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ESA4 > Head and Neck > Flashcards

Head and Neck Flashcards

1
Q

State the boundaries of the pharynx

A

base of the skull

inferior border of the cricoid cartilage

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2
Q

State the boundaries of the anterior triangle

A

Superior - inferior border of the mandible
Laterally - medial border of SCM
Inferior - sagittal line down midline

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3
Q

What is the action of the suprahyoid muscles?

A

elevate the hyoid bone

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4
Q

What is the action of the infrahyoid muscles?

A

depress the larynx

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5
Q

State the boundaries of the carotid triangle

A

Superior - posterior belly of the digastric muscle
Laterally - medial border of SCM
Inferior - superior belly of the omohyoid

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6
Q

What are the contents of the carotid triangle?

A 
common carotid artery (which bifurcates here)
internal jugular vein
hypoglossal nerve
vagus nerve
carotid sinus
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7
Q

State the boundaries of the posterior triangle

A

anterior - posterior border of SCM

posterior - anterior border of the trapezius

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8
Q

Between what layers does the superficial cervical fascia lie?

A

dermis

deep cervical fascia

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9
Q

What are the contents of the superficial cervical fascia?

A 
neurovascular supply to skin
superficial veins
superficial lymph nodes
fat
platysma
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10
Q

What are the attachments of the platysma?

A

two heads from fascia of the pec major and deltoid

fuse in midline with muscles of the face

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11
Q

How is the platysma innervated?

A

cervical branch of the facial nerve

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12
Q

What structures are enclosed by the investing layer of deep cervical fascia?

A

SCM
trapezius
submandibular glands
parotid glands

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13
Q

What is enclosed by the pretracheal fascia?

A

infrahyoid muscles
thyroid gland
trachea
oesophagus

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14
Q

To what structures is the pretracheal fascia attached?

A

carotid sheaths laterally

fibrous pericardium inferiorly

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15
Q

What are the contents of the carotid sheath?

A

common carotid artery
internal jugular vein
vagus nerve
deep cervical lymph nodes

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16
Q

name the components of the deep cervical fascia

A

investing layer
pretracheal
prevertebral

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17
Q

Where does the prevertebral fascia extend to?

A

from the base of the cranium to the third thoracic vertebra inferiorly
as the axillary sheath, surrounding axillary vessels and brachial plexus

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18
Q

If an infection occurs between the investing and pretracheal fascia, where can it spread to?

A

thoracic cavity anterior to the pericardium

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19
Q

What is the retropharyngeal space?

A

potential space between the prevertebral fascia and the fascia surrounding the pharynx+

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20
Q

What complications could an infection in the retropharyngeal space cause?

A

spread of infection to thorax

retropharyngeal abscess - dysphagia and difficulty speaking

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21
Q

What are the four muscles of mastication?

A

masseter
temporalis
medial pterygoid
lateral pterygoid

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22
Q

How are the muscles of mastication innervated?

A

mandibular nerve

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23
Q

What is the actionof the lateral pterygoids?

A

bilateral action - protraction of the mandible

unilateral action - side to side movement of mandible

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24
Q

From where do the common carotid arteries arise?

A

Right - bifurcation of the brachiocephalic trunk at the sternoclavicular joint
Left - arch of the aorta

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25
Q

Where do the common carotid arteries split?

A

superior margin of the thyroid cartilage
C4
carotid triangle

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26
Q

What is the purpose of carotid sinus massage?

A

stimulates the baroreceptors
leads to decreased sympathetic activity and increased parasympathetic activity
slows heart rate

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27
Q

What nerve transmits information from the carotid sinus to the brain?

A

glossopharyngeal

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28
Q

Where are the baroreceptors located?

A

carotid sinus at the bifurcation of the common carotid artery

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29
Q

What are the carotid bodies?

A

peripheral chemoreceptors detecting arterial pO2

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30
Q

What are the problems involved with carotid sinus hypersensitivity

A

external pressure on the carotid sinus can cause slowing of heart rate and a decrease in blood pressure
syncope

therefore, do not check pulse in carotid triangle

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31
Q

Why does an atheroma often develop at the bifurcation of the common carotid artery?

A

turbulence of flow

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32
Q

`What are the symptoms of a carotid artery atheroma?

What is the cause of these symptoms?

A

headache
dizziness
muscular weakness

reduced blood flow to the brain

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33
Q

What is a possible complication of a carotid artery atheroma?

A

rupture
embolus
stroke or TIA

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34
Q

What is a possible treatment for carotid artery atheroma?

A

carotid endarterectomy

atheromatous tunica intima is removed

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35
Q

Describe the course of the external carotid artery

A

travels posterior to the mandibular gland
anterior to the lobule of the ear
ends within the parotid gland
divides into the superficial temporal artery and maxillary artery

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36
Q

What are the branches of the external carotid artery?

A
  • Superior thyroid artery
  • Lingual artery
  • Facial artery
  • Ascending pharyngeal artery
  • Occipital artery
  • Posterior auricular artery
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37
Q

Which branch of the external carotid artery supplies the deep structures of the face?

A

maxillary

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38
Q

Where does the internal carotid artery enter the cranial cavity?

A

the carotid canal in the petrous part of the temporal bone

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39
Q

Which arteries supply the scalp?

A

From the external carotid:
posterior auricular
occipital
superficial temporal

From the internal carotid:
supraorbital
supratrochlear

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40
Q

What bones make up the Pterion?

A

frontal bone
parietal bone
temporal bone
sphenoid bone

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41
Q

What is the clinical significance of the pterion?

A

a fracture at this site can rupture the middle meningeal artery, causing an extradural haematoma - collection of blood between the dura mater and the skull
or haemorrhage
increases intracranial pressure

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42
Q

What are the symptoms of an extradural haematoma?

What is the cause of these symptoms?

A 
nausea
vomiting
seizures
bradycardia
limb weakness

increased intracranial pressure

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43
Q

What is the treatment for an extradural haematoma?

A

diuretics

drilling burr holes

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44
Q

Which arteries of the face are branches of the internal carotid artery?

A

supraorbital

supratrochlear

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45
Q

Where can the pulse of the facial artery be felt?

A

inferior border of the mandible anterior to the masseter

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46
Q

What is a thyroglossal cyst?

