Head and Neck Flashcards
1
Q
Which cranial nerves have only motor function?
A
3, 4, 6, 11, 12
2
Q
Which cranial nerves have both sensory and motor function?
A
5, 7, 9, 10
3
Q
Which cranial nerves are associated with parasympathetic function? Name each function.
A
3 - pupil constriction
7 - lacrimal, submandibular and sublingual
9 - parotid
10 - heart, viscera
And all vasodilation
4
Q
Which cranial nerves pass through the superior orbital fissure? What other important vessel travels through it?
A
3, 4 and 6
Superior and inferior ophthalmic veins
5
Q
Which cranial nerves pass through the internal auditory meatus and middle ear? What is the significance of this?
A
7 and 8
Otitis media can cause facial palsy
6
Q
Which cranial nerves pass through the foramen magnum?
A
9 10 and 11
7
Q
What type of fracture might cause rhinorrhea? Why is this dangerous?
A
Cribiform plate of ethmoid.
Bone is weak and CN1 has meningeal coverings so easily leaks CSF.
Risk of spread of infection to brain.
8
Q
How would you examine the first cranial nerve?
A
Ask if the patient has noticed a change in sense of smell or taste.
9
Q
Which cranial nerves are involved in the sense of taste?
A
1 (smell)
7 - chorda tympani - (anterior 2/3)
9 - (posterior 2/3)
10
Q
Where does the optic nerve exit the skull? What is the clinical significance of this?
A
Optic canal through sphenoid.
Close to sella turcica so pituitary adenoma can cause bitemporal hemianopia.
11
Q
How would you examine the optic nerve?
A
Snellen chart with each eye Visual fields (wiggle finger in peripheries) Fundoscopy
12
Q
What are the key symptoms to rule out with Fundoscopy?
A
Papilloedema - swollen optic disc - sign of raised intracranial pressure
Diabetic retinopathy - bleeding and proliferation of vessels
13
Q
Which muscles are innervated by the Oculomotor nerve?
A
Superior rectus
Medial rectus
Inferior rectus
Levator palpabrae superioris
Inferior oblique
14
Q
What parasympathetic chain is associated with the Oculomotor nerve?
A
Edinger Westphal nucleus joins Oculomotor.
Parasympathetic fibres branch off to the ciliary ganglion and short ciliary nerves supply the pupil for constriction.
EWN - Oculomotor - ciliary ganglion - short ciliary - pupil
15
Q
What symptoms are associated with an Oculomotor nerve palsy?
A
Complete Ptosis - drooping eyelid
Eye in the down and out position
Dilated pupil
16
Q
Name three common causes of Oculomotor nerve palsy.
A
Diabetic retinopathy/ neuropathy
Cavernous sinus infection
Aneurysm/ stroke of posterior cerebral artery
17
Q
Name 4 disorders of the eyelid.
A
Complete Ptosis - Oculomotor - levator palpabrae superioris
Partial Ptosis - Horner’s syndrome - sympathetic to superior tarsus
Ptosis - myasthenia gravis - autoimmune destruction of ach receptors
Can’t close - facial - orbicularis oculi
18
Q
How would you examine the Oculomotor, trochlear and abducens nerves?
A
Follow H with finger, ask for double vision (diplopia), check for head tilt
Pupil reflex
Accommodation
19
Q
What muscle is innervated by the trochlear nerve?
A
Superior oblique
20
Q
What muscle is innervated by the abducens nerve?
A
Lateral rectus
21
Q
What are the symptoms of a trochlear nerve palsy?
A
Eye in up and in position
Head tilt - neck pain
Diplopia when reading or climbing stairs
22
Q
What are the symptoms of an abducens nerve palsy?
A
Medially rotated
Diplopia side by side
23
Q
What are the branches of the trigeminal nerve?
A
Ophthalmic v1
Maxillary v2
Mandibular v3
24
Q
Give a reversible cause of a blown pupil.
A
Adie’s pupil. Infection and inflammation affecting ciliary ganglion (before short ciliary nerves - pupil)
25
What parasympathetic chains are associated with branches of the trigeminal nerve?
Pterygopalatine ganglion - v2 - lacrimal glands and nose
Submandibular ganglion - v3 - submandibular and sublingual glands
Otic ganglion - v3 - parotid and mouth mucosa
Travel together but provide no function - function provided by facial nerve (and Glossopharyngeal for parotid)
26
Which nerves are associated with the corneal reflex?
