CAS 3 Flashcards
What kind of joint is the atlanto occipital joint and Atlanto-axial joints ?
synovial joints
between what
between convex occipital condyles and concave facets on the lateral mass of the atlas
what does it allow
The Atlanto-occipital joints allow nodding and lateral flexion movements of the head
The curved surfaces are adapted for
head flexion and extension, and abduction (lateral flexion) of the skull on the atlas vertebra. In the erect position, the centre of gravity of the skull lies anterior to the joints and the head is held in position by the tone of the extensor muscles (postvertebral group of muscles) in the back of the neck.
Testing the movements at atlanto-occipital joints
Patient sits with their head held in erect position looking straight ahead. The examiner stands behind the patient and holds the neck just below the jaws with one hand, and instructs the patient to nod the head up and down, as if to say “yes”, while the examiner keeps check of the rest of the cervical spine does not bend.
The dense of axis is held in position by the what
the transverse limb of the cruciate ligament.
the atlanto-axial joints allow
rotation of the head.
The muscles responsible for rotation are
sterno-mastoids and sub-occipital muscles (splenius capitis, inferior oblique).
Testing the movements at atlanto-axial joints
Patient is seated with their head held in erect position looking straight ahead. The examiner stands behind the patient and holds the neck just below the jaws with one hand, and instructs the patient to rotate their head side to side, as if to say “no”, while the examiner keeps check of the rest of the cervical spine does not bend.
The submandibular ducts from the right and left submandibular glands open at the
sublingual caruncle on either side of the frenulum of the tongue
The duct of the parotid gland opens into the vestibule of the mouth opposite to
the upper 1st molar tooth.
where can opening of the auditory tube can be seen
on the lateral wall of the nasopharynx, on a level with the inferior concha of the nasal cavity
In human there are how many sets of dentition
here are two sets of dentition
what are they
the deciduous and the permanent§
deciduous
set has 20 teeth that erupt between 6 months to 2.5 years
permanent
The permanent set has 32 teeth. The 1st permanent tooth (1st permanent molars) erupts at 6 years and the rest of the permanent teeth continue until 18 years and very often beyond ( the 3rd molars can vary)
Between 6-12 years
mixed d
Glossopharyngeal Nerve (CN IX) Function
Motor: Innervates the stylopharyngeus muscle of the pharynx
Sensory: Innervates the oropharynx, posterior 1/3 of the tongue.
Special Sensory: Taste sensation to the posterior 1/3 of the tongue.
Parasympathetic: Parasympathetic innervation to the parotid glan
anatomical course
The glossopharyngeal nerve arises from the medulla oblongata of the brain and leaves the cranium via the jugular foramen.
Testing
To test the glossopharyngeal nerve (CN IX) elicit the gag reflex using a tongue depressor against the posterior of the tongue.
This allows us to test CN IX because CN IX provides sensory innervation to the oropharynx, acting as an afferent limb for the gag reflex.
Clinical Relevance
When a foreign object touches the back of the mouth, this stimulates CN IX, beginning the reflex. The efferent nerve in this process is the vagus nerve, CN X. An absent gag reflex can indicate damage to the glossopharyngeal nerve.
Vagus Nerve (CN X) function
Motor: Innervation to most of the muscles of the pharynx and larynx.
Sensory: Innervation to the skin of the external acoustic meatus and some of the surfaces of the laryngopharynx and superior larynx. Also provides visceral sensory information from the trachea, lungs, heart oesophagus and most of the abdominal organs.
Parasympathetic: innervating the lungs and most of the gastrointestinal tract as well as helping to control heart rate
Anatomical Course
The vagus nerve arises from the medulla oblongata of the brainstem and exits the cranium via the jugular foramen.
In the neck
Pharyngeal branches – innervates most of the muscles of the pharynx and soft palate.
Superior laryngeal nerve – innervates the cricothyroid muscle of the larynx and sensation to the laryngopharynx and superior larynx.
Recurrent laryngeal nerve - On the right side only (hooks around the right subclavian artery and innervates most of the muscles of the larynx
Testing
To test the vagus nerve (CN X), ask the patient to open their mouth out wide and say “Ahh”. This allows us to test CN X because CN X provides motor innervation to levator veli palatini. If both vagus nerves are intact then the small palate, and thus uvula, will rise symmetrically when saying “ahh”.
Clinical Relevance
If the right vagus is damaged, then the right palate will not raise, but the left will still rise, so the uvula will deviate to the left (away from the side of the lesion).
Spinal Accessory Nerve (CN XI)
Accessory nerve (CN XI) has only somatic motor function innervating the sternocleidomastoid and trapezius muscles.
Anatomical Course
The spinal portion of the accessory nerve arises from the upper spinal cord (C1-C5 roots) and then enters the cranial cavity via the foramen magnum then heading to the jugular foramen.
The cranial portion of the accessory nerve arises from the medulla oblongata before exiting the cranial cavity via the jugular foramen coming in contact with spinal portion. The then nerve passes near to the internal carotid artery heading to the sternocleidomastiod and then trapezius muscle.
Testing
To test the spinal accessory nerve (CN XI), ask the patient to turn their head against your hand. This allows us to test CN XI because CN XI provides motor innervation to the sternocleidomastoid muscle, which allows you to turn your head to the opposite side of the muscle.
Clinical Relevance
If one of the pair of accessory nerves is damaged, the patient may not be able to turn their head against resistance (weakness of sternocleidomastoid muscle) on the affected side. Such damage can occur as a complication of a posterior triangle lymph node biopsy or excision.
Hypoglossal Nerve (CN XII)
Hypoglossal Nerve (CN X) has a only somatic motor function, innervating the muscles of the tongue.
Anatomical Course
Hypoglossal nucleus is located in the medulla oblongata of the brainstem, the nerve leaves the cranium via the hypoglossal canal.
Testing
To test the hypoglossal nerve (CN XII) ask the patient to stick their tongue out. This allows us to test CN XII innervation of the genioglossus muscle, which allows you to stick out (protract) your tongue.
Clinical Relevance
If the right hypoglossal nerve was damaged, then the left side of the tongue would still protrude, but the right side would not. The tongue would steer to the right- towards the lesioned side
The anterior triangle is further subdivided into
4 smaller triangles: submental, submandibular, carotid and muscular triangles.
Important tip
when palpating from one set of lymph nodes to another, make sure to continue palpating in a circular motion without lifting your fingers off the patient. This is to ensure no lymph nodes are missed.
what are the cervical lymph nodes to be palpated
Submental nodes –inferior to the chin
Submandibular nodes –inferior to the angle of the mandible
Preauricular/parotid nodes –anterior to the ear (technically the preauricular and parotid nodes are two separate sets of nodes, but because of their close proximity, they are usually palpated at the same time.)
Postauricular nodes - posterior to the ear
Occipital nodes - base of the occipital
Superior deep cervical nodes - superior part of the sternocleidomastoid
Inferior deep cervical nodes - inferior part of the sternocleidomastoid
Supraclavicular nodes - superior to the clavicle
structures present in the neck that you need to be aware of
hyoid bone thyroid notch laarngeal prominecne cricothyroid ligament arch of cricord left/right lobe of thyroid isthmus
Before palpating the thyroid it is important to
expose the neck in full, preferably removing the patient’s clothing above the waist.
Then insepect carefully from the front to spot any obvious massess or any scars. Thyroid scars may not be obvious as they are often low, transverse, and may be hidden in Langer’s lines
Then insepect carefully from the front to spot any obvious massess or any scars. Thyroid scars may not be obvious as they are often low, transverse, and may be hidden in Langer’s lines
it is important to know this before palpating the thyroid!
If a patient has undergone a thyroidectomy
what to do first
After inspecting carefully for scars and massess
whats the first manouvre
Firstly, ask the patient to stick their tongue out
what will move and what wont
(a thyroglossal cyst will move upwards with the tongue, whilst a thyroid nodule or lymph node will not)
2nd manouvre
Then, ask the patient to take a drink of water: a mass in the thyroid (or a thyroglossal cyst) will move upwards with swallowing whilst a lymph node will not.
what is the best orientation for the palpitation
The thyroid (as with the cervical lymph nodes) is best palpated from behind. Preferably, it is best to examine the neck in front of a mirror so that you can make eye contact with the ‘patient’ (as you like to do for every examination). Whether or not this is possible, when examining from behind it is particularly important to signpost to the patient what you are planning to do as they may not have any non-verbal cues from you.
To locate the thyroid cartilage
find the laryngeal prominence, this is made from an anterior protrusion of the thyroid cartilage.
To locate the hyoid bone
start from the laryngeal prominence and the hyoid bone is above it. You can feel it if the patient swallows, as it moves up and then down. Get them to swallow water and have your index finger and thumb in a pincher position to exactly locate the hyoid bone
To locate the cricoid cartilage
start from the laryngeal prominence, and move your figner down. First you feel a depression, which is the cricothyroid membrane, and below this is a ridge, which is the cricoid cartilage.
To locate the spinous process of C7
ask the patient to bend their head forward, you can see a prominent bump at the bottom of the back of the neck. This is the spinous process of C7, and an important surface landmark to be able to countdown to find vertebral levels.
To locate the lateral mass of the atlas,
place your fingers at the base of the skull and allow their head to sink into your hands. Palpating upwards should allow you to feel the lateral mass of the atlas.
To palpate the thyroid gland,
starting from the laryngeal prominence, move your fingers lateral to the midline of the laryngeal prominence by around 2-3cm. Then repeat the process from inspection and ask the patient to stick their tongue out and to take a sip of water. Sometimes it can be helpful to ask the patient to take a sip and hold the water in their mouth whilst you position your hands, so that they can swallow at the right time.
how to find Locating the Carotid Pulse
Ask the patient to turn their head, the prominent muscle seen in the neck is the sternocleidomastoid. Place your index finger and middle finger between the medial border of sternocleidomastoid and the lateral border of the thyroid cartilage to find the carotid pulse. Ask the patient to face forward again whilst actually measure the pulse.
what to record about pulse
After you’ve found the pulse, remember to measure the pulse for 15 seconds before reporting back to the examiner the rate and rhythm.
what is rate
Rate = measured beats in 15 seconds x 4 = beats per minute (normal: 60-100bpm)
and rhythm
Rhythm = regular or irregular
how to locate Internal jugular vein:
To surface mark the internal jugular veins are easy. First find the common carotid arteries, which run from the sternoclavicular joint to the ear lobe on the same side. The internal jugular veins are just lateral to the common carotid arteries.
External jugular veins
The external jugular veins run from the angle of the mandible to the middle of the clavicle.
The borders of the triangle used for central line access are:
Medial sternal head of the SCM
Medial 1/3 of the clavicle
Lateral clavicular head of the SCM.
what angle is the needle inserted
The needle is inserted at a 30 degree angle
Right-sided jugular cannulation is preferred owing to the direct path to the superior vena cava and to avoid risk to the left-sided thoracic duct.
Right-sided jugular cannulation is preferred owing to the direct path to the superior vena cava and to avoid risk to the left-sided thoracic duct.
where is the needle pointed
directed towards the ipsilateral nipple
where does the facial vien drain
internal jugular vein
test motor function of the vagus
say ahh
motor function of the hypoglossal
stick your tongue out move ot side to side
testing accessory nerve (via sternocleidomastoid)
turn your head against your hand
pull shirt doen to see neck fully
testing acc nerve via upper fibres of trapezius
shrug your shoulders whilst i try push them back down
cervival lymph nodes
can you sit edge of couch facing forward
then each lymph nodes