A

mass in midline of neck

persistence of thyroglossal duct in the adult

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47
Q

Describe the anatomical location of the thyroid

A

in anterior neck
below thyroid cartilage
C5 to T1

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48
Q

Describe the blood supply of the thyroid

A

paired superior thyroid arteries - first branch of external carotid. supplies superior and anterior gland
paired inferior thyroid arteries - from thyrocervical trunk of subclavian artery. supplies posterior and inferior gland

superior, inferior and middle thyroid veins drain into plexus.
superior and middle to internal jugular.
inferior to brachiocephalic

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49
Q

How are the thyroid and recurrent laryngeal nerves related?

A

the nerves pass underneath the thyroid to the larynx

damaged in surgery of the thyroid

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50
Q

Name the infrahyoid muscles

A

sternoyhoid
omohyoid
sternothyroid
thyrohyoid

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51
Q

Which infrahyoid muscles are in the superficial plane?

A

sternohyoid

omohyoid

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52
Q

Which infrahyoid muscles are in the deep plane?

A

sternothyroid

thyrohyoid

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53
Q

How are the superficial infrahyoid muscles innervated?q

A

anterior rami of C1-C3, carried by the ansa cervicalis

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54
Q

Describe the action of the superficial infrahyoid muscles

A

depress the hyoid bone

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55
Q

Describe the attachements of the omohyoid

A

inferior belly arises from scapuka
moves underneath SCM superomedially
intermediate tendon attached to clavicle
superior belly to hyoid bone

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56
Q

Describe the action of the sternothyroid

A

depresses the thyroid cartilage

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57
Q

Describe the innervation of the sternothyroid

A

anterior rami of C1-C3, carried by the ansa cervicalis

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58
Q

Describe the action of the thyrohyoid

A

depresses the hyoid

if hyoid fixed, raises larynx

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59
Q

Describe the innervation of the thyrohyoid

A

anterior ramus of C1, carried with hypoglossal nerve

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60
Q

Name the parts of the pharynx

A

nasopharynx
oropharynx
laryngopharynx

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61
Q

State the boundaries of the pahrynx

A

base of the skull

inferior cricoid cartilage

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62
Q

What is the action of the circular muscles of the pharynx

A

contract sequentially, superior to inferior
constrict the lumen
propel bolus of food inferiorly into oesophagus

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63
Q

Name the three circular muscles of the pharynx, and state their location

A

Superior pharyngeal constrictor - oropharynx
Middle pharyngeal constrictor - laryngopharynx
Inferior pharyngeal constrictor - laryngopharynx

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64
Q

Describe the two components of the inferior pharyngeal constrictor

A 
superior = thyropharyngeus. oblique fibres
inferior = cricopharyngeus. horixontal fibres
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65
Q

Describe the action of the longitudinal muscles of the pharynx

A

shorten and widen the pharynx

elevate the larynx in swallowing

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66
Q

Name the longitudinal muscles of the pharynx

A

stylopharyngeus
palatopharyngeus
salpingopharyngeus (from Eustachian tube)

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67
Q

Describe the innervation of the longitudinal muscles of the pharynx

A

stylopharyngeus - glossopharyngeal
palatopharyngeus - vagus
salpingopharyngeus - glossopharyngeal

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68
Q

Describe the innervation of the circular muscles of the pharynx

A

vagus nerve

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69
Q

describe the sensory innervation of the pharynx

A

nasopharynx - maxillary nerve CN V V2
oropharynx - glossopharyngeal nerve
laryngopharynx - vagus nerve

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70
Q

Describe the blood supply of the pharynx

A

ascending pharyngeal, lingual, facial and maxillary branches of the external carotid artery

pharyngeal venous plexus to interbal jugular vein

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71
Q

State the boundaries of the nasopharynx

A

Superior - base of the skull
Inferior - soft palate
Anterior - posterior conchae
Posterior - adenoid tonsils

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72
Q

Describe the epithelium of the nasopharynx

A

ciliated pseudostratified columnar epithelium with goblet cells

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73
Q

What can recurrent infections of the adenoid tonsils lead to?

A

adenoids chronically enlarged
obstruction of Eustachian tube
prevention of pressure equalisation and drainage of fluid
chronic otitis media and effusion

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74
Q

State the boundaries of the oropharynx

A

Superior - soft palate
Inferior - superior border of epiglottis
Anterior - oral cavity
Posterior - C2-C3 vertebrae

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75
Q

Describe the epithelium of the oropharynx

A

stratified squamous

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76
Q

What structures does the oropharynx contain?

A

posterior 1/3rd of tongue
lingual tonsils
palatine tonsils
superior pharyngeal constrictor muscle

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77
Q

Which lymph nodes are enlarged in tonsillitis?

A

jugolodigastric

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78
Q

What happens if infection spreads from the palatine tonsils to the peritonsillar tissue?

A 
abscess
deviation of uvula
quinsy
MEDICAL EMERGENCY
obstruction of pharynx
needs draining and antibiotics
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79
Q

State the boundaries of the laryngopharynx

A

Superior - superior border of epiglottis
Inferior - inferior border of the cricoid cartilage
Anterior - larynx
Posterior - C3-C6 vertebrae

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80
Q

Describe the epithelium of the laryngopharynx

A

stratified squamous

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81
Q

Where does a pharyngeal diverticulum form?

A

weak area between the two parts of the inferior pharyngeal constrictor: thyropharyngeus and cricopharyngeus.
= Killian’s dehiscence

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82
Q

How do the inferior pharyngeal constrictors work together in swallowing?

A

thyropharngeus contracts
cricopharyngeus relaxes
prevents intrapharyngeal pressure from rising

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83
Q

How does a pharyngeal diverticulum form?

A

no coordinated relaxation of the cricopharyngeus

high intrapharyngeal pressure

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84
Q

What are the symptoms of a pharyngeal diverticulum?

A

dysphagia
regurgitation
halitosis

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85
Q

Describe the phases of swallowing

A
  1. Pushing of food from the oral cavity to the oropharynx
    - Tongue and suprahyoid muscles pull the hyoid bone and larynx up
    - this is the voluntary phase of the swallowing process
  2. The soft palate elevates, closing off the nasopharynx
    - This is a reflex-driven process during which the contraction of the suprahyoid muscles and the longitudinal pharyngeal muscles elevate the larynx.
  3. The superior constrictors contract
    - From now on, the process is automatic
  4. The middle and inferior constrictors move the bolus into the laryngopharynx
  5. The larynx is protected by the overhanging tongue, epiglottis and vocal cords
  6. The cricopharyngeus muscle relaxes; allowing the bolus of food to be propelled into the oesophagus and preventing the intrapharyngeal pressure from rising.
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86
Q

Which arteries supplying the neck arise from the subclavian artery?

A

vertebral
internal thoracic
thyrocervical trunk

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87
Q

Which arteries arise from the thyrocervical trunk?

