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My ESA4 > Applied Head & Neck > Flashcards

Applied Head & Neck Flashcards

0
Q

What nerve supplies muscles of facial expression?

A

Facial nerve CNVII

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1
Q

Which pharyngeal arch do muscles of facial expression originate from?

A

2nd pharyngeal arch

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2
Q

What nerve is the second pharyngeal arch associated with?

A

Facial nerve CN VII

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3
Q

What are the muscles of facial expression?

A

Orbital group- orbicularis oculi, corrugator supercilii, depressor supercilii
Nasal group- nasalis, procerus, depressor septi nasi
Oral group- orbicularis oris, buccinator

Others
Lower group- depressor annuli oris, depressor labii inferioris, mentalis, Upper group- risorius, zygomatticus major and minor, levator labii superioris, levator labii superioris alaeque nasi, levator anguli oris

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4
Q

What is the action of the orbicularis oculi?

A

Orbital part- closes eye lid more forcefully

Palpebral part- closes eye lid

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5
Q

What is the action of corrugator supercilii?

A

Draws eyebrows together forming the vertical wrinkles at the bridge of the nose

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6
Q

What is the action of the depressor supercilii?

A

Depresses the eyebrow

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7
Q

What is the action of the nasalis?

A

Transverse- compresses the nares

Alar- opens nares

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8
Q

What is the action of procerus?

A

Pulls eyebrows down to produce transverse wrinkles over the nose

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9
Q

What is the action of depressor septor nasi?

A

Opens nares

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10
Q

What is the action of orbicularis oris?

A

Purses lips

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11
Q

What is the action of the buccinator?

A

Pulls cheek inwards against teeth preventing the accumulation of food in that area
Blows up cheeks

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12
Q

How may an individual with facial nerve palsy present as a result of the muscles of facial expression not functioning?

A

Cannot close eyelids - cornea dry out - exposure keratitis
Lower eyelid drops - ectropion - accumulation of lacrimal fluid in lower eyelid; it does not spread across the surface of the eye - failure to remove debris and ulceration of corneal surface
Difficulty eating - food collecting in space between cheeks and teeth
Tissue around cheeks and mouth sags - drawn across to opposite side while smiling

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13
Q

Which pharyngeal arch are the muscles of mastication derived from?

A

First pharyngeal arch

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14
Q

Which nerve supplies the muscles of mastication?

A

Mandibular nerve (branch of Trigeminal nerve CNV)

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15
Q

What nerve is the first pharyngeal arch associated with?

A

Mandibular nerve (branch of Trigeminal nerve CNV)

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16
Q

What are the muscles of mastication?

A

Masseter
Temporalis
Medial pterygoid
Lateral pterygoid

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17
Q

What is the action of the masseter muscles?

A

Elevates the mandible closing the jaw

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18
Q

What are the action of the Temporalis muscle?

A

Elevates the mandible closing the mouth

Retracting the mandible pulling jaw posteriorly

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19
Q

What is the action of the medial pterygoid muscle?

A

Elevates the mandible closing the mouth

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20
Q

What is the action of the lateral pterygoid?

A

Protracts the mandible, pushing the jaw forwards

Side to side movement of jaw

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21
Q

What are the extraocular muscles?

A

Levator palpebrae superioris
Recti muscles - superior rectus, inferior rectus, medial rectus and lateral rectus
Oblique muscles - superior oblique and inferior oblique

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22
Q

What innervates levator palpebrae superioris?

A

Oculomotor nerve CNIII

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23
Q

What is the action of levator palpebrae superioris?

A

Elevates upper eyelid

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24
Q

What innervates superior rectus, inferior rectus and medial rectus muscles?

A

Oculomotor nerve CNIII

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25
Q

What is the action of superior rectus?

A

Elevation of eyeball

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26
Q

What is the action of inferior rectus?

A

Depression of eyeball

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27
Q

What is the action of medial rectus?

A

Adducts eyeball

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28
Q

What is the innervation of the lateral rectus?

A

Abducens nerve CNVI

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29
Q

What is the action of the lateral rectus?

A

Abducts the eyeball

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30
Q

What is the innervation of superior oblique?

A

Trochlear nerve CNIV

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31
Q

What is the action of the superior oblique?

A

Depresses, abducts and medially rotates eyeball

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32
Q

What is the innervation of the inferior oblique?

A

Oculomotor nerve CNIII

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33
Q

What is the action of the inferior oblique?

A

Elevates, abducts and laterally rotates eyeball

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34
Q

Where is the Temporalis muscle found? What is it covered by and how is this clinically significant?

A

Temporal fossa in lateral skull
Covered by a tough fascia
Can be harvested surgically and used to repair a perforated tympanic membrane (myringoplasty)

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35
Q

What is the most common non traumatic cause of facial paralysis?

A

Inflammation of the facial nerve near its exit from the cranium at the stylomastoid foramen
Inflammation causes oedema and compression of the nerve (Bells palsy) in the intracranial facial canal

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36
Q

What are three common causes of facial nerve palsy?

A

Inflammation of facial nerve near its exit from the cranium at the stylomastoid foramen (Bells palsy) due to infection
Damage to superficial branches of facial nerve in wounds, cuts and in child birth
Damage to parotid gland/ parotitis as facial nerve passes through the parotid gland

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37
Q

How may parotid gland disease present besides facial nerve palsy?

A

Pain in auricle of ear, external acoustic meatus, temporal region and TMJ

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38
Q

Where can the pulse of the facial artery be palpated?

A

As the artery winds around the inferior border of the mandible

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39
Q

Why must we compress more than one artery when the facial artery is lacerated?

A

As the facial artery has many anastamoses with other arteries of the face

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40
Q

What are the two main muscle groups found in the neck and what are they found in relation to?

A

Suprahyoid and infrahyoids

In relation to the hyoid bone

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41
Q

What is the main action of all the suprahyoid muscles?

A

Elevates the hyoid bone - initiating swallowing

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42
Q

What are the four suprahyoid muscles?

A

Stylohyoid
Digastric
Mylohyoid
Geniohyoid

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43
Q

What nerve supplies Stylohyoid?

A

Facial nerve CNVII

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44
Q

What nerve supplies digastric?

A

Anterior belly- Trigeminal nerve CNV

Posterior belly- Facial nerve CNVII

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45
Q

What nerve supplies mylohyoid?

A

Trigeminal nerve CNV

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46
Q

What nerve supplies geniohyoid?

A

C1 roots that run with the hypoglossal nerve

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47
Q

What is the main action of the infrahyoids?

A

Depresses the hyoid bone (or thyroid cartilage- sternothyroid)

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48
Q

What are the four infrahyoids?

A

Sternohyoid
Sternothyroid
Omohyoid
Thyrohyoid

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49
Q

What innervates sternohyoid?

A

Anterior rami of C1-C3 (ansa cervicalis branch)

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50
Q

What innervates sternothyroid?

A

Anterior rami of C1-C3 (ansa cervicalis branch)

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51
Q

What innervates omohyoid?

A

Anterior rami of C1-C3 (ansa cervicalis branch)

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52
Q

What innervates thyrohyoid?

A

Anterior ramis of C1 (with hypoglossal nerve)

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53
Q

What are the two main fascial layers of the neck?

A

Superficial cervical fascia

Deep cervical fascia

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54
Q

What does the superficial cervical fascia comprise of?

A

Skin and subcutaneous fat

Containing: cutaneous nerves, blood/lymphatic vessels, superficial lymph nodes, fat, platysma

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55
Q

What are the 3/4 layers of the deep cervical fascia?

A

Investing layer of fascia
Prevertebral fascia
Pretracheal fascia
Carotid sheath (comprised of all three fascia above)

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56
Q

What is found contained within the investing layer of fascia?

A

Trapezius
SCM
Submandibular and parotid salivary glands

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57
Q

What is found contained within the prevertebral fascia?

A

Vertebra (base of skull to T2/3)

Muscles surrounding the vertebra

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58
Q

What is found contained within the pretracheal fascia?

A

Visceral part- Thyroid, oesophagus and trachea

Muscular part- muscles surrounding the visceral part

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59
Q

What is found contained within the carotid sheath fascia?

A

Common carotid artery
Internal jugular vein
Vagus nerve
Deep cervical lymph nodes

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60
Q

What is the retropharyngeal space? And it’s clinical significance?

A

Potential space between the pretracheal fascia and alar fascia
Manifests in presence of retropharyngeal abscesses
Extends down into mediastinum but not as low as prevertebral/ danger space- potential route of spread of infection to mediastinum

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61
Q

What is the prevertebral/ danger space? And it’s clinical significance?

A

Potential space between the alar fascia and the prevertebral fascia
Extends down into mediastinum lower than retropharyngeal space- potential route of spread of infection to mediastinum

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62
Q

What are the borders of the anterior triangle of the neck?

A

Medial - imaginary Sagittal line down the midline of the body
Lateral - medial/ anterior border of SCM
Superior - inferior border of mandible

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63
Q

What are the borders of the posterior triangle of the neck?

A

Medial/ anterior- lateral/ posterior border of SCM
Lateral/posterior- anterior border of trapezius
Inferior- middle 1/3 of clavicle

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64
Q

What four smaller triangles is the anterior triangle of the neck composed of?

A

Submandibular
Su mental
Carotid
Muscular (omotracheal)

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65
Q

What are the boundaries of the submandibular triangle?

A

Superior- Inferior mandible
Medial- Omohyoid
Lateral- Posterior belly of digastric muscle

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66
Q

What is the contents of the submandibular triangle?

A

Submandibular gland
Submandibular lymph nodes
Hypoglossal and mylohyoid nerves
Parts of facial artery and vein

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67
Q

What are the borders of the submental triangle?

A

Medial- midline of neck
Lateral- omohyoid
Inferior- Posterior belly of digastric muscle

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68
Q

What is the contents of the submental triangle?

A

Submental lymph nodes

Small veins which unite to form anterior jugular vein

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69
Q

What are the boundaries of the carotid triangle?

A

Superior- posterior belly of digastric muscle
Medial- omohyoid
Lateral- SCM

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70
Q

What is the contents of the carotid triangle?

A 
Carotid sheath (CCA- bifurcation, IJV, deep cervical lymph nodes and vagus nerve)
Thyroid
Larynx
Pharynx
Hypoglossal nerve
Spinal accessory nerve
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71
Q

What are the boundaries of the muscular triangle?

A

Medial- posterior belly of digastric muscle
Lateral- omohyoid
Inferior- SCM

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72
Q

What is the contents of the muscular triangle?

A

Sternohyoid
Sternothyroid
Thyroid
Parathyroid

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73
Q

What two triangles is the posterior triangle of the neck made up of?

A

Occipital

Subclavian/ omoclavicular

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74
Q

What is the contents of the occipital triangle?

A 
Spinal accessory nerve 
Trunks of brachial plexus 
Parts of EJV 
Posterior branches of cervical plexus
Cervicodorsal trunk 
Cervical lymph nodes
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75
Q

What is the contents it the subclavian triangle?

A

Third part of subclavian artery
Part if subclavian vein
Suprascapular artery
Supraclavicular lymph nodes

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76
Q

What type of bone is the skull?

