anatomy review for NMBE Flashcards
blinking - what nerve?
facial nerve
The oculomotor nerve innervates the muscles moving the eyeball, except the rectus lateralis muscle, which is supplied by the abducens nerve. The supraorbital nerve and the lacrimal nerve are branches of the trigeminus nerve.
The optic nerve is part of a reflex protecting the cornea from visual danger but not at all involved in the process of blinking.
In the forearm, the lateral antebrachial cutaneous nerve arises from the
musculacutaneous
Which nerve arises from the medial cord and if injured results in numbness of the medial aspect of the forearm?
The medial antebrachial cutaneous nerve (medial cutaneous nerve of the forearm) arises from the medial cord of the brachial plexus. It lies between the axillary artery and vein, and descends medial to the brachial artery. Below the middle of the arm it pierces the fascia, becomes subcutaneous and divides into anterior and ulnar branches. The anterior branch supplies the skin on the anterior and medial side of the forearm and the ulnar branch supplies the skin on the medial and posteromedial aspects of the forearm.
The middle meningeal artery descends through which foramen?
F. spinosum
severe facial injuries; there is marked ptosis of her left eye. The left pupil is dilated, but the right eye is normal.
ciliary ganglion
Question Highlights
What muscle’s denervation is responsible for the blurred vision in this case?
Pupilloconstrictor
Correct Answer: Pupilloconstrictor
The correct response is the pupilloconstrictor. Injury to this muscle causes mydriasis and results in blurry vision and light sensitivity.
The clinical picture is suggestive of injury to the oculomotor nerve, which is the third cranial nerve. It innervates the following muscles:
Superior rectus Inferior rectus Medial rectus Inferior oblique Pupilloconstrictor Levator palpebrae superioris The superior rectus causes elevation of the eye with adduction.
The inferior rectus causes depression of the eye with adduction.
The medial rectus causes adduction of the eye.
The levator palpebrae superioris causes elevation of the eyelid.
Causes of third cranial nerve palsy include:
Intracranial and intraorbital lesions (e.g., neoplasms)
Head and orbital trauma
Ocular myopathies
Cerebral aneurysms
Transtentorial herniation
The valve of Thebesius
Is a semicircular fold of the lining membrane of the right atrium, protecting the orifice of the coronary sinus. It prevents the regurgitation of blood into the sinus during the contraction of the auricle. This valve is occasionally double
ankle jerk is a reflex twitch of the triceps surae (gastrocnemius and soleus) induced by tapping the tendo calcaneus (Achilles tendon). Where is the reflex center?
first or 2nd sacral spine
Which one of the following cranial nerves passes through the stylomastoid foramen
facial nerve
How does the lumbar spine differ from the cervical and thoracic vertebrae?
There is an absence of costal facets in the lumbar and sacral spine
?
Anterior to the trachea, anterior and medial to the vagus nerve, posterior and medial to the sternothyroid muscle, and medial to the jugular veins
The lower posterior part of the acetabulum is contributed by
the ischeum
The etiology of facial paralysis is multiple. If a patient has bilateral function of the frontalis and the orbicularis oculi but only unilateral function of the rest of the muscles of facial expression, the lesion is most likely to be at which level? Answer Choices Ico-marker Ico-abct 1 Stylomastoid foramen Ico-marker Ico-abct 2 Facial nucleus in the pons Ico-marker Ico-abct 3 Supranuclear level Ico-marker Ico-abct 4 Middle ear Ico-marker Ico-abct 5 Facial cana
Supranuclear level
Show Explanation
Which of the following ligaments arises from the floor of the acetabular fossa and attaches to the fovea capitus of the femur?
Ligament of the head of the femur
The temporalis muscle is innervated by which nerve?
Mandibular branch of the trigeminal nerve
A patient is not only unable to turn the eyeball laterally, but the eyeball seems to be pulled medially also. This problem indicates damage to the
If this nerve is damaged, not only will the patient be unable to turn the eyeball laterally, but because of the lack of muscle tonus to the lateral rectus muscle, the eyeball will be pulled medially.
Abducent nerve
The small abducent nerve (CN-VI) originates from a nucleus within the pons and emerges from the lower portion of the pons and the anterior border of the medulla oblongata. It is a mixed nerve that transverses the superior orbital fissure of the orbit to innervate the lateral rectus eye muscle. If this nerve is damaged, not only will the patient be unable to turn the eyeball laterally, but because of the lack of muscle tonus to the lateral rectus muscle, the eyeball will be pulled medially.
Damage to the trochlear nerve (CN-IV) impairs movement in the direction permitted by the superior oblique eye muscle. A person whose oculomotor nerve (CN-III) is damaged may have a drooping upper eyelid or a dilated pupil or be unable to move the eyeball in the directions permitted by the four extrinsic muscles innervated by this nerve. Trauma to the facial nerve (CN-VII) results in inability to contract facial muscles on the affected side of the face and distorts taste perception, particularly of sweets. Damage to both vagal nerves (CN-X) will cause death. The injury of one nerve causes vocal impairment, difficulty in swallowing, or other visceral disturbances.
The central perineal tendon
a mass of tissue present in central area in front of the anus and behind the perineal membrane.
All four mastication muscles are supplied by which of the following?
Mandibular division of the trigeminal nerve
Which one of the following muscles of the pharynx has its origin in the lower part of the stylohyoid ligament and from the lesser and greater cornua of the hyoid bone?
Middle Constrictor muscle
The ischiopubic or conjoint ramus is formed when the ischial ramus joins which of the following structures?
Inferior pubic ramus
Branches of the maxillary artery gain entrance to the pterygopalatine fossa via which of the following structures?
Pterygomaxillary fissure
A 42-year-old man sees his physician because of hearing loss and a sensation of the room spinning while he is standing. A lesion to which cranial nerve would most likely result in these symptoms?
CN VIII
A 14-year-old girl arrives at the dentist’s office to have a cavity in her lower right incisor filled. Which nerve will the dentist most likely block before beginning the procedure?
CN V-3
Sweat glands within the S2 dermatome along the posterior region of the thigh most likely receive innervation via preganglionic sympathetic neurons originating from which of the following central nervous system levels?
L2 spinal cord level
Radiographic imaging reveals puss building up around the ear ossicles. Which of the following is the most likely location of the puss?
middle ear
A 27-year-old man is brought to the emergency department after being involved in an automobile accident. Radiographic imaging studies indicate that he has sustained a fracture of the L1 vertebral arch and has a partially dislocated bone fragment impinging upon the underlying spinal cord. Which spinal cord level is most likely compressed by this bone fragment?
A
C1
s3
In an adult, the caudal end of the spinal cord is at the L1–L2 vertebral level. Therefore, a bone fragment from the L1 vertebra would have the potential of touching the caudal end of the spinal cord, not the L1 spinal cord level. C1, L2, and T4 are spinal cord levels superior to the fracture.
A blue dye is placed into the right eye of a patient to assess the patency of the tear duct system. Assuming the lacrimal system is patent, at which structure would the physician see the eventual flow of the dye?
Inferior nasal meatus
The nasolacrimal duct drains into the nasal cavity, into the space inferior to the inferior nasal concha called the inferior nasal meatus.
The pterygopalatine ganglion houses postganglionic neuronal cell bodies for visceral motor (parasympathetic) components of which of the following cranial nerves?
CN VII
The ganglia associated with the sympathetic trunk typically contain which of the following cell bodies?
Preganglionic sympathetic cell bodies are located in the lateral horn gray matter of the T1–L2 spinal cord levels.
Synapses occur with postganglionic sympathetic neurons within the paravertebral ganglia of the sympathetic trunk for sympathetics en route to blood vessels, sweat glands, and arrector pilae muscles in the associated dermatome. Preganglionic sympathetic cell bodies are located in the lateral horn gray matter of the T1–L2 spinal cord levels.
A 26-year-old woman presents with unilateral paralysis of facial muscles consistent with Bell’s palsy. Which of the following cranial nerves is most likely affected that would result in this patient’s condition?
Facial nerve
: The facial nerve (CN VII) innervates muscles of facial expression. Therefore, a lesion of CN VII would result in unilateral facial paralysis. The trigeminal nerve (CN V) is responsible for conducting sensory information from the skin of the face, but does not provide motor innervation.
During sexual arousal, an erection is caused by a dilation of arteries filling the erectile tissue of the penis. Innervation of the penile arteries is provided by which of the following nerves?
The genitofemoral, ilioinguinal, and pudendal nerves are all somatic and do not cause an erection.
The sacral splanchnics are responsible for transporting the sympathetics and will result in ejaculation.
Pelvic splanchnic nerves
Dilation of penile arteries resulting in blood filling erectile tissue is under parasympathetic innervation. Therefore, the pelvic splanchnic nerves carry parasympathetic nerves to the penile arteries. The genitofemoral, ilioinguinal, and pudendal nerves are all somatic and do not cause an erection. The sacral splanchnics are responsible for transporting the sympathetics and will result in ejaculation. Remember, “point” and “shoot” (“p” parasympathetic; “s” sympathetic)
For general surgical procedures, anesthetics and muscle relaxants are used routinely. However, anesthetics and muscle relaxants may decrease nerve stimulation to skeletal muscles, including the intrinsic muscles of the larynx, which results in closure of the vocal folds. Therefore, tracheal intubation is necessary. Which of the following intrinsic muscles of the larynx may be unable to maintain an open glottis because of the anesthetics?
Posterior cricoarytenoid muscles
The posterior cricoarytenoid is the only muscle in the list of choices, which, when stimulated to contract, will open the vocal folds and therefore open the glottis. The other muscles (i.e., cricothyroid, lateral cricoarytenoid, thyroarytenoid, and the transverse arytenoids) will either tense or close the vocal folds.
After surgery, a 62-year-old patient began experiencing complications. After examination, the physician determined that an important structure located immediately behind the ligamentum arteriosum was damaged during surgery. Which of the following symptoms was the patient most likely experiencing?
Hoarseness of voice
The left vagus nerve gives rise to the recurrent laryngeal nerve, located immediately behind the ligamentum arteriosum. The recurrent laryngeal nerve innervates laryngeal muscles that are associated with speaking. Therefore, if the recurrent laryngeal nerve is damaged, the patient will experience a raspy voice or hoarseness.
A 19-year-old woman is taken to the emergency department after falling and lacerating her scalp. The scalp bleeds profusely when cut because the arteries most likely:
Bleed from both cut ends due to rich anastomoses of scalp vessels.
Which of the following paired muscles of the back is primarily responsible for extension of the vertebral column?
Iliocostalis
A surgeon dissects through subcutaneous fat in the neck and identifies lobulated, slightly paler glandular tissue that will be surgically removed. A vein coursing superficial to the gland and an artery coursing deep to the gland are isolated. The hypoglossal nerve is retracted to avoid risk of damage during the procedure. This surgery is most likely occurring in which of the following cervical triangles?
Submandibular
The question outlines the course of the facial vessels in relation to the submandibular salivary gland (the vein is superficial and the artery is deep). The hypoglossal nerve (CN XII) courses within the submandibular triangle. Therefore, the relation of the facial vessels to the submandibular gland and identification of CN XII indicate the location of the surgery within the submandibular triangle.
nerve roots going with long thoracic?
c 5 6 7 - keeps the wing flying to heaven - scapula winging
foramina of V - mneumonic for this trigeminal nerve?
Standing Room Only (SRO) for the Superior orbital fissure, foramen Rotundum, and foramen Ovale, which transmit cranial nerves (CNs) V1, V2, and V3, respectively.
branches out of aorta?
three coming out -
heading to right - brachiocepahlic - that divides into the right subclavian and right common carotid (which then divides into external and internal carotid -
left common carotid
left subclavian
The arch of the aorta has three branches: the brachiocephalic artery, which itself divides into right common carotid artery and the right subclavian artery, the left common carotid artery, and the left subclavian artery. These arteries provide blood to both arms and the head
related to the rectouterine pouch - woman with endometriosus?
Dr sees: The uterosacral ligaments have nodules…
placing a central line?
aim the needle lateral to the common carotid artery because the line should be placed within the internal jugular vein
Within this sheath, the common carotid artery is medial, the internal jugular vein is lateral, and the vagus nerve runs posteriorly.
Placing a central line requires a needle to be inserted into the chosen vein; a wire is then threaded through the needle, and the catheter is passed over the wire and into the vein. The most common central veins used for access are the internal jugular, femoral, and subclavian veins. In the neck, the internal jugular vein runs alongside the common carotid artery and the vagus nerve within a fibrous, tubular sheath called the carotid sheath, shown in the red portion in the image.
Within this sheath, the common carotid artery is medial, the internal jugular vein is lateral, and the vagus nerve runs posteriorly. Therefore when placing the central line, the emergency physician should aim the needle lateral to the common carotid artery because the line should be placed within the internal jugular vein. This procedure can be performed by using ultrasound guidance or external judgment of anatomy. The emergency physician can easily palpate the common carotid and should aim the needle lateral to the pulse to enter the internal jugular.
straddle injuries to males?
can lead to damage of the urethra, specifically the bulbous urethra.
A complete rupture of the anterior part of the bladder wall could result in flow of urine into the retropubic space. A penile urethra rupture would most often occur following a penetrating injury or catheter insertion. Membranous urethra rupture typically occurs in high-velocity pelvic fractures as this is the weakest point of attachment. Prostatic urethra rupture rarely occurs and is caused by a fractured pelvis or improper catheter insertion.
sucking chest wound—
Pneumothorax is seen on x-ray of the chest as a collapsed lung.
a bubbling wound with surrounding skin moving in and out with respiration. These clinical features suggest a traumatic right pneumothorax.
most twin pregnancies?
Most twin pregnancies (about two thirds) are dizygotic, with two chorions, two amnions, and two zygotes (dichorionic diamniotic dizygotic twins). These “fraternal” twins are generally at lower risk for complications than monozygotic, “identical” twins.
There are four masticatory muscles;
Masseter.
Temporalis.
Lateral pterygoid.
Medial pterygoid.
In hand - 19 muscles - 5 innervated by median?
The abductor pollicis brevis muscle is a thenar (thumb) muscle innervated by the recurrent branch of the median nerve and functions in abduction and opposition of the thumb. The first and second lumbricals and opponens pollicis are also innervated by the median nerve.
slashing of wrist?
deep - median -
light - ulnar and can affect the Adductor pollicis -
and if the ulnar nerve is affected may be also (along with other ulnar nerve muscles)
the adductor pollicis muscle is a muscle in the hand that functions to adduct the thumb. It has two heads: transverse and oblique. It is a fleshy, flat, triangular, and fan-shaped muscle deep in the thenar compartment beneath the long flexor tendons and the lumbrical muscles at the center of the palm.
what one muscle opens the mouth - lower the jaw
Lateral lower
3 Ms MUNCH
lateral lowers Of the four muscles of mastication, only the lateral pterygoids lower the jaw; the other muscles close the jaw. Remember “Lateral Lowers” and “M’s Munch” (Medial pterygoids, Masseter, teMporalis)
smiling muscle?
buccinator muscle is involved in facial expressions, such as smiling. The masseter muscles elevate the jaw. The medial pterygoids allow for elevation and side-to-side movements of the mandible. The temporalis muscles elevate and retract the jaw.
20-year history of alcohol abuse. His abdomen is distended with shifting dullness to percussion, and the liver is palpated 7 cm below the right costal margin. Examination of the eye shows scleral icterus
Left gastric vein
`
This patient has a history of alcohol abuse, evidence of hepatomegaly, ascites (shifting dullness) and jaundice, and elevated liver function tests. He most likely has cirrhosis of the liver as a result of his alcoholism, which has resulted in hepatic portal hypertension and consequently the generation and rupture of esophageal varices.
sciatic pain in leg?
trouble plantar flexing - often occurs by hurting back - lifting things - at L4–L5 or the L5–S1
broad ligament?
cardinal?
round? - thru inguinal
ovarian suspensory?