A

inferior thyroid -> ascending cervical artery
transverse cervical artery
suprascapular artety

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88
Q

Through what foramina do the vertebral arteries enter the cranial cavity?

A

foramen magnum

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89
Q

The vertebral arteries converge to form the:

Supplying the:

A

basilar arteries

brain

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90
Q

Which veins unite to form the angular vein?

Where?

A

supraorbital and supratrochlear

medial angle of the eye

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91
Q

How are the veins of the scalp connected to the dural venous sinuses?

A

emissary veins
connect to diploic veins
connect to dural venous sinuses

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92
Q

What are dural venous sinuses?

A

space between periosteal and meningeal layers of the dura mater
lined by endothelial cells
collect venous blood
drain into the internal jugular veins

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93
Q

What is the cavernous sinus?

A

a dural venous sinus
plexus if veins on the upper surface of the sphenoid
receives blood from ophthalmic veins, cerebral veins and sphenopalatine sinus

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94
Q

What is the danger triangle?

A

deep facial veins drain into the pterygoid venous plexus, which drains into the cavernous sinus
Facial vein is connected to the cavernous sinus by the superior ophthalmic vein
Veins are valveless
infection can spread from the face to the venous sinuses

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95
Q

What structures are located within the cavernous sinus?

A 
internal carotid artery
abducens nerve
occulomotor nerve
trochlear nerve
ophthalmic nerve (V2)
maxillary nerve (V3)
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96
Q

Describe the course of the external jugular vein

A

posterior auricular and retromandibular veins converge posterior to the angle of the mandible, inferior to the outer ear
descends within the superficial fascia anterior to SCM
receives posterior external jugular, transverse cervical and suprascapular veins
crosses SCM in an oblique, posterior and inferior direction
passes under clavicle and drains into subclavian

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97
Q

What are the clinical consequences if the external jugular vein is severed?

A 
lumen held open by investing fascia
air drawn into vein
cyanosis
blood flow though right atrium stopped
MEDICAL EMERGENCY
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98
Q

How is a severed external jugular vein managed?

A

pressure to wound

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99
Q

Describe the course of the internal jugular vein

A

continutaiton of sigmoid sinus
exits skull via jugular foramen
descends within the carotid sheath deep to the sternocleidomastoid lateral to common carotid artery
receives blood from the facial, lingual, occipital and superior and middle thyroid veins
combines with subclavian vein to form brachiocephalic vein posterior to sternal end of clavicle

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100
Q

Which of the blood vessels within the carotid sheath is more lateral?

A

internal jugular vein is lateral to the common carotid artery

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101
Q

Why do injuries to the scalp bleed profusely?

A

artery walls are tightly bound to connective tissue of the scalp. prevents constriction
anasatamoses mean the scalp is densely vascularised
if the epicranial aponeurosis is severed, the occipital and frontalis muscles pull from opposite ends

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102
Q

Describe the blood supply of the skull

A

middle meningeal artery

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103
Q

What does the JVP tell us?

A

An estimation of the right atrial pressure

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104
Q

How is the JVP measured?

A

patient lies at 45 degrees

height of pulsation measured from 5cm above sternal angle

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105
Q

How is the flow of lymph within the lymphatic system ensured?

A

passive constriction by skeletal muscles

intrinsic constriction of smooth muscle cells

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106
Q

Describe the route of fluid from tissue fluid to lymphatic duct

A 
Tissue fluid
Lymphatic capillary
•	The fluid becomes lymph here
Lymphatic vessels – afferent
•	Multiple afferent vessels drain into one lymph node
Lymph node
Lymphatic vessel – efferent
Lymphatic trunk
Lymphatic duct
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107
Q

Where do the lymphatic ducts drain into?

A

subclavian veins
Right lymphatic duct into right subclavian vein
thoracic duct into left subclavian vein

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108
Q

What regions of the body drain into the right lymphatic duct?

A

Right side of head, neck, arm and thorax

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109
Q

What are lymph nodes?

A

connective tissue structures
reticular inside - physical filter
tough fibrous outer capsule

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110
Q

Describe the immune function of lymph nodes

A

phagocytes act as phagocytic filter

lymphocytes for immune surveillance, allowing body to mount appropriate response

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111
Q

What is a superficial lymph node?

A

drains a specific area. in superficial cervical fascia

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112
Q

What is a deep lymph node?

A

receives drainage from superficial lymph nodes. deep to the investing layer of deep cervical fascia, mostly within the carotid sheath

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113
Q

What drains into the submandibular lymph nodes?

A 
upper lip and teeth
lateral part of lower lip
most of face
anterior nasal cavity
cheeks
middle tongue
submandibular gland
sublingual gland
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114
Q

What drains into the submental lymph nodes?

A

lower lip/teeth
anterior chin
tip of tongue
floor of mouth

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115
Q

What drains into the anterior and posterior superficial cervical lymph nodes?

A

skin of neck

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116
Q

What drains into the pre auricular lymph nodes?

A

middle-posterior scalp
skin of lateral ear
parotid gland

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117
Q

What drains into the post auricular lymph nodes?

A

posterior scalp
cranial surface of pinna
back of external acoustic meatus

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118
Q

What drains into the occipital lymph nodes?

A

posterior scalp and neck

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119
Q

What will an infected swollen lymph node feel like?

A

tender
firm
mobile

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120
Q

What will an metastatic swollen lymph node feel like?

A

hard
matted
non-tender

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121
Q

What drains into the jugulodigastric lymph nodes?

A

palatine tonsil

posterior 1/3rd of tongue

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122
Q

What drains into the juguloomohyoid lymph nodes?

A 
tongue
oral cavity
trachea
larynx
oesophagus
thyroid gland
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123
Q

Name the superficial lymph nodes

A 
submental
submandibular
pre auricular
post auricular
occipital
posterior cervical
anterior cervical
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124
Q

Name the deep lymph nodes

A

jugulo digastric
jugulo omohyoid
supraclavicular

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125
Q

What is the significance of Virchow’s node

A

left supraclavicular
drainage from abdominal cavity
enlarged indicates cancer in abdomen - esp gastric

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126
Q

What is lymphoedema?

A

fluid retention and tissue swelling due to a compromised immune system

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127
Q

What is lymphoedema caused by?