A

Flat bone

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77
Q

Describe the composition of the skull bone?

A

Made from 22 discrete bones
Bones joined by fibrous joints- sutures
Trilaminar - inner and outer compact bone, with middle layer of spongy bone - diploe

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78
Q

What is the diploe? What is its function?

A

Spongy bone layer found in the middle of the trilaminar skull bone helps reduce the weight of the cranium- contains lots of bone marrow

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79
Q

What is the function of the skull?

A

Encloses and protects - brain and special sense organs (eyes, ears, vestibular, taste, olfaction)
Creates a specialised environment - in which the brain thrives- cranial cavity
Acts as a site of attachment of muscles and meninges (periosteal layer of dura mater)

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80
Q

What is the viscerocranium?

A

Facial bones - supports the soft tissues of the face and determine facial appearance

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81
Q

What is the neurocranium?

A

Superior aspect of the skull- encloses and protects the brain, meninges and cerebral Vasculature

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82
Q

What is fascia? What are its functions?

A

Connective tissue of the body- undifferentiated tissues of mesenchymal origin
It has many functions
- enveloping all organs
- provides lining to organs
- separates tissues of organs
- provides slipperiness between tissues allowing them to move over one another

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83
Q

What bones are the neurocranium comprised of?

A 
Frontal
Occipital
2 Parietal 
2 Sphenoid
2 Ethmoid
2 Temporal
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84
Q

What bones is the viscera cranium comprised of?

A 
2 Zygomatic 
2 Lacrimal
2 Nasal
Inferior nasal conchae
Palatine
2 Maxilla
Vomer
Mandible
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85
Q

Where is the temporal bone found?

A

Lower lateral walls of the skull
Contains middle and inner portions of ear and is crossed by majority of the cranial nerves
Lower part articulates with mandible at TMJ
Comprised of 5 parts

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86
Q

What are the 5 parts of the temporal bone?

A 
Squamous
Zygomatic process
Tympanic
Petromastoid
Styloid process
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87
Q

Describe the squamous part of the temporal bone

A

Largest part, flat plate like superiorly located
Outer facing surface is convex –> temporal fossa
Lower part is the site of origin of the Temporalis muscle
Articulates with sphenoid bone anteriorly and parietal bone laterally

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88
Q

Describe the zygomatic process of the temporal bone

A

Lower part of the squamous part of the temporal bone
Projects anteriorly - articulating w/ temporal process of zygomatic bone -forms the zygomatic arch which is palpable as cheekbones
One of the processes attachments to the temporal bone forms the articular tubercle - anterior boundary of mandibular fossa, part of TMJ
Masseter muscles attaches some fibres to its lateral surface

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89
Q

Describe the tympanic part of the temporal bone

A

Inferior to the squamous part
Anterior to Petromastoid part
Surrounds external auditory opening - leads to external auditory meatus of the external ear

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90
Q

Describe the Petromastoid part of the temporal bone

A

Posterior most part
Can be split into mastoid and petrous parts
On lateral view- only mastoid part is visible

MASTOID
Mastoid process - inferior projection of bone palpable behind the ear/ SCM attachment
Mastoid air cells- hollowed out area within the temporal bone; act as a reservoir of air - equalising pressure within the middle ear in case of auditory tube dysfunction
PETROUS
Pyramidal shape, base of temporal bone, contains inner ear

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91
Q

Describe the styloid process of the temporal bone

A

Located underneath opening to the auditory meatus

Attachment point for muscles and ligaments - e.g. Stylomandibular ligament of TMJ

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92
Q

What can happen in mastoiditis?

A

Mastoid air cells can become damaged and full of pus as middle ear infections can spread to the mastoid air cells and replicate
This can thus spread to the mastoid process, middle cranial fossa and meninges causing meningitis
Pus must be drained from the air cells - be careful not to damage the facial nerve

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93
Q

What are the main adult sutures found in the skull?

A

Coronal suture
Sagittal suture
Lambdoid suture

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94
Q

In neonates what are the names of the incompletely fused sutures joints?

A

Frontal / Bregma fontanelle

Occipital / Lambda fontanelle

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95
Q

What are the two main causes of cranial fractures?

A

Blunt force

Penetrating trauma

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96
Q

What are some obvious features of cranial fractures?

A

Visible injuries and bleeding

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97
Q

What are some subtle features of cranial fractures?

A

Clear fluid draining from ears and nose (CSF), poor balance, confusion, slurred speech, stiff neck

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98
Q

What areas of the skull are common to be fractured?

A

Pterion
Anterior cranial fossa
Middle cranial fossa
Posterior cranial fossa

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99
Q

What is the Pterion?

A

H shaped junction between the temporal, parietal, frontal and sphenoid bones which forms the thinnest part of the skull

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100
Q

What is the anterior cranial fossa?

A

Depression of the skull formed by frontal, ethmoid and sphenoid bones

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101
Q

What is the ethmoid cranial fossa?

A

Depression formed by sphenoid, temporal and parietal bones

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102
Q

What is the posterior fossa?

A

Depression formed by squamous and mastoid temporal bone and occipital bone

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103
Q

What is an example of a facial fracture? How would an individual present?

A

Maxillofacial fracture/ Le Forts fracture - due to trauma with large amounts of force, affects maxilla bones
Profuse bleeding, swelling, deformity, anaesthesia of skin, fracture of nasal bones

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104
Q

Describe a temporal bone fracture

A

Caused by a very strong blunt trauma
Varied presentation - ear related disorders - vertigo or hearing loss
Damage to facial nerve (as it travels throughout he temporal bone) - paralysis of muscles of facial expression
Bruising around mastoid process
Bleeding from ear

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105
Q

What are the main broad types of cranial fractures?

A

Simple- break in bone / no break in skin
Linear- thin line with out splintering, depression or distortion of bone
Depressed- bone pushed towards brain
Compound- break in/ loss of skin, splintering of bone –> brain injury and bleeding

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106
Q

What is a basal skull fracture?

A

Affects the base of the skull
Presents with bruising behind the ears - Battle’s sign (mastoid ecchymosis)
Presents with bruising around eyes - Raccoons eyes

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107
Q

What is a diastatic fracture?

A

Fracture along the suture line - widening of the suture

Most often in children

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108
Q

Describe three features of the typical vertebra of the cervical spine

A

C3- C6
Triangular vertebral foramen
Bifid spinous processes
Transverse foramina - give passage to vertebral artery, vein and sympathetic nerves

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109
Q

Which of the cervical spine vertebra are atypical?

A

C1, C2 and C7

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110
Q

Describe C1

A

Atlas
No vertebral body
No spinous process
Articular facet anteriorly articulates with dens of the axis
Lateral masses on either side of vertebral arch- attachment for transverse ligament of atlas
Posterior arch- groove for vertebral artery and C1 spinal nerve

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111
Q

Describe C2

A

Axis
Dens/ Odontoid process- extends superiorly from anterior portion of vertebra
Articulates with articular facet of atlas
Medial atlanto-axial joint- rotation of head independent of torso

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112
Q

Which joints are unique to the cervical spine?

A

Lateral atlanto-axial joint
Medial atlanto-axial joint
Atlanto-occipital joint

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113
Q

Which joints are present throughout the spine that are not unique to the cervical spine?

A

Joint of vertebral bodies

Vertebral arch joints

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114
Q

What ligaments are unique to the cervical spine?

A

Nuchae ligament - C7 upwards, continuation of supraspinous ligaments, attaches tips of spinous processes
Transverse ligament of the atlas - attaches lateral masses of atlas- anchors dens in place

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115
Q

What ligaments are present throughout the spine, that are not unique to the cervical spine?

A 
Interspinous ligament (adjacent spinous processes)
Anterior and posterior longitudinal ligaments (anterior and posterior vertebral bodies)
Ligamentum flavum (adjacent laminae)
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116
Q

Where do the spinal nerves exit the cervical spine from?

A

Extend from above respective vertebrae through intervertebral foramen created by joints at articular processes
C7 is an exception- has spinal nerves extending above (C7) and below (C8)
So there are 8 cervical nerves with 7 cervical vertebra

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117
Q

Describe C7

A

Prominent spinous process, not bifid (easily palpable)
Large transverse process
Vertebral artery runs around vertebra instead of passing through transverse foramen

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118
Q

Describe a Jefferson fracture of the atlas bone

A

Vertical fall on extended neck (diving into shallow water)
Compresses lateral masses of atlas between occipital condyles and atlas - fractures half of anterior or posterior arches
Transverse ligament of atlas may also be damaged
Unlikely C1 damage- as the vertebral foramen is large - but damage down the column is likely

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119
Q

Describe the hyperextension (whiplash) injury

A

Anterior longitudinal ligament damaged in minor injury
Any cervical vertebrae can be fractures in severe injury
Unlikely spinal nerve damage as vertebral foramen is large
Worst case- subluxation/ dislocation of C2/C3 or C6/C7
Causes quadriplegia and death- affects phrenic nerve which supplies diaphragm- important in breathing

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120
Q

Describe hangmans fracture

A

Sudden deceleration
Fracture of pars interarticularis (bony column between superior and inferior articular facets of axis (C2))
Lethal injury - fracture fragments/ force –> rupture spinal cord - deep unconsciousness, resp and cardiac failure and death

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121
Q

Describe fracture to the dens

A

In traffic collisions or falls
High risk of avascular necrosis (isolation of distal fragment from any blood supply)
Long healing time- may have spinal cord involvement (low risk)

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122
Q

What does potential space (as applied to fascial planes of the neck) indicate?

A

Adjacent fascial compartments of the neck are normally so close to one another as to be adherent
And normally there are no anatomical spaces between tissues
Blood from perforated vessels or pus from infections can collect in these potential spaces making them into actual spaces

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123
Q

Why is it important to know about the fascia in the neck?

A

Allows us to understand how infections or metastases may spread in the neck from one site to another

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124
Q

In new born babies how and why may the SCM become damaged?

A

In forceps delivery- compression damage of SCM or being pulled in a difficult birth

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125
Q

How may a baby with SCM damage present? What is this called?

A

Head will be slanted and rotated towards side of affected muscle - due to SCM being in a spasm
This is called true torticollis

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126
Q

How may a baby with damage to the spinal accessory nerve present ?

A

Head rotated and tilted to normal side, due to unopposed action of functioning SCM muscle

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127
Q

What actions does the SCM do?

A

Rotation of the neck and tilting to the side

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128
Q

What nerve innervates the SCM?

A

Spinal accessory nerve CNXI

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129
Q

What action does the platysma do?

A

Grimace

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130
Q

What nerve innervates platysma?

A

Facial nerve CNVII

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131
Q

What action does the trapezius do?

A

Shrug

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132
Q

What innervates the trapezius?

A

Spinal accessory nerve CNVII

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133
Q

What consequence during may result from a relatively small mastoid process?

A

Mastoid air cells don’t develop until the 2nd/3rd years- small mastoid process leaves facial nerve exposed as it leaves for the stylomastoid foramen- superficially placed nerve can be damaged in forceps delivery
Children with significantly smaller mastoid cells are more often susceptible to complications of glue ear

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134
Q

What is the Antrum of the facial skeleton?

A

Maxillary sinus

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135
Q

What is Paget’s disease and it’s affect on the skull?

A

Rapid irregular and exaggerated reabsorption and replacement of bone, causing thickening, swelling and increased vascularity often with severe pain
When skull is involved, it slowly enlarges
Mandible and maxilla enlarge, maxilla at a faster rate so that adjustment of dentures occurs
Teeth may become displaced and become fused with bone; oral surgery may become complicated by sever haemorrhage

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136
Q

Why may a fracture of the lower mandible cause numbness of the lower lip?

A

Fracture may easily involve the inferior alveolar nerve that lies within the bone. It’s terminal branches exit the mandible via the mental foramen where they supply the mucous membrane of the lower lip and chin. The numbness is reminiscent of what happens following an inferior alveolar nerve block while undergoing dental treatment.

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137
Q

What’s the difference between the retropharyngeal space and the prevertebral/ danger space?

A

Retropharyngeal space is anterior to the alar fascia and ends more superiorly than the prevertebral space
The prevertebral space is posterior to the alar fascia and extends right the way down to the mediastinum

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138
Q

In what three ways can you treat a supra ventricular tachycardia? (SVT)

A

Carotid sinus massage- stimulates the spinal accessory nerve which has a reflex arc to the vagus nerve stimulating that- only on one side otherwise person may faint
Cold water- dunk kids head in an ice bucket stimulating the vagus nerve
Valsalver manoeuvre reflex-expirate against a closed glottis- blow into a syringe; increases intrathoracic pressure- increases blood flow to the area- stretches walls and baroreceptors and stimulates vagus nerve

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139
Q

What may cause facial nerve palsy?

A

Trauma and difficult birth
Tumour
Parotitis
Infection in general- Bell’s palsy

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140
Q

What are the three main types of haemorrhage in the head?

A

Extradural haematoma
Subdural haematoma
Subarachnoid haematoma

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141
Q

On which side of the body is the brachiocephalic trunk found?

A

Right

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142
Q

What are the divisions of the brachiocephalic trunk?

A

Right common carotid artery

Subclavian artery

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143
Q

What are the three main branches of the subclavian artery?

A

Thyrocervical trunk
Vertebral arteries
Internal thoracic artery

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144
Q

What does the subclavian artery continue as?

A

Axillary artery

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145
Q

What are the four main branches of the the thyrocervical trunk?

A

Suprascapular artery
Ascending cervical artery
Transverse cervical artery
Inferior thyroid artery

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146
Q

At what level does the bifurcation of the brachiocephalic trunk occur?

A

At level of the sternoclavicular joint

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147
Q

How does the common carotid artery ascend up the neck? Does it give any branches?

A

Ascends laterally to the oesophagus and trachea and gives off NO branches in the neck

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148
Q

At what level does the bifurcation of the common carotid artery occur and in what region?

A

Superior margin of thyroid cartilage (C4)

Carotid triangle

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149
Q

What is the significance of the arteries in the carotid triangle?

A

Bifurcation of the CCA into ICA and ECA
CCA and ICA are slightly dilated in this region- carotid sinus, has baroreceptors which detect changes in blood pressure here- carotid sinus massage
Outside the arteries in the region, there are peripheral chemoreceptors which detect changes in pO2 of the blood

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150
Q

Which of ICA and ECA sits more anteriorly?

A

ECA

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151
Q

How do the vertebral arteries ascend through the neck into the head and what do they supply?

A

Arise from the subclavian arteries - medial to anterior scalene muscles
Ascend up posterior neck through transverse foramina in cervical vertebra
Enter the cranial cavity via foramen magnum / carotid canal
Give rise to basilar arteries which supply the brain
Give off no branches to the neck or extracranial structures)

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152
Q

What are the 6 branches of the external carotid artery?

A 
Posterior auricular artery
Lingual artery
Occipital artery
Ascending pharyngeal artery
Facial artery 
Superior thyroid artery
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153
Q

What are the two terminal branches of ECA?

A

Superficial temporal artery

Maxillary artery

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154
Q

How does the ECA travel up the neck?

A

Travels up the neck posterior to the mandible and anterior to the lobule of the ear

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155
Q

Where does the ECA terminate and divide into its terminal branches?

A

Parotid gland

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156
Q

What does the ICA broadly supply?

A

Brain, eyes and forehead within the cranial cavity

Does not supply any structures in the neck

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157
Q

Where does the ICA enter the cranial cavity?

A

Via carotid canal in the petrous part of the temporal bone

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158
Q

What artery supplies the deep and superficial muscles/ structures of the face?

A

ECA via PLOAFS

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159
Q

What artery supplies the brain, eyes and forehead region (within the cranial cavity)?

A

Internal carotid artery

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160
Q

What are the two terminal branches of the ICA?

A

Superorbital artery

Supertrochlear artery

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161
Q

What artery supplies the neck?

A

Subclavian artery via thyrocervical trunk and 3 of its branches

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162
Q

What arteries supply the scalp?

A

Branches of ECA - posterior auricular, occipital, superficial temporal)
Branches of ICA - superorbital and supertrochlear

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163
Q

What are the 5 layers of the scalp?

A 
Skin
Connective tissue
Aponeurosis
Loos connective tissue
Periosteum
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164
Q

What arteries supply the thyroid gland?

A

Inferior thyroid artery from TCT

Superior thyroid from ECA

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165
Q

What supplies the posterior prevertebral muscles?

A

Inferior thyroid artery gives rise to the ascending cervical artery which supplies them

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166
Q

What supplies the trapezius and rhomboid muscles?

A

Transverse cervical artery from TCT

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167
Q

What supplies the posterior shoulder area?

A

Suprascapular artery

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168
Q

What is the consequence of having hypersensitive baroreceptors in the carotid triangle region?

A

In some people baroreceptors are hypersensitive to touch and stretch
So when an external pressure is applied on the carotid sinus–> slowing HR and lowering BP occurs
Brain therefore becomes under perfused
And syncope can result
Therefore it is not advised to check pulses at the carotid triangle

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169
Q

What artery supplies the skull and the dura mater?

A

ECA - maxillary artery - middle meningeal artery

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170
Q

In what injury can the middle meningeal artery be damaged? And what are the sequelae?

A

Fracture at the Pterion (weakest point)- completely lacerated MMA
Blood collects between the dura mater and the skull
Dangerous increase in intracranial pressure - extradural haematoma
Symptoms of nausea, vomiting, seizures, bradycardia, limb weakness
Treated by diuretics (minor) and draining burr holes (major)

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171
Q

When an artery supplying the scalp is damage why is there excessive bleeding?

A

Walls of arteries are tightly and closely bound to the undying connective tissue of the scalp- preventing them from constricting to limit blood loss following injury or laceration
Numerous anastamoses formed by arteries produce a very densely vascularised area
Deep lacerations can involve epicranial aponeurosis - worsened by opposing pulls of occipital and frontalis muscle

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172
Q

Describe atherosclerosis of the carotid arteries

A

Swelling and bifurcation of CCA produces turbulent blood flow in this region
Increases the risk of atheroma (ICA more susceptible than others)
Mild- headache, dizziness, muscular weakness
Severe- stroke/ cerebral Ischaemia

Doppler study- can assess the severity of the thickening
Severe cases- artery opened and atheroma removed - CAROTID ENDATERECTOMY

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173
Q

What is a craniotomy?

A

Gain access to the cranial cavity - bone and scalp flax reflected inferiorly to preserve blood supply

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174
Q

Describe the venous drainage of the scalp and face

A

Face drained by superficial temporal and maxillary veins which drain into posterior auricular vein and retromandibular vein
Posterior auricular vein and retromandibular veins unite to form EJV
Receives tributary veins- posterior external jugular, transverse cervical and suprascapular veins

Sigmoid sinus continues as IJV
Receives tributary veins- facial, lingual, occipital, superior, middle thyroid veins draining blood from face, trachea, thyroid, oesophagus, larynx and neck muscles

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175
Q

Describe the course of EJV

A

EJV is a continuation to posterior auricular vein and retromandibular vein
EJV descends down the neck within the superficial fascia
Runs anterior to SCM crossing it in an oblique, posterior and inferior direction
At the root of the neck the vein passes under clavicle
Vein terminates by draining into the subclavian vein

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176
Q

Describe the course of the IJV

A

Begins in cranial cavity as a continuation of sigmoid sinus
The initial part is dilated (superior bulb)
Vein exits the skull via the jugular foramen and descends within the carotid sheath, deep to SCM and lateral to CCA
At the bottom of the neck, posterior to sternal end of the clavicle - IJV combines with SCV to form the brachiocephalic vein
End part is dilated (inferior bulb) - has a valve that stops the back flow of blood

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177
Q

Describe the venous drainage of the neck

A

Anterior jugular vein- drains anterior neck, communicates with jugular venous arch and descends down the midline of the neck into the subclavian artery

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178
Q

Describe venous drainage of the brain and meninges

A

Via dural venous sinuses which drain into the IJV

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179
Q

What are dural venous sinuses?

A

Spaces between periosteal and meningeal layers of the dura mater - lined by endothelial cells
They collect blood from veins that drain the brain and bony skull
And drain into IJV

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180
Q

How can the EJV be damaged?

A

Severance of the EJV
EJV has a superficial course down the neck which makes it vulnerable to damage
In a knife slash- lumen is opened and held open - due to a thick layer of investing fascia
Air can be drawn into the veins producing cyanosis and stopping blood flow through the right atrium
It can be a medical emergency managed by application of pressure to the wound, stopping bleeding and entry of air
Air embolism

181
Q

What is jugular venous pressure?

A

IJV can be observed for pulsations - estimates RA pressure
When the heart contracts pressure wave passes upwards which can be observed
No valves in the brachiocephalic trunk or subclavian vein and so pulsations are fairly accurate indication of RA pressure

182
Q

What are the cavernous sinuses and where are they located?

A

Clinically important pair of dural sinuses, located next to the lateral aspect of the body of the sphenoid bone

183
Q

Where does the cavernous sinuses originate from?

A

Sinus receives blood from the superior and inferior opthalmic veins, middle superficial cerebral veins and from the sphenoparietal sinus

184
Q

What structures are found within the cavernous sinus?

A

ICA
Abducens nerve (VI)
In wall of sinus- oculomotor nerve (III), trochlear nerve (IV), opthalmic nerve (Vi) and maxillary nerve (Vii)

185
Q

What is the problem if the cavernous sinus becomes infected?

A

Nerves are at risk of damage

Facial vein is connected to the cavernous sinus via the superior opthalmic vein
Facial vein is valveless so blood can reverse direction and flow from facial vein to cavernous sinus - providing a potential route of infection spread

186
Q

What are the 6 extracranial branches of the facial nerve?

A 
Temporal nerve
Zygomatic nerve
Buccal nerve
Mandibular nerve
Cervical nerve
Posterior auricular nerve
187
Q

Describe the venous drainage of the scalp

A

Superficial temporal, occipital, posterior auricular, superorbital and supertrochlear veins

1) Drain into angular vein at medial angle of the eye and then into the facial vein
OR
2) Drain via the emissary veins into diploid veins of skull into dural venous sinuses (between periosteal and meningeal layers of dura)

188
Q

Describe the venous drainage of the face

A

Facial and superior opthalmic vein
Drain into the cavernous sinus at the medial angle of the eye

Deep facial veins which drain into the pterygoid plexus

189
Q

What are the 8 main lymph nodes of the head?

A 
Occipital nodes
Posterior auricular nodes
Anterior auricular nodes
Parotid nodes
Facial nodes 
Deep facial nodes 
Lingual nodes
Retropharyngeal nodes
190
Q

What are the main 6 lymph nodes of the neck?

A 
Submaxillary nodes
Submental nodes
Anterior cervical nodes
Deep cervical nodes (superior and inferior)
Superficial cervical
191
Q

Where do 6 of the lymph nodes of the head drain to?

A

Occipital, posterior auricular, anterior auricular, parotid, deep facial and retropharyngeal nodes drain to the superior deep cervical nodes
Then to inferior deep cervical nodes
Jugular trunk

192
Q

Where do the facial nodes of the head drain to in the neck?

A

Into the submaxillary nodes
Then to superior deep cervical nodes
Then to inferior deep cervical nodes
Jugular trunk

193
Q

Where do the submental nodes of the neck drain to?

A

To the Submaxillary nodes
Then to the superior deep cervical nodes
Then to inferior deep cervical nodes
Jugular trunk

194
Q

Where do the superficial cervical nodes in the neck drain to?

A

Superficial cervical nodes drain to the superior deep cervical nodes
Then to inferior deep cervical nodes
Jugular trunk

195
Q

Where do all lymph nodes from the head and neck eventually drain to?

A

Jugular trunk

196
Q

What two ducts does the jugular trunk drain to?

A

Right lymphatic duct
And
Thoracic duct

197
Q

What is an example of a superior deep cervical node

A

Jugulodigastric node or tomsillar node

- found in the angle between the lower body of the mandible and anterior border of SCM

198
Q

What is an example of an inferior deep cervical node?

A

Juguloomohyoid node or lingual node

- found in angle between SCM and clavicle

199
Q

What is the lymphatic tree hierarchy?

A 
Lymphatic capillary -->
Lymphatic vessel -->
Lymph node -->
Lymphatic vessel -->
Lymphatic trunk -->
Collecting duct -->
Subclavian vein
200
Q

Where do the right lymphatic duct and the thoracic duct drain into?

A

Subclavian vein

201
Q

Which part of body does the right lymphatic duct drain?

A

Right half of the head, the neck, the trunk of the body and the right upper limb

202
Q

Which part of body does the thoracic duct drain?

A

Left half of the head, the neck, the trunk of the body, the left upper limb and both left and right lower limbs

203
Q

What are two broad categories of nerves?

A

Spinal nerves & Cranial nerves

204
Q

Briefly describe spinal nerves (have been covered previously)

A

Issued from the spinal cord
There are 31 pairs
Supply:
- general motor function to rest of the body
- general sensation to rest of the body
- autonomic functions to the rest of the body
-* NONE HAVE SPECIAL SENSE FUNCTIONS

205
Q

What are dermomyotomes?

A

Embryonic precursors of skin and muscle units
Each one eventually differentiates into skin and muscle in the adult
Develop in relation to a specific neural level of the embryonic neural tube tissue that will become the adult spinal cord
Differentiated skin and muscle units of a dermomyotome will always have a common source of neural supply

206
Q

What are cranial nerves?

A

Issued from the brain
12 pairs - largely bilaterally symmetrical
All axons apart from 2 lie in the PNS - 2 are atypical - they are the brain tracts and not nerves
Supply largely the head and neck region - muscles (efferent), viscera (afferent and efferent), general sensation (afferent) and special sense organs (afferent)
Exit brain from its inferior surface apart from one
Short sections attaching the nerve to the brain are found within the cranium

207
Q

Describe the foramina of the cranium

A

They are holes in the base of the cranium though which nerves and blood vessels pass
Due to them being large- reduce the mass of the cranium, making it lighter; make the skull base physically weak
Trauma to the skull often leads to fractures at the base
Nerves can be compressed as they pass through the foramina
Peripheral nerve diseases and metastases can pass to the brain via the foramina

208
Q

Cranial nerve I

A

Olfactory nerve (not a true nerve- it’s a brain tract)
Sensory
Subserves sense of smell
Derived from prosencephalon

209
Q

How is the CNI tested for?

A

Using smelling salts (coffee, peppermint, vanilla) can be used to reboot the brain after loss of consciousness
Some hallucinations involve sensation of smell without sensory source
Smell tested from each nostril separately

210
Q

What is anosmia?

A

Loss of sense of smell

211
Q

Cranial nerve II

A

Optic nerve
Sensory
Subserves sense of vision
Derived from diencephalon

212
Q

How is CNII tested for?

A

Examination

  • apparatus of eye itself- fundoscopy, visual acuity, colour vision
  • reflexes of pupils
  • connection of retina (eye) to visual cortex

Assessing visual field defects, early signs of meningitis, tumour of hypothalamus (disturbance of vision)

213
Q

Cranial nerve III

A

Oculomotor nerve
Mixed nerve- somatic MOTOR (levator palpebrae superioris muscle of upper eyelid and all extra ocular muscles except superior oblique and lateral rectus); autonomic PS (constrictor pupillae of eye); autonomic S (dilator pupillae of eye)
Subserves movement of eye
Derived from mid brain

214
Q

How is CNIII tested for?

A

Patient asked to look upwards- test elevation of eyelid
Patient asked to look at finger as it moves in Gearbox shape (test for adduction, abduction, elevation and depression)
Shining light in patients eye- should constrict
Shielding light from patients eye- should dilate

215
Q

What is ptosis?

A

Droopy eyelid- seen in patients with damage to CNIII

216
Q

How would a patient with CNIII damage present?

A

Eye would be down and out at rest
Eye would be drooping
Pupil would be dilated

217
Q

Cranial nerve IV

A

Trochlear nerve
Motor
Subserves superior oblique muscle only
Derived from dorsal aspect of midbrain- pons

218
Q

How is CNIV tested for?

A

Ask patient to look downwards and inwards

219
Q

How would patient with CNIV damage present?

A

Patient would look medially and upwards as they would get double vision upon looking downwards and inwards - diplopia

In particular patient would get double vision when going down stairs

220
Q

Cranial nerve V

A

Trigeminal nerve
Largest cranial nerve in the body
Mixed - 3 divisions:
- Vi- Opthalmic- Sensory- supplies scalp forehead, dorsum of nose and upper eyelid and sensations of the eye (cornea and conjunctiva)
- Vii- Maxillary- Sensory- supplies lower eyelid, cheek, upper lip, mucosa of nasal cavity and paranasal sinuses and lining of palate and toots of upper teeth
- Viii- Mandibular- Mixed- Sensory and Motor- skin of temples, cheek, chin, mucosa of inner cheek, anterior 2/3s of tongue and roots of lower teeth muscles of mastication - opening (medial pterygoids and anterior digastric) and closing (Temporalis, masseter and lateral pterygoids)

Derived from pons

221
Q

How is CNVi tested for?

Presentation if damaged?

A

Responsiveness of skin and forehead- soft and sharp touch

Defective corneal reflex - neither eyelid blinks

222
Q

How is CNVii tested for?

Presentation if damaged?

A

Responsiveness of cheek skin to soft and sharp touch (rest of sensory supply not routinely tested)

223
Q

How is CNViii tested for?

Presentation if damaged?

A

Responsiveness to skin of cheek side and over the chin
General sensation in front of the tongue - lingual nerve
Strength of masseter and pterygoids

224
Q

Cranial nerve VI

A

Abducent nerve
Motor
Supplies lateral rectus muscle only
Derived from medulla pontine junction

225
Q

How is CNVI tested for?

Presentation if damaged?

A

Tested with CNIII by asking patient to follow finger making a gearbox shape in the air
Patient unable to look outward - squint on looking outward
Therefore liable to damage in cases of raised intracranial pressure

226
Q

Cranial nerve VII

A

Facial nerve
Mixed nerve:
- Facial nerve - Motor (muscles of facial expression)
- Nervus intermedius - Sensory (general sensation of concha of auricle and behind ear and taste in anterior 2/3 via chorda tympanii)
- Part of Nervus intermedius and Greater Petrosal Nerve- Autonomic (glands- lacrimal, submandibular, sublingual) (mucous membranes- nasopharynx, paranasal sinuses, hard and soft palate)
Derived from medulla pontine junction

227
Q 
How CNVII (facial nerve) tested for? 
Presentation if damaged?
A

Raise eyebrows
Shut your eyes as tight as possible
I’m going to try and open them, don’t let me
Puff out cheeks; Don’t let me squeeze them
Big smile

Loss of facial expression
Loss of sphincter function
Loss of nasolabial fold
Loss of taste in anterior 2/3 of tongue on salivation and lacrimation

228
Q

Bell’s palsy vs facial nerve palsy

A

Bell’s palsy- strangulation of nerve in petrous part of temporal bone - loss of muscles of facial expression and altered sensation
Facial nerve palsy- strangulation outside cranial cavity - only loss of muscles of facial expression

229
Q

Cranial nerve VIII

A

Vestibulocochlear nerve - vestibular nerve (balance) and cochlear nerve (hearing)
Sensory
Derived from medulla pontine junction

230
Q

How is CNVIII tested for?

Presentation if damaged?

A

Simple tests of hearing- whisper something in ear and ask them to repeat it
Rinne’s test and Weber’s test- used to differentiate type of deafness (below)
(Cannot isolate cochlear in terms of balance tests as many other parts of the brain contribute to balance such as cerebellum)

Loss of balance, vertigo, nausea, nystagmus, impairment of caloric response (don’t compare with cerebellar damage- stroke)
Deafness: sensorineural (nerve) conductive (blockage)

231
Q

Cranial nerve IX?

A

Glossopharyngeal nerve
Mixed:
- motor - branchiomotor- stylopharyngeus
- visceromotor/ autonomic/ PSNS- (parotid gland)
- sensory- visceral sensory (carotid body and sinus), pharynx and middle ear
- special sensory- posterior 1/3 of tongue

232
Q

How is CNIX tested for?

Presentation if damaged?

A

Swallowing reflex- ask patient to drink some water

Gag reflex/ pharyngeal reflex - consists of reflex pharyngeal constriction when back wall of oropharynx is touched by non food substances
Loss if taste in posterior 1/3 tongue
Lack of salivation (parotid gland)

233
Q

Cranial nerve X

A

Vagus nerve
Mixed nerve:
- motor - intrinsic muscles of larynx and pharynx, muscles of palate, smooth muscle of bronchi and digestive tract, secretomotor- thoracic and abdominal viscera
- sensory - external ear, auditory canal and ear drum, pharynx and larynx, visceral sensation- thorax and abdomen
Derived from medulla

234
Q

How is CNX tested for?

Presentation if damaged?

A 
Check phonation, cough
Ask them to drink a drink
Sing in high pitched voice 
Inspect soft palate and uvula (any deviation) 
Gag reflex

Right recurrent laryngeal nerve damage - vocal cord on that side slightly adducted - hoarse voice, weak cough and risk of aspiration of fluids
Left recurrent laryngeal nerve damage - in bronchial or oesophageal carcinoma/ enlarged mediastinal lymph nodes or aortic arch

235
Q

Cranial nerve XI

A

Accessory nerve (anatomically has 2 divisions)
Combined divisions exit brain via jugular foramen
Motor
Subserves sternocleidomastoid and trapezius
Derived from spinal cord

236
Q

How is CNXI tested for?

Presentation if damaged?

A

Shrug shoulders I’m going to push them down resist it
Rotate your head and I’m going to push it, resist it
Inspect for wasting SCM and trapezius
Compare 2 sides

Patient will find it difficult to rotate head and shrug shoulder on affected side

237
Q

Cranial nerve XII

A

Hypoglossal nerve
Motor
Supplies muscles of tongue
Derived from Medulla

238
Q

How is CNXII tested for?

A

Stick tongue out, wiggle it from side to side, inspect tongue for wasting and fasisculation
Any deviation? Able to wiggle it?

Damage- dysarthria
Lower motor neurone lesions - tongue deviates to side of weakness

239
Q

What are the 4 general classes of spinal nerves?

A

General somatic afferents (general sensation)
General visceral afferents (visceral sensation)
General somatic efferents (supply skeletal muscle)
General autonomic efferents (autonomic fibres innervating visceral structures)

240
Q

What are the classes of cranial nerves?

A

Those of spinal nerves:
General somatic afferents (general sensation)
General visceral afferents (visceral sensation)
General somatic efferents (supply skeletal muscle)
General autonomic efferents (autonomic fibres innervating visceral structures)

And

Special visceral efferents (muscles derived from branchial arches CNV, VII, IX, X)
Special somatic afferents- equilibration, sight and hearing
Special visceral afferents- taste

241
Q

What is the parasympathetic outflow from the brain and spinal cord?

A

Craniosacral outflow

CNIII,VII, IX, X (only CNS with autonomic supply) and S2,S3 and S4

242
Q

What are the 4 cranial nerves involved in the parasympathetic nervous system?

A

CNIII - oculomotor
CNVII - facial
CNIX glossopharyngeal
CNX - vagus

243
Q

What is the nucleus of the oculomotor nerve (CNIII) in PSNS outflow?

A

Edinger Westphal nucleus

244
Q

What is the preganglionic arrangement of the PSNS outflow from oculomotor nerve (CNIII)?

A

Travels within the motor root of the oculomotor nerve

245
Q

What is the ganglion of the oculomotor nerve (CNIII) in PSNS outflow?

A

Ciliary ganglion

246
Q

What is the postganglionic arrangement of the PSNS outflow from oculomotor nerve (CNIII)? And the target organ?

A

Travels via short ciliary nerves to target:

- Spinchter pupillae and ciliary muscles

247
Q

What is the nucleus of the facial nerve (CNVII) in PSNS outflow?

A

Superior salivatory nucleus

248
Q

What is the preganglionic arrangement of the PSNS outflow from facial nerve (CNVII)?

A

Travels within the greater petrosal nerve and nerve to pterygoid canal
Or
Travels within chorda tympanii a branch of facial nerve

249
Q

What is the ganglion of the facial nerve (CNVII) in PSNS outflow?

A

Ptergyopalantine ganglion
Or
Submandibular ganglion

250
Q

What is the postganglionic arrangement of the PSNS outflow from facial nerve (CNVII)? And the target organ?

A

Hitchhikes on branches of the maxillary nerve to lacrimal glands, nasopharynx, palate and nasal cavity
Or
Fibres travel directly to target organs - submandibular and sublingual glands

251
Q

What is the nucleus of the Glossopharyngeal nerve (CNIX) in PSNS outflow?

A

Inferior salivatory nucleus

252
Q

What is the preganglionic arrangement of the PSNS outflow from glossopharyngeal nerve (CNIX)?

A

Travels within the lesser petrosal nerve

253
Q

What is the ganglion of the Glossopharyngeal nerve (CNIX) in PSNS outflow?

A

Otic ganglion

254
Q

What is the postganglionic arrangement of the PSNS outflow from Glossopharyngeal nerve (CNIX)? And the target organ?

A

Hitchhikes on the auriculotemporal nerve to the parotid gland

255
Q

What is the nucleus of the vagus nerve (CNX) in PSNS outflow?

A

Dorsal Vagal motor nucleus

256
Q

What is the preganglionic arrangement of the PSNS outflow from vagus nerve (CNX)?

A

Travels within the vagus nerve

257
Q

What is the ganglion of the vagus nerve (CNX) in PSNS outflow?

A

Many- located within the target organs

258
Q

What is the postganglionic arrangement of the PSNS outflow from vagus nerve (CNX)? And the target organ?

A

Ganglion is located on target organs (there are no postganglionic nerve fibres)
Smooth muscles of trachea, bronchi and digestive tract

259
Q

Which ganglia are associated with sensory and sympathetic nerves which don’t actually synapse in the PSNS outflow?

A

Ciliary ganglion- sympathetic nerves for internal carotid plexus and sensory fibres from nasociliary nerve
Pterygopalantine ganglion- sympathetic nerves for internal carotid plexus and sensory fibres from maxillary nerve
Submandibular ganglion- sympathetic branches from facial artery plexus
Otic ganglion- sympathetic branches from superior cervical chain

260
Q

What are the four main ganglia of the PSNS important to the H&N region?

A

Ciliary
Pterygopalantine
Submandibular
Otic

261
Q

What are the three main ganglia of the SNS important to the H&N region?

A

Superior cervical
Middle cervical
Inferior cervical

262
Q

Describe the arrangement of the SNS

A

As a general simplification axons of most preganglionic neurones terminate immediately in the para/prevertebral chain of ganglia (sympathetic trunk)
Chain of ganglia extends from base of the skull to coccyx
Fusion of ganglia reduces their number:
- 2/3 cervical (8 cervical neural levels)
- 11 thoracic (12 thoracic neural levels)
- 4 lumbar (5 lumbar neural levels)
- 4 sacral (5 sacral neural levels)
Sympathetic ganglia give rise to 2 sets of branches with 2 destinations
- somatic: travel alongside segmental nerves
- visceral: ganglionated trunks

263
Q

What is the difference between the paravertebral and prevertebral chain of ganglia?

A

Paravertebral- lie alongside the vertebral column bilaterally
Prevertebral- lie anteriorly to vertebral bodies in relation to carotids and anterior to AA (SMA and IMA)

264
Q

At what level is the superior cervical ganglion found?

A

Anterior to C1-C4

265
Q

What arteries does the postganglionic branches of the superior cervical ganglion ascend with into the head?

A

Common, external and internal carotid arteries

266
Q

What are the effector organs of the superior cervical ganglion?

A 
Eyeballs
Face
Nasal gland
Pharynx
Glands in the palate and nasal cavity 
Salivatory gland 
Lacrimal gland
Sweat glands
Pineal gland
Dilator pupillae
Superior tarsal muscle
Carotid body
Heart
Artery smooth muscle
267
Q

At what level is the middle cervical ganglion found?

A

C6

268
Q

What arteries does the postganglionic branches of the middle cervical ganglion ascend with into the head?

A

Inferior thyroid artery

269
Q

What are the effector organs of the middle cervical ganglion?

A 
Larynx
Trachea
Pharynx
Upper oesophagus
Heart
Artery smooth muscle
270
Q

At what level is the inferior cervical ganglion found?

A

C7

271
Q

What arteries does the postganglionic branches of the inferior cervical ganglion ascend with into the head?

A

Vertebral and subclavian arteries

272
Q

What are the effector organs of the inferior cervical ganglion?

A

Heart

Artery smooth muscle

273
Q

Is there sympathetic outflow from the cervical segments of the spinal cord?

A

No- they (superior middle and inferior cervical ganglia) are displaced upper 3 thoracic ganglia from the thoracic sympathetic trunk

274
Q

What two bones articulate at the temporomandibular joint?

A

Mandible and temporal bone

275
Q

At what level is the TMJ found?

A

Anterior and roughly at level of tragus of the ear

276
Q

What type of joint is the TMJ?

A

Synovial

277
Q

What are the articular surfaces of the TMJ?

A

Superior (cranial) articular surface (on under surface of squamous part of temporal bone)

  • -> has 2 articular sites
  • mandibular fossa of temporal bone (medial and concave)
  • articular tubercle of temporal bone (anterior and convex) (aka. eminentia articularis)

Inferior (mandible)
- condyle of the mandible has a rounded superior edge and ellipsoid circumference with its major axis posteromedial

278
Q

What type of cartilage is the TMJ lined with?

A

Fibrocartilage (not hyaline)

279
Q

Describe the articular disc of the TMJ

A

Aka meniscus
Dense fibrous connective tissue
Has same position as fibrocartilage lining the articular surfaces
Intervenes between superior and inferior articular surfaces of bones of TMJ
- upper surface: concave-convex to fit both the mandibular fossa and articular tubercle
- under surface: concave for reception of condyle of the mandible
Thicker at its periphery where it attaches to its articular capsule
Can recoil or stretch a little with movement
Thinner centrally- sometimes almost perforated
Function is to make the articular surfaces congruent (as superior and inferior articular surfaces are morphologically incongruent) and to create 2 cavities within the TMJ- allow for particular movements

280
Q

Describe the capsule of the TMJ

A

Fibrous capsule- very strong but thin to permit movements of the joint
Capsular attachments- superior- circumference of mandibular fossa and articular tubercle // inferior- neck of condyle of mandible
Strengthened by extracapsular ligaments

281
Q

Describe the extracapsular ligaments of the TMJ

A

Temporomandibular ligament

  • laterally placed
  • strongest ligament of TMJ
  • deep fibres blend with capsule
  • lower border of zygoma to posterior border of neck and ramus of mandible
  • it tightens the head in retrusion (closing and pulling the jaw backwards)

2 medial ligaments / accessory ligaments that strengthen the joint capsule but a re relatively less significant

  • sphenomandibular ligament (remains constant in length and tension for all positions of mandible)
  • stylomandibular ligament (extends from near apex of styloid process to posterior border of ramus of mandible nears it’s angle; thickening of deep parotid fascia, separates parotid gland from submandibular gland)
282
Q

Describe movements of the TMJ

A

It’s always the mandible that moves in relation to the cranium in order for movements to occur
Movements occur by displacement in the:
- superior joint cavity - gliding, translation, protusion, retrusion
- inferior joint cavity - hinge, rotation

Opening movements- simple movement -

  1. Condyles pulled forward - protrusion / gliding
    - lateral pterygoids (x3), upper joint cavity
  2. Chin pulled down and back - hinge
    - digastric muscles- not a prime mover in jaw opening, lower joint cavity

Closing movements-

  1. Mandible moves backwards
    - posterior fibres of Temporalis muscle pull the mandible backwards, superior joint cavity
  2. Mandible elevates
    - remainder of Temporalis muscle, masseter muscles (all it’s layers), medial pterygoid muscles, inferior joint cavity
283
Q

What are some disorders of the TMJ?

A

Bruxism- grinding teeth when asleep
Temporomandibular pain dysfunction disorders: muscular pain
Malocclusion syndromes: muscular pain

284
Q

What is the infratemporal fossa?

A

Irregularly shaped cavity of anatomical and clinical importance

  • lies below the middle cranial fossa, medial and deep to the zygomatic arch and behind the maxilla
  • communicates with the Temporal fossa through the interval between the zygomatic arch and cranial bones
285
Q

What are the boundaries of the infratemporal fossa ?

A

Anterior border- infra temporal surface of maxilla and descending ridge of its zygomatic process
Posterior border- articular tubercle of temporal bone and spina angularis of sphenoid
Superior border- infratemporal surface of greater wing of sphenoid
Inferior border- alveolar border of maxilla
Medial border- lateral pterygoid muscle

286
Q

Generally what is found in the infratemporal fossa?

A 
Muscles
Nerves
Arteries
Veins
Foramina
Canals
Fissures
287
Q

What muscles are found in the infratemporal fossa?

A

Lower part of medial pterygoid muscle
Lower part of lateral pterygoid muscle
Lower part of Temporalis muscle

288
Q

What nerves are found in the infratemporal fossa?

A

Mandibular nerve and most of its branches (auriculotemporal, inferior alveolar, lingual, buccal, chorda tympanii) and otic ganglion

289
Q

What arteries are found in the infratemporal fossa?

A

Main deep artery - maxillary artery - middle meningeal artery- anterior branch is clinically significant (Pterion fracture)
Main superficial artery - superficial temporal artery

290
Q

What veins are found in the infratemporal fossa?

A

Maxillary veins, middle meningeal vein, pterygoid venous plexus

291
Q

What foramina are found in the infratemporal fossa?

A 
Foramen ovale (mandibular division of 5th nerve) 
Foramen spinosum (middle meningeal artery)
292
Q

What canal is found in the infratemporal fossa?

A

Alveolar canal

293
Q

What fissure is found in the infratemporal fossa?

A

Inferior orbital fissure and pterygomaxillary fissure

294
Q

What is the clinical significance of the infratemporal fossa?

A

Pathologies within this region can evolve without detection up until it is too late - tumour growth- likely to be advanced when symptomatic
Mandibular nerve block- anaesthetic injected adjacent to nerve as it enters infratemporal fossa- nerves affected are inferior alveolar, lingual, buccal and auriculotemporal nerves
Inferior alveolar nerve block- during dental treatment, anaesthetic is injected around the mandibular foramen on medial side of mandible; all mandibular teeth anaethetised to medial side and skin and MM of lower lip also anaesthetised (supplied by mental branch)

295
Q

What is the orbital axis?

A

Angle of the eyeball along the optic nerve

296
Q

What is the clinical relevance of the optic chiasm?

A

Cross over point for some nerves
- above which L–>L and R–>R
- below which L–>R and R–>L
Therefore a stroke/ high motor nerve lesion on one side will result in sensation in the forehead on the expected side, but rest of the body will be affected on the other side

297
Q

What is the general shape of the orbit?

A

Pyramidal

298
Q

What makes up the roof of the orbit?

A

Frontal and sphenoid bone

299
Q

What makes up the floor of the orbit?

A

Maxilla, zygomatic (and palatine) bones

300
Q

What makes up the medial wall of the orbit?

A

Ethmoid, maxilla and lacrimal bones

301
Q

What makes up the lateral wall of the orbit?

A

Zygomatic and sphenoid bone

302
Q

Which two walls of the orbit are the most prone to fracture and why?

A

Medial and inferior (floor) walls because they are the ethmoid and maxilla bones which both contain air filled sinus spaces

303
Q

What are 5 main features of the orbit?

A 
Fossa for the lacrimal gland
Fossa for lacrimal sac to nasolacrimal duct
Superior orbital fissure
Inferior orbital canal
Optic canal
304
Q

What is found in the fossa for the lacrimal gland?

A

Lacrimal gland - where tears are produced, then move across the eye in a downwards, medial direction

305
Q

What is found in the fossa for lacrimal sac?

A

Lacrimal sac, where tears pool forming a lacrimal lake, before leaving the eye at the medial canthus

306
Q

What structures are found in the superior orbital fissure? LFTSNIAOS

A 
Large- Lacrimal nerve
French- Frontal nerve
Teenagers- Trochlear nerve
Sit- Superior branch of oculomotor nerve
Numb- Nasociliary nerve
In- Inferior branch of oculomotor nerve
Anticipation- Abducent nerve
Of- Opthalmic veins
Sweets- Sympathetic nerve
307
Q

What structure is found in the inferior orbital fissure?

A

Infra orbital nerve

308
Q

What structures are found in the optic canal?

A 
Optic nerve (CNII) 
Opthalmic artery
309
Q

How many axons does the optic nerve have?

A

1.2m axons from retinal cells

310
Q

How can infections spread via the optic nerve?

A

Coverings of the brain- pia mater, arachnoid mater and dura mater are continuous with the brain
Infection can spread in the back of the eye socket via the optic nerve

Raise ICP, venous engorgement, Papilloedema (optic nerve and disk pushed forward- swelling on the optic disk)

311
Q

Describe blow out fractures of the bony orbit

A

Usually at bony sutures - medial (ethmoid sinuses) and inferior (maxillary sinus) walls are weakest and most likely to fracture
BLOW OUT FRACTURE- displaces the wall and contents of the orbit
- muscle entrapment, double vision, infection, enopthalmos, infra orbital bleeding, pulsatile exopthalmos (eye beats with HR)

312
Q

What are the 6 main muscles of eyeball movement?

A

Medial, lateral, superior and inferior recti

Superior and inferior oblique

313
Q

What do the recti muscles attach to?

A

Attach to the eye socket - tendons go through the annular ring

314
Q

What is the action of the superior recti muscle?

A

Elevation of eye- eye looks up

Intorsion- superomedially

315
Q

What is the action of the inferior recti muscle?

A

Depression of eye- eye looks down

Extorsion- inferomedially

316
Q

What is the action of the lateral recti muscle?

A

Abduction of eye- eye looks laterally

317
Q

What is the action of the medial rectus muscle?

A

Adduction of eye- eye looks medially

318
Q

What is the action of the superior oblique muscle?

A

1) Intorsion - inferolaterally
2) Depression
3) Abduction

When the eye is turned toward the nose, the superior oblique muscle is responsible for depressing the eye
When looking directly forward superior oblique assists other muscles (SR, IO, IR) in vertical movement

319
Q

What is the action of the inferior oblique muscle?

A

1) Extorsion- superolaterally
2) Elevation
3) Abduction

When the eye is turned toward the nose, the inferior oblique muscle is responsible for elevating the eye
When looking directly forward inferior oblique assists other muscles (SR, SO, IR) in vertical movement

320
Q

What muscles of the eye does the abducent nerve (CNVI) supply?

A

Lateral rectus

321
Q

What muscles of the eye does the trochlear nerve (CN IV) supply?

A

Superior oblique

322
Q

What muscles of the eye does the superior branch of the oculomotor nerve (CNIII) supply?

A

Superior rectus

323
Q

What muscles of the eye does the inferior branch of the oculomotor nerve (CNIII) supply?

A

Inferior rectus
Medial rectus
Inferior oblique

324
Q

What branches of the ICA and ECA supply the eye?

A

ICA- opthalmic arteries

ECA- infra orbital artery

325
Q

What are the main opthalmic arteries? And what do they supply?

A

Central artery of the retina - terminal branches- supra trochlear and supraorbital artery
Lacrimal artery
Posterior ciliary artery
Muscular branches to extraocular muscles
Other separate branches to ethmoidal and frontal sinuses, eyelids, forehead and scalp etc.

326
Q

What is the venous drainage of the eye?

A

Superior opthalmic vein- drains from inner angle of the orbit to the superior orbital fissure
Inferior opthalmic vein- drains from the venous plexus on the floor and medial wall of the orbit to the superior or inferior orbital fissure
Central vein of the retina either drains into the superior or inferior opthalmic veins or directly into the cavernous sinus
Inferior and superior orbital fissure drain into the cavernous sinus

327
Q

What can result from occlusion of the veins of the eyes?

A

Slow, painless loss of vision

328
Q

How can infection spread via the veins of the eye to the brain?

A

Danger triangle around nose- communication between facial vein to the cavernous sinus via the opthalmic veins - cavernous sinus thrombosis, meningitis or abscess

329
Q

What are the functions of the upper and lower eyelids?

A

Protecting from light and injury

Prevent corneal drying, through controlled spread of lacrimal fluid (tears)

330
Q

What is the space between the eyelids called?

A

Opening = palpebral fissure - left and right not often equal in size

331
Q

What is the palpebral conjunctiva?

A

Part of the conjunctiva which covers the outer surface of the eye and lines the eyelids

332
Q

What is the bulbar conjunctiva?

A

Covers the eyeball over the anterior sclera

333
Q

What is the fornix conjunctiva?

A

Forms junction between the palpebral and bulbar conjunctiva

334
Q

What are the layers of the upper eyelid?

A 
Skin
Areolar tissue
Fibres of orbicularis oculi
Levator palpebrae superioris
Superior tarsus- dense CT strengthening the skeleton (inferior lower lid) 
Tarsal (Meibomian) glands- secrete oil- dry eye
Ciliary glands (sebaceous) - stye
Palpebral conjunctiva
335
Q

What is reflex bilateral blinking?

A

Involuntary blinking of eyelids stimulated by stimulation of cornea
Triggers- corneal drying, corneal irritation/contact (perceived as pain), expectation of contact
Controlled by CNVi - opthalmic division of Trigeminal nerve & CNVII - facial nerve

336
Q

What muscles are involved in opening the eyelids?

A

Levator palpabrae superioris

Superior tarsal muscles (Muller’s muscle)

337
Q

What muscle is involved in closing the eyelid?

A

Orbicularis oculi

338
Q

What happens when levator palpabrae superioris becomes paralysed?

A

Paralysis when oculomotor nerve CNIII becomes DAMAGED

  • drooping of upper eyelid- ptosis
  • vision compromised
  • residual opening of eye due to presence of superior tarsal muscle (smooth muscles)
339
Q

What happens when the superior tarsal muscles become paralysed?

A

Paralysis (smooth muscle of upper eyelids)
Minor drooping of upper eyelid - partial ptosis
Vision usually okay
Eye opening okay due to levator palpabrae superioris
Horner’s syndrome- paralysis of superior tarsal muscles with pupil constriction

340
Q

What is Horner’s syndrome?

A

Paralysis of superior tarsal muscles with pupil constriction

341
Q

What happens when the orbicularis oculi muscles becomes paralysed?

A 
Paralysis (facial nerve CNVII DAMAGE)
Failure to close eyes- Bell's palsy
Loss of blink and corneal reflex
Dry eyes- need eye drops
Infection likely
342
Q

What is lacrimation?

A

Crying
Lacrimal fluid/ tears are produced in the lacrimal gland in the fossa for the lacrimal gland under the influence of the PSNS fibres of the facial nerve CNVII
Eyes close lateral to medial, pushing tears across the anterior surface of the eye, and towards the medial canthus, where the fluid collects in the lacrimal sac/ lake in the fossa for the lacrimal sac

Sensory supply via lacrimal branch of the opthalmic division of the Trigeminal nerve (CNVi) to the eyelid and conjunctiva

343
Q

What 3 different parts of the ear exist?

A

Outer/ external ear
Middle ear
Inner/ internal ear

344
Q

What is the outer ear comprised of?

A

Auricle/ pinna

External acoustic meatus

345
Q

What is the auricle/pinna of the ear?

A

External, lateral, paired structure

All cartilaginous except lobe

346
Q

What are the main parts of the auricle of the ear?

A 
Helix
Anti helix- superoposterior and inferoanterior crus
Triangular fossa
Concha
Tragus
Antitragus
Lobe
347
Q

What is the innervation of the auricle of the ear?

A

Cutaneous innervation - greater auricular, lesser occipital and branches of the facial and vagus nerves

348
Q

What is the vascular supply to the auricle of the ear?

A

Posterior auricular, superficial temporal and occipital arteries and veins

349
Q

Why may a patient cough when clearing their ears out?

A

Auricular branch of the vagus nerve may be stimulated causing a cough too

350
Q

What is an auricular haematoma?

A

Blood collects between cartilage and overlying perichondrium
Usually due to trauma (contact sports)
Accumulation of blood disrupts the vascular supply to the cartilage of the auricle - necrosis of the cartilage
If not drained quickly - gross deformity results as cauliflower ear
I

351
Q

What is the external acoustic meatus of the ear?

A

Sigmoid shaped tube which connects the deep part of the concha of the auricle to the tympanic membrane
Support given to walls from the auricle and the temporal bone

352
Q

Describe the shape of the external acoustic meatus

A

Initially superoanterior in direction
Turns slightly to move superoposteriorly
Ends in an inferoanterior direction

353
Q

What is the tympanic membrane?

A

Double layered- (skin and MM) membrane which marks the division between the outer and middle ear

354
Q

How is the tympanic membrane connected to the temporal bone?

A

Connected to temporal bone by fibrocartilaginous ring

355
Q

What does it mean that the tympanic membrane is translucent?

A

Translucent - so structures within the middle ear can be seen

356
Q

What are the main features of the tympanic membrane?

A

Malleus
- most superiorly- lateral process of malleus
- extending down from lateral process- handle of malleus
- most inferiorly- Umbo
Parts of tympanic membrane moving away from the lateral processes are called the anterior and posterior malleolar folds
Pars flaccida and pars tensor
Cone of reflex

357
Q

What is the nervous supply to the EAM and tympanic membrane?

A

Sensory innervation from branches of mandibular and vagus nerves

358
Q

Describe perforation of the tympanic membrane

A

Caused by trauma or infection

  • infection of middle ear/ otitis media - causes pus and fluid build up
  • causes an increase in pressure and rupture of the eardrum
  • many cases it heals itself
  • large perforations - a surgical intervention might be necessary
359
Q

What is the middle ear comprised of?

A

Tympanic cavity- malleus, incus and stapes
Epitympanic recess- mastoid air cells

Extends from tympanic membrane to oval and round window of inner ear

360
Q

What two broad areas can the middle ear be divided into?

A

Tympanic cavity

Epitympanic recess

361
Q

What are the borders of the middle ear cavity of the ear?

A

Roof- petrous part of temporal bone
Floor- jugular wall (thin layer of bone)
Lateral- tympanic membrane and lateral wall of epithelia of recess
Medial- lateral wall of internal ear
Anterior- thin bony wall with 2 openings- for auditory tube and tensor tympani muscle
Posterior- mastoid wall- bony partition between tympanic cavity and mastoid air cells- superiorly has a hole (aditus to mastoid antrum) allowing communication with mastoid air cells

362
Q

What is the malleus?

A

Largest most lateral auditory ossicle
Attaches to tympanic membrane via handle of malleus
Head of malleus lies in the epitympanic recess where it articulates with next auditory ossicle - incus

363
Q

What is the incus?

A

Middle auditory ossicle
Has a body and two limbs
Body articulates with the malleus
Short limb attaches to the posterior wall of the middle ear cavity
Long limb joins the last ossicle - stapes

364
Q

What is the stapes?

A 
Smallest bone in the body
Medial most auditory ossicle
Head, base and two limbs in  a stirrup shape
Head articulates with long limb of incus
Base joins with the oval window
365
Q

Where do the three auditory ossicles extend from and to?

A

Malleus, incus and stapes are connected in a chain like manner linking the tympanic membrane to the oval window of the inner ear

366
Q

What two muscles are found in the middle ear?

A

Tensor tympani

Stapedius

367
Q

What are the main functions of the muscles of the middle ear?

A

Tensor tympani and Stapedius
Both serve protective function of the middle ear
Contract on response to a loud noise inhibiting vibrations of malleus incus and stapes to such a degree to cause damage- reduces the transmission of sound to the inner ear - acoustic reflex

368
Q

Describe tensor tympani

A

Originates from the auditory tube and attaches to the handle of malleus, pulling it medially when contracting

369
Q

What is the innervation of tensor tympani?

A

Mandibular nerve branch of Trigeminal nerve (CNViii)

370
Q

Describe the stapes muscle

A

Attaches to the stapes

371
Q

What is the innervation of the Stapedius muscle?

A

Facial nerve

372
Q

What are the mastoid air cells?

A

Located posterior to the epitympanic recess
Collection of air filled spaces in the mastoid process of the temporal bone
Contained within the mastoid Antrum cavity - communicates with the middle ear via the aditus of the mastoid Antrum in posterior wall
Acts as a buffer system of air - releasing air into the tympanic cavity when the pressure is too low

373
Q

What is the auditory/ Eustachian tube?

A

Cartilage and bony tube that connects the middle ear to the nasopharynx
Acts to equalise the pressure of the middle ear to that of the EAM
Extends from anterior wall of middle ear in an anterior, medioinferior direction opening onto the lateral wall of the nasopharynx

374
Q

What is cholesteatoma?

A

Growth of stratified squamous epithelia of middle ear- congenital or acquired
Destructive growth- causes damage to bones of middle ear by increased pressure or release of osteolytic enzymes
Hearing loss/ facial nerve palsy

375
Q

What is mastoiditis?

A

Otitis media spreads to mastoid air cells (porous nature)
Infection of mastoid process –> middle cranial fossa –> brain: Meningitis
Drainage of pus necessary- careful not to damage the facial nerve

376
Q

What is glue ear?

A

Otitis media with effusion
Dysfunction of Eustachian tube
Inflammation, blockage or genetic mutation
Fluid build up in middle ear causes a negative pressure
Transudate from mucosa drawn out by NP- pathogens
Upon inspection - tympanic membrane appears inverted and fluid can be seen in middle ear

377
Q

What is the inner ear comprised of?

A

Vestibulocochlear organs
Bony labyrinth- vestibule, cochlea, 3 semi circular canals
Membranous labyrinth- cochlear duct, saccule, utricle, semicircular ducts

378
Q

What are the two main functions of the inner ear?

A

Convert mechanical signals from the middle ear into electrical signals which can transfer information to the auditory pathway in the brain
Maintains balance by detecting position and motion

379
Q

What is the anatomical position of the inner ear?

A

Located within the petrous part of the temporal bone

Between the middle ear and internal acoustic meatus

380
Q

Broadly describe the bony labyrinth

A

Consists of a series of bony cavities within the petrous part of the temporal bone; comprised of the cochlea, vestibule and 3 semicircular canals- all these structures lined internally with periosteum and contain a fluid- perilymph

381
Q

What is the vestibule?

A

Central part of the bony labyrinth - separated from the middle ear by oval window
Communicates anteriorly with cochlea and posteriorly with semicircular canals
Saccule and utricle (parts of the membranous canal) are located I the vestibule

382
Q

What is the cochlea?

A

Houses the cochlear duct of the membranous labyrinth - auditory part of ear
Twists around itself around a central portion of bone called the modiolus, producing a cone shape that points in an anterolateral direction
Branches of cochlear portion of the Vestibulocochlear nerve (VIII) are found at the base of the modiolus
Extending outwards from the modiolus is a ledge of bone - spiral lamina- which attaches to the cochlear duct holding it in position

383
Q

What two chambers does the presences of the cochlear duct in the cochlea create?

A

Above- scala vestibuli (continuous with vestibule)

Below- scala tympani (ends at round window)

384
Q

What are the semicircular canals?

A

Anterior, lateral and posterior canals in the bony labyrinth
Contain semicircular ducts (membranous labyrinth) responsible for balance (saccule and utricle)
Canals are superoposterior to the vestibule and at right angles to one another
Swelling at one end is known as the ampulla

385
Q

Broadly describe the membranous labyrinth

A

Lies within the bony labyrinth, It consists of the cochlear duct, semicircular ducts, utricle and saccule- filled with the endo lymph

386
Q

What is the cochlear duct?

A

Located within the bony scaffolding of the cochlea
Held in place by spiral lamina
Presence of duct creates two canals above (scala vestibuli) and below (scala tympani)
Triangular in shape

387
Q

What are the borders of the cochlear duct?

A

Triangular shape
Lateral- thickened periosteum= spiral ligament
Roof- membrane that separates cochlear duct from scala vestibuli- Reissners
Floor- membrane that separates cochlear duct from scala tympani- Basillar

388
Q

What are the saccule and utricle?

A

2 membranous sacs in the vestibule
Utricle- larger of the two receiving 3 semicircular ducts
Saccule- globular in shape and receives the cochlear duct

Endolymph drains from the saccule and utricle into the endo lymphatic duct- travels through the aqueduct to posterior aspect of the petrous part of temporal bone- here it expands into a sac where endolymph can be secreted and absorbed

389
Q

What are the semicircular ducts?

A

Located within the semicircular canals and share their orientation
Upon movement of the head, flow of endo lymph within these ducts changes speed and/or direction
Sensory receptors in the ampullae of the semicircular canals send signals to the brain allowing for processing of balance

390
Q

What is the innervation of the middle ear?

A

Vestibulocochlear nerve (CNVIII) - enters inner ear via interal acoustic meatus where it divides into the vestibular nerve and the cochlear nerve

  • vestibular nerve enters to form the vestibular ganglion which then splits into superior and inferior parts to supply the utricle, saccule and 3 semi circular ducts
  • cochlear nerve enters at the base of the modiolus and it’s branches pass through the lamina to supply receptors of organ of Corti

Facial nerve (CNVII) - passes through inner ear but does not innervate any of the structures present

391
Q

What is the arterial supply to the bony labyrinth?

A

3 arteries which supply the surrounding temporal bone

  • anterior tympani branch (maxillary artery)
  • petrosal branch (middle meningeal artery)
  • stylomastoid branch (posterior auricular artery)
392
Q

What is the arterial supply to the membranous labyrinth?

A

Labyrinthine artery (inferior cerebellar artery/ basillar artery)
Divides in pro 3 branches
- cochlear branch –> cochlear duct
- 2x vestibular branches –> vestibular apparatus

393
Q

What is the venous drainage of the inner ear?

A

Labyrinthine vein- empties into the sigmoid sinus or inferior petrosal sinus

394
Q

What is Ménière’s disease?

A

Disorder of the inner ear characterised by episodes of vertigo, low pitched tinnitus and hearing loss
Symptoms caused by excess accumulation of endo lymph within the membranous labyrinth, causing progressive distension of the ducts
Resulting pressure fluctuations damage thin membranes of the ear that detect balance and sound.

395
Q

What is the nerve supply to the tympanic membrane?

A

External - auriculotemporal branch of mandibular division of Trigeminal nerve (CNViii) and small branch of vagus nerve (CNX)
Internal- Glossopharyngeal nerve (CNIX)

396
Q

Briefly describe how we hear

A

Sound travels through EAM and is transmitted to movement via the 3 auditory ossicles which move upon receiving sound signals
Stapes then presses on the oval window transmitting movement in the perilymph of the scala vestibuli and then tympani
Hairs found in the scala vestibuli pick up movement of perilymph/ sounds at different frequencies
- high pitched sounds are absorbed proximally to Oval window
- low pitched sounds are absorbed more distally to Oval window
Sound Is absorbed into the endo lymph of the cochlear duct and transferred to the brain
Excessive sound leaves via the round window to relieve any pressure

397
Q

Briefly describe how we maintain balance

A

Fluid in the semicircular ducts move when we become unbalanced and restore our balance

398
Q

What are the 5 main functions of the nose?

A 
Warms and humidifies air
Filters air- removes and traps pathogens and particulate matter from the inspired air
Olfaction- sense of smell
Drains and clears paranasal sinuses 
Respiration
399
Q

What three regions does the nasal cavity consist of?

A

Vestibule
Olfactory region
Respiratory region

400
Q

Describe the location of the vestibule of the nose

A

Area surrounding external opening to nasal cavity

401
Q

Describe the location of the olfactory region of the nose

A

Area located next to the apex of the nasal cavity- lined by olfactory cells with olfactory receptors

402
Q

Describe the location of the respiratory region of the nose

A

Largest area - lined by ciliated pseudostratified columnar epithelia - within which the mucus secreting goblet cells are interspersed

403
Q

What bones contribute to the skeleton of the nose?

A 
Frontal
Nasal
Ethmoid
Sphenoid
Vomer
Palatine process of maxilla
Horizontal process of palatine bone
Inferior concha
404
Q

What are the conchae of the nose?

A

Curved shelves of bone that project out the lateral walls of the nasal cavity - inferior, middle and superior

405
Q

What creates the 4 pathways of airflow in the nose?

A

Conchae

406
Q

What are the 4 pathways of airflow in the nose?

A

Inferior meatus
Middle meatus
Superior meatus
Sphenoethmoidal recess

407
Q

Where is the inferior meatus?

A

Between inferior meatus and floor of nasal cavity

408
Q

Where is the middle meatus?

A

Between middle and inferior conchae

409
Q

Where is the superior meatus?

A

Between the middle and superior conchae

410
Q

Where is the sphenoethmoidal recess?

A

Superior and posterior to superior concha

411
Q

What are the two main functions of the nasal conchae?

A

Increases SA of the nasal cavity. - increasing the amount of inspired air that can come into contact withthecavity walls
Disrupt fast, laminar flow of air- making it slow and turbulent so that air spends longer in the nasal cavity and can be humidified

412
Q

What 8 structures drain into the nasal cavity?

A 
Frontal sinus
Maxillary sinus
Anterior, posterior and middle ethmoidal sinuses
Sphenoid sinus
Nasolacrimal duct
Eustachian tube
413
Q

Where does the posterior ethmoidal sinus drain into?

A

Superior meatus

414
Q

Where does the anterior ethmoidal sinus drain into?

A

Semilunar hiatus in middle meatus

415
Q

Where does the middle ethmoidal sinus drain in to?

A

Ethmoid bulla of the middle meatus

416
Q

Where does the maxillary sinus drain into?

A

Base of semilunar hiatus of middle meatus

417
Q

Where does the frontal sinus drain into?

A

Middle meatus

418
Q

Where does the sphenoid sinus drain into?

A

Sphenoethmoidal recess

419
Q

Where does the nasolacrimal duct drain into?

A

Inferior meatus

420
Q

Where does the Eustachian tube drain into?

A

Inferior meatus

421
Q

What is the ethmoid bone made up of?

A

Crista galli
Cribriform plate
Perpendicular plate

422
Q

Describe the Cribriform plate

A

Part of the ethmoid bone
Forms portion of the roof of the nasal cavity
Contains very small perforations allowing fibres of the olfactory nerve to enter and exit

423
Q

What is the sphenopalatine foramen?

A

Opening that allows communication between nasal cavity and pterygopalatine fossa

424
Q

What three structures pass through the sphenopalatine foramen?

A

Sphenopalatine artery, nasopalatine nerve and greater palatine artery pass through here

425
Q

What is the incisive canal?

A

Pathway between the nasal cavity and incisive fossa of the oral cavity

426
Q

What two structures pass through the incisive canal?

A

Nasopalatine nerve and greater palatine artery

427
Q

Why is it important that the nose has such a rich vascular supply?

A

Allows it to effectively change the humidity and temperature of inspired air

428
Q

Which 2 branches of the ICA does the nose receive blood supply from?

A

Anterior and posterior ethmoidal arteries (branches of the opthalmic artery)

429
Q

Which 2 branches of the ECA does the nose receive blood supply from?

A

Sphenopalatine artery, greater palatine artery, superior labial artery, lateral nasal artery

430
Q

What is the venous drainage of the nose?

A

Drain into pterygoid plexus, facial nerve of cavernous sinus
In some individuals a few nasal veins join with the Sagittal sinus (a dural venous sinus - represents potential pathway via which infection can spread)

431
Q

Describe the special sensory innervation of the nose

A

Ability of nose to smell
Olfactory nerves
Olfactory bulb (part if brain - lies on superior surface of Cribriform plate) –> olfactory nerve branches via the Cribriform plate perforations –> nose = SMELL

432
Q

Describe the general sensory innervation of the nose

A

Sensation to septum and lateral walls
- Nasopalatine nerve - branch of maxillary nerve
- Nasociliary nerve - branch of opthalmic nerve
Sensation to external skin of nose
- Trigeminal nerve

433
Q

What is the function of the paranasal sinuses

A

Unclear
Contribute to humidifying of inspired Air
Reduce weight of skull

434
Q

When do the sinuses generally formed and how?

A

In childhood by nasal cavity eroding into the surrounding bone

435
Q

Describe the frontal sinus

A

The Right and Left Frontal Sinuses are between the outer and inner tables of the frontal bone, posterior to the superciliary arches and the root of the nose. They are usually detectable in children by 7 years of age (not present at birth).
They each drain through a Frontonasal Duct into the ethmoidal infundibulum, which opens into the semilunar hiatus of the Middle Nasal Recess.

436
Q

Describe the ethmoidal sinuses

A 
Ethmoidal Cells (Sinuses)
The Ethmoidal cells (Sinuses) are small invaginations of the mucous membrane of the middle and superior nasal recesses into the Ethmoid bone.
The Ethmoidal cells usually are not visible in plain radiographs before 2 years of age.
The Anterior Ethmoidal Cells drain directly or indirectly into the middle nasal recess through the ethmoidal infundibulum.
The Middle Ethmoidal Cells open directly into the middle nasal recess.
The Posterior Ethmoidal Cells open directly into the superior nasal recess.
437
Q

Describe the sphenoid sinus

A

The Sphenoidal Sinuses are located in the body of the sphenoid and may extend into the wings of the bone.
The body of the sphenoid is fragile, and only thin plates of bone separate the sinuses from several important structures (Optic nerves and chiasm, the pituitary gland, internal carotid arteries). They are small at birth, enlarging after puberty.

They drain directly into the Sphenoethmoidal Recess.

438
Q

Describe the maxillary sinus

A

The Maxillary Sinuses are the largest of the paranasal sinuses. They occupy the bodies of the Maxillae.
They drain by one or more openings, the Maxillary Ostium (ostia), into the middle nasal recess by way of the semilunar hiatus.

439
Q

Briefly describe a nasal fracture

A

Most common fracture of face bones
History of force to face
May resulting a deformity
Complications include septal haematoma, abscess formation, septal deviation, CSF leakage

440
Q

Describe a fracture to the Cribriform plate

A

Can occur as a result of nose trauma
Fractured directly by trauma or by fragments of the ethmoid bone
Fracture can penetrate meningeal linings of the brain causing leakage of CSF
- increases risks of meningitis, encephalitis and brain abscesses
Olfactory bulb lies on the Cribriform plate and can be damages irreversibly in the fracture - in which case the patient presents with anosmia - loss of smell

441
Q

What is Kiesselbach’s plexus?

A

Lies in Kiesselbach’s/ Little’s area
Region in the anterior ferero part of nasal septum where 4 arteries anastamose:
- anterior ethmoidal artery (opthalmic)
- sphenopalatine artery (maxillary artery terminal branch)
- greater palatine artery
- septal branch of superior labial artery (facial artery)
* 90% nose bleeds (epistaxis) occur in this area as it is exposed to drying- the effect of the inspiratory current

442
Q

What is epistaxis?

A

Bleeding from the nose - very common
Cause can be local (trauma) or systemic (hypertension)
Anterior - 90% in Kiesselbach’s area
Posterior- sphenopalatine artery

443
Q

Briefly describe nasal septum deviation

A

Can be congenital or acquired

Narrowing / obstruction

444
Q

Briefly describe nasal septum necrosis

A

Injury to nasal septum

Saddle nose deformity

445
Q

Describe 4 pathways of infection spread from the nose

A

Anterior cranial fossa –> sinuses
Middle ear –> Eustachian tube
Paranasal sinuses
Lacrimal apparatus and conjunctiva –> nasolacrimal duct

446
Q

Describe rhinitis

A

Inflammation of nasal mucosa
Leads to swelling and increased volume of secretion
Causes include: infective (viral), allergic and nasal polyps

447
Q

Describe nasal polyps

A

Prevalence - ~2-4%
Linked to chronic rhinosinusitis
Grows close to ostiomeatal complex of the nasopharynx
Nasal obstruction - snoring/ obstructive sleep apnoea

448
Q

Describe sinusitis

A

Inflammation of mucosal lining of sinuses
Acute 7-30 days
Subacute 4-12 weeks
Chronic >90 days
Infection-viral with secondary bacterial infection, S.Pneumoniae and H.Influenzae

449
Q

What are some risks of epistaxis?

A

Trauma, tumours, EToH, coagulation defects, vascular abnormalities mucosal drying, infections, NSAID’s, granulomas

450
Q

What are 7 methods of management of epistaxis?

A

1) Pinch nose and lean forward
2) Cautery (silver nitrate of electro)
3) Nasal tampons
4) Bolster- support
5) Posterior packing
6) Surgical intervention with ligation of branches - SPA ligation, maxillary ligation, ECA ligation
7) Radiological embolisation

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