion to affect this site is an acoustic neuroma.
Therefore the vestibulocochlear nerve is commonly compromised. Larger lesions may also affect the facial nerve which lies closest to this site.
23- 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.
22- 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.
24- A builder falls off a ladder whilst laying roof tiles. He sustains a burst fracture of L2. The MRI scan shows complete nerve transection at this level, as a result of the injury. Which clinical sign will not be present initially?
Flaccid paralysis of the legs
Extensor plantar response(Right)
Sensory loss in the legs
Incontinence
Areflexia
…………………………………………….
In lower motor neuron lesions everything is reduced
The main purpose of this question is to differentiate the features of an UMN lesion and a LMN lesion. The features of a LMN lesion include:
· Flaccid paralysis of muscles supplied
. Atrophy of muscles supplied.
· Loss of reflexes of muscles supplied.
· Muscles fasciculation
For lesions below L1 LMN signs will occur. Hence in an L3 lesion, there will be loss of the patella reflex but there will be no extensor plantar reflex.
25- 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.
26- 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
27- 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
28- 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.
29- 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”)
30- Which of the following structures attaches periosteum to bone?
Sharpeys fibres
Periosteum is attached to bone by strong collagenous fibers called Sharpey’s fibres, which extend to the outer circumferential and interstitial lamellae. It also provides an attachment for muscles and tendons.
31- 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.
32- Which of the following relationship descriptions regarding the scalene muscles is incorrect?
The brachial plexus passes anterior to the middle scalene muscle
The phrenic nerve lies anterior to the anterior scalene muscle
The subclavian artery passes posterior to the middle scalene( Right)
The subclavian vein lies anterior to the anterior scalene muscle at the level of the first rib
the anterior scalene insert in firist rib
………………………………………….
The subclavian artery passes anterior to the middle scalene.
33- 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.
34- What is the level of the hyoid bone?
C3
35- 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.
36- A 53 year old man presents with unilateral hyperacousia. Which of the following nerves is least likely to be functioning normally?
Facial
Damage to the nerve in the bony canal may result in impaired innervation to stapedius and therefore sounds are no longer dampened.
37- An injury to the spinal accessory nerve will have the greatest effect on which of the following movements?
Upward rotation of the scapula
The spinal accessory nerve innervates trapezius. The entire muscle will retract the scapula. However, its upper and lower fibres act together to upwardly rotate it.
38- 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.
39- 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).
40- 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.
41- 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.
45- 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 innervated by the vagus.
42- 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.
43- A 40 year old woman had the anterior lobe of the pituitary removed because of a tumour. Without postoperative supplements, which of the following could occur?
Failure to produce adequate amounts of thyroxine
Its an anterior pituitary lesion and that is the reason thyroxine secretion is affected. ADH is released by the posterior pituitary.
44- 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.
46- A 36 year old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region.
Post operatively the patient has difficulty shrugging his left shoulder. What is the most likely reason?
Accessory nerve lesion
The accessory nerve lies in the posterior triangle and may be injured in this region. Apart from problems with shrugging the shoulder, he may also have difficulty lifting his arm above his head.
47- 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
48- 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.
50- 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.
49- Which option is false in relation to the trigeminal nerve?
The nerve originates at the pons
The posterior scalp is supplied by the trigeminal nerve(Right)
The maxillary nerve exits via the foramen rotundum
The maxillary nerve is purely sensory
The motor root is not in the trigeminal ganglion
…………………………………………
The posterior scalp is supplied by C2-C3.
51- 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.
52- 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 surface.
53- 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.
54- Which of the following nerve roots contribute nerve fibres to the ansa cervicalis?
C1, C2 and C3
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.
55- 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.
56- 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.
57- 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?
Mentalis
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
58- 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?
Loss of sweating on the entire ipsilateral side of the face
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.
59- 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?
Anterior cerebral artery
Ophthalmic artery
Middle cerebral artery
Maxillary artery(Right)
None of the above
…………………………….
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.
60- Which of the following structures separates the intervertebral disks from the spinal cord?
Posterior longitudinal ligament
The posterior longitudinal ligament overlies the posterior aspect of the vertebral bodies. It also overlies the posterior aspect of the intervertebral disks.
61- 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.
62- A man is stabbed in the chest to the right of the manubriosternal angle. Which structure is least likely to be injured in this case?
Right pleura
The trachea
Right phrenic nerve
Right recurrent laryngeal nerve( Right)
Brachiocephalic vein
…………………………………..
The right recurrent laryngeal nerve branches off the right vagus more proximally and arches posteriorly round the subclavian artery. So of the structures given it is the least likely to be injured.
63- 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.