A 
removal or enlargement of lymph nodes
infection
damage to system
immobility
congenital problems
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128
Q

Describe the frontal bone

A

forms anterior part of the skull
upper border of occipital margins
contains frontal sinus
forms roof of orbit

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129
Q

Describe the parietal bone

A

forms side and roof of cranial cavity

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130
Q

Name the 6 parts of the temporal bone

A 
squamous
mastoid
tympanic
styloid process
zygomatic process
petrous part
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131
Q

Which bone contains the foramen magnum?

A

occipital

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132
Q

What are some key features of the ethmoid bone?

A

cribiform plate
crista galli
ethmoid bulla
air cells

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133
Q

What is an ethmoid fracture likely to cause?

A

anosmia

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134
Q

Describe the mandible

A

two separate bones combine in the midline - mental symphysis

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135
Q

Where is the coronal suture found?

A

anterior from left to right

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136
Q

Where is the sagittal suture found?

A

midline from front to back

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137
Q

Where is the lambdoidal suture found?

A

posterior from left to right

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138
Q

Where is bregma found?

A

anterior

between coronal and sagittal sutures

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139
Q

Where is lamda found?

A

posterior

between sagittal and lambdoidal sutures

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140
Q

In a baby, what are the precursors of bregma and lambda?

A

anterior and posterior fontanelles

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141
Q

How is a newborn baby’s skull different to the skull of an adult?

A

wide cranial sutures

held together by connective tissue that allows for movement

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142
Q

During labour, how does the baby’s skull change?

A

cranial bones pushed together
serrated bone edges interlock
protects the brain from injury

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143
Q

Why does a pre-term labour have an increased risk of brain damage for the fetus?

A

cranial sutures are too wide to interlock

brain not protected

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144
Q

define skull

A

cranium and mandible

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145
Q

define cranium

A

superior aspect of the skull

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146
Q

What features allow the cervical vertebrae to be identified?

A

triangular vertebral foramen
bifid spinous process
transverse foramina = holes in transverse process for vertebral artery, vein and sympathetic nerves

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147
Q

Describe the atlas

A

C1
no vertebral body
no spinous process
articular facet anteriorly for articulation with dens of axis
lateral masses for transverse ligament of atlas
superior articular surface on later mass for occipital condyle
groove on posterior arch for vertebral artery and C1

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148
Q

describe the axis

A

C2

dens extends superiorly form anterior portion

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149
Q

Where are the atlanto-occipital joints found?

What movement of the head do these joints allow?

A

superior facets of lateral masses of the atlas
occipital condyles of base of cranium

flexion of the head

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150
Q

Where are the atlanto-axial joints found?

What movement of the head do these joints allow?

A 
lateral: 
inferior facets of lateral masses of C1
superior facets of C2
Medial:
articular facet C1
dens

rotation of the head

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151
Q

What are common signs and symptoms of a skull fracture?

A 
bleeding
clear fluid draining from ears and nose
poor balance
confusion
slurred speech
stiff neck
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152
Q

What bones form the anterior cranial fossa?

A

frontal, ethmoid and sphenoid bones

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153
Q

What bones form the posterior cranial fossa?

A

occipital bone and temporal bones

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154
Q

What bones form the middle cranial fossa?

A

sphenoid, temporal

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155
Q

Describe a depression fracture

A

fracture of skull
depression of bone inwards
result of a direct blow

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156
Q

What are the possible consequences of a depression fracture?

A

skull indentation

brain injury

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157
Q

Describe a linear fracture of the skull

A

simple break in the bone traversing its full thickness

radiating (stellate) fracture lines away from the point of impact

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158
Q

State the boundaries of the anterior cranial fossa

A

Anteriorly and laterally - inner surface of the frontal bone.
Posteriorly and medially - limbus of the sphenoid bone.
Posteriorly and laterally - lesser wings of the sphenoid bone
Floor - frontal bone, ethmoid bone and the anterior aspects of the body and lesser wings of the sphenoid bone

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159
Q

State the boundaries of the middle cranial fossa

A

Anteriorly and laterally - lesser wings of the sphenoid bone.
Anteriorly and medially - limbus of the sphenoid bone.
Posteriorly and laterally - superior border of the petrous part of the temporal bone.
Posteriorly and medially - dorsum sellae of the sphenoid bone
Floor - body and greater wing of the sphenoid, and the squamous and petrous parts of the temporal bone

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160
Q

State the boundaries of the posterior cranial fossa

A

Anteriorly and medially - dorsum sellae of the sphenoid bone
Anteriorly and laterally - superior border of the petrous part of the temporal bone
Posteriorly - internal surface of the squamous part of the occipital bone
Floor - mastoid part of the temporal bone and the squamous, condylar and basilar parts of the occipital bone

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161
Q

Where is the cribriform plate found?

A

ethmoid bone

either side of crista galli

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162
Q

What passes through the cribriform plate?

A

olfactory nerve fibres CN I

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163
Q

Where are the optic canals found?

A

anteriorly on the sphenoid bone
connected by chiasmatic sulcus
route from middle cranial fossa into orbital cavities

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164
Q

What passes through the optic canals?

A

the optic nerves (CN II)

ophthalmic arteries

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165
Q

Where are the superior orbital fissures found?

A

anteriorly in the sphenoid bone
lateral to the optic canals
route from middle cranial fossa into orbit

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166
Q

What passes through the superior orbital fissure?

A 
oculomotor nerve (CN III)
trochlear nerve (CN IV)
opthalmic branch of the trigeminal nerve (CN V1)
abducens nerve (CN VI)
opthalmic veins 
sympathetic fibres
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167
Q

Where are the foramen rotundum found?

A

anteriorly in the sphenoid bone
posterior to the superior orbital fissure
route from middle cranial fossa into pterygopalatine fossa

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168
Q

What passes through the foramen rotundum?

A

maxillary branch of the trigeminal nerve (CN V2)

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169
Q

Where are the foramen ovale found?

A

posterior part of the sphenoid bone
posterior to foramen rotundum
medial to foramen spinosum
route from middle cranial fossa to infratemporal fossa

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170
Q

What passes through the foramen ovale?

A

mandibular branch of the trigeminal nerve (CN V3)

accessory meningeal artery

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171
Q

Where are the foramen spinosum found?

A

posterior part of the sphenoid bone
lateral to foramen spinosum
route from middle cranial fossa to infratemporal fossa

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172
Q

What passes through the foramen spinosum?

A

middle meningeal artery
middle meningeal vein
meningeal branch of CN V3

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173
Q

Where is the carotid canal found?

A

in the temporal bone

posterior and medial to the foramen ovale

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174
Q

What passes through the carotid canal?

A

internal carotid artery

deep petrosal nerve

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175
Q

Where is the internal acoustic meatus found?