UTERine artery and URETER - bridge goes over the water
The broad ligament contains the blood vessels to the ovaries, fallopian tubes, and uterus. The ovarian arteries branch from the abdominal aorta and run through the suspensory ligaments of the ovaries, also known as the infundibulopelvic ligaments. The suspensory ligaments attach each ovary to the pelvic sidewall.
lower back pain. He was lifting some heavy boxes
decreased pinprick sensation around the inguinal ligament region. A herniated disk is suspected, and an MRI confirms the diagnosis.
L1 dermatome is at the level of the inguinal ligament. This dermatome also includes the femoral triangle, the superolateral quadrant of the buttock, and the upper part of the medial thigh. Pain radiating to the groin and decreased sensation in the region around the inguinal ligament suggest L1 nerve root compression. Therefore, this patient has a T12-L1 disc herniation which is affect the L1 nerve root.
carpal tunnel - which muscles most often weakened?
carpal tunnel syndrome, which occurs in individuals whose work involves repetitive hand motions. The muscles supplied by the recurrent branch of the median nerve (opponens pollicis, flexor pollicis brevis, and abductor pollicis brevis) are most commonly weakened in patients with carpal tunnel syndrome.
3 branches coming out of aortic arch?
the brachiocephalic artery (which divides into right common carotid artery and the right subclavian artery), the left common carotid artery, and the left subclavian artery.
the patient’s left pupil is dilated compared with the right, and the patient’s left eye is deviated laterally and inferiorly compared with the right. His left eyelid appears lower than the right.
Which of the following muscles is functioning normally in this patient?
Lateral rectus muscle
CN III is the oculomotor nerve. It moves the eye superiorly and medially and innervates the levator palpebrae muscle, which is responsible for elevation of the eyelid. The levator palpebrae muscle is also responsible for pupillary constriction. When CN III is affected by an aneurysm, signs of a “blown pupil” (the patient’s left pupil more dilated than the right), a “down and out” gaze (patient’s left eye is deviated laterally and inferiorly compared to the right), and ptosis (drooping eyelid) can present.
and diaphoresis. The patient’s eye exam shows neurologic deficits (dilated left pupil and left eye deviation). The patient’s age, gender, race, and past medical history put him at a very high risk for a stroke or aneurysm.
A berry aneurysm,
S1-S2 — “buckle my shoe” (Achilles reflex)
L2-L4 — “kick the door” (patellar reflex)
C5-C6 — “pick up sticks” (biceps reflex)
C7-C8 — “lay them straight” (triceps reflex)
Other reflexes include:
L1-L2 — “testicles move” (cremaster reflex)
S3-S4 — “winks galore” (anal wink reflex)
lesion of the ascending colon. what lymph to check?
Superior mesenteric lymph nodes
The lymphatic drainage of the gastrointestinal tract follows supplying arteries.
diverticulitis?
focal areas of weakness in the muscularis propria layer of the colon.
The patient has a history of constipation, crampy pain, and tenderness in the left lower abdomen; diarrhea; a low fever; and blood in his stool. This clinical picture is consistent with diverticulitis. Diverticulitis is an inflammation of colonic diverticula, which are caused by focal areas of weakness in the muscularis propria layer of the colon.
midshaft fracture of the humerus
radial nerve problem - wrist drop
A protruding scapula is seen in damage to the long thoracic nerve usually due to injury to the axilla or lateral wall of the thorax.
Inability to fully abduct the arm is seen with axillary nerve injury due to injury to the surgical neck of the humerus or anterior dislocation of the shoulder. Inability to hold a piece of paper between fingers is seen with damage to the ulnar nerve, usually due to injury to the medial epicondyle of the humerus. Pain over the palmar aspects of the first three and a half digits is seen with median nerve injury usually due to injury to the distal end of the humerus.
epigastric abdominal pain, nausea, and vomiting for 2-3 weeks. The pain is relieved by eating.
duodenal ulcer. 1st section most common - brunner glands found there
2nd section - where bile enters
The common bile duct passes through the pancreas before it empties into the first part of the small intestine (duodenum). The lower part of the common bile duct joins the pancreatic duct to form a channel called the ampulla of Vater or it may enter the duodenum directly.
deviation of the uvula
(Cranial nerves 9 & 10) Description: When the patient says “ah” there is excessive nasal air escape. The palate elevates more on the left side and the uvula deviates toward the left side because the right side is weak.
Motor innervation of the palatal arches and uvula is mediated, in part, by the vagus nerve (CN X), which innervates one of the muscles of the soft palate, the levator veli palatini. Deviation of the uvula to one side implicates a lower motor neuron (LMN) lesion contralateral to the side to which the uvula is deviating. So damage to the left CN X leads to right-sided uvular deviation, whereas damage to the right CN X would lead to left-sided uvular deviation.
He is able to lift his right arm away from the body but grimaces in pain when bringing it back down to his side.
Subscapularis
This patient presents with a history of painless, bright red stools, nausea, vomiting, and an inability to pass gas.
arterial supply? SMA
These symptoms suggest Meckel diverticulum with intestinal obstruction. Meckel diverticulum results from failure of the vitelline duct to obliterate, a structure that connects the developing midgut lumen to the yolk sac. The diverticulum usually lies within 2 feet of the ileocecal valve.
patient’s jaw deviates to the right when he attempts to open his mouth
OVALE _ Standing Room Only (SRO) for the Superior orbital fissure, foramen Rotundum, and foramen Ovale, which transmit cranial nerves (CNs) V1, V2, and V3, respectively.
Jugular foramen? spinosum? stylomastoid?
The foramen spinosum houses the middle meningeal artery, while the jugular foramen houses CNs IX, X, and XI. CN VII exits through the stylomastoid foramen.
paralyzed right diaphragm?
paralyzed right hemidiaphragm. It is possible for the phrenic nerve to become damaged during heart surgery (as in this patient), since it runs along the fibrous pericardium. It is not unusual for a patient to remain asymptomatic, since there is sufficient movement of the diaphragm with only one nerve. However, symptoms may begin to manifest at times of significant physical exertion.
Appearance of a paralyzed diaphragm on the right side of the x-ray indicates a defect in the right phrenic nerve, not the left phrenic nerve.
hemerrhoids - venous drainage route?
In external hemorrhoids, the venous drainage of the tissue is from the inferior rectal vein, to the internal pudendal vein, to the internal iliac vein, to the common iliac vein, then to the inferior vena cava (IVC).
The superior rectal vein drains internal hemorrhoids, which are painless, not external hemorrhoids, as in this patient. Although the inferior rectal vein is the initial venous drainage for external hemorrhoids, it ultimately drains into the IVC and not the portal system. Similarly, although the internal pudendal vein is part of the external hemorrhoid drainage system, the final pathway is the IVC and not the portal system.
vitamin A analog, tagged with a radioactive isotope, is given orally to informed and consenting volunteers. Twenty-four hours later the isotope-labeled drug is detectable in hepatic stellate cells.
Through which of the following structures does this drug most likely pass first on the way to being stored in the liver?
most nutrients are drained from the gastrointestinal tract via the hepatic portal system. However, fats and fat-soluble substances (such as vitamin A) first enter lacteals, which are small lymphatic capillaries in the villi of the intestinal epithelium. From there, the lacteals merge, and the chyle flows into progressively larger lymphatics and ultimately the thoracic duct, which drains into the left jugular venous angle (the union of the internal jugular vein and subclavian vein). Vitamin A is then stored in the stellate cells (aka perisinusoidal cells, Ito cells) in the liver.
Esophageal atresia with distal tracheoesophageal fistula
This newborn has copious mucus and signs of aspiration (rattling sounds during inspiration, coughing, choking, and cyanosis), as well as evidence of air in his stomach (gastric distension and tympanic sounds). Spitting up of his feedings, and excess saliva with aspiration suggest that normal secretions and/or breast milk are unable to pass normally through the esophagus to the stomach, which in a newborn is most likely due to congenital esophageal atresia (ie, an esophagus that does not connect all the way from the mouth to the stomach). The air in his stomach further suggests that there is most likely an extra connection between the airway and the gastrointestinal tract, as may occur with a tracheoesophageal fistula (ie, an opening joining the trachea and esophagus).
Five types of tracheoesophageal anomalies may occur congenitally, as shown in the illustrations. Any one of these would likely manifest with significant coughing, choking, and cyanosis, because fluids either pass from the esophagus to the trachea through a proximal fistula or overflow from the proximal blind-ended esophageal pouch into the nearby trachea. Given this infant’s presentation with air in his stomach, the only possible variants are those that also involve a distal connection from the trachea to the stomach: Esophageal atresia with distal transesophageal fistula, isolated transesophageal fistula, and esophageal atresia with double transesophageal fistula.
Of the five types, the most common variant in newborns is esophageal atresia with distal transesophageal fistula. The presenting signs and symptoms also fit this diagnosis. So, this is the most likely cause of the patient’s condition.
Transposition of the great vessels
TGV is a cyanotic, right-to-left heart defect caused by a failure of the aorticopulmonary septum to spiral. In addition, the infant was born to a mother with diabetes, and TGV is a known complication in infants born to mothers with diabetes. This congenital anomaly is characterized by an aorta that arises from the right ventricle and a pulmonary artery that arises from the left ventricle. If left uncorrected, TGV is incompatible with life.
internal jugular catheter route?
Lateral to the common carotid artery and anterior to the vagus nerve, within the carotid sheath
The internal jugular vein is found within the carotid sheath lateral to the common carotid artery and anterior to the vagus nerve. (Its location is outlined in red in the image). The correct location for placement of an internal jugular line is found by palpating the carotid pulse and inserting the needle lateral to that pulse. Recall that it is the opposite in the femoral triangle, where the vein is medial to the artery. The sympathetic chain is also posterior to the internal jugular vein, but unlike the vagus nerve, the sympathetic chain is not contained within the carotid sheath.
cleft lip, palate? 4 - 6 weeks - nasal pit develops
1/1000 births - common
medial and lateral nasal process form
at 8 weeks failure of
failure of fusal of medial nasal processes to form intermaxillary nasal process - cleft lip
maxillary process with medial nasal process - failure to fuse - lateral cleft palate - can be uni or bilateral.
feeding issue if cleft palate
cervical cysts - midline mass below hyoid
moves when swallowing, remnant of thyroglossal canal
thyroid gland originally from epithelium of tongue
lateral cervical cysts - not midline
remnant of 2,3,4 grooves - filled up by ectoderm, along sternocleidomastoid muscle - DO NOT MOVE when swallowing
recurrent laryngeal nerve X - vocal cords?
6th ARCH
posterior cricoarytenoid abducts vocal folds - HOARSENESS - if problem if nerve interuption
cricothyrotomy - relieves airway obstruction
emergency procedure - needle just below midline of neck - below thyroid cartilage
more frequently - cricothyroid membrane - incision in skin - and antoher thru membrane between circo and thyroid cartilageg - tube insertion
posterior triangle of neck
STERNOclidomastoid m - face looks upward to opposite side - TURNS HEAD TO OPPOSITE SIDE
veins - external jugular, subclavian
arteries - occipital
nerves XI, trunks of brachial plexus, phrenic nerve
lymph- superficial cervical and external jugular
XI nerve -
STERNOclidomastoid m - face looks upward to opposite side - TURNS HEAD TO OPPOSITE SIDE
TRAPEZIUM - riase shoulders, depress
skull, scalp malformations - scaphocephaly LONG WEDGE
plagiocephaly TWISTED
oxycephaly HIGH TOWER
PREMATURE closure
scaphocephaly - premature sagital suture closure - long narrow wedge shape
plagiocephaly - premature closure one side only
oxycephaly - premature closure coronal - high tower like cranium
SCALP layers
top three moves as one
skin
CT dense - severe bleeding, not gape
Aponuerois epicranial - tape wide
Loose areolar - dangerous - infection can distend with fluid - potential space
Pericranium- bleed between this and calvaria (difficult birth) CEPHALHEMATOMA
3 cranial fosses
anterior
middle
posterior
anterior - frontal lobe - dura v1 and anterior meningeal A (from ethmoidal a)
middle - temporal lobe - dura v2, v3, middle meningeal (from maxillary a)
posterior - cerebellum, dura spinal nerves via X and XII, posterior meningeal aa - (from ascending pharangeal and occipital aa)
fracture of anterior cranial fossa?
cribriform plate of ethmoid - anosmia (loss sense of smell), periorbital bruising (raccoon eyes) and CSF leak from nose
epidural hematoma?
Talk and Die syndrome (lucid moment)
lemon biconvex pattern
Death rapid -
often near pterion - middle meningeal a (foramen spinosum) - from maxillary artery -
unconsciouness and death are rapid - strips dura from inner surface of skull because of rapid bleed
Biconvex pattern
subdural hematoma - crescent
rupture of bridging veins - crescent shape (shaken baby syndrome)
subarachnoid hematoma -
worst headache of life
rupture of aneruysm in circle of Willis -
intracerebral hemaoma
terminal branches of circle of willis rupture
cavernous sinus infection - dangerous triangle of face
infection can spread rapidly - leads to meningitus
spread thru facial (angular) vein to cavernous sinus via superior opthamic vein
or thru upper molars via pterygoid venous plexus
cavernous sinus thrombosis?
internal carotid artery (lacerations)
VI nerve - internal squint if lesion
raises eyelid, moves eyeball in all directions?
III, ciliary glanglion? constrict pupil
facial VII - travels thru?
internal auditory meatus -
VII parasympethic?
secretomotor for sumandibular, sublingual, lacrimal and nasal, palaline glands
Vii and taste?
2/3 - chora tympani
VII blink?
along w. V
dry red eye?
VII - lack of secretion
Bell Palsy?
temporary paralysis of the facial muscles, causing drooping and weakness on one side of the face, and is sometimes mistaken for a stroke
VII The cause of Bell’s palsy is unknown. Swelling and inflammation of the cranial nerve VII is seen in individuals with Bell’s palsy. Most scientists believe that reactivation of an existing (dormant) viral infection may cause the disorder
what travels thru internal auditory meaturs?
VII, VII
what travels thru jugular foramen?
IX, X, XII
loss of gag reflex?
IX and X
4 ganglion on head?
ciliary III (constricts pupil) submandibular VII (submandibular/sublingual glands) pterygopalatine VII (lacrimal, nasal/palaline glands) Otic (parotid) IX
different kind of ganglion - I am lost here
I think these are sensory ganglion??
trigeminal - v1, v2, v3
geniculate VII (taste 2/3)
spiral VIII (hearing) vestibular VII (linear and angular accelerator
superior and inferior gg - IX - post. 1/3 tongue, pharnyx, carotid sinus
sup and inf gg X - sensation in larynx and larynxgopharynx
geniculate ganglion is a sensory ganglion of the facial nerve (CN VII). It contains the cell bodies of the fibers responsible for conducting taste sensation from the anterior two-thirds of the tongue.
vagus problem?
dysphagia (diff swallowing), , palate droop, uvula pointing AWAY from lesion side, Horasreness/loss of voal cord ABDucion - loss of gag RF (+CNIX), loss of cough RF
XII problem?
deviation of tongue TOWARD lesion - licks its wound
trigeminal nerve - what area not cover on face?