Sensory - Trigeminal v1
| Motor - facial
27
What are the boundaries of the sensory innervation of the trigeminal nerve?
V1 - above the inferior border of the orbit - eyes
V2 - corner of mouth to top of ear - nose and nasopharynx
V3 - below corner of mouth to top of ear - ears and anterior tongue
28
What is the motor function of the trigeminal nerve?
V3 - muscles of mastication
Masseter
Temporalis
Lateral and medial pterygoids
29
How would you examine the trigeminal nerve?
Cotton wool to each sensory region
Clench jaw and wiggle - deviates towards lesion
Corneal reflex
30
Name and describe the functions of the intracranial branches of the facial nerve?
Stapedius - middle ear dampens loud sounds on stapes
| Chorda tympani - anterior 2/3 taste
31
Name and describe the functions of the extracranial branches of the facial nerve?
```
Temporal
Zygomatic
Buccal
Mandibular
Cervical
```
Muscles of facial expression, digastric, stylohyoid and platysma
32
Which foramen does the facial nerve pass through internally? What is the clinical significance of this?
Internal acoustic meatus
Middle ear infection or tumour can cause facial nerve palsy
33
Which foramen does the facial nerve pass through externally? What is the clinical significance of this?
Stylomastoid foramen close to parotid
Parotid infection or mastoid compression during birth can cause facial nerve palsy
34
What is the name given to idiopathic facial nerve palsy?
Bell's palsy
35
What is the parasympathetic chain associated with the facial nerve?
Superior salivatory nucleus - greater petrosal of 7 - pterygopalatine ganglion - v2 - lacrimal gland and nose
Superior salivatory nucleus - chorda tympani of 7 - submandibular ganglion - v3 - submandibular and sublingual glands
NOT PAROTID
36
What are the symptoms of facial nerve palsy?
Decreased salivation (still some from parotid)
Hypersensitivity to sound
Decreased sense of taste
Weakness of facial muscles on one side
37
How do you differentiate between an upper motor neurone and lower motor neurone lesion of the facial nerve? What is the clinical significance of this distinction?
Upper spares frontalis because there is bilateral innervation
Lower is whole ipsilateral face
Upper caused by stroke
Lower idiopathic Bell's palsy
38
How would you examine the facial nerve?
Raise eyebrows
Scrunch eyes
Puff out cheeks
Smile with teeth
39
What are the motor functions of the Glossopharyngeal nerve?
Stylopharyngeus - raises oropharynx for swallowing
40
What are the sensory functions of the Glossopharyngeal nerve?
Oropharynx for gag reflex
Taste for posterior 1/3 tongue
Pressure in carotid sinus baroreceptors
41
What is the parasympathetic function associated with the Glossopharyngeal nerve?
Inferior salivatory nucleus - lesser petrosal of IX - optic ganglion - parotid and oral mucosa
42
What sympathetic nerves are responsible for the gag reflex?
Sensory - Glossopharyngeal
| Motor - vagus
43
How would you examine the Glossopharyngeal nerve?
Gag reflex
| Could check response to carotid massage
44
What is the motor function of the Hypoglossal nerve?
Muscles of the tongue
Hyoglossus
Styloglossus
Genioglossus
45
How would you examine the hypoglossal nerve?
Ask to stick out tongue - deviates towards lesion
| Press tongue against side of mouth
46
What is the motor function of the vagus nerve?
Pharyngeal constrictors and oropharynx for gag reflex and swallowing
Larynx
47
What is the sensory function of the vagus nerve?
Laryngopharynx
| Larynx
48
What is the parasympathetic chain associated with the vagus nerve?
Dorsal Vaal motor nucleus - vagus - viscera and heart
49
What is the mechanism of vasovagal syncope?
Stress - increase firing of vagus nerve - slow heart rate/syncope - low bp - faint
50
What disorders may be associated with dysphonia (hoarseness) by pressing on vagus?
Laryngeal tumour
Thyroid tumour / thyroidectomy
Thyroid disease
Apical lung tumour (pancoast)
Aortic aneurysm
Patent ductus arteriosus
Oesophageal tumour
51
How would you examine the vagus nerve?
Ask to speak
| Say ah - uvula deviates away from lesion
52
What are the symptoms of vestibulocochlear nerve palsy?
Vestibular neuritis - Vestibule only inflamed
- Vertigo
- Imbalance
- nausea
- Nystagmus
Labyrinthitis - Whole inner ear inflamed
Plus
- neural hearing loss
- tinnitus
53
How would you examine the vestibulocochlear nerve?
Close eyes and balance
Rustle fingers for gross hearing
Weber - tuning fork on head
Rinne - tuning fork on mastoid process versus air
54
What is the motor innervation of the accessory nerve?
Trapezius
| Sternocleidomastoid
55
How would you examine the accessory nerve?
Look for muscle wasting and asymmetry
Rotate head with and without resistance
Shrug with and without resistance
56
Where in the sympathetic chain does the innervation to the head and neck originate?
Superior, middle and inferior cervical ganglia
57
What is Horner's syndrome? What are the key symptoms.
Damage to sympathetic chain.
- partial Ptosis (superior tarsus)
- miosis (dilator pupillae)
- anhydrosis (sweat glands)
58
What are some causes of Horner's syndrome?
Pancoast tumour
| Trauma to sympathetic ganglia
59
List the cranial nerves in order.
```
Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducent
Facial
Vestibulocochlear
Glossopharangeal
Vagus
Accessory
Hypoglossal
```
60
Name the cranial bones
```
Frontal
Parietal
Occipital
Temporal
Sphenoid
Ethmoid
```
61
Name the bones of the calvarium
Frontal
Parietal
Occipital
62
Name the facial bones
```
Maxilla
Mandible
Nasal
Lacrimal
Zygomatic
Palatine
Vomer
```
63
Which bones meet at the pterion?
Frontal
Parietal
Temporal
Sphenoid
64
Which artery is at risk following trauma to the pterion? Which type of haematoma is most likely?
Medial meningeal artery
| Extradural haematoma due to high pressure
65
Give three signs of a basal skull fracture.
Bruising:
Behind eyes - Raccoon eyes
Behind ears - Battle's sign
CSF leaking through ear
66
Which blood vessels travel in the grooves on the underside of the parietal bone?
Middle meningeal vessels
67
What is contained in the petrous part of the temporal bone?
Middle and inner ear
68
What are the main features of the ethmoid bone?
Cribiform plate - flat bit across top. Olfactory nerve travels through
Crista Galli - blob in middle of cribiform, meets falx cerebri
Perpendicular plate - runs straight down to meet vomer
69
Where is the pituitary gland situated? What is the clinical significance of this?
Sella turcica / hypophyseal fossa
Behind sphenoid sinus, in close proximity to optic chiasm
Can be accessed surgically through the nose, ethmoid and sphenoid sinus
Pituitary adenoma can cause bitemporal hemianopia via optic nerve
70
Which type of ossification is used by the bones of the head and neck?
Intramembranous - de novo from mesenchyme
71
Which bones make up the orbit?
```
Frontal
Maxilla
Zygomatic
Lacrimal
Ethmoid
Sphenoid
(Palatine)
```
72
Which bones are visible through the piriform aperture?
Perpendicular plate of ethmoid
Vomer
Inferior nasal concha
73
What are the components of the temporomandibular joint?
Mandibular head
Articular disc
Mandibular fossa
Capsule
Articular tubercle
74
What are the ligaments of the temporomandibular joint?
Lateral
Stylomandibular
Sphenomandibular
75
What acts to prevent anterior dislocation of the temporomandibular joint? Are these mechanisms weak or strong?
Articular tubercle of temporal bone
Stylomandibular and Sphenomandibular ligaments
Weak
76
What acts to prevent posterior dislocation of the temporomandibular joint? Are these mechanisms weak or strong?
Lateral ligament
Strong
77
What nerves are at risk after a dislocation of the temporomandibular joint?
Facial and v3 of trigeminal
78
What is exposure keratitis? What nerve palsy causes it?
Facial nerve palsy - orbicularis oculi paralysis
Can't close eye so tears pool, debris stays and ulcers form
79
What is the motor innervation of the tongue?
Palatoglossus - vagus
| All the rest hypoglossal
80
What is the basic sensory innervation of the tongue?
Anterior 2/3 - v3 of trigeminal
| Posterior 1/3 - Glossopharyngeal
81
What is the taste innervation of the tongue?
Anterior 2/3 - chorda tympani of facial
| Posterior 1/3 - Glossopharyngeal
82
Name the muscles of mastication. Which nerve innervates them?
Masseter
Temporalis
Lateral pterygoid
Medial pterygoid
V3 of trigeminal
83
Name the key facial muscles. Which nerve innervates them?
Frontalis
Orbicularis oculi
Orbicularis oris
Buccinator
Facial nerve
84
What are the borders of the anterior triangle of the neck?
Mandible
Sternocleidomastoid
Midline
85
What are the contents of the anterior triangle of the neck?
Internal jugular vein - JVP
Common carotid
Supra and infra hyoids
Cranial nerves 7, 9, 10, 11, 12
86
What are the borders of the posterior triangle of the neck?
Trapezius
Clavicle
Sternocleidomastoid
87
What are the contents of the posterior triangle of the neck?
External jugular vein - central line
88
What are the fascial divisions of the neck?
Carotid sheaths
Pretracheal fascia
Prevertebral fascia
(Investing fascia)
89
What are the contents of the carotid sheaths?
Internal jugular vein
Common carotid
Vagus
90
What are the contents of the pretracheal fascia?
Trachea
Oesophagus
Thyroid
91
Infection can travel from the upper respiratory tract to the mediastinum through which fascial space?
Retro pharyngeal space
| Between the pretracheal and prevertebral fascia
92
What is the name given to the ridges and recesses on the inside of the nose?
Ridges - Superior, middle and inferior turbinates
Recesses- (underneath) superior, middle and inferior meatus
Recess above superior turbinate is the sphenoethmoidal recess
93
Give three functions of the nasal turbinates.
Increase surface area
Slow down air
Make air turbulent
.....all to humidify and adjust temperature with efficiency.
94
Which paranasal sinus opens into the superior meatus?
Posterior ethmoidal
95
Which paranasal sinuses open into the middle meatus?
On the ethmoid bulla: middle ethmoidal
On the semilunar hiatus: anterior ethmoidal
Maxillary
Frontal
96
Which paranasal sinus opens into the inferior meatus?
Nasolacrimal duct
97
Which cranial nerves have only sensory function?
1, 2, 8
97
Where does the paranasal sinus open into?
The sphenoethmoidal recess
99
Why does your nose stream when you cry?
Nasolacrimal duct drains to inferior meatus in nose.
100
What is the sensory innervation to the nose?
V1 and v2 of trigeminal
| Olfactory for smell
101
Where does epistaxis most commonly occur?
Nosebleeds.
Little's area in anterior nose. Where arteries converge.
102
Name 4 risk factors for epistaxis
Warfarin
Very young or very old
Haemophilia
Oxygen dependence
103
In a cribiform plate fracture leaking CSF, what is the primary concern?
Exposed meninges/ brain.
| Vulnerable to meningitis. Give antibiotics.
104
What is the mechanism of formation of the saddle nose deformity?
Septal haematoma between cartilage and perichondrium - blockage of fresh O2 - septal necrosis
105
How does sinusitis become chronic?
Obstruction of drainage
106
Why does sinusitis sometimes present with toothache?
Maxillary sinuses use the same sensory afferent as the teeth - v2
107
What is the basic sensory innervation of the ear?
Outer ear:
Top - v3 of trigeminal
Bottom - c3
Inside - vagus
Middle ear - Glossopharyngeal
108
How should you examine the tympanic membrane in an adult and child?
Adult - pull pinna up and back
Child - pull pinna down and back
To straighten the sinuous auditory canal
109
What type of epithelia make up the tympanic membrane?
Middle is fibrous cartilage
Rest is keratinised stratified squamous
110
How would you tell whether you are looking at the right or left tympanic membrane?
Umbo (hook of malleus) points towards bum
111
What are the contents of the Middle ear?
Facial nerve including chorda tympani
3 ossicles - malleus, incus, stapes
2 muscles - stapedius and tensor tympani
112
What are the openings of the middle ear?
```
Auditory canal (tympanic membrane)
Eustachian tube
Oval window
Round window
```
113
What is the function of the Eustachian tube?
Equalises pressure in the middle ear to maintain good sound conduction
114
Why are children at greater risk of otitis media?
Eustachian tube is shorter wider and flatter so there is a faster link between upper respiratory tract and middle ear.
115
Where does the Eustachian tube drain from and to?
From middle ear to nasopharynx
116
What is the function of the stapedius muscle? What is it innervated by? Therefore which palsy causes hypersensitivity to sound?
Dull vibrations of stapes in loud sounds
Facial nerve
Bell's palsy
117
What is the function of the mastoid air cells? Where are they found?
Another way of equalising middle ear pressure. Compensates when Eustachian tube is blocked.
Found in mastoid process of temporal bone. Access middle ear via mastoid Antrum
118
What is mastoiditis and why is it life threatening?
Infection of mastoid air cells. Pus is close to brain and threatens brain infection. Treat by draining and giving antibiotics.
119
What mechanism causes cauliflower ears?
Auricular haematoma between cartilage and perichondrium - block fresh O2 - necrosis
120
What are the symptoms of acute otitis media? How are they caused?
Red, swollen, pus, bulging tympanic membrane
Simple inflammatory response
121
What are the symptoms of chronic otitis media. How are they caused?
Retracted ear drum with some pus/ effusion
Acute infection - blocked Eustachian tube - lack of drainage - chronic - bacteria use up O2 in closed space - negative pressure - retracted drum
122
Why does otitis media sometimes present with toothache?
Referred pain from v3
123
What are the 2 types of cyst found around the eye? What is the difference?
Stye - from blocked ciliary gland
| Meibomiam - from blocked tarsus gland
124
What are the functions of the glands around the eye?
Tarsus - sebum prevents tear spillage
Ciliary - sebum prevents tear evaporation
Lacrimal - tear flow down and in towards lacrimal sac
125
Give 1 cause of exophthalmos and 1 cause of enopthalmos.
Increase in fatty and connective tissue due to Graves' disease
Retracted pulsatile orbit due to blow out fracture
126
What is meant by the triangle of danger?
Infection can easily spread through the facial veins in the triangle to the cavernous sinus. This can spread infection to a number of nearby nerves - 3, 4, 6, v2
127
What is significant about the blood supply to the eye?
Only one end artery - ophthalmic artery so thrombosis can cause permanent blindness within 90 minutes.
128
What are the borders of the nasopharynx?
Base of skull to soft palate
129
What type of epithelia are found in the nasopharynx?
Respiratory. Pseudostratified ciliated columnar with goblet cells.
130
What are the borders of the oropharynx?
Soft palate to epiglottis
131
What type of epithelia are found in the oropharynx and laryngopharynx?
Oesophageal. Stratified squamous.
132
What are the borders of the laryngopharynx?
Epiglottis to the cricoid cartilage
133
What nerves are implicated in swallowing?
Hypoglossal - tongue action
Facial and v3 - raise hyoid and larynx
Glossopharyngeal - soft palate closes nasopharynx
Vagus - pharyngeal constrictors
134
Which muscle is susceptible to pharyngeal diverticulum? Why?
Inferior pharyngeal constrictor
Because it is made of two parts - thyropharyngeus and cricopharyngeus
135
What are the symptoms of a pharyngeal diverticulum?
Dysphagia and halitosis
136
What patient group are susceptible to adenoid tonsillitis?
Under 8s because the adenoid tonsils regress after this
137
What is the key complication of adenoid tonsillitis?
Can block Eustachian tube and lead to glue ear
138
What is the lymph drainage of the palatine tonsils? Why is this significant?
Jugular digastric lymph nodes
| Always enlarged in tonsillitis
139
What is a quinsy? What are the possible complications?
Post tonsillectomy spread infection forms access behind uvula
Can block airway
140
Where might a bleed originate in a tonsillectomy?
External palatine vein
| Facial artery
141
What symptom is associated with recurrent laryngeal nerve palsy?
Dysphonia - hoarseness
142
What is significant about the fact that the cricoid cartilage is a complete ring of cartilage?
Cricoid pressure blocks oesophagus and prevents gastric reflux during rapid sequence intubation
143
How would you create an emergency airway in the neck if intubation was failing?
Cricothyrotomy - puncture the cricothyroid membrane
144
What is the innervation of the larynx?
Cricothyroid muscles are the external superior laryngeal nerve.
Everything else is RECURRENT LARYNGEAL