A

posterior aspect of the petrous part of the temporal bone.

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176
Q

What passes through the internal acoustic meatus?

A 
facial nerve (CN VII)
vestibulocochlear nerve (CN VIII)
labrynthine artery
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177
Q

Where is the foramen magnum found?

A

occipital bone
centrally in the floor of the posterior cranial fossa
largest foramen in the skull

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178
Q

What passes through the foramen magnum?

A 
the medulla of the brain
meninges
vertebral arteries 
spinal accessory nerve (ascending) 
dural veins
anterior and posterior spinal arteries
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179
Q

Where are the jugular foramina found?

A

occipital bone

either side of the foramen magnum

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180
Q

What passes through the jugular foramina?

A 
glossopharyngeal nerve
vagus nerve
spinal accessory nerve (descending)
internal jugular vein
inferior petrosal sinus
sigmoid sinus 
meningeal branches of the ascending pharyngeal and occipital arteries
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181
Q

Describe a basal skull fracture

A

Affects the base of the skull

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182
Q

How does a basal skull fracture present?

A

bruising behind the ears = Battle’s sign (mastoid ecchymosis)
bruising around the eyes/orbits = Raccoon eye’s

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183
Q

What is a diastatic skull fracture?

A

occurs along a suture line
causes a widening of the suture
most often seen in children

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184
Q

Describe a Jefferson Fracture

A

compression of the lateral masses of the atlas (C1) between the occipital condyles and the axis
they are driven apart, fracturing one or both of the anterior/posterior arches.

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185
Q

How does a patient get a Jefferson Fracture?

A

vertical fall onto an extended neck e.g. diving into excessively shallow water

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186
Q

Does a Jefferson Fracture damage the spinal cord?

A

Since the vertebral foramen is large, it is unlikely that there will be damage to the spinal cord at the C1 level. However, there may be damage further down the vertebral column

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187
Q

What is a Hangman’s Fracture?

A

fracture of the pars interarticularis, the bony column between the superior and inferior articular facets of the axis.

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188
Q

What are the consequences of a Hangman’s Fracture?

A

injury is likely to be lethal
the fracture fragments or the force involved are likely to rupture the spinal cord
causing deep unconsciousness, respiratory and cardiac failure, and death

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189
Q

How does a fracture of the dens occur?

A

traffic collisions and falls

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190
Q

What are the consequences of a fractured dens?

A

fractures are unstable
high risk of avascular necrosis, due to the isolation of the distal fragment from any blood supply
fractures of the dens often take a long time to heal.
risk of spinal cord involvement.

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191
Q

What causes a Whiplash Injury?

A

Hyperextension

head being whipped back on the shoulders

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192
Q

What are the consequences of whiplash?

A

minor cases:
anterior longitudinal ligament of the spine is damaged which is acutely painful for the patient.

severe cases:
fractures can occur to any of the cervical vertebrae as they are suddenly compressed by rapid deceleration

worst-case scenario:
dislocation or subluxation of the cervical vertebrae
This often happens at the C2 level, where the body of C2 moves anteriorly with respect to C3.
spinal cord involvement, and as a consequence quadraplegia or death may occur.
More commonly, subluxation occurs at the C6/C7 level (50% of cases).

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193
Q

Describe the location of the larynx

A 
in anterior compartment of neck
suspended from the hyoid
C3-C6
opens superiorly into laryngopharynx
opens inferiorly into trachea
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194
Q

How can the larynx be divided into sections?

A

Supraglottis
Glottis
Subglottis

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195
Q

State the boundaries of the supraglottis

A

inferior surface of the epiglottis

vestibular folds

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196
Q

State the boundaries of the glottis

A

vocal cords

1cm below

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197
Q

State the boundaries of the subglottis

A

inferior border of the glottis

inferior border of the cricoid cartilage

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198
Q

Name the cartilages that combine to form the larynx

A 
epiglottis
thyroid
cricoid
arytenoid x2
corniculate x2
cuneiform x2
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199
Q

Describe the cricoid cartilage

A

complete ring

broader posteriorly

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200
Q

What type of cartilage is the epiglottis?

A

elastic

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201
Q

Describe the arytenoid cartilages

A

pyramidal
sit on the cricoid
articulate with conrniculate cartilage superiorly
vocal process anteriorly - vocal ligament attaches
muscular process posteriorly - attachment for the posterior and lateral cricoarytenoid muscles

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202
Q

How can the muscles of the larynx be grouped?

A

intrinsic

extrinsic

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203
Q

Describe the action of the external laryngeal muscles

A

elevate or depress the larynx during swallowing

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204
Q

Describe the action of the internal laryngeal muscles

A

move the components of the larynx
control the shape of the rima glottidis
control length and tension of the vocal folds

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205
Q

What muscles is the external laryngeal group of muscles composed of?

A

suprahyoid
infrahyoid
stylopharyngeus

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206
Q

How are the internal laryngeal muscles innervated?

A

inferior laryngeal nerve - terminal branch of the recurrent laryngeal nerve - vagus nerve

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207
Q

How is the cricothyroid innervated?

A

external branch of the superior laryngeal nerve - vagus nerve

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208
Q

What is the action of the cricothyroid?

A

tilts the thyroid forward to help tense the vocal cords

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209
Q

Describe the histology of the vocal folds from superficial to deep

A
  • Non-keratinised stratified squamous epithelium
  • Reinke’s space – This watery, amorphous layer is rich in glycosaminoglycans. Due to its fluidity, the epithelium is able to vibrate freely above it to create sound.
  • Vocal ligament
  • Vocalis muscle
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210
Q

Describe the arterial blood supply to the larynx

What is the course of these vessels?

A

Superior laryngeal artery – a branch of the superior thyroid artery (derived from the external carotid). It follows the internal branch of the superior laryngeal nerve into the larynx.
• Inferior laryngeal artery – a branch of the inferior thyroid artery (derived from the thyrocervical trunk). It follows the recurrent laryngeal nerve into the larynx.

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211
Q

Describe the venous drainage of the larynx

A

The superior laryngeal vein - drains to the superior thyroid then the internal jugular vein
the inferior laryngeal vein - drains to the inferior thyroid vein then the left brachiocephalic vein

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212
Q

Describe the sensory innervation of the larynx

A

supraglottis - superior laryngeal nerve

infraglottis - recurrent laryngeal nerve

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213
Q

In full bilateral palsy of the vocal folds, what are the clinical consequences?

A

both folds paralysed between adduction and abduction
breathing impaired
no phonation possible

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214
Q

In partial bilateral palsy of the vocal folds, what are the clinical consequences?