SRO
opthalmic v1
maxillary v2
mandibular v3
angle of mandible (great auricular nerve c2,c3 - cervical plexus
v1 - opthalmic
forehead
external nasal intratrochlear
lacrimal
supragrochlear
supraorbitial
v3 mandible
buccal
mental
sygomaticofacial
auriculotemporal
v2 maxillary - upper lip
near eye
infraorti
parotid cancer - or other surgery?
stylomastoid foramen - unilateral facial paralysis
VII -
unable to close lips and eyelips - DRY EYE - can’t whistle, chew
epistaxis
nose blooed - most often in kiesselbach’s area - facial artery convergence - sphemopalatine, etc
Lateral wall of nasal cavity
lots of things open up here
ethmoiditis
infection of ehmoidal insurus can erod medial wall of obit - orbital cellulites - can spread to cranila cavity
parotid duct and gland perforate what muscle?
buccinator (cheek) - opposite 2nd upper molar
TMJ
muscles of mastication innervated by v3 - if damage, deviate toward side of lesion because lateral pteryhoid weakness
innervation of tongue?
sensory anterior 2/3 lingual v3, taste chorda tympani VII
sensory posterior 1/3 - IX
motor XII - likes its wounds
gag reflex?
afferent IX
efferent X
injury to IX will show negative gag reflex
blow out fracture?
blows out to maxillary sinus
v2,
infraorbital artery hemmorrage
lips and palate defects during fetal life?
intermaxillary segments form when two medial nsala prominences fuse at wk * - give rise to phitrum of lip, four incisor teeth and primary palate of adult
maxillary prominences fused with medial (palate)
stabismus
one eye not tracking
III
VI abducts pupil - looks laterally
IV - down and lateral
muscle raising eyelid?
levetor pulpebra III
oculomotor nerve palsy
down and out
trochlear nerve palsy
Up and out
Abducens Nerve palsy
adducted
horner syndrome
interruption of sympathetic fibers anywhere from T1
injury to nec, pancoast tumor, thyroid carcinoma -
interrupts ascending preganglionic sympathetic fibers
signs: constrictuion of pupil (miosis)
dropping of superior eyelig (ptosis)
redness and increased temp (vasodilation)
absense of sweating (anhydrosis)
Otitis Media
hearing diminshed, taste may be altered because chorda tympani affected
infection spreading posteriorly causing mastoitidis
infection to middel cranial fossa can cause meningitus
perforation of tympanic membrane
may also damage chorda tympani - loss of taste 2/3 and secretion of glands
minor perforations heal spontaneously, others require surgery
Inner ear - VIII
choclea - spiral organ of Corti - recptors for hearing
vetibulte
smicircular canals
thyroid and parathyroid -
thyroid largest endocrine glands - T3, T4 - inscreases temp of body, and calcitonin (reduce blood calcium)
after total thyroidectomy - may develop lower temp and hypercalcemia (increased calcium)
parathyroid glands produce PTH - increasee Cal
Thyroid - anatomical issues
infrahyoid muscles anterolateral
posterolateral - COMMON CAROTID Art
Medial - larynx, TRACHEA, recurrent layngeal nerve
posterio parathyroid gland
list of foramen w/ cranial nerves
1 - cribiform 2 - optic canal 3, 4,6 - SOF - Superior Orbital Fissure v - SRO SOF Rotundum Ovale VII - Internal Acoustic Meatus (sylomastoid f) VIII - Internal Acoustic Meatus IX, X, XI - jugular XII - Hypoglossal Canal
Muscles of face - groups
orbital, nasal, oral
orbital muscles of face?
ONE OTHER mentioned by Holla?
if facial nerve damaged - eyelids can’t shut - exposure keratitis
lower eyelid droop - can’t spreak tears - dry eye - failure to remove debris and ulceratin of corneal surface -
Test for palsy? raise eyebrows and close eyelids
Orbicularis Oculi -
surrounds eye socket and extends into eyelid
Palpebral (gently closes eyelid)
Lacrimal (drains tears)
Orbital part (tightly closes eyelids
VII
corrugator supcillii = draws eyebrows together - vertical wrinkles - concern
orbital muscles of face?
if facial nerve damaged - eyelids can’t shut - exposure keratitis
lower eyelid droop - can’t spreak tears - dry eye - failure to remove debris and ulceratin of corneal surface -
Test for palsy? raise eyebrows and close eyelids
Orbicularis Oculi -
surrounds eye socket and extends into eyelid
Palpebral (gently closes eyelid)
Lacrimal (drains tears)
Orbital part (tightly closes eyelids
VII
corrugator supcillii = draws eyebrows together - vertical wrinkles - concern
Nasal facial muscles?
nasalas - largest - trasnverse compresses nares - alar open
Procerus
Depressor Septi Nasi
Oral group
Orbicularis Oris and Buccinator
purses the lips
Buccinator - pulls teeth inwards toward cheeks - preventing accumulation of food
upper and lower groups around lips -
if muscle paralyzed , maybe be difficult to eat - tissue around mouth and cheeks sags - drawn across to opposite side while smiling
tongue tied?
frenulum - can do surgery - under tongue in midline
why tongue so tricky?
during development, four arches contribute - tiving rise to lontitudinal line (median sulcus) down centre of tongue - majority of tongue is V and IS
sulcus terminalis in back of tongue where in center meets median sulcus - pit. this is now closed top of deep pit (foramen cecum) - at end is thyroid gland - IF descent didn’t happen from tongue down to neck - doesn’t close - midline thyroglossal cysts main remain
lymph drainage of tongue?
2/3 - submental, submandibular - empty to deep cervical
posterior 1/3 directly into deep cervical
vasculature of tongue?
lingual artery (branch of ext carotid) mostly, tonsillar artery may supply aslo
drainage is lingual vein
vasculature of tongue?
lingual artery (branch of ext carotid) mostly, tonsillar artery may supply also
drainage is lingual vein
Pterygopalatine Fossa
TO DO - from 100 concepts? or from?? I don’t remember any more
Pterygopalatine Fossa
TO DO - from 100 concepts? or from?? I don’t remember any more
Posterior Triangle BRS
two triangles Large - occipital
smaller
subclavian
accessory nerve external jugular trunks of brachial plexus nerve to long thoracid, suprascapular, etc cutaneous branch of cervical plexus, sometimes subclavian vein etc
Torticollis - wryneck
at birth- accessory nerve damaged - sternocleido muscle can’t grown longer as body grows
Hyoid bone -
many muscles attached - body, greater horn, lesser horn (has STYLOHYOID LIG running from STYLOID process
styloid process
The styloid process is a cylindrical, slender, needle-like projection of varying lengths averaging 2 to 3 cm. The styloid process projects from the inferior part of the petrous temporal bone and offers attachment to the stylohyoid ligament, and the stylohyoid, stylopharyngeus, and styloglossus muscles
All muscles of tongue except one are supplied by XII -
palatoglossus, a muscle of the soft palate, is innervated by the pharyngeal branch of X.
tongue and sensation
The anterior two-thirds of the tongue receives its sensory supply from the lingual branch of V which also transmits the gustatory fibres of the chorda tympani (VII).
Common sensation and taste to the posterior one-third, including the vallate papillae, are derived from IX. Afew fibres of the superior laryngeal nerve (X) carry sensory fibres from the posterior part of the tongue.
harm to XII muscle?
hemiatrophy of the tongue and deviation of the projected organ towards the paralysed side. - licks the wound
floor of mouth formed by?
The floor of the mouth is formed principally by the mylohyoid muscles
Although lymphatics pierce the floor of the mouth (i.e. the mylohyoid muscle) to reach the submental and submandibular lymph nodes, it is an interesting fact that these tissues are not affected by lymphatic spread of malignant cells (although they may be invaded by direct extension of growth).
Ludwig’s angina
is a cellulitis of the floor of the mouth, usually originating from a carious molar tooth. The infection spreads above the mylohyoid.
Ludwig’s angina
is a cellulitis of the floor of the mouth, usually originating from a carious molar tooth. The infection spreads above the mylohyoid.
Edema forces the tongue upwards and the mylohyoid itself is pushed downwards so that there is swelling both below the chin and within the mouth.
There is considerable danger of spread of infection backwards with edema of the glottis and asphyxia.
deglutition
swallowing
Waldeyer’s ring
The nasopharyngeal tonsil (‘the adenoids’) consists of a collection of lymphoid tissue beneath the epithelium of the roof and posterior wall of this region. It helps to form a continuous lymphoid ring with the palatine tonsils and the lymphoid nodules on the dorsum of the tongue
pharyngotympanic or auditory tube (Eustachian canal)
lies on the side-wall of the nasopharynx level with the floor of the nose.
kids and tonsils
nasopharyngeal tonsils (adenoids) are prominent in children but usually undergo atrophy after puberty. When chronically inflamed they may all but fill the nasopharynx, causing mouth-breathing and also, by blocking the auditory tube, deafness and middle ear infection
The Eustachian tube
provides a ready pathway of sepsis from the pharynx to the middle ear and accounts for the frequency with which otitis media complicates infections of the throat.
quinsy?
a pocket filled with pus (abscess) between your tonsils and the wall of your throat. This is called quinsy.
. It is drained by an incision in the most prominent part of the abscess where softening can be felt.
common carotid? how to find?
The carotid sheath lies immediately deep to the junction between the sternal and clavicular heads of the sternocleidomastoid and is revealed either by retracting this muscle laterally or by splitting between its heads. Opening the sheath then reveals the artery lying medial to the internal jugular vein.
major branches of circle of willis?
clockwise from 12
anterior cerebral into ring
anterior
communicating
internal carotid
posterior communication
posterior cerebral
superior cerebellar
basilar (STEM)
anterior inferior cerebella
vertebral
posterior inferior cerebella (off of vertebral)
veins of head and neck - two pathways
superfilicial - nearest dural sinus - thin walled beins
deep structure - thru internal cerebral vein - choroid vein w/ thalamostriate vein (draining basal ganglia)
two internal cerebral veins unit to form great cerebral vein (of Gelan) which emerges under splenium to join inferior sagitall sinus
what cranial nerves are near the interal carotid artery?
5, 4, and 3 - also near sphenoid sinus
pituitary on top (nearest to 3)
sinus sepsis?
The cavernous sinus is liable to sepsis and thrombosis as a result of spread of superficial infection from the lips and face via the anterior facial and ophthalmic veins, or from deep infections of the face via the pterygoid venous plexus around the pterygoid muscles, or from suppuration in the orbit or accessory nasal sinuses along the ophthalmic vein and its tributaries.
A characteristic picture results—blockage of the venous drainage of the orbit causes edema of the conjunctiva and eyelids and marked exophthalmos, which demonstrates transmitted pulsations from the internal carotid artery.
Pressure on the contained cranial nerves results in ophthalmoplegia.
Examination of the fundus shows papilloedema, venous engorgement and retinal haemorrhages, all resulting from the acutely obstructed venous drainage.
fracture of skull?
Fractures of the skull or penetrating injuries of the skull base may rupture the internal carotid artery within the cavernous sinus.
A caroticocavernous arteriovenous fistula results with pulsating exophthalmos, a loud bruit easily heard over the eye and, again, ophthalmoplegia and marked orbital and conjunctival edema due to the venous pressure within the sinus being raised to arterial level.
sigmoid and transerse sinuses?
The sigmoid and transverse sinuses are often together termed the lateral sinus by clinicians. Close relationship to the mastoid and middle ear renders these sinuses liable to infective thrombosis secondary to otitis media.
It is also possible for sagittal sinus thrombosis to follow infections of the skull, nose, face or scalp because of its diploic and emissary vein connections.
if there were no emissary veins, infections of the face and scalp would never have achieved their sinister reputation.
internal jugular vein?
runs from its origin at the jugular foramen to its termination behind the sternal extremity of the clavicle, where it joins the subclavian vein to form the brachiocephalic vein.
What does the maxillary vein drain?
pterygoid plexus - starts at superficial temporal
Subclavian venepuncture?
under clavicle - between clavicle and first rib upward - will find subclavian vein
infraclavicular approach.
The needle is inserted below the clavicle of the junction of its medial and middle thirds.
The needle is advanced medially and upwards behind the clavicle in the direction of the sternoclavicular joint to puncture the subclavian vein at its junction with the internal jugular.
When a free flow of blood is obtained by syringe aspiration, a radio-opaque plastic catheter is threaded through the needle to pass into the brachiocephalic vein.
lymph nodes of neck can group in horizontal and vertical
The vertical nodes drain the deep structures of the head and neck.
The most important is the deep cervical group, which extends along the internal jugular vein from the base of the skull to the root of the neck
The lymph then passes via the jugular trunk to the thoracic duct or the right lymphatic duct.
The horizontal nodes form a number of groups which encircle the junction of the head with the neck and which are named, according to their position, the submental, submandibular, superficial parotid (or preauricular), mastoid and suboccipital nodes.
These nodes drain the superficial tissues of the head and efferents then pass to the deep cervical nodes
The superficial cervical nodes ?
A constant lymph node lies at the junction of the internal jugular and common facial veins—the jugulodigastric or tonsillar node.
This becomes enlarged in tonsillitis and is therefore the commonest swelling to be encountered in the neck.
lie along the external jugular vein, serve the parotid and lower part of the ear and drain into the deep cervical group.
removing lymph nodes in neck?
Tuberculous disease of the neck usually involves the upper part of the deep cervical chain (from tonsillar infection). These infected nodes may adhere very firmly to the internal jugular vein which may be wounded in the course of their excision.
styloid mastoid foramen?
between the styloid and mastoid processes of the temporal bone. It is the termination of the facial canal, and transmits the facial nerve and stylomastoid artery.
foramen spinosa?
all foreman of skull
https://teachmeanatomy.info/head/osteology/cranial-foramina/#:~:text=The%20Cranial%20Foramina&text=A%20foramen%20(pl.,to%20as%20the%20cranial%20foramina.
The foramen spinosum is located within the middle cranial fossa, laterally to the foramen ovale.
It allows the passage of the middle meningeal artery, the middle meningeal vein and the meningeal branch of CN V3.
foramen spinosa?
all foreman of skull
https://teachmeanatomy.info/ head/osteology/cranial-foramina/#:~:text=The%20 Cranial%20Foramina&text =A%20foramen%20(pl.,to% 20as%20the%20cranial% 20foramina.
The foramen spinosum is located within the middle cranial fossa, laterally to the foramen ovale.
It allows the passage of the middle meningeal artery, the middle meningeal vein and the meningeal branch of CN V3.
muscles of face
Orbicularis oris surrounds/closes lips
Orbicularis oculi muscle surrounds eye and closes eyelids
Platysma pulls mandible downward/ backward (mournful expression)
Muscles of mastication?
Muscles of Mastication are:
Masseter (most powerful), closes the jaw by elevating/drawing mandible backward, responsible for the tension felt by clenching jaw.
Pterygoid
Temporalis insert on mandible
nerves of face?
Trigeminal 5th CN carries sensory afferent fibers from face, oral cavity, teeth and efferent motor fibers to muscles of mastication
Facial Nerve 7th CN supplies motor function of facial muscles
anterior, posterior triangles
ANTERIOR TRIANGLE
POSTERIOR TRIANGLE
MIDLINE
Sternocleidomastoid muscle divides neck into Anterior (medial) and Posterior (lateral) Triangle.
Sternocleidomastoid muscle innervated by spinal accessory (11th CN)
Anterior Triangle formed by anterior border of Sternocleidomastoid muscle , clavicle inferiorly and midline anteriorly.
Posterior Triangle formed by posterior border Sternocleidomastoid muscle anteriorly, posteriorly by trapezius muscle and inferiorly by clavicle
Thyroid gland
produce thyroid hormone (T₃ & T₄
Thyroid gland (largest endocrine gland)
Wrapped around anterolateral larynx/trachea
Consists of two lobes (butterfly-shaped) connected by isthmus below laryngeal cricoid cartilage
Lateral lobes extend bilaterally on each side larynx
Lower margin reaches down to fifth to sixth tracheal ring
Upper margin extends upward to the middle of the thyroid cartilage, occasionally, may extend downwards and enlarge within thorax
Fascial envelope of the gland is continuous with the pretracheal fascia of both the hyoid and cricoid the isthmus will ascend and descend with the larynx upon swallowing.
Function of thyroid gland is to produce thyroid hormone(T₃ &T₄ production)
lymph drainage in head
Lymphatic Drainage is important enlarged lymph nodes may signal disease in drainage area
Posterior-to Anterior Occipital Posterior auricular Posterior cervical Superficial and deep cervical Tonsillar Submaxillary Submental (tip jaw in midline) Anterior auricular Supraclavicular (above clavicle)
Systemic disease? can see this in face?
Most common symptoms are Hair Problems Like Hair Loss Thinning Of Hair Coarse Hair Change In Facial Features Swelling Deformity Neck Stiffness Masses In The Neck
Most Symptoms of the face may be due to Systemic Disease(s)
Hoarseness?
recurrent laryngeal nerve impingement
If neck swelling
maybe thyroid cancer
neck stiffness?
Caused by cervical muscle spasm
Tension headache common cause
Sudden onset stiff neck, fever, headache suggests Meningeal irritation
Association with referred pain from chest suggests angina and myocardial infarction
trauma to skull?
Battle’s sign: Traumatic bruise over/behind the mastoid process due to basilar skull fracture
with bleeding into the middle cranial fossa. Can present at times as blood behind the eardrum. Battle’s sign may occur on the ipsilateral or contralateral side of the skull fracture.
Raccoon eyes: Periorbital bruises from external trauma to the eyes, basal skull fracture, and intracranial bleeding.
neck lumps - differential diagnosis?
Thyroglossal cyst – lump moves when patient sticks tongue out
Ask patient to protrude tongue – Thyroglossal cyst will rise / thyroid masses will not
The location of the lump within the neck can sometimes be useful in narrowing the differential diagnosis.
Mid-line
Thyroid isthmus swelling – most common cause in adults
Thyroglossal cyst – lump moves when patient sticks tongue out
Ask the patient to swallow some water – thyroid masses will rise / as will Thyroglossal cysts
Ask patient to protrude tongue – Thyroglossal cyst will rise / thyroid masses will not
Laryngeal swellings
Submental lymph nodes
Dermoid cysts
Lipoma –painless / smooth mass
Thyroglossal cysts
remnant of development
midline -
move when swallow
can be defined as an irregular neck mass or a lump which develops from cells and tissues left over after the formation of the thyroid gland during developmental stages. Thyroglossal cysts are the most common cause of midline neck masses and are generally located caudal to (below) the hyoid bone.
ASSESSING A NECK LUMP
Size – width / height / depth
Location – can help narrow the differential – anterior / posterior triangle / mid-line
Shape – well defined?
Consistency – smooth / rubbery / hard / nodular / irregular
Fluctuance –if fluctuant, this suggests it is a fluid filled lesion – cyst
Trans-illumination – suggests mass is fluid filled – e.g. cystic hygroma
Pulsatility –suggests vascular origin – e.g. carotid body tumour / aneurysm
Temperature – increased warmth may suggest inflammatory / infective cause
Overlying skin changes – erythema / ulceration/punctum
Relation to underlying / overlying tissue – tethering / mobility
Auscultation – to assess for bruits – e.g. carotid aneurysm
malignant nodule?
signs it is malignant vs. benig?
Malignant Nodule
Adult
Male
Previous x-ray treatment to head or neck
onset Rapid
change in voice Present
number of nodules One
ASSESSING A NECK LUMP
90 % thyroglossal cysts present before age 10
Size – width / height / depth
Location – can help narrow the differential – anterior / posterior triangle / mid-line
Shape – well defined?
Consistency – smooth / rubbery / hard / nodular / irregular
Fluctuance –if fluctuant, this suggests it is a fluid filled lesion – cyst
Trans-illumination – suggests mass is fluid filled – e.g. cystic hygroma
Pulsatility –suggests vascular origin – e.g. carotid body tumour / aneurysm
Temperature – increased warmth may suggest inflammatory / infective cause
Overlying skin changes – erythema / ulceration/punctum
Relation to underlying / overlying tissue – tethering / mobility
Auscultation – to assess for bruits – e.g. carotid aneurysm
congenital neck cyst
Location
Can occur anywhere along the course of the thyroglossal duct
Infrahyoid location is most common:
Typically located in the midline (~70%)
If off-midline characteristically tucked next to the thyroid cartilage
Almost all located within 2 cm of the midline
Pathophysiology
A swelling in the remnant of the thyroglossal duct
The duct usually disappears in the adult
Leaves a pit at its site of departure (the foramen cecum of the tongue)
Typically located in the midline
Most common midline neck mass in young patients.
Epidemiology
Thyroglossal duct cysts typically present during childhood (90% before the age of 10)
Remain asymptomatic until they become infected present at any time.
Account for 70% of all congenital neck anomalies
Second most common benign neck mass, after lymphadenopathy.
Clinical presentation
Typically a painless rounded midline anterior neck swelling
May move with swallowing and classically elevates on tongue protrusion
Branchial cyst
Common congenital and familial masses
Lateral aspect of the anterior triangle
Usually absent at birth
Becomes evident later on in life usually by early adulthood
At times bilaterally.
Pathophysiology
Failed closure of the second branchial cleft
Second pharyngeal arch grows downward covering the third and fourth arches burying clefts eventually disappear ~7th week
Failure of this process will lead to the formation of an epithelium-lined cyst (branchial cyst)
middle meningea artery enters skull thru?
The middle meningeal artery enters the skull through the foramen spinosum in the greater wing of the sphenoid bone. This vessel’s anterior division runs in close proximity to the pterion, a very thin area of the skull. Subsequently, it can easily rupture secondary to a skull fracture involving the pterion, as seen in this patient. An epidural hematoma is a medical emergency in which urgent craniotomy is essential.
Noise-induced hearing loss
is caused by the destruction of cochlear hair cells, also known as the organ of Corti. In a normally functioning ear, sound waves are transmitted mechanically through the tympanic membrane, via the ossicles, and through the oval window to the perilymph-filled inner ear. The resulting vibrations are transmitted to the cochlear hair cells, from where neurologic impulses are transmitted via the vestibulocochlear nerve.
bones that are pneumatized in viscerocranium -
frontal, temporal, sphenoid, ethmoid
The supraorbital foramen or notch
supra-orbital nerve, artery and vein.
is the small opening at the central edge of the superior orbital margin in the frontal bone just below the superciliary arches that transmits the supra-orbital nerve, artery and vein.
Where is the middle meningeal artery located?
The middle meningeal artery runs through the foramen spinosum, underneath the temporal bone at the side of the head, and above the dura mater, a layer of protective brain tissue.
piriform aperture,
the anterior nasal opening in the cranium
maxilla
infraorbital foramen inferior to each orbit for passage of the infraorbital nerve and vessels
their alveolar processes include the tooth sockets (alveoli) and constitute the supporting bone for the maxillary teeth.
surround most of the piriform aperture
form the infraorbital margins medially.
have a broad connection with the zygomatic bones laterally
an infraorbital foramen inferior to each orbit for passage of the infraorbital nerve and vessels
The two maxillae are united at the intermaxillary suture in the median plane
Le Fort 1, 2, 3
1 - horizontal fracture above lip
2 Pyramidal fracture
the entire central part of the face, including the hard palate and alveolar processes, are separated from the rest of the cranium.
3 - Craniofacial dysjunction: horizontal fracture that passes through the superior orbital fissures and the ethmoid and nasal bones and extends laterally through the greater wings of the sphenoid and the frontozygomatic sutures. Concurrent fracturing of the zygomatic arches causes the maxillae and zygomatic bones to separate from the rest of the cranium.
Le Fort 1, 2, 3
palate 1
nose and palate 2
entire face 3
1 - horizontal fracture above lip
2 Pyramidal fracture
the entire central part of the face, including the hard palate and alveolar processes, are separated from the rest of the cranium.
3 - Craniofacial dysjunction: horizontal fracture that passes through the superior orbital fissures and the ethmoid and nasal bones and extends laterally through the greater wings of the sphenoid and the frontozygomatic sutures. Concurrent fracturing of the zygomatic arches causes the maxillae and zygomatic bones to separate from the rest of the cranium.
fractures of mandible
most common - neck (often with dislocation of TMJ
- near canine tooth
The mental foramen
is one of two foramina (openings) located on the anterior surface of the mandible. It transmits the terminal branches of the inferior alveolar nerve and vessels (the mental artery).
malar flush
associated with certain diseases - eg - systemic lupus erythematosus SLE
lateral aspect of neurocraniam -
temporal fossa
external acoustic opening
mastoid process
Temporal Fossa: Its contents consist of:
Temporal muscle.
Superior temporal artery.
A branch of the mandibular nerve (V3)
The anterior and posterior branches of the deep temporal nerve.
The auriculotemporal nerve.
The temporal branches of the facial nerve.
lateral viscerocranial head
infratemporal fossa
zygomatic arch,
lateral aspects of the maxilla and mandible.
pterion
the pterion
It is usually indicated by an H-shaped formation of sutures that unite the frontal, parietal, sphenoid (greater wing), and temporal bones.
In a contrecoup (counterblow) injury,
no fracture occurs at the point of impact, but injury occurs on the opposite side of the cranium.
In comminuted fractures,
the bone is broken into several pieces. If the area of the calvaria is thick at the site of impact, the bone may bend inward without fracturing; however, a fracture may occur some distance from the site of direct trauma where the calvaria is thinner.
Linear calvarial fractures, - most common
the most frequent type, usually occur at the point of impact; but fracture lines often radiate away from it in two or more directions.
fracture at pterion?
EPIDURAL Hematome
Lucid period
biconcave - lemon
NO lumbar puncture - may speed up hemorrahage
underneath - on the inside is the anterior branch of middle meningeal artery - often if pterion fractures - will rupture vessel -
subdural hemorrahge
crescent
tears bridging veins where enter into superior sagital sinus -
subarachnoid
BERRY aneuysm
circle of Willis
aspirating CSF through lumbar puncture
stiff neck
congenital anerysm of circle of Willis or angioma - - headache of their life
Polycystic kidney disease risk factor
cerebral hemorrahge
paralysis of one side of the body
rupture of thin walled branch of middle cerebral = produces hemiplegia on opposite side of body - immediate loss of consciousness - paralysis when regained
inion?
nape of neck - tip of occipital bone
bregma
sagital and coronal suture
emissary foramina
that transmit emissary veins, veins connecting scalp veins to the venous sinuses of the dura mater
incisive fossa
Posterior to the central incisor, into which the incisive canals open (nasopalatine nerves and greater palatine artery pass from the nasal cavity through the incisive canal)
Greater and lesser palatine foramina (3) (transmitgreater and lesser lesser palatine vessels and nerves onto the posterior surface of the hard palate)
temporal bone
The bones consist of 4 parts
Petrous part- The petrous and mastoid regions form the thick pyramidal base that projects anteromedially and houses the middle andinner ear.
Squamous part- Thin lateral plate contributing to the lateral wall of thecranium. Anteroinferiorly, it forms themandibular fossafor thetemporomandibular joint.
Styloid part- Represented by the styloid process.
Tympanic part- Forms the walls of theexternal acoustic meatus.
at base of cranium - foramen magnum
The major structures passing through foramen magnum (2) are
the spinal cord
the meninges
the vertebral arteries,
the anterior and posterior spinal arteries,
the accessory nerve (CN XI)
On the lateral parts of the foramen magnum, the occipital bone has two large protuberances, the occipital condyles (3), by which the cranium articulates with atlas
jugular foramen - at base of cranium
The large opening between the occipital bone and the petrous part of the temporal bone
from which the internal jugular vein (IJV) and several cranial nerves (CN IX-CN XI) emerge from the cranium .
other structures at base of cranium
Carotid canal (1)-
for the internal carotid artery is just anterior to the jugular foramen
The stylomastoid foramen (2)- transmitting the facial nerve (CN VII) and stylomastoid artery, lies posterior to the base of the styloid process.
The mastoid processes (3)-
provide for muscle attachments (splenius capitis, longissimus capitis,digastric posterior belly, andsternocleidomastoid)
anterior cranial fossa
The frontal crest is a median bony extension of the frontal bone.
Foramen cecum of the frontal bone, which gives passage to vessels during fetal development.
The crista galli projects superiorly from the ethmoid.
Cribriform plate of the ethmoid .Its numerous tiny foramina transmit the olfactory nerves (CN I).
sella turcica - bed of the pituitary (saddle)
houses pituitary - sphenoid
back of saddle - ? dorsum sallae
foramina in spehnoid - 4 and one fissure
Superior orbital fissure (1): Located between the greater and lesser wings, it communicates with the orbit and transmits the ophthalmic veins and nerves (CN III, CN IV, CN V1, CN VI, and sympathetic fibers) entering the orbit.
Foramen rotundum (round foramen)(2): Located posterior to the medial end of the superior orbital fissure, it transmits the maxillary nerve (CN V2) that supplies the skin, teeth, and mucosa related to the maxilla (i.e., lining the upper jaw and maxillary sinus).
Foramen ovale (oval foramen)(3): A large foramen posterolateral to the foramen rotundum, it opens inferiorly into the infratemporal fossa and transmits the mandibular nerve (CN V3) and a small accessory meningeal artery.
Foramen spinosum (spinous foramen) (4): Located posterolateral to the foramen ovale, it transmits the middle meningeal vessels and the meningeal branch of the mandibular nerve.
The foramen lacerum (lacerated or torn foramen) (5) is not part of the crescent of foramina
This ragged foramen is an artifact of a dried cranium
In life, it is closed by a cartilage plate
Some meningeal arterial branches and small veins are transmitted vertically through the cartilage, completely traversing this foramen.
The internal carotid artery and its accompanying sympathetic and venous plexuses pass across the superior aspect of the cartilage (i.e., pass over the foramen)
posterior cranial fossa?
cerebellum, pons, medulla oblongate
largest and deepest fossa
, the clivus
, in the center of the anterior part of the fossa leading to the foramen magnum.
is partly divided by the internal occipital crest into bilateral large concave impressions, the cerebellar fossae.
at base - jugular foramen and sigmoid sinus
hypoglossal canal
middle cranial foramens
Optic canals
Optic nerves (CN II) and ophthalmic arteries
Superior orbital fissure
Ophthalmic veins; ophthalmic nerve (CN V1); CN III, IV, and VI; and sympathetic fibers
Foramen rotundum
Maxillary nerve (CN V2)
Foramen ovale
Mandibular nerve (CN V3) and accessory meningeal artery
Foramen spinosum
Middle meningeal artery and vein and meningeal branch of CN V3
Foramen laceruma
Internal carotid artery and its accompanying sympathetic and venous plexuses (pass above not through foramen lacerum)
Anterior cranial fossa
Foramen cecum
Nasal emissary vein (1% of population)
Cribriform foramina in cribriform plate
Axons of olfactory cells in olfactory epithelium that form olfactory nerves
Anterior and posterior ethmoidal foramina
Vessels and nerves with same names
posterior cranial fossa
Foramen magnum
Medulla and meninges, vertebral arteries, CN XI, dural veins, anterior and posterior spinal arteries
Jugular foramen
CN IX, X, and XI; superior bulb of internal jugular vein; inferior petrosal and sigmoid sinuses; and meningeal branches of ascending pharyngeal and occipital arteries
Hypoglossal canal
Hypoglossal nerve (CN XII)
Condylar canal
Emissary vein that passes from sigmoid sinus to vertebral veins in neck
Mastoid foramen
Mastoid emissary vein from sigmoid sinus and meningeal branch of occipital artery
infratemporal fossa contents
nerves: mandibular, inferior alveolar lingual buccal and choda typani merves and otic ganglion
maxillary artery - larger of two termianl branches of external cartoid
inferior temporal m
lateral and medial pterygoid mus
pteygoid venous plexus
mandibular, inferior alveolar lingual buccal and choda typani merves and otic ganglion
maxillary artery
3 parts - from external cartoid
pterygoid venous plexus -
anastomoses with facial vein, and superiorly w/ cavernou sinus via emissary veins
mandibular nerve descends thru
foramen ovale - into infrtemporal fossa - divides sensory and motor
v3 branches
sensory and motor -
auriculotemporal, inferior alveolar, lingual, and buccal nerves.
Branches of the CN V3 also supply the four muscles of mastication (masseter, temporalis, medial pterygoid, lateral pterygoid) but not the buccinator, which is supplied by the facial nerve.
otic ganglion parasympathetic
located in the infratemporal fossa, just inferior to the foramen ovale, medial to CN V3 and posterior to the medial pterygoid muscle.
Presynaptic parasympathetic fibers, derived mainly from the glossopharyngeal nerve (CN IX), synapse in the otic ganglion.
Postsynaptic parasympathetic fibers, which are secretory to the parotid gland, pass from the otic ganglion to this gland through the auriculotemporal nerve (V3).
The auriculotemporal nerve
encircles the middle meningeal artery and divides into numerous branches, the largest of which passes posteriorly, medial to the neck of the mandible, and supplies sensory fibers to the auricle and temporal region.
The auricotemporal nerve also sends articular fibers to the temporomandibular Joint and parasympathetic secretomotor fibers to the parotid gland.
The inferior alveolar nerve
enters the mandibular foramen and passes through the mandibular canal, forming the inferior dental plexus, which sends branches to all mandibular teeth on its side.
mental nerve
Another branch of the plexus, the mental nerve, passes through the mental foramen and supplies the skin and mucous membrane of the lower lip, the skin of the chin, and the vestibular gingiva of the mandibular incisor teeth.
The lingual nerve lies anterior to the inferior alveolar nerve.
It is sensory to the anterior two thirds of the tongue, the floor of the mouth, and the lingual gingivae.
It enters the mouth between the medial pterygoid muscle and the ramus of the mandible and passes anteriorly under cover of the oral mucosa, just inferior to the 3rd molar tooth.
The chorda tympani nerve
, a branch of CN VII carrying taste fibers from the anterior two thirds of the tongue, joins the lingual nerve in the infratemporal fossa.
The chorda tympani also carries secretomotor fibers for the submandibular and sublingual salivary glands.
mandibular nerve block?
injected near mandibular nerve where enters fossa
The injection usually anesthetizes the auriculotemporal, inferior alveolar, lingual, and buccal branches of CN V3.
the extraoral approach, the needle passes through the mandibular notch of the ramus of the mandible into the infratemporal fossa.
inferior alveolar nerve block?
wisdom tooth extraction -
The site of the anesthetic injection is around the mandibular foramen, the opening into the mandibular canal on the medial aspect of the ramus of the mandible.
This canal gives passage to the inferior alveolar nerve, artery, and vein.
The skin and mucous membrane of the lower lip, the labial alveolar mucosa and gingivae, and the skin of the chin are also anesthetized because they are supplied by the mental nerve, a branch of the inferior alveolar nerve.
sensory nerves of scalp?
supratrochlear v1 supraorbital v1 zygomaticotemporal v2 auriculotemporal v3 great auricular C2, C3 ant rami lesser occipital c2 an rami greater occipital c2 post ramus third occipital c3 post ramus
arteries to scalp - rich supply - bleeds a lot
venous system not mentioned - emissary veins have no valves
supratrochlear, supraorbital (branches of Ophthalmic art) forehead
superficial temporal w/ auriculotemporal nerve
divides into anterio and posterio
posterior auricular artery
occipital artery w/ greater occipital nerve
lymph drainage
anterior and forehead - submandibular
lateral scalp above ear
superficial partoid
above and behind earn - mastoid noces
back of scalp - occipital noces
why superficial scalp wounds don’t gape?
strength of aponeurosis
deep scalp wound gape widely - and big risk of infection
scalp infections - how spread?
fourth layer - loose CT - pus, blood spread easily
can also pass into cranial cavity via emissary veins - passing through parietal foramina
why can’t facial infection pass to neck?
occipital bellies of occipitofrontalis muscle attachment blocks - can’t spread laterally beyond zygomatic arch because epicranial aponeurosis
subaceous cysts
part of skin, move with scalp
muscles of facial expression
lots of facial bone growth during childhood - takes longer than calvaria
cutaneous nerves of head
facial - v1 opthalmic v2 maxillary v3 mandibular c2 c3 greater auricular- (under ear, mandibular angle) c2, c3 - transverse cutaneous of neck c3, c4, supraclavicular c345 - back/back of lower neck c2 - behind ear c23 back of upper head
3 important muscle of face
Buccinator is innervated by the buccal branches of facial nerve (CN VII).
buccinator - cheeks -
orbicularis oris - kissing around mouth, blowing
orbicularis oculi (closes eyelids -
platysma
neck to lower lip
bell’s palsy
Injury to the facial nerve (CN VII) or its branches produces paralysis of some or all facial muscles on the affected side (Bell palsy).
The affected area sags and facial expression is distorted, making it appear passive or sad. The loss of tonus of the orbicularis oculi causes the inferior eyelid to evert (fall away from the surface of the eyeball). As a result, lacrimal fluid is not spread over the cornea, preventing adequate lubrication, hydration, and flushing of the surface of the cornea. This makes it vulnerable to ulceration. A resulting corneal scar can impair vision. If the injury weakens or paralyzes the buccinator and orbicularis oris, food will accumulate in the oral vestibule during chewing, usually requiring continual removal with a finger.
Through what opening does the middle meningeal artery enter the skull?
spinosa
From which major vessel(s) in the upper thorax do the left and right common carotid arteries (CCAs) originate, respectively?
The left CCA originates directly from the aortic arch; the right CCA originates from the brachiocephalic artery
3 branches from aorta
the brachiocephalic artery (which divides into right common carotid artery and the right subclavian artery), the left common carotid artery, and the left subclavian artery.
Describe auscultation points of the heart valves
Aortic Valve Area Second right intercostal space (ICS), right sternal border
Erb’s Point Third left ICS, left sternal border
Tricuspid Valve Area Fourth left ICS, left sternal border
Mitral Valve Area Fifth ICS, left mid-clavicular line
A- Right 2nd intercostal space
P- Left 2nd intercostal space
T- xiphisternal joint
M- Left 5th intercostal space, midclavicular line
What are the 5 cardiac landmarks?
The aortic, pulmonic, tricuspid, and mitral valves are four of the five points of auscultation. The fifth is Erb’s point, located left of the sternal border in the third intercostal space.
Where do you listen to s1 and s2 heart sounds?
S1 can be best heard over the apex, using a stethoscope’s bell or diaphragm. The first heart sound is caused by turbulence created when the mitral and tricuspid values close. S1 and S2 heart sounds are often described as lub - dub.
Which heart valve is most important?
The aortic valve is the most common valve to be replaced. The mitral valve is the most common valve to be repaired. Only rarely is the tricuspid valve or the pulmonic valve repaired or replaced
erb’s point
“Erb’s point” is also a term used in head and neck surgery to describe the point on the posterior border of the sternocleidomastoid muscle where the four superficial branches of the cervical plexus—the greater auricular, lesser occipital, transverse cervical, and supraclavicular nerves—emerge from behind the muscle.
What do you listen for at Erb’s point?
a point of auscultation, which corresponds approximately to the centre of the general area where the heart sits. It is located at the 3rd ICS (intercostal space) to the left, about two (transverse) fingers parasternally. Cardiac murmurs caused by aortal insufficiency and mitral stenosis can in particular be heard.
What is the function of ductus arteriosus?
During fetal development, the ductus arteriosus serves as a shunt between the pulmonary artery and the aorta. In the fetus, the blood is oxygenated in the placenta before being returned to the body. The lungs are filled with amniotic fluid and therefore cannot be used to oxygenate the blood.
levels of lesser splanchnic nerve?
t 10 - 11
greater T5 - 9
least t12
innervation of mediastnum pluera?
phrenic -
What does the parietal pleura cover?
which doesn’t feel pain? visceral
The pleural cavity is the potential space between the two pleurae (visceral and parietal) of the lungs. … There are two layers; the outer pleura (parietal pleura) is attached to the chest wall and the inner pleura (visceral pleura) covers the lungs and adjoining structures, via blood vessels, bronchi and nerves.
The mediastinum?
contains the heart and its vessels, the esophagus, the trachea, the phrenic and cardiac nerves, the thoracic duct, the thymus and the lymph nodes of the central chest.
The mediastinum is the central compartment of the thoracic cavity, located between the two pleural sacs. It contains most of the thoracic organs, and acts as a conduit for structures traversing the thorax on their way into the abdomen.
Is the mediastinum a cavity?
The mediastinum is a true anatomical cavity within the thoracic cavity that contains all organs and major central vessels of the thoracic cavity except the lungs (and diaphragm). … The mediastinum itself can be subdivided into superior, inferior, anterior and posterior subdivisions.
what nerve at risk during closure of patent ductus anteriosa?
left recurrent laryngeal
which heart cavity has the greatest sternocostal projection?
right ventricle
cristae terminalis?
SA node location
moderator band?
right ventricle of the heart.
What is the function of the Septomarginal Trabecula?
Its main function is to convey the right branch of the atrioventricular bundle of the conducting system. The septomarginal trabecula forms the anteroinferior border between the superior, smooth outflow tract of the ventricle and the trabeculated inflow tract.
which thoracic structures can compress esophogus?
aorta, diaphagm, left bronchus
which chamber forms base of heart?
left atrium
most common cause of systolic ejection murmur?
Aortic valve stenosis — or aortic stenosis — occurs when the heart’s aortic valve narrows. This narrowing prevents the valve from opening fully, which reduces or blocks blood flow from your heart into the main artery to your body (aorta) and onward to the rest of your body.
structures with esophogus at diagraph - passing thru
aorta w?
vagal trunks
aorta w/ thoracic duct
structures transversing diaphagm thru cura?
greater, lesser and least splanchnic nerve
portocaval anastamoses
esophogeal: left gastric w/ azygos
rectal - superior rectal (above pectate) w/ middle/inferior
liver - portal vein and inferior vena Cava CAPUT
remnant of umbilical cord?
round ligament? The round ligament of the liver (or ligamentum teres, or ligamentum teres hepatis) is the remnant of the umbilical vein that exists in the free edge of the falciform ligament of the liver. The round ligament divides the left part of the liver into medial and lateral sections
celiac artery vertebrae level
t12
structure forming superficial inguinal ring?
external oblique muscle
Horner syndrome - may go with Kllumke -lower brachial palsy - c8, t1
is a combination of signs and symptoms caused by the disruption of a nerve pathway from the brain to the face and eye on one side of the body. Typically, Horner syndrome results in a decreased pupil size, a drooping eyelid and decreased sweating on the affected side of your face.
horner syndrome vs bell’s palsy?
What is the difference between Bell’s palsy and facial palsy?
Essentially, Bell’s palsy is a diagnosis of exclusion.
If none of the known causes can be confirmed, then the facial palsy is considered idiopathic, i.e. “from unclear or undetermined causes”. In other words, if the causes of your facial palsy cannot be determined and confirmed, the diagnosis will be “Bell’s palsy”
lateral winging of scapula?
accessory nerve, dorsal scapulary nerve
median nerve - what forearm muscles does it not innervate?
flexor carpi ulnaris and the ulnar head of flexor digitorum profundus,
important dermatomes?
Upper extremity
C6 - Thumb
C7 - Middle finger
C8 - Little finger
T1 - Inner forearm
T2 - Upper inner arm
Lower extremity
L3 - Knee
L4 - Medial malleolus
L5 - Dorsum of foot
L5 - Toes 1-3
S1 - Toes 4 and 5; lateral malleolus
Other
C2 and C3 - Posterior head and neck
T4 - Nipple
T10 - Umbilicus
cardia catheterization route thru femoral?
femoral, external iliac, common iliac, aorta, left ventricle
tibial collateral ligament?
most frequently torn at knee - == MCL same as medial collateral ligament
fibular collateral ligament - CL
not part of joint, not attach to lateral meniscus
connects lateral epicondyle of femur to head of fibula
ACL
attached to lateral condyle LAMP
PCL - attached to medial condyle
deltoid ligament eversion injury?
avulses MEDIAL MALLEOLUS, and after that fibular fractures at higher level
injury at neck of fibula?
foot drop - PED - common peroneal nerve - can’t dorsiflex - need brace
nerves sole of foot?
medial and lateral plantar - looks to me like mainly the lateral - with medial running along instep to toe - does supply flexor digitorum
mostly medial plantar + 1st lumbrical, flexor -
lateral plantar 1.5 digits - all but one lumbrical
intercostal blood vessels and nerve?
nerve and posterior intercostal artery most vulnerable
run under rib - vein most superior and protected - vein, artery, nerve -
skin, fascia, external intercostal m, internal vessles, innermost intercostal, endothoracic fascia, parietal pleura, pleural cavity, visceral plueura, lung
nerve injuries from mastectomy?
long thoracic during ligation of lateral thoracic artery - (winged scap, can’t raise arm above 90 - serratus anterior m)
intercostobrachial nerve may also be damaged = skin deficit of medial arm -
diaphragm openings -
I 8 10 eggs at 12
IVCPr
EVL
ATA
t8 - IVC and right phrenic
T10 - esop, both vaugs, L gastric vesslect
t12 - aorta, thoracic duct/ azygous vein
diaphragm paralysis?
phrenic nerve - damaged side - inhald raises damaged side
root of lung - nerves?
phrenic anterior
vagus posterior
layers of heart - outermost fibrous pericardium - (phrenic)
parietal (phrenic
cavity
vsiceral pericardium VAGUS
most common side of diaphragamatic ruptures?
LEFT
bochadalek congenital diaph hernia?
intestines protrude thru hole in diaphram
MORTALITY hgih - left lung hypoplasia
failure of pluro peritoeal membrane to fust
high mortality -
hernia of stomach of intestine
sliding hiatal hernia - old people
cardia of stomach - into thorax via esophageal hitus - VAGAL nerves damage
hyposecretion of gastric juices
heart and where to listen
between 2/3
All People Enjoy Time Magazine
ERBS -Cardiac murmurs caused by aortal insufficiency and mitral stenosis can in particular be heard.
a between 2/3 p between 2/3 e (erbs 3 ICS t - tricuspid mag - mitral
heart murmurs heard up or downstream from valve?
DOWNSTREAM -
mitral valve is between? ERBS point
LEFT heart chambers - 90%, mitral stenosis, aortic insufficiency
aortic valve runs betwe?
left ventrical to aorta - anortic stenosis 8%
stenosis is orthograde (AFTER valve)
Cardiac insufficiency, more commonly known as heart failure, is when the heart muscle’s pump function is reduced. This leads to the heart being unable to produce the power to pump the required amount of blood throughout the body.
insufficiendy is retrograde - heard BEFORE valve
bundle of His -
The electrical signal starts in a group of cells at the top of your heart called the sinoatrial (SA) node. The signal then travels down through your heart, triggering first your two atria and then your two ventricles. … The AV node sends an impulse into the ventricles.
from AV
where pacemaker of heart starts?
SA at SVC, to AV (coronary sinus)
bundle of His (perkinje fibers) decesnse from AV node to ventricular septum - right bundle to MODERATOR band, left to ventricular septum
when do coronary arteries fill?
during disstoli
sistoli is contraction - distoli is filling
blood supply to conducting system of heart?
SA node - RCA
AV node - RCA
AV bundle and moderator band - LCA
fetal circulation - 3 shunts
ductus venouse (umbilica vein into IVC
ductus anteriosos - pulmonary art to prox descending aorta
foramen ovale - between left and right atrium
ductus venous (umbilical vein into IVC
ductus anteriosos - -near left recurrent laryngeal FROMS WITHIN 3 weeks of birth - connects aorta and pulmonary trunk
foramen ovale - between left and right atrium
after birth - 4 things change
ductus venous - lig vevosum (in liver - left branch of portal vein - ROUND LIG Of LIVER
ductus arteriosos - 3 weeks of birth - connects aorta and pulmonary trunk - leg anteriosum
foramen ovale Foss OVALE
umbilicAL arteries and vein - closure - mediAL umbilical ligament
AlleNtois - MediaAN urachus - mediaAN umbilical ligament - between bladder and umbilicus
Umbilical Vein - (round) - Terest hepatis - found lig - in falciform
Notocord - Nuclus pulposus
PDA newborn?
keep open - indomethacin
close - prostaglandin
closes within 3 weeks normally
Patent ductus arteriosus (PDA) is a persistent opening between the two major blood vessels leading from the heart. The opening, called the ductus arteriosus, is a normal part of a baby’s circulatory system before birth that usually closes shortly after birth.
Blue Baby 5 Ts
Truncus arteriosus is a rare type of heart disease in which a single blood vessel (truncus arteriosus) comes out of the right and left ventricles, instead of the normal 2 vessels (pulmonary artery and aorta).
truncus arteriosos 1
transposition of vessels 2 (incompatible w life)
tricuspid atressia 3
tetralogy of fallot 4
TAPVR 5 Total anomalous pulmonary venous return (TAPVR) is a birth defect of the heart. In a baby with TAPVR, oxygen-rich blood does not return from the lungs to the left atrium. Instead, the oxygen-rich blood returns to the right side of the heart.
Atrial septal defect - less common than ventral
NON cyantoic
ovale failure to close - after birth result is left to right shunting (between right and left atrium)
may need to repair
Ventral septal defect - VSD
Non - cyanotic
another left to right shunt
opening between wall of two venticles
membrane doesn’t grow to meet muslce - membrane 1/3, muscle 2/3 down and up correctly -
membrane more prone to defect -
surgery neccsaary if large
Tetralogy of fallot 4
Cyanotic - RIGHT to LEFT SHUNT
P
R
O
V
Pulmonary stenosis
Right ventricular hypertopy
Overriding aorta
VSD
PDA common when?
LEFT to RIGHT shunting - increasing pumonary circulation
non - cyanotic
CAREFUL re hoarseness - nerve wraps around aorta
mother rubella infection - premature infants
PDA is opening between pulmonary trunk and aorta
Patent ductus arteriosus (PDA) is a persistent opening between the two major blood vessels leading from the heart. The opening, called the ductus arteriosus, is a normal part of a baby’s circulatory system before birth that usually closes shortly after birth.
Coarctation of aorta
congenital narrowing of aorta distal to offshoot of left subclavian art
cardinal sign - higher blood pressure in upper limbs
intercostal arteries end up providing circulation to lower limbs
rib notching is a sign
(TAPVR)
oxygen-rich blood returns to the right side of the heart.
Total anomalous pulmonary venous return (TAPVR) is a birth defect of the heart. In a baby with TAPVR, oxygen-rich blood does not return from the lungs to the left atrium. Instead, the oxygen-rich blood returns to the right side of the heart. Here, oxygen-rich blood mixes with oxygen-poor blood.
aneurysm of aortic arch?
compresses laryngeal nerve - HOARSENESS, paralysis of ipisilateral vocal cord - may cause dysphagia (diff swallowing)and dyspnea (dff in breathing) resulting from pressur on trachea - root of lunges, phrenic, may be able to palpatet at sternal notch T2
aspiring foreigh bodies?
right primary bronchus - usually falls into posterior basal segment of right inferior lobe
pneumonia?
inflammation of lung - cause infection, or chemical injury to lung -
three common - bacteria, virus, fungi
pancoast tumor?
Horners
c8 - t1
at apex of lung - thoracic outlet syndrome - compresses nerves, vessels betwe clavicle and first rib - pain to should, neck, numb fingers
horner syndrome?
sympathetic nerve prob
miosis - constriction of pupil
pthosis - droop eyelid (paralysis of sueprior tarsal
hemianhydrosis - loss of sweating
superior vena cava syndrome -
Hoarsemess - recurrent laryngeal nerve
paralysis of diaphramg
dilation of head and neck veins, facial swelling, cyanosis - ma be bronchogenic carcinoma -
Lungs auscultation -
listen side of chest - for inferior lobse - posterior chest wall
middle lobe - 4 - 6 rib
superior lobes - above 4th right, above 6th for left
stab - pneumothorax
he emergency treatment of a tension pneumothorax starts with the needle decompression which can be done in one of two locations. The most common location is in the midclavicular line in the second intercostal space which is just above the third rib.
air into pleural cavity - lung collapse
visceral plerua sensitive to ?
stretch - autonomic nerve supply
thoracic duct location?
internal jugular vein and left subclavian vein
right - right internal jug and right subclavian
3 constrictions of esophagus
c6 - pharynx joins
T4-5 aortic arch
T10 - where passes through diaphragm
referred pain of abdomen?
foregut - epigastric
midgut - umbilical
hindgut - hypogastric
in abdomen - where are most nerves and vessels?
neurovascular plane - betwe internal oblique and trasnversus
cause of omphalocele
Some babies have omphalocele because of a change in their genes or chromosomes. Omphalocele might also be caused by a combination of genes and other factors, such as the things the mother comes in contact with in the environment or what the mother eats or drinks, or certain medicines she uses during pregnancy.
lesser omentum?
window over the lesser sac
two ligaments - hepatogastric, heaptoduodenal
contents
right and left gastric vessel
portal triad (bile duct, portal vein, proper hepatic artery)
epiplic foramen - Winslow
opening into lesser sac
portal triad _ DVA
post - IVC
superiorily - caudate of liver
inferior - duodenal
Douglas pouch
RECTOUTERINE pouch
drain? needle - posterior vaginal fornix
pelvic abscess location - when verticle - betwe rectum and cervix of uterus
posterior gastric ulcer?
erode into lesser sac (omental bursa) affecting pancrease - referred pain to back
erode splenic artery
meckel’s diverticulum - rule of 2s
remanant of vitelline duct/yolk sac
persistent portion of vitellointestinal duct - can become inflamed - on elium about 2 feet before ileocecal junction and SMA supply - 2% patients - 2 inches long - mimics appendicitis -
mcBurney’s point?
BASE of appendix - retrocecal is most common position of appendix
Hirshcpring diase signs?
failure of Neural crest to migrate - downs
no meconium 24 - 48 hours, reluctance to eat, bil vomit, abdomincal distention - Remedy - REMOVEAL of aganglionic portion of colon
t12, L1, L2, L3, L4
Celiac 12 SMA - L1 Renal arteries L2 IMA - L3 common illiac L4
celiac artery - three branches
clockwise
left gastric - lesser curvature - branches - eophageal, gastric (anastamose w/ right gastric from proper hepatic)
splenic
common hepatic
common hepatic?
at first part of duodenum - divides two terminal branches - proper hepatic
gastroduodenal
proper hepatic?
gives off
right gastric artery (climb up along lesser curvature stomach when anastamose with left gastric)
then ascends w/ hepatoduodental ligament of lesser omentum to reach portal hepatis - divides into right and left hepatic arteries
right hepatic gives off cystic
gastroduodenal artery
meets up with SMA of inferior pancreatico
duodenal artery
may erode by ulcer of duodenum,
divides two branches -
right gastroepiplic (great curvature)
superior pancreticoduodenal - supplies head of pancreas) anastamose with inferior pancreaticoduodenal artery from SMA
collateral circulation to liver?? says you can ligate the hepatic artery and will get collateral circulation from left and right gastric, gastroepiploic and gastroduodenal -
?? I don’t understand this
if right heptic artery mistakenly ligated in Calot triangle - w cystic artery
right lobe hepatic necrosis may occur
splenic artery - branches
retriperitoneal until reaches tail of pancreas
branch to spleen, neck, body and tail of pancrease
left gastroepiploic artery
short gastric (supply fundus to stomach)
connect btwee SMA and IMA?
marginal artery of Drummond
ima branches
left colic, sigmoid, superior rectal
sma - branches
interior pancratic ( jejunal, iliul
ileocolic - BRANCHES - ascending, anterior cecal, poterior cecal
appendicular
right colic
middle colic
Vasa recta
(intestines) Vasa recta are straight arteries coming off from arcades in the mesentery of the jejunum and ileum, and heading toward the intestines. The arcades are anastomoses of the jejunal and ileal arteries, branches of superior mesenteric artery.
major duodenal papilla?
where common bile duct and pancreatic duct enter duodenum
ampulla of Vater - 2nd duod
spincter of Oddi - muscle controls opening
most common site for gallstones?
distal common bile duct - is narrowest - distal end of heptopancretic ampulla -
Why does stone blocking cystic duct of gallbladder cause biliary colic (pain) but not jaundice?
because vile still leaving liver and flowing through common bile duct
how can transverse colon be affected by gallstones?
fundus of gallbladder in contact with transverse colon - gallstones can erod thru posterior wall and enter trasnverse colon
if in BODY of gallbladder - may ulcerate into duodenum - maybe produce intestinal obstruction at ileocecal junction
gallbladder referred pain?
right shoulder - phrenic c3 - 5
portal vein formed by?
splenic vein and SMvein
portocaval shunts that are possible? 2 ??
- splenic to renal vein (after removing spleen)
2. ? intrahelpatic shunt - betw portal vein and hepatic veins
Vomiting red blood?
may be because eophageal varices caused by portal hypertension
uncinate process of pancrease -
superior mesenteric vessels cross -
what’s in the head of the pancreas?
cancer in head of pancrase compreses bile duct - jaundice
behind neck of pancreas?
posterior - formation of portal vein
splenchic vein ?
posterior to body of pancreas
tail of pancreas?
if accidentally removed during splenectomy? sugar diabetese because lots of endocrine cells there
blood supply to pancreas 3 - celiac and SMA
at head - superior pancreticoduodental - celiac
uncinate - inferior pancreticoduo SMA
neck body tail - splenic - celiac
annular pancreas
malformation before brith ventral and dorsal pancreatic budy for ring around duodenum - obstructing - polyhydramnios - baby can’t swallow fluid
feeding intolerance, bile vomit
half of cases not diagnosed until audtlhood
is spleen periotoneal?
Yes - left shoulder referred pain
if ruptures - can not be sutured
staghorn calculi?
renal stones
horseshoe kidney?
hooks under origin of IMA
pelvic kidney?
failure of one kidney to ascend
3 constrictions of ureter?
pelviureteric junction L1
pelvic brim (sacroiliac joint level)
wall of urinary bladder - ischial spine
suprarenal glands?
secrete costicosteriods: aldosterione, genital hormones, etc
chomaffin cells of adrenal medula - secrete?
catecholmines: epinephrine and NE
sympathetic stimulation - hypersecretion? tachycardia, sweating, high blood pressure
unpaired tributaries of IVC
right suprarental vein and right gonadal vein drain directly to IVC
varicocele?
may result in low sperm count
left side common -
enlargement of pampinoform plexus
The pampiniform plexus is a loose network of small veins found within the male spermatic cord. The plexus begins in the scrotum with veins arising from the mediastinum testis, an area of connective tissue at the back of the testis.
hydrocele?
processus vaginalis
it precedes the testis in their descent down within the gubernaculum, and closes.
Persistent Müllerian duct syndrome is a disorder of sexual development that affects males. Males with this disorder have normal male reproductive organs, though they also have a uterus and fallopian tubes, which are female reproductive organs.
tunica vaginalis testis or remnants of processus vaginalis may create -
WOLFIAN DUCTS _ When the ducts are exposed to testosterone during embryogenesis, male sexual differentiation occurs: the Wolffian duct develops into the rete testis, the ejaculatory ducts, the epididymis, the ductus deferens and the seminal vesicles. The prostate is formed separately from the urogenital sinus.
Testosterone, produced by Leydig cells, promotes development of Wolffian duct derivatives and masculinization of the external male genitalia. Finally, insulin-like 3 (Insl3) mediates transabdominal testicular descent into the scrotum
why do alcoholics often have internal hemorrhoids?
superior rectal vein tributary into IMA - gets backs up - because of liver cirrhosis
perineal pounches
contains:
sphincter urethrea muscles
deep transverse perineal mus
cowper’s glands (male only)
where is The internal jugular vein ?
is found within the carotid sheath lateral to the common carotid artery and anterior to the vagus nerve.
superficial perineal pouch?
ischiocavernosus muscle - related to crus of penis and clit
bulbospongeosis musc - bulb of penis - male - bulb of vestibule female
superficial transferse perineal muscle - both sexes
urine leaks?
after crushing blow - spongy urethra commonly ruptures within bulb of penis - urine leaks into superficial perineal pouch
superficial perineal fascia keeps urine from passing into thigh or anal traible - but after distending scrotum and penis - urine can pass over the pubis into anterior abdominal wall deep to deep layer of superficial abdominal fasci
ischiorectal abscess?
surgical condition - from spread of infection through external sphincter ani into ischiorectal fossa -
emergency -
danger = should avoid lateral wall of fossa because pudendal (Alcock’s) canal w/ pudental nerve and internal pudendal artery here
urinary bladder - cystocele - hernia of bladder
also known as a prolapsed bladder, is a medical condition in which a woman’s bladder bulges into her vagina. Some may have no symptoms. Other may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention.
loss of bladder support in females - babies - pelvic floor - levator ani m -
bladder can protrude onto anterio vagical wall -
patent urachus?
distal portion of allantois - need to surgically remove - main sign is leakage of urine thru umbilicus =
3 types
fistula - free communication
cyst - no communication
sinus - pouch opens toward umbilicus
draining bladder w/ needle?
just above pubic symphysis - w/o penetrating - passes thru skin, facias, linea alba, transversalis fascia, extraperitoneal CT and wall of bladderperitoneum
embryo and develop reproductive glands
paramesonephric duct mullerian (female - uterine tubes, uterus, cervix , upper part of vagina
mesonephric duct Woflian - male - epididymis, duct def, seminal vesicle, ejac duct
phallus - clit, penis
urogential folds - labia minor/ ventraal aspect of penis
labioscrotal swellings - labia majora/ scrotom
hypospadias
COMMON _ ventral
urethral folds fail to fuse
epispadies not common on top
hypo - ventral
epi - dorasal -
prostate tumors - why spread so easily?
venous plexus of prostate has many connections w/ vertebral venous plexus via sacral veins
usually begins in posterio lobe -
benign hypertrophys of prostate
common in older men -
removal of prostate?
impotence and or urinary incontinenece risk - re caernosus nerve around urethra
pelvic splanchnic nerve can also be injured - in case of pelvic lymph nodes removal
male urethra - route
prostatic part
ejac ducts
membraneous part - urogential diaph surround by extenral sphincter
bulbourethral glands (ddep perineal pound)
spongy penile part = longer - pass through bulb and corpus spongiosum two dilatiations - bulbar fossa and navicular fossa - ducts of baulbourethral glands open into bulbar fossa
2 spincters of urethra
internal - neck of bladder - sympathetics
external - skeletal muscle fiber surround membranous part - perineal branch of pudendal nerve
ejaculatory duct?
union of ductus deference and seminal vesicles
passage of seminal fluid from ductus deferns to prostatic urethra
pudendal nerve?
branches -
1.inferior rectal (external anal sphincter)
2/ perineal nerve (motor nerve to urogenital triagngel
posterior scrotal/labial branches
- dorsal nerve of penis/clit
pudendal nerve block - birthing
uterine contraction pain still exists -
two methods - pierceing vagnial wall near ischial spine
percutaneously along medial side of ischial tuberosity -
micturition reflex
parasympthetic - pelvic splanchnic stimulate detrusor m
somatic motor fibers (pudental) cause voluntary relation of external urethral sphincter
inhibiting emptying - sympathetic fibers - sacral splanchnic - in hibit detruso and stiumulate internal sphincter
erection / ejaculation?
point - shoot
point - para
shoot - sympathetic L1 - L2 - inferior hypgatric plexus - sacral splanchnic nerve - stim to internal urethral sphnicter to prevent semen from entering bladder
incontinence?
3 parts of levator ani
puboretalis
puboccygeus
ilioccygeus
weakness of levator ani - rectal incontintnene
weakness of external sphyincter urethra in urogential diaphragm may result in urinary incontinence
crytochisms
failure of testis to come down - tumor / sterility
torsion of sprematic cord
pain - twisting of testicular artery - necrosis
lymphatic drainage of male viscera
testis/ lumbar
scrotum, penis - superficial
prostate/bladder/ anal canal - internal iliac
testis/epid - lumbar
scrotum - superficial
penis - skin - superficial,
glans deep inguinal
body and roots
internal iliac
prostate and bladder - internal ilia
anal cala - above pecttinate - internal
below pectinate superficial inguinal
lymph drainage for female
ovary/uterine tubes - lumbar
uterus - complicated - various
all external gentialia - superficial
clit - deep inguinal
hysterectomy - arterial supply
Ovarian suspensory ligament - contains ovarian artery and vein - AORTA
risk pelvic splanchnic nerve affected - bladder dysfunction detrussor loses parasympathetic innervation
uterus - uterine arteries INTERNAL ILIAC)
crosses pelvic floor in CARDINAL LIG - at base of broad lig
URETER passes posterior and inferior - bridge over the water
internal iliac artery - branches
anterior division
posterior
iliolumbar
lateral sacral
superior gluteal
obturator
umbilical
inferior gluteal
internal pudendal
inferior vesical/vaginal
middle rectal
uterine (females only)
smiling muscle?
zygomaticus major is perhaps the most noticeable. Sitting between the corners of our lips and the upper part of our cheeks, it controls the way in which we smile. The muscle sits atop the zygomatic bone, otherwise known as the cheekbone.
keyhold pupil?
failure of fusion of retinal fissure
sore throat?
glossophayngeal IX
how do neural crest cells affect facial development
hugely - but not the neck. Maxillary bone, etc
4 extra muscles developed in 1st pharan arch MATT
myelhyoid, anterior belly of digast, Tensor Veli, Tensor tympnaic
assymetrical neck?
2nd arch
facial artery pulse
interior margin of mandible
mumps, parotid gland swollen - what structure at risk?
auriculotemporal nerve
accident - can’t close your lips?
orbicularis oris mus
four branches of subclavian artery?
VITamin C
Vertebral artery. Internal thoracic artery. Thyrocervical trunk. Costocervical trunk. Dorsal scapular artery.
birthing - what nerve vulnerable?
facial - at stylomastoid foramen - may not be able to close eyes or other things needed for facial movement - Careful!
during surgery - anestheseologist checks pressure on head anterior to tragus of ear?
superficial temporal - smaller terminal branch of external cartodi - through partotid gland - anterior to auricle - can be palpated anterior to the tragus where lies agaisnt underlying zygomatic arch
how to plug lacrimal area during eye surgery to keep eyes moist?
plug lacrimal punctum
if allowerd to drain- tears pass thru lacrimal calaiculus, lacrimal sad, nasolacrimal duct, enter nasal cavity via interior nasal meatus
ansa cervicalis - if accidentally cut during neck lymph surgery ?
paralysis of several strap mus of infrahyoid
a loop of nerves that are part of the cervical plexus. It lies superficial to the internal jugular vein in the carotid triangle. Its name means “handle of the neck” in Latin.
removal of thyroid gland danger?
paralyzing true focal fold
brachial plexus trunk found in which neck triangle?
occipital
odontoid process?
dens - c2
Parotid gland
duct passes thru which muscle?
buccinator most likely place for bloackage by a calculus
The parotid glands are a pair of mainly serous salivary glands located below and in front of each ear canal, draining their secretions into the vestibule of the mouth through the parotid duct. Each gland lies behind the mandibular ramus and in front of the mastoid process of the temporal bone.
cushing disease?
hypopheseal fossa
non cancerous tumor in pituitary
Cushing’s disease is a serious condition of an excess of the steroid hormone cortisol in the blood level caused by a pituitary tumor secreting adrenocorticotropic hormone (ACTH). ACTH is a hormone produced by the normal pituitary gland.
thinning of skin, rapid weight gain in trunk and face - excess sweating - tunnel vision
tumor in tympanic cavity?
may damage facial nerve - many other structures nearby also -
struck with hammer during fight on pterion- what bone damaged?
greater wing of sphenoid
martial art fight - hyoid broken in neck - which muscle most affected
middle pharyngeal constrictor - swallowing
diGeorge - what pouch?
3rd - thyroid and parathyroid dervided from third
soft palate - what arch?
4th
superior mesenteric artery syndrome
3rd duod
SMA crushes duod against aorta - typically after weigh lost -
off of aorta?
right brachial - rt subclav, rt common carotid
left common carotid - ext, int carotid
left SUBCLAVIAN - vertebral, thyrocervical, intral thoraic (off of both of subclavians)
vertigo?
VIII
A 34-year-old woman sees her physician because of difficulties with her vision. Examination under dim light reveals pupils that are 5 mm in diameter. When light is shone in the right eye, neither pupil constricts. When light is shone in the left eye, both pupils constrict to 3 mm.
Which of the following cranial nerves is most likely to be affected?
CN II
The afferent information for this reflex is carried by the optic nerve CNII and the efferent response is carried by the oculomotor nerve. CNIII
A 30-year-old man has lost 4.5 kg in the past three months because “the food that I eat has lost its flavour”. Three months ago he was involved in a serious motor vehicle collision resulting in severe head trauma.
Which of the following cranial nerves is most likely to have been affected?
Sense of smell should always be evaluated after head trauma, because the olfactory nerve may be sheared off as it penetrates the cribriform plate. The sense of smell is heavily connected with the taste of food. Because this patient has a history of head trauma and a current complaint of decreased sensation of the flavour of food, cranial nerve I is the most likely nerve to be injured in this scenario.
It is important to note the difference between flavour and taste: taste refers to the special visceral afferent function of three cranial nerves, the facial (VII), glossopharyngeal (IX), and vagus (X). Flavour refers to a hedonic integration of taste and smell, which is a function of the olfactory nerve.
Considering how this man suffered severe head trauma, and not both pontine and medulla trauma, it is unlikely that he suffered damage to any of the three cranial nerves involved with taste, and more likely to the one cranial nerve involved with the sense of smell.
What is the name of the vessel that connects the anterior and posterior circulation of the brain?
The correct answer is the posterior communicating artery.
This artery is also sometimes referred to as ‘PComm’. It connects the middle cerebral artery and the posterior cerebral artery. The posterior communicating artery’s main purpose is to provide redundancy for blood circulation throughout the brain, such that if one circulatory system was affected by disease (e.g. stroke), the other circulatory system could take over and provide blood and oxygen to the affected part of the brain.
Clinically, aneurysms of the PComm artery can cause oculomotor nerve palsy given its relation to the oculomotor nucleus.
Hyperacusis
is a rare debilitating hearing disorder characterized by an increased sensitivity to certain frequencies and volume ranges of sound (a collapsed tolerance to usual environmental sound). A person with severe hyperacusis has difficulty tolerating everyday sounds, which become painful or loud.
The chorda tympani
is a branch of the facial nerve that originates from the taste buds in the front of the tongue, runs through the middle ear, and carries taste messages to the brain.
Which of the following branches of the facial nerve (cranial nerve VII), when damaged, may result in hyperacusis?
stapedius muscle is to dampen the vibration of the stapes to loud environmental noise.
STAMP it down
The correct answer is nerve to stapedius.
This is a branch of cranial nerve VII supplying the stapedius muscle, which is the smallest muscle in the body. The purpose of the stapedius muscle is to dampen the vibration of the stapes to loud environmental noise. When this nerve is damaged, there is no dampening effect, resulting in more pronounced vibrations of the stapes which makes loud sounds seem louder (hyperacusis).
The other options are incorrect.
The lesser petrosal nerve is NOT a branch of cranial nerve VII. It is a branch of cranial nerve IX.
The lesser petrosal nerve (also known as the small superficial petrosal nerve) is the general visceral efferent (GVE) component of the glossopharyngeal nerve (CN IX), carrying parasympathetic preganglionic fibers from the tympanic plexus to the parotid gland.
The temporal branch of cranial nerve VII is an extracranial branch of the facial nerve and is responsible for muscles of facial expression.
The chorda tympani nerve supplies taste to the anterior two-thirds of the tongue.
Apart from cranial nerve VIII (vestibulocochlear nerve), which of the following nerves runs through the internal auditory meatus (otherwise known as the internal auditory canal)?
The correct answer is the facial nerve.
The facial nerve is one of four structures passing through the internal auditory meatus (IAM). The structures of the IAM are - facial nerve, vestibulocochlear nerve, labyrinthine artery and vestibular ganglion.
This is clinically significant as acoustic neuromas arising from the vestibulocochlear nerve can grow and compress the facial nerve within the IAM, resulting in Bell’s palsy.
The other options do not pass through the IAM.
Which of the following arteries is a branch of the external carotid artery?
The correct answer is the superior thyroid artery.
The superior thyroid artery is the first branch of the external carotid artery as it arises from the bifurcation of the common carotid. An easy way to remember the branches of the external carotid artery is the following mnemonic: Some Anatomists Like Freaking Out Poor Medical Students.
S: Superior thyroid artery A: Ascending pharyngeal artery L: Lingual artery F: Facial artery O: Occipital artery P: Posterior auricular artery M: Maxillary artery S: Superficial temporal artery These are also the branches of the external carotid ascending in order from its bifurcation from the common carotid. The external carotid supplies structures around the skull and the internal carotid supplies the structures in the skull (brain, eyes, etc.).
The other options are incorrect for the following reasons.
The inferior thyroid artery is a branch of the subclavian artery arising from the thyrocervical trunk
The basilar artery is the continuation of the two vertebral arteries as they meet at the base of the skull and continue to form the main arterial supply of the posterior circulation of the brain.
The ophthalmic artery is a branch of the internal carotid and supplies the eyes.
Which of the following structures does not pass through the superior orbital fissure?
Ophthalmic vein Abducens nerve Optic nerve Oculomotor nerve Trochlear nerve
The optic canal contains the optic nerve and ophthalmic artery.
The correct answer is the optic nerve (CN II).
The optic nerve passes through the optic canal, which is a continuation of the optic foramen. The optic canal contains the optic nerve and ophthalmic artery.
The other options are incorrect as they all pass through the superior orbital fissure (SOF).
The structures passing through the superior orbital fissure are:
Superior and inferior divisions of oculomotor nerve
Trochlear nerve
Abducens nerve
Ophthalmic division of the trigeminal nerve (V1)
Ophthalmic vein
Sympathetic fibres from the carotid plexus.
Apart from the internal carotid artery, what other structure passes through the carotid canal of the temporal bone?
Parasympathetic fibres
Oculomotor nerve
Optic nerve
Sympathetic fibres
The correct answer is sympathetic fibres.
The sympathetic nerve fibres arise from the sympathetic plexus (also known as the internal carotid plexus) which runs along the lateral side of the internal carotid artery into the middle cranial fossa via the carotid canal. The sympathetic fibres have two main motor functions: to raise the eyelid and dilate the pupil. The fibres also provide innervation to the sweat glands of the face. They can be damaged if there is a base-of-skull fracture and can result in an ipsilateral Horner’s syndrome.
The other options are incorrect for the reasons below.
Parasympathetic fibres do not arise from the carotid plexus.
The optic nerve (cranial nerve II) does not pass through the carotid canal. It passes through the optic canal as an extension of the central nervous system.
The oculomotor nerve (cranial nerve III) passes through the superior orbital fissure. Incidentally, parasympathetic fibres do arise from the Erdinger-Westphal nucleus and travel along the superior orbital fissure to cause constriction of the pupil.
Which of the following cranial nerves passes through the stylomastoid foramen?
Facial nerve
It emerges from the pons of the brainstem, controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. The nerves typically travels from the pons through the facial canal in the temporal bone and exits the skull at the stylomastoid foramen.
The facial nerve enters the internal auditory meatus, passes through the petrous part of the temporal bone, and exits the skull through the stylomastoid foramen. The nerve then enters the parotid gland and breaks up into its five terminal branches: temporal, zygomatic, buccal, mandibular, and cervical.
The correct answer is the facial nerve.
The stylomastoid foramen is the exit point of the facial nerve from the skull. From this point, the facial nerve will split into its constituent extracranial branches and innervate the muscles of facial expression. Clinically, at this point, there is a possibility of compression due to inflammation/ infection as the facial nerve exits the skull resulting in compression and ipsilateral Bell’s palsy.
The other options are incorrect for the following reasons:
The vestibulocochlear nerve passes through the internal auditory meatus. Acoustic neuromas can also arise from this nerve and compress the intracranial portion of the facial nerve as it passes through the meatus, also resulting in ipsilateral Bell’s palsy.
The glossopharyngeal nerve passes through the jugular foramen.
The abducens nerve passes through the superior orbital fissure.
The trigeminal nerve is split into three parts - V1 passes through the superior orbital fissure, V2 passes through the foramen rotundum and V3 passes through the foramen ovale.
The stylomastoid foramen
transmits the facial nerve and stylomastoid artery.
is between the styloid and mastoid processes of the temporal bone. It is the termination of the facial canal, and transmits the facial nerve and stylomastoid artery.
Which of the following muscles is not innervated by the facial nerve (CN VII)?
Temporalis48% Frontalis9% Orbicularis oris9% Orbicularis oculi12% Buccinator
The other options are all muscles of facial expression and are innervated by branches of the facial nerve.
Buccinator - action: blowing out cheeks. Innervated by the buccal branch of the facial nerve
Orbicularis oculi - action: closes eyelids. Innervated by the temporal branch of the facial nerve
Frontalis - action: wrinkles forehead. Innervated by the temporal branch of the facial nerve
Orbicularis oris - action: purses lips. Innervated by the mandibular branch of the facial nerve
left 4th IC stab wound
The right ventricle forms most of the anterior wall of the heart and extends from approximately the right border of the sternum to approximately 2 inches to the left of the sternum at the level of the fourth intercostal space.
The left atrium forms the posterior wall of the heart. The only portion of the left atrium seen on the anterior surface of the heart is the left auricular appendage, which is at the level of the second intercostal space on the left.
The left ventricle forms most of the left border of the heart and the diaphragmatic surface of the heart. It forms the anterior wall of the heart in a region from approximately 2-3 inches from the left border of the sternum from the third to the fifth intercostal space.
The right atrium forms the right border of the heart. Its anterior surface is on the right side of the sternum from approximately the third rib to the sixth rib.
The left lung is displaced away from the sternum on the left side by the presence of the heart.
how many cranial nerves are involved in the sensory innervation of the external ear?
Four cranial nerves are involved in the sensory innervation of the external ear. The auriculotemporal nerve (branch of V3) and the great auricular nerve (branch of the cervical plexus) supply sensation to the majority of the external ear. The region of the concha and external auditory canal receives contributions from the VIIth, IXth, and Xth cranial nerves.
An obstetrician administers a pudendal nerve block to his patient in labor by injecting the nerve as it enters the pudendal (Alcock’s) canal. The patient, however, continues to complain of extreme pain, gesturing to the anterior part of her perineum, as her contractions continue. What additional nerve or nerves does the obstetrician need to anesthetize?
Genital branches of the ilioinguinal nerve (L1), supplying the perineum through the inguinal canal, and the genitofemoral nerve (L1-2), supplying the perineum from the inferior anterior abdominal wall, are injected along the lateral margins of the labia majora. This injection also anesthetizes the small perineal branch of the posterior cutaneous nerve of the thigh, also innervating this region. The iliohypogastric nerve (T12, L1) does not supply the perineum and the inferior rectal nerve is a branch of the pudendal nerve (S2-4), already blocked. The perineal nerve and dorsal nerve of the clitoris are branches of the pudendal nerve. The posterior labial nerves are branches of the perineal nerve.
median nerve injury in cubital fossa causes?
The median nerve would be cut by a laceration here and would cause a paralysis of the muscles of the thenar eminence that effect opposition of the thumb - opponens pollicis and flexor pollicis brevis.
Which of the following muscles originates from the outer surface of the alveolar margins of the maxilla and mandible opposite the molar teeth, and from the pterygomandibular ligament?
buccinator
Which of the following structures contributes to the amplification of sound in hearing?
ossicles
how many layers of the uterus?
The uterus is defined by three distinct layers. The layers are the serosa, the myometrium, and the endometrium. The serosa is the outer connective tissue cover and is shiny and tough. It also gives strength and shape. The myometrium is the inner layer that is composed of muscle fibers that run longitudinally. These fibers act under the influence of estrogen to contract and relax (peristaltic motion) to move the sperm up the reproductive tract. The third and innermost layer, the endometrium, is composed of several parts; the stroma, glands and epithelium. The epithelium lines the innermost part of the endometrium. The glands and stroma compromise the area beneath the epithelium and are important to the proper function of the uterus.
The clavipectoral fascia continues upward from the axillary fascia, ensheathes the subclavius, and becomes attached to the clavicle. 3 structures pierce this fascia. Choose the correct combination.
Cephalic vein, thoraco-acromial artery, lateral pectoral nerve
Which of the following muscles is supplied by the abducens nerve?
Rectus lateralis muscle
The submental triangle of the neck is bounded by the body of the hyoid bone inferiorly and by the anterior belly of the digastric muscle of each side. What is the innervation of the anterior belly of the digastric muscle?
The anterior belly of the digastric muscle is supplied by the mylohyoid branch of the inferior alveolar nerve, which is a branch of the posterior division of the mandibular nerve (V3). The posterior belly of the digastric is innervated by a branch of the facial nerve (VII). Both the anterior and posterior digastric muscles are supplied by the cranial nerves and are not innervated by any branches of the cervical or brachial plexuses. The accessory nerve (XI) innervates the trapezius and the sternomastoid muscles.
the area cribosa
Contains the perforations of 10 to 40 uriniferous collecting ducts opening at the apex of the renal papilla situated at the tip of the renal pyramid inside the medulla of the kidney
Paralysis of the teres minor muscle will make it difficult for the patient to do what with their shoulder?
Lateral rotation
The head of the radius is stabilized to the radial notch of the ulna by the
annular ligament
The head of the radius in the radial notch of the ulna
badge over deltoid
supraclavicular nerves
foot muscles
3 x2aBD +1 flex
2
3 x2f plus Add
2
The superficial layer or the first layer consists of the flexor digitorum brevis, abductor hallucis, and the abductor digiti minimi muscles.
The second layer consists of the quadratus plantae and the lumbrical muscles.
The third layer includes the flexor hallucis brevis, adductor hallucis, and the flexor digiti minimi brevis.
The fourth layer, the deepest layer, contains the interossei muscles.
anal triangle?
It is bounded behind by the tip of the coccyx, and on each side, by the ischial tuberosity and the sacrotuberous ligament, overlapped by the border of the gluteus maximus muscle
The ischiorectal fossa is a wedge-shaped space located on each side of the anal canal. The base of the wedge is superficial and formed by the skin. The edge is formed by the junction of the medial and lateral walls. The medial wall is formed by the sloping levator ani muscle and the anal canal. The lateral wall is formed by the lower part of the obturator internus muscle, covered with pelvic fascia. The perineum is diamond-shaped and is bounded anteriorly by the symphysis pubis, posteriorly by the tip of the coccyx, and laterally by the ischial tuberosities. The pelvic diaphragm is formed by levatores ani muscles and the small coccygeus muscles and their covering fasciae. It is incomplete anteriorly, to allow for the passage of the urethra in males and females, and the vagina in females. The anus lies in the midline, with each side possessing the ischiorectal fossa. The skin is supplied by the inferior hemorrhoidal nerve, and the lymph vessels drain into the medial group of the superficial inguinal nodes.
most common obstetrical error in brachial plexus?
Upper brachial plexus palsy (Erb’s palsy) involves C5, C6, and sometimes C7. The mechanism of action is the result of extreme lateral traction on the head of the infant away from the shoulder during the last phase of delivery. Paralysis of the upper roots is the most common obstetrical brachial plexus injury. Complete paralysis may occur with involvement of all of the roots of the brachial plexus. Klumpke’s paralysis, with isolated involvement of the distal roots (C8, T1), occurs in 0.6% of cases. Lower obstetrical brachial plexus palsy occurs as a result of failure to deliver the upper arm before the head in cases of breech delivery with extended arms. This forcible abduction of the arms puts the C8 and T1 nerve roots on the stretch as the infant is delivered.
Continued production of estrogen and progesterone from the corpus luteum of the ovary is essential during the implantation process. The corpus luteum of the ovary (now known as the corpus luteum of pregnancy) is maintained by the secretion of human chorionic gonadotropin from which source
trophoblast
n Human chorionic gonadotropin is produced by the cells of the trophoblast cells, which blocks the degeneration of the corpus luteum, allowing it to continue to produce steroids essential to facilitate the implantation process in the uterine endometrium, at least for the first 10-12 weeks of embryonic development. The embryoblast cells subsequently divide to form a bilaminar germ disc consisting of the hypoblast (endoderm) and epiblast (ectoderm).
What is the function of the M. peroneus longus?
plantarflexion and eversion
The external conjugate diameter of the pelvis
Is a measurement made from symphysis pubis to the tip of the fifth lumbar spine
stomach cells?
The vagus nerve directly stimulates:
1. parietal cells to secrete hydrogen ions
2. G cells in the antrum to secrete gastrin
3. chief cells, that produce pepsinogen
4. mucous-secreting cells, which are involved in the mucous barrier that protects the gastric mucosa
Receptive relaxation is a vagovagal reflex involving both the afferent and efferent limbs of the vagus nerve. Interruption of the vagus nerve abolishes this reflex. In this reflex, when the food reaches the lower esophagus, the distention of the esophagus causes the normally tight lower esophageal sphincter to open. At the same time it also causes the proximal part of the stomach to relax.
G cells can only affect gastric secretion of hydrogen ions and not receptive relaxation in the stomach.
Chief cells produce pepsinogen, which gets converted to pepsin, an enzyme involved in digestion of protein. It has no effect on gastric secretion of acid or on gastric motility.
Secretin is a hormone secreted in the duodenum. It goes decrease gastric hydrogen ion secretion by inhibiting the effect of gastrin on the parietal cells, but has no effect on gastric motility.
Somatostatin is an inhibitory hormone secreted by endocrine cells of the GI mucosa and delta cells of the endocrine pancreas. It inhibits secretion of GI hormones like gastrin, cholecystokinin, secretin etc.
Calcitonin is a thyroid hormone that inhibits gastrin secretion.
What is the area called that is responsible for a majority of epistaxis? nosebleeds?
ophthalmic branch of the internal carotid artery, and other arteries here - see
Kiesselbach’s plexus (Little’s area)
Kiesselbach’s plexus also know as Little’s area, is a rich anastomosis on the anterior septum. The arteries that join to form the Kiesselbach’s plexus are the ophthalmic branch of the internal carotid artery, which branches into the anterior and posterior ethmoidal arteries, supplying the superior posterior septum. The internal maxillary branch of the external carotid artery branches into the sphenopalatine supplying the posterior septum. These and the superior labial branch of the facial artery supply the vestibule and lower anterior septum. Ninety percent of all nosebleeds occur at the Kiesselbach’s plexus. Arteriosclerosis does seem to predispose an individual to anterior or posterior epistaxis even though the association remains unexplained.
Surgical resection of the ascending colon and terminal ileum (A) and establishment of an ileotransverse colostomy (B), seen on the Barium-enema radiograph, was a preferred treatment for Crohn’s Disease. Which peritoneal structure provides a primary support for the resulting colostomy and the left colic flexure, indicated by the asterisk?
The phrenicocolic ligament attaches the left (splenic) colic flexure to the undersurface of the diaphragm. The true mesentery, attaching the ileum and jejunum to the posterior abdominal wall, would have been cut during the surgery to free and excise the distal ileum and its remnant would not be a strong supporting structure for the area of bowel indicated. The Ligament of Treitz supports the fourth part of the duoedenum and duodenojejunal juncture, not the left colic flexure. The right, not the left, colic flexure is variably connected to the liver by an extension of the right coronary or hepatoduodenal ligaments known as the hepatocolic ligament. The gastrocolic ligament is a part of the greater omentum extending from the greater curvature of the stomach to the transverse colon and would play no role in supporting the left colic flexure, although the underlying transverse mesocolon would contribute to supporting this area.
Which part of the facialis nerve can be seen if the tympanic membrane is very thin?
The chorda tympani, as part of the facialis nerve, can be observed with an otoscope if the tympanic membrane is very thin, hence translucent. It crosses the malleus and the tympanic membrane. The chorda tympani means “string of the tympanic cavity.”
Which statement regarding the blastocyst is correct?
he zona pellucida degenerates on day five. Its disappearance results from enlargement of the blastocyst and degeneration caused by enzymatic lysis. The lytic enzymes are released from the acrosomes of the many sperms that surround and partially penetrate the zona pellucida.
The blastocyst attaches to endometrial epithelium(day 6). The trophoblast begins to differentiate into two layers, syncytiotrophoblast and cytotrophoblast (day 7). The syncytiotrophoblast erodes endometrial tissues (capillaries, glands, stroma) and the blastocyst starts to embed in the endometrium (day 8). Blood-filled lacunae appear in the syncytiotrophoblast (day 9).
Which tendons insert on the first metatarsal bone?
Peroneus longus and tibialis anterior
Tibialis anterior is the main dorsiflexor of the ankle, and also assists with foot inversion. It is located on the anterior aspect of the leg. Its tendon descends over the front of the ankle, and continues over the dorsum of the foot onto the medial side. There it inserts on the medial cuneiform and first metatarsal.
Tibialis posterior is the main invertor of the foot and also assists with plantar flexion of the ankle. It is located deep inside the calf. Its tendon descends on the medial side of the ankle, passes behind the medial malleolus, and continues onto the foot. It inserts primarily on the navicular bone, but also sends slips to the cuboid, cuneiforms, and 2nd-4th metatarsals.
Peroneus longus and peroneus brevis are the main evertors of the foot, and also assist with plantar flexion of the ankle. They are located on the lateral side of the leg. Their tendons descend together on the lateral side of the ankle, passing behind the lateral malleolus, and continuing forward along the lateral surface of the calcaneus. Peroneus brevis inserts on the tuberosity of the fifth metatarsal. Peroneus longus crosses the cuboid bone, travels in a groove on the cuboid’s plantar surface, and continues medially across the sole of the foot to insert on the medial cuneiform and first metatarsal.
Flexor hallucis longus is primarily a plantar flexor of the big toe; it also assists with plantar flexion of the ankle. It is located deep inside the calf. Its tendon descends on the medial side of the ankle, alongside that of tibialis posterior. After passing behind the medial malleolus, it continues onto the sole of the foot and inserts on the distal phalanx of the big toe.
Extensor hallucis longus is a dorsiflexor of the big toe and also assists with ankle dorsiflexion. It is located on the anterior aspect of the leg. Its tendon descends on the anterior aspect of the ankle and continues onto the dorsum of the foot, inserting on the distal phalanx of the big toe.
The main plantar flexors of the ankle are the gastrocnemius and soleus muscles, located in the posterior calf. They join to form a common tendon, the Achilles tendon, which descends on the posterior aspect of the ankle to insert on the calcaneal tuberosity.
Flexor digitorum longus plantar flexes the 2nd-5th digits and also assists with ankle plantar flexion. It is located deep inside the calf, its tendon running alongside those of tibialis posterior and flexor hallucis longus. On the sole of the foot, the tendon separates into 4 divisions, which insert on the distal phalanges of the 2nd-5th digits.
Extensor digitorum longus dorsiflexes the 2nd-5th digits and also assists with ankle dorsiflexion. It is located on the anterior aspect of the leg. It gives rise to 5 tendons, which descend on the anterior aspect of the ankle and continue onto the dorsum of the foot. 4 of these tendons insert on the distal phalanges of the 2nd-5th digits. The fifth tendon (peroneus tertius) inserts on the fifth metatarsal; it is not a toe dorsiflexor, but assists with ankle dorsiflexion and foot eversion.
posterior cord of brachial plexus gives rise to? LATS< shoulder, etc
From the posterior cord arises the upper and lower subscapular nerves, articular branches to the shoulder, radial and axillary nerves, and the thoracodorsal nerve, which innervates the latissimus dorsi muscle.
The valve of Thebesius
Is a semicircular fold of the lining membrane of the right atrium, protecting the orifice of the coronary sinus. It prevents the regurgitation of blood into the sinus during the contraction of the auricle. This valve is occasionally double
The cubital fossa is a triangular space below the elbow crease. It is bounded laterally by an extensor muscle, the brachioradialis, and medially by a flexor muscle, the pronator teres. It has three chief contents. What is the correct relationship of these structures from medial to lateral?
Median nerve, brachial artery, biceps tendon
Argyll Robertson pupils
late-stage syphilis, a disease caused by the spirochete Treponema pallidum. Neurosyphilis occurs due to an invasion of the cerebrospinal fluid (CSF) by the spirochete which likely occurs soon after the initial acquisition of the disease
(AR pupils) are bilateral small pupils that reduce in size on a near object (i.e., they accommodate), but do not constrict when exposed to bright light (i.e., they do not react to light).
There are two cranial nerves that innervate the tongue and are used for taste: the facial nerve (cranial nerve VII) and the glossopharyngeal nerve (cranial nerve IX).
the lingual branch of the trigeminal nerve (cranial nerve V) carries pain, tactile, and temperature
The hypoglossal nerve is the twelfth cranial nerve, and innervates all the extrinsic and intrinsic muscles of the tongue, except for the palatoglossus which is innervated by the vagus nerve.[a] It is a nerve with a solely motor function. The nerve arises from the hypoglossal nucleus in the medulla as a number of small rootlets, passes through the hypoglossal canal
baroreceptor
The carotid sinus baroreceptors are innervated by the sinus nerve of Hering, which is a branch of the glossopharyngeal nerve (IX cranial nerve). The glossopharyngeal nerve synapses in the nucleus tractus solitarius (NTS) located in the medulla of the brainstem.
what runs thru the parotid gland?
The facial nerve and its branches pass through the parotid gland, as does the external carotid artery and retromandibular vein. The external carotid artery forms its two terminal branches within the parotid gland: maxillary and superficial temporal artery. The gland usually contains several intraparotid lymph nodes.
pick up at 54 to 200
and then need to do
and pharangeal arches
