Gray's - Head & Neck - Kate Flashcards
A 46-year-old woman is admitted to the hospital
with a large mass in her lower anterior neck. Ultrasonic
examination reveals a benign tumor of her thyroid
gland. During the procedure to remove the tumor the
superior thyroid artery is identifi ed and used as a landmark
in order not to damage its small companion
nerve. Which of the following nerves is most likely to accompany the superior thyroid artery?
A. Cervical sympathetic trunk
B. External branch of the superior laryngeal
C. Inferior root of the ansa cervicalis
D. Internal branch of the superior laryngeal
E. Recurrent laryngeal
B. The external branch of the superior laryngeal
nerve courses together with the superior thyroid artery for much of its route.
A 3-year-old girl ruptured her eardrum when she
inserted a pencil into her external ear canal. She was urgently admitted to the emergency department. Physical examination revealed pain in her ear and a few drops of blood in the external auditory meatus. There was the concern that there might possibly have been an injury to the nerve that principally innervates the external surface of the tympanic membrane. Which of the following tests is most likely to be performed during physical examination to check for injury to this nerve?
A. Check the taste in the anterior two thirds of
the tongue.
B. Check the sensation to the pharynx and
palate.
C. Check if there is paraesthesia at the TMJ.
D. Check for sensation in the larynx.
E. Check for sensation in the nasal cavity.
C. The external surface of the tympanic membrane
is innervated primarily by the auriculotemporal
nerve, a branch of the mandibular division of the trigeminal nerve. Damage to this nerve would additionally result in painful movements of the TMJ because this joint receives innervation from the same nerve.
A 27-year-old woman is admitted to the emergency
department after she was thrown from a motor
scooter. Radiographic evaluation reveals a type I Lefort fracture and comminuted fracture of the mandible and TMJ. Despite reconstructive surgery, the patient develops hyperacusis (sensitivity to loud sounds) due to facial nerve paralysis. Which of the following muscles is most likely paralyzed?
A. Posterior belly of digastric B. Stapedius C. Tensor tympani D. Stylohyoid E. Cricothyroid
B. Both the stapedius and tensor tympani normally
function to dampen movements of the middle
ear ossicles, thereby muting sound and preventing
hyperacusis. The stapedius would be the source of
hyperacusis in this problem because it receives its
innervation from the facial nerve. The tensor tympani
receives motor innervation from the mandibular
division of the trigeminal nerve.
A 43-year-old man is admitted to the emergency
department with a fracture of the base of his skull. A thorough physical examination reveals that a number of structures have been injured, possibly including the right greater petrosal nerve. Which of the following conditions needs to be identified during physical examination to confirm the diagnosis of greater petrosal nerve injury?
A. Partial dryness of the mouth due to lack of
salivary secretions from the submandibular
and sublingual glands
B. Partial dryness of the mouth due to lack of
salivry secretions from the parotid gland
C. Dryness of the right cornea due to lack of lacrimal secretion
D. Loss of taste sensation from the right anterior
two thirds of the tongue
E. Loss of gener l sensation from the right anterior
two thirds of the tongue
C. The greater petrosal nerve carries parasympathetic fibers that are involved in the innervation of the lacrimal gland, as well as the mucosal glands of the nose, palate, and pharynx. As a result, an injury to the right greater petrosal nerve would be expected to result in decreased lacrimal secretions for the right eye.
A 12 year old girl is admitted to the emergency
department with a middle ear infection. Physical examination reveals a long history of chronic middle ear infections that have produced a lesion in the tympanic plexus in the middle ear cavity. Since the preganglionic parasympathetic fibers that pass through the plexus have been lost, which of the following conditions will be detectable during physical examination?
A. Diminished mucus in the nasal cavity
B. Diminished mucus on the soft palate
C. Diminished saliva production by the parotid
gland
D. Diminished saliva production by the submandibular and sublingual glands
E. Diminished tear production by the lacrimal
gland
C. Parasympathetic innervation of the parotid
gland is provided by axons carried by the glossopharyngeal nerve that emerge from the tympanic plexus of the middle ear as the lesser petrosal nerve. These preganglionic parasympathetic fibers terminate by synapses in the otic ganglion, which supplies the secretory
parasympathetic innervation to the parotid gland.
A 38-year-old patient is admitted to the dental
clinic with acute dental pain. The attending dentist
found penetrating dental caries (tooth decay) affecting one of the mandibular molar teeth. Which of the following nerves would the dentist need to anesthetize to remove the caries in that tooth?
A. Lingual B. Inferior alveolar C. Buccal D. Mental E. Mylohyoid
B. The inferior alveolar branch of the mandibular
division of the trigeminal nerve provides sensory innervation to the mandibular teeth and would require anesthesia to abolish painful sensation.
A 59-year-old man is admitted to the emergency
department with acute pain on his mandible. An MRI examination reveals an acute inflammation of the TMJ due to arthritis. Which of the following muscles will most likely be affected by the inflammatory process of the TMJ?
A. Temporalis B. Medial pterygoid C. Masseter D. Lateral pterygoid E. Buccinator
D. Part of the lateral pterygoid muscle has its
insertion on the articular disk within the TMJ and
would be most affected by the inflammation of this joint.
A 56-year-old female complains of diplopia (double
vision) when walking down stairs. A lesion of
which of the following nerves is most likely responsible for this patient’s complaint?
A. Optic B. Oculomotor C. Abducens D. Trochlear E. Frontal
D. The trochlear nerve innervates the superior
oblique muscle, which acts to move the pupil downward and laterally. It is the only muscle that can depress the pupil when the eye is adducted When an individual walks down stairs, this eye motion is initiated, and diplopia results if it is not functioning properly
A 43-year-old male is admitted to the hospital
complaining of diplopia (double vision) when walking
down stairs. During physical examination of the extraocular muscles the patient experiences diplopia, and when he is asked to turn his right eye inward toward his nose and look down, he is able to look inward but not down. Which nerve is most likely involved?
A. Abducens B. Nasociliary C. Oculomotor, inferior division D. Oculomotor, superior division E. Trochlear
E. The superior oblique muscle turns the pupil
downward from the adducted position. Inability to
perform this motion, in conjunction with diplopia
when walking down stairs, indicates damage to the
trochlear nerve.
A 44-year-old patient is admitted to the hospital
with Raynaud’s disease. A sympathetic blocking drug is administered in high doses. Which of the following conditions will be expected to occur as an adverse effect of the drug?
A. Exophthalmos and dilated pupil
B. Enophthalmos and dry eye
C. Dry eye and inability to accommodate for
reading
D. Wide-open eyelids and loss of depth perception
E. Ptosis and miosis
E. Ptosis and miosis occur in response to blocking
of sympathetic innervation. Ptosis (drooping of
the eyelid) results from lack of innervation of the
superior tarsal muscle (of Müller), and miosis (pupillary constriction) results from unopposed parasympathetic innervation of the pupil.
A 47-year-old woman is admitted to the hospital
with signs of cavernous sinus thrombosis. Radiographic examination reveals a pituitary tumor involving the cavernous sinus, confirming the initial diagnosis ( Fig 7-3 ). During physical examination it is suspected that the right abducens nerve of the patient has been damaged by the tumor. In which direction will the physician most likely ask the patient to turn her right eye to confirm the abducens nerve damage, assuming she is unable to perform this task?
A. Inward B. Outward C. Downward D. Down and out E. Down and in
B. The right abducens nerve innervates the right
lateral rectus, which mediates outward movement
(abduction) of the right eye.
An 8-year-old male is admitted to the hospital
with a drooping right eyelid (ptosis). The initial diagnosis is Horner’s syndrome ( Fig. 7-4 ). Which of the following additional signs on the right side would confirm the diagnosis?
A. Constricted pupil B. Dry eye C. Exophthalmos D. Pale, blanched face E. Sweaty face
A. Horner’s syndrome involves inte ruption of
sympathetic supply to the face This results in ptosis
(drooping eyelid) miosis (constricted pupil), and anhydrosis (lack of sweating) of the face
A 32-year-old woman is admitted to the hospital
with headaches and dizziness. During physical examination it is noted that the patient has partial ptosis (drooping eyelid). Which of the following muscles is most likely paralyzed?
A. Orbicularis oculi, lacrimal part B. Orbicularis oculi, palpebral part C. Levator palpebrae superioris D. Superior oblique E. Superior tarsal (of Müller)
E. The superior tarsal muscle (of Müller), innervated
by sympathetics, assists in elevating the eyelids
and holding them up. Damage would result in partial
ptosis of the eyelid.
A 16-year-old boy is admitted to the hospital with
fever, confused mental state, and drowsiness. During physical examination it is noted that the boy suffers from severe acne. Radiologic examination reveals cavernous sinus thrombosis. Which of the following routes of entry to the cavernous sinus would most likely be responsible for the infection and thrombosis?
A. Carotid artery B. Mastoid emissary vein C. Middle meningeal artery D. Ophthalmic vein E. Parietal emissary vein
D. Cavernous sinus thrombosis can often result
from squeezing pimples or other infectious processes located around the danger area of the face, which includes the area of the face directly surrounding the nose. This physical pressure has the potential to move infectious agents from the pimple into the ophthalmic vein, which then carries i to the cavernous sinus.
The pterygoid venous lexus and ophthalmic vein both communicate with the cavernous sinus and therefore offer a route of travel for the spread of infection, but the path provided by the superior ophthalmic vein is a more direct route. Additionally, the superior ophthalmic vein receives blood supply from the supraorbital supratrochlear, and angular veins that supply the area around the nose and lower forehead. (Venous blood in the head can flow in either direction because these veins do not possess valves.)
A 68-year-old man is admitted to the emergency
department after an acute cerebral vascular accident (stroke). Radiographic studies reveal that the primary damage was to the anterior inferior cerebellar artery, resulting in a small hemorrhage of the artery at its origin from the main trunk. Which of the following nerves will most likely be immediately affected by the hemorrhage?
A. Optic nerve B. Oculomotor nerve C. Trochlear nerve D. Trigeminal nerve E. Abducens nerve
E. The anterior inferior cerebellar artery (AICA)
is a major supplier of the anterior inferior portion of
the cerebellum. Nerves located in close proximity
would likely be affected by hemorrhage of this artery.The abducens nerve is situated at the pontomedullary junction and is therefore most likely to be damaged following
hemorrhage of the AICA.
A 5-year-old boy is admitted to the hospital with
otitis media. Otoscopic examination reveals a bulging and inflamed eardrum. It is decided to incise the tympanic membrane to relieve the painful pressure and allow drainage of the infection associated with otitis media. Which of the following is the best location to make an opening (myringotomy) for drainage?
A. The anterior superior quadrant of the eardrum
B. The posterior superior quadrant of the eardrum
C. Directly through the site of the umbo
D. The posterior inferior quadrant of the eardrum
E. A vertical incision should be made in the
eardrum, from the 12 o’clock position of the
rim of the eardrum to the 6 o’clock position
of the rim.
D. The posterior inferior quadrant of the eardrum
is the only portion of the tympanic membrane that
would allow for an incision with minimal or no damage to adjacent important structures.
A 56-year-old man is diagnosed with an extradural
tumor in the posterior cranial fossa. When the patient protruded his tongue during physical examination, the tongue deviated to the right. Which of the following muscles and nerves are most likely injured?
A. Right hypoglossal nerve and right genioglossus
B. Left hypoglossal nerve and left genioglossus
C. Right hyoglossus and left styloglossus
D. Right geniohyoid and fi rst cervical nerve
E. Contralateral vagus and hypoglossal nerves
A. The hypoglossal nerve innervates the muscles
of the tongue and is therefore directly involved
in alteration of shape and movement of the tongue
A lesion in this nerve would cause deviation of the
tongue toward the injured side, which could be observed upon protrusion of the tongue.
A 62-year old man is admitted to the hospital
with blurred vision. Physical examination reveals a
long history of gradual loss of his visual field. The intraocular pressure is high, and a diagnosis of glaucomais made. Which of the following spaces first receives the aqueous humor secreted by the epithelium of the ciliary body?
A. Anterior chamber B. Posterior chamber C. Pupil D. Vitreous E. Lacrimal sac
B. The posterior chamber receives ciliary body
secretions first. The ciliary body produces aqueous
humor and is located in the posterior chamber. Increased production of fluid from this site would
cause an increase in intraocular pressure if drainage is inadequate. The iridoscleral angle of the anterior chamber is the location of drainage of the aqueous humor; therefore, a blockage of drainage in this location can cause increased intraocular pressure.
A 17-year-old woman is admitted to the hospital
with tonsillitis. A tonsillectomy is performed and the
patient complains postoperatively of ear pain. Which
of the following nerves was most likely injured during
the surgical procedure?
A. Auriculotemporal B. Lesser petrosal C. Vagus D. Glossopharyngeal E. Chorda tympani
D. The glossopharyngeal nerve mediates general
somatic sensation from the pharynx, the auditory
tube, and from the middle ear. Painful sensations
from the pharynx, including the auditory tube, can be referred to the ear by this nerve, as in this case of tonsillectomy.
A 49-year old woman is admitted to the hospital
with headaches and dizziness. Radiographic examination reveals a tumor in the jugular canal. Upon physical examination, when the right side of the pharyngeal wall is touched with a tongue depressor, the uvula deviates to he left and the left pharyngeal wall contracts upward. When the left pharyngeal wall is touched, the response is similar. Which of the following nerves is most likely to have been injured by the tumor?
A. Right glossopharyngeal B. Left glossopharyngeal C. Right mandibular D. Left hypoglossal E. Right vagus
E. A tumor of the jugular canal would likely affect
the glossopharyngeal, vagus, and accessory
nerves as they exit the cranium through the jugular
foramen. The uvula deviates toward the unaffected
side of the pharyngeal muscles because of the pull of the unopposed levator veli palatini. In this case, the uvula deviates to the left, indicating that the left
palatal muscles are unaffected whereas the right
muscles are not working properly. The pharyngeal
wall on the left side is also drawn upward by the
nonparalyzed stylopharyngeus, supplied by the left
glossopharyngeal nerve. The pharyngeal constrictor
muscles, as well as muscles of the palate, are all innervated by the vagus nerve, except for the tensor
veli palatini, which is supplied by the trigeminal
nerve.
A 45-year-old man is admitted to the emergency
department with severe dyspnea. During physical examination there is swelling in the floor of his mouth and pharynx so that his airway is nearly totally occluded. In addition, there is a swelling in his lower jaw and upper neck. His physical history indicates that one of his lower molars was extracted a week ago and he had been feeling worse every day since that event. Which of the following conditions will be the most likely diagnosis?
A. Quinsy B. Torus palatinus C. Ankyloglossia D. Ranula E. Ludwig’s angina
E. An infection of the submandibular space is
usually the result of a dental infection in the mandibular molar area in the floor of the mouth (Ludwig’s angina). If the patient is not treated with antibiotics promptly, the pharyngeal and submandibular swelling can lead to asphyxiation.
A 5-year-old girl is admitted to the hospital with
an upper respiratory tract infection. During physical
examination her sense of hearing appears to be poor. Her right ear is painful, and upon otoscopic examination a golden brown fluid can be observed through the tympanic membrane. Which is the most likely direct route for the spread of an infection from the upper respiratory
tract to the middle ear cavity?
A. Pharyngotympanic tube B. Choanae C. Nostrils D. Facial canal E. Internal acoustic meatus
A. The auditory (eustachian or pharyngotympanic)
tube is a mucosal-lined tube that provides a direct
connection from the nasopharynx to the middle
ear cavity. A respiratory infection can travel from the
upper respiratory tract to the oropharynx or nasopharynx and then on into the middle ear via the auditory tube.
A 54-year-old man is admitted to the hospital
with severe pain in his nasal cavity. Radiographic examination reveals a carcinoma in his nasal cavity. In which of the following locations would the carcinoma block the hiatus of the maxillary sinus?
A. Inferior meatus B. Middle meatus C. Superior meatus D. Nasopharynx E. Sphenoethmoidal recess
B. The maxillary sinus drains via the middle
meatus, specifically via the semilunar hiatus. The
middle meatus and semilunar hiatus are ocated under the middle nasal concha
A 54-year-old male is diagnosed with an aneurysm of the basilar artery close to the cavernous sinus
An anterior approach to the sella turcica through the
nasal cavity is performed. Through which of the following routes is the surgeon most likely to enter the cranial cavity?
A. Cribriform plate B. Cavernous sinus C. Frontal sinus D. Maxillary sinus E. Sphenoidal sinus
E. The sphenoidal sinus provides the most direct
access to the pituitary gland, which is situated directly above this sinus.
A 10-year-old girl is admitted to the hospital with
tonsillitis. A tonsillectomy is performed and the tonsils are removed On physical examination one week later the patient has absence of the gag reflex on the left when the posterior part of the tongue is depressed. The sensory portion of which of the following nerves was most likely injured?
A. Facial B. Glossopharyngeal C. Mandibular D Maxillary E. Hypoglossal
B. The gag reflex is composed of both an afferent
and an efferent limb. These reflexes are mediated
by the glossopharyngeal and vagus nerves, respectively. Together, the glossopharyngeal and vagus nerves are responsible for the contraction of the muscles of the pharynx involved in the gag reflex. In this case the glossopharyngeal nerve was injured when the tonsils were excised, resulting in the loss of the sensory side of the reflex.
A 56-year-old woman has just undergone a complete thyroidectomy. After she recovers from the anesthesia a hoarseness of her voice is noted that persists for 3 weeks. Subsequent examination shows a permanently adducted vocal fold on the right side. Surgical trauma to the innervation of which of the following muscles is most likely to be responsible for the position of the right vocal fold?
A. Aryepiglottic B. Posterior cricoarytenoid C. Thyroarytenoid D. Transverse arytenoids E. Vocalis
B The recurrent laryngeal nerve is often at risk
of being damaged during a thyroidectomy. Patients
who have a transected or damaged recurrent laryngeal will often present with a characteristic hoarseness following surgery. The posterior cricoarytenoid is supplied by the recurrent laryngeal and would thus be impaired following damage to the nerve. The posterior cricoarytenoid is the only muscle responsible for abduction of the vocal cords, and paralysis of this muscle would result in a permanently adducted position of the involved vocal cord.
A 45-year-old man with a complaint of ear pain
and difficulty hearing is diagnosed with tonsillitis. Otoscopic examination reveals fluid in the middle ear cavity. Hypertrophy of which of the following structures would be most likely to compromise the drainage of the auditory tube?
A. Lingual tonsil B. Palatine tonsil C. Pharyngeal tonsil D. Superior constrictor muscle E. Uvula
C. The pharyngeal tonsil is situated in a slitlike
space, the pharyngeal recess, in the nasopharynx
behind the opening of the auditory (eustachian)
tube, and a pharyngeal tonsil in this location can
lead to blockage of the drainage of the auditory tube.