A

vocal folds paralysed in fully adducted position
airway obstruction
MEDICAL EMERGENCY

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215
Q

What is a cricothyroidectomy?

A

an emergency procedure to provide a temporary airway used in situations where there is an obstruction at or above the larynx
To perform the technique, the thyroid cartilage is palpated in the neck – below which there is a depression representing the cricothyroid ligament. A small incision is made in the midline of this ligament, and an endotracheal tube is inserted to secure the airway.

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216
Q

What type of cancer are most laryngeal cancers?

A

squamous cell carcinomas

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217
Q

Which area of the larynx is most affected by laryngeal cancer?

A

glottis

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218
Q

State some of the risk factors of laryngeal cancer

A

smoking
alcohol
occupational exposures (asbestos, formaldehyde, nickel, isopropyl alcohol and sulphuric acid mist)
insufficient fruit and vegetables intake
HPV16 seropositivity.

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219
Q

What are the symptoms of laryngeal cancer?

A 
Chronic hoarseness
pain
dysphagia
a lump in the neck
earache 
persistent cough

Patients may also describe breathlessness, aspiration, haemoptysis, fatigue and weakness, or weight loss

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220
Q

Why can epiglottitis be life threatening?

A

swelling

complete obstruction of the airway

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221
Q

What age group is epiglottis most common in?

A

2-5 years

immunocompromised adults in their 40s and 50s

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222
Q

What are the symptoms of epiglottitis?

A

Sore throat.
Odynophagia (painful swallowing).
Inability to swallow secretions (drooling in children).
Muffled voice - ‘hot potato’ voice.
Fever
The ‘tripod sign’ - the patient leans forward on outstretched arms to move inflamed structures forward, thereby easing the upper airway obstruction
Stridor

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223
Q

What is the cause of croup?

A

viral URTI

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224
Q

Describe the pathophysiology of croup

A

Viral URTI causes nasopharyngeal inflammation that may spread to the larynx and trachea
subglottal inflammation, oedema and compromise of the airway at its narrowest portion occurs
movement of the vocal cords is impaired leading to the characteristic cough

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225
Q

What age group is croup most common in?

A

children aged 6 months to 3 years, with a peak incidence during the second year of life

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226
Q

What are the symptoms of croup?

A

runny nose, sore throat, fever and cough.
progresses over the course of a couple of days to include the characteristic barking cough and hoarseness.
Stridor (harsh, low-pitched noise heard during inspiration) may be heard at rest or only when the child is agitated or active.
Chest sounds are usually normal but can be decreased in volume where there is severe airflow limitation.

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227
Q

What is laryngomalacia?

A

congenital laryngeal abnormality
larynx is soft and floppy - abnormal cartilages
collapses during breathing

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228
Q

What are the symptoms of laryngomalacia?

A

noisy respiration
inspiratory stridor
normal cry

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229
Q

How is laryngomalacia treated?

A

conservative management

99% of cases resolve by 18-24 months

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230
Q

Where is the infratemporal fossa found?

A

below the middle cranial fossa

deep to the masseter and zygomatic arch

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231
Q

What shape is the infratemporal fossa?

A

wedge

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232
Q

Which spaces does the infratemporal fossa communicate with?

A

pterygopalatine fossa by the pterygomaxillary fissure

temporal fossa superiorly

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233
Q

State the boundaries of the infratemporal fossa

A
  • Lateral – ramus of the mandible.
  • Medial – lateral pterygoid plate of the sphenoid.
  • Anterior – posterior surface of the maxilla.
  • Posterior – carotid sheath.
  • Floor - medial pterygoid muscle
  • Roof - greater wing of the sphenoid bone
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234
Q

How is the infratemporal fossa connected to the cranial cavity?

A

foramen ovale

foramen spinosum

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235
Q

What are the contents of the infratemporal fossa?

A 
medial pterygoids
lateral pterygoids
mandibular nerve V3
chorda tympani
otic ganglion
maxillary artery -> middle meningeal artery
pterygoid venous plexus
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236
Q

How does the middle meningeal artery reach the cranial cavity?

A

maxillary artery in infratemporal fossa becomes middle meningeal artery
foramen spinosum to cranial cavity

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237
Q

What branches of the mandibular nerve begin in the infratemporal fossa?

A

auricotemporal
buccal
lingual
inferior alveolar

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238
Q

How does the mandibular nerve enter the infratemporal fossa?

A

foramen ovale

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239
Q

What is the process of and result of a mandibular nerve block?

A

anaesthetic injection in infratemporal fossa

affects inferior alveolar, lingual, buccal and auricotemporal nerves

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240
Q

What is the process of and result of an inferior alveolar nerve block?

A

Within the mandibular canal, the inferior alveolar nerve forms the inferior dental plexus
A major branch of this plexus, the mental nerve, supplies the skin and mucous membranes of the lower lip, skin of the chin, and the gingiva of the lower teeth.
The anaesthetic is administered at the mandibular foramen

The anaesthetic fluid also spreads to the lingual nerve which originates near the inferior alveolar nerve, causing numbness of the anterior 2/3 of the tongue.

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241
Q

Name the articulating surfaces of the TMJ

A

mandibular fossa of the temporal bone
articular tubercle of temporal bone
head of mandible

covered by fibrocartilage NOT HYALINE

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242
Q

What separates the articular surfaces of the TMJ?

A

articular disk

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243
Q

Describe the articular disk of the TMJ

A

upper surface = concavoconvex
lower surface = concave
thinner in the middle

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244
Q

Name the extracapsular ligaments of the TMJ

A

Temporomandibular ligament
Sphenomandibular ligament
Stylomandibular ligament

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245
Q

What is the function of the temporomandibular ligament

A

lies laterally and runs from the lower border of the zygomatic process to the mandibular neck.
acts to prevent posterior dislocation of the joint

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246
Q

What is the function of the sphenomandibular ligament

A

Remains at a constant length and tension for all positions of the mandible, preventing inferior dislocation.

247
Q

What is the function of the stylomandibular ligament

A

extends from the styloid process to the posterior ramus of the mandible.
A thickening of the deep fascia of the parotid gland, separating the parotid and submandibular glands.
Along with the facial muscles, it supports the weight of the jaw.

248
Q

What is posterior displacement of the mandible at the TMJ limited by?

A

the postglenoid tubercle

temporomandibular ligament

249
Q

What is anterior displacement of the mandible at the TMJ limited by?

A

the articular tubercle

250
Q

What is inferior displacement of the mandible at the TMJ limited by?

A

spenomandibular ligament

stylomandinular ligament

251
Q

What muscles perform retraction of the mandible?

A

geniohyoid

digastric

252
Q

What muscles perform protrusion of the mandible?

A

lateral pterygoid

medial pterygoid

253
Q

What movements does the upper part of the TMJ allow?

A

translational movements
= protrusion
= retraction

254
Q

What movements does the lower part of the TMJ allow?

A

rotational movements
= elevation
= depression

255
Q

What muscles perform elevation of the mandible?

A

temporalis
masseter
medial pterygoid

256
Q

What muscles perform depression of the mandible?

A 
mostly produced by gravity
digastric
omohyoid
geniohyoid
mylohyoid
257
Q

What movements produce opening of the mouth?

A

protrusion

depression

258
Q

What movements produce closing of the mouth?

A

retraction

elevation

259
Q

What causes dislocation of the TMJ?

A

blow to side of face
yawning
taking a large bite

mandibular head slips out of the mandibular fossa anteriorly

260
Q

What is a collection of cell bodies called in the CNS?

A

nucleus

261
Q

What is a collection of cell bodies called in the PNS?

A

ganglion

262
Q

Name the cranial nerves

A 
olfactory
optic
occulomotor
trochlear
trigeminal
abducens
facial
vestibulocochlear
glossopharyngeal
vagus
accessory
hypoglossal
263
Q

Where do cranial nerves III and IV originate from?

A

midbrain

264
Q

Where do cranial nerves V to VIII originate from?

A

pons

265
Q

Where do cranial nerves IX to XII originate from?

A

medulla oblongata

266
Q

What is the function of CN I?

A

special sensory

smell

267
Q

What is unique about CN I and CN II?

A

brain tracts

surrounded by cranial meninges

268
Q

Describe the course of CN I

A

olfactory receptor neurons in olfactory mucosa
ascends through cribriform plate of ethmoid to form olfactory bulb, which lies in the olfactory groove
then reaches the olfactory tract

269
Q

Which foramina does CN I pass through?

A

cribriform plate

270
Q

What is the function of CN II?

A

special sensory

sight

271
Q

Describe the course of CN II

A

Starts at retina

continues to the optic tract and then the primary visual cortex (in the occipital lobes)

272
Q

Which foramina does CN II pass through?

A

optic canal

273
Q

What is the function of CN III?

A

motor
superior and inferior rectus, medial rectus, inferior oblique and levator palaebae superioris

Carries parasympathetic fibres to sphincter pupillae and ciliary muscles

274
Q

Describe the course of CN III

A

Starts in the oculomotor nucleus of the midbrain
enters lateral aspect of the cavernous sinus
travels through the superior orbital fissure
splits to form a superior and inferior division

parasympathetic fibres travel with inferior division

275
Q

Which foramina does CN III pass through?

A

superior orbital fissure

276
Q

State causes of an occulomotor nerve lesion

A

Increasing intracranial pressure – compresses the nerve against the temporal bone.
Aneurysm of the posterior cerebral artery.
Cavernous sinus infection or trauma.
diabetes
multiple sclerosis
myasthenia gravis
giant cell arteritis.

277
Q

What are the clinical signs associated with an occulomotor nerve lesion?

A

Ptosis (drooping upper eyelid) – due to paralysis of the levator palpabrae superioris.
Eyeball resting in the ‘down and out‘ location – due to the paralysis of the superior, inferior and medial rectus, and the inferior oblique. The patient is unable to elevate, depress or adduct the eye.
Dilated pupil = mydriasis due to the unopposed action of the dilator pupillae muscle

278
Q

What is the function of CN IV?

A

motor

superior oblique - moves eye down and in

279
Q

Describe the course of CN IV

A

Starts in the trochlear nucleus of the dorsal midbrain
runs anteriorly and inferiorly within the subarachnoid space before piercing the dura mater adjacent to the posterior clinoid process of the sphenoid bone.
Moves along the lateral wall of the cavernous sinus which contains the:
enters the orbit of the eye

280
Q

Which foramina does CN IV pass through?

A

superior orbital fissure

281
Q

What are the causes of trochlear nerve palsy?

A

congenital fourth nerve palsy
diabetic neuropathy
thrombophlebitis of cavernous sinus
raised intracranial pressure

282
Q

What are the symptoms of trochlear nerve palsy?

A

diplopia when looking down and in

subtle head tilt

283
Q

What is the function of CN V?

A

Motor
medial pterygoid, lateral pterygoid, masseter, temporalis

Sensory
skin, mucous membranes and sinuses of the face

284
Q

Describe the course of CN V

A

Starts in the trigeminal sensory nuclei within the pons which then forms a sensory root.
In the middle cranial fossa, the sensory root expands into the trigeminal ganglion, located lateral to the cavernous sinus, in a depression of the temporal bone = the trigeminal cave.
the trigeminal ganglion gives rise to 3 divisions: ophthalmic (V1), maxillary (V2) and mandibular (V3).
The ophthalmic nerve and maxillary nerve travel lateral to the cavernous sinus exiting the cranium via the superior orbital fissure and foramen rotundum respectively.
The mandibular nerve exits via the foramen ovale entering the infra-temporal fossa.
The motor root passes inferiorly to the sensory root, along the floor of the trigeminal cave. Its fibres are only distributed to the mandibular division.

285
Q

Which foramina does CN V pass through?

A

ophthalmic - superior orbital fissure
maxillary - foramen rotundum
mandibular - foramen ovale

286
Q

How is the motor function of the trigeminal nerve tested?

A

ask the patient to clench their jaw
palpate superior to the zygomatic arch to feel for contraction of the temporalis repeat palpating inferiorly for the masseter.
Ask the patient to open their mouth and deviate their mandible to the right and left to check for competence of the medial and lateral pterygoid muscles

287
Q

What is the function of CN VI?

A

Motor

lateral rectus - lateral eye movement

288
Q

Describe the course of CN VI

A

Starts in the abducens nucleus in the pons
enters the subarachnoid space and pierces the dura mater to run in a space known as Dorello’s canal.
The nerve travels through the cavernous sinus entering the orbit of the eye through the superior orbital fissure.

289
Q

Which foramina does CN VI pass through?

A

Superior orbital fissure

290
Q

What causes palsy of the abducens nerve?

A

downward pressure on the brainstem (e.g. brain tumour, extradural haematoma)
Wernicke-Korsakoff syndrome (caused by thiamine deficiency and generally seen in alcoholics) is a rare cause of sixth nerve palsy.
diabetic neuropathy and thrombophlebitis of the cavernous sinus

291
Q

What are the signs and symptoms of abducens nerve palsy?

A

diplopia
medially rotated eye which cannot be abducted past the midline
rotating the head to allow the eye to look sideways

292
Q

What is the function of CN VII?

A

Special sensory
taste to anterior 2/3rds of tongue

Motor
frontalis, orbicularis occuli, orbicularis oris, buccinators, zygomaticus, mentalis, platysma, stapedius

293
Q

Describe the course of CN VII

A

the sensory and motor roots originate in the pons and then travel through the internal acoustic meatus, a 1cm long opening in the petrous part of the temporal bone.
within the temporal bone, the roots leave the internal acoustic meatus, and enter into the Z shaped facial canal
Within the canal, the two roots fuse to form the facial nerve.
The nerve gives rise to the greater petrosal nerve (parasympathetic fibres to glands), the nerve to stapedius (motor fibres to stapedius muscle), and the chorda tympani (special sensory fibres to the anterior 2/3 tongue) within the facial canal
the nerve exits the facial canal via the stylomastoid foramen as the facial nerve, located just posterior to the styloid process of the temporal bone.
Between the stylomastoid foramen, and the parotid gland, three more motor branches
Within the parotid gland, the nerve terminates by splitting into its five branches.

294
Q

Which branches of the facial nerve are given off before it passes through the stylomastoid foramen?

A

greater petrosal nerve - parasympathetic fibres to glands,
nerve to stapedius - motor fibres to stapedius muscle chorda tympani - special sensory fibres to the anterior 2/3 tongue

295
Q

Which foramina does CN VII pass through?

A

exits cranium via internal acoustic meatus

exits facial canal via stylomastoid foramen

296
Q

What are the names of the motor branches of the facial nerve?

A 
temporal
zygomatic
buccal
mandibular
cervical
297
Q

Where do intracranial lesions of the facial nerve occur?

A

proximal to the stylomastoid foramen

298
Q

Where do extracranial lesions of the facial nerve occur?

A

distal to the stylomastoid foramen

299
Q

What are some causes of intracranial lesions of the facial nerve?

A

middle ear pathology - tumour or infection

Bell’s palsy

300
Q

What are some causes of extracranial lesions of the facial nerve?

A

Parotid gland pathology – e.g a tumour, parotitis, surgery.
Infection of the nerve – particularly by the herpes virus.
Compression during forceps delivery – the neonatal mastoid process is not fully developed, and does not provide complete protection of the nerve.
Idiopathic – If no definitive cause can be found, the disease is termed Bell’s palsy.

301
Q

How is examination of the motor facial nerve carried out?

A

look for symmetry of face

Ask patient to:
raise eyebrows
close eyes tightly
blow out their cheeks
smile
302
Q

What is the function of CN VIII?

A 
Special Sensory
from cochlea (hearing) and semicircular canals (balance)
303
Q

Describe the course of CN VIII

A

Originates in the cerebellopontine angle

splits into the vestibular nerve and cochlear nerve to innervate the semicircular canals and cochlea in the inner ear

304
Q

Which foramina does CN VIII pass through?

A

internal acoustic meatus

305
Q

What is a vestibular schwannoma?

What does this cause?

A

benign overgrowth of schwann cells of vestibulocochlear nerve

leading to compression of the facial nerve

306
Q

What are the symptoms of vestibular neuritis?

A

Vertigo – a false sensation that oneself or the surroundings are spinning or moving.
Nystagmus – a repetitive, involuntary to-and-fro oscillation of the eyes.
Loss of equilibrium (especially in low light).
Nausea and vomiting.

307
Q

What are the symptoms of labyrinthitis?

A

Vertigo – a false sensation that oneself or the surroundings are spinning or moving.
Nystagmus – a repetitive, involuntary to-and-fro oscillation of the eyes.
Loss of equilibrium (especially in low light).
Nausea and vomiting
sensorineural hearing loss
tinnitus

308
Q

What is the function of CN IX?

A

Sensory
oropharynx, posterior 1/3rd of the tongue, carotid sinus and body

Motor
stylopharyngeus

309
Q

Describe the course of CN IX

A

Originates in the medulla oblongata and continues through the jugular foramen and down the neck to innervate the tongue, parotid, carotid and stylopharyngeus

310
Q

Which foramina does CN IX pass through?

A

jugular foramen

311
Q

How is the glossopharyngeal nerve part of the gag reflex?

A

sensory innervation of oropharynx

afferent branch of gag reflex

312
Q

What is the function of CN X?

A

sensory
laryngopharynx
external acoustic meatus

motor
muscles of pharynx and larynx

313
Q

Describe the course of CN X

A

Originates in the medulla and continues through the jugular foramen
travels in carotid sheath
Left and right asymmetry – recurrent laryngeal nerves
oesophageal plexus

314
Q

Which foramina does CN X pass through?

A

jugular foramen

315
Q

What are the signs of vagus nerve lesion in the oropharynx?

A

palatoglossal arch drops

uvula deviates away from affected side

316
Q

How is the vagus nerve part of the gag reflex?

A

motor efferents

317
Q

What is the function of CN XI?

A

motor

sternocleidomastoid and trapezius

318
Q

Describe the course of CN XI

A

Originate at spinal nerve roots C1-C5
travels through the foramen magnum to enter cranial cavity
then the jugular foramen to exit cranial cavity
travels along the internal carotid artery to the SCM and the trapezius.

319
Q

Which foramina does CN XI pass through?

A

foramen magnum to enter cranial cavity

jugular foramen to exit cranial cavity

320
Q

What are the causes of accessory nerve palsy?

A

iatrogenic - cervical lymph node biopsy or cannulation of the internal jugular vein

321
Q

What is the function of CN XII?

A

motor

extrinsic and intrinsic movement of the tongue

322
Q

Describe the course of CN XII

A

o Originates in the hypoglossal nucleus in the medulla

Travels through the hypoglossal canal to the tongue

323
Q

Which foramina does CN XII pass through?

A

Hypoglossal canal

324
Q

What are the causes of hypoglossal nerve palsy?

A

tumours

penetrating traumatic injuries. dissection of the internal carotid artery

325
Q

What are the signs of a hypoglossal nerve palsy?

A

deviation of the tongue towards the damaged side on protrusion,
muscle wasting and fasciculations on the affected side

326
Q

Which muscles does the superior branch of the occulomotor nerve supply?

A

superior rectus

levator palpabrae superioris

327
Q

Which muscles does the inferior branch of the occulomotor nerve supply?

A

inferior rectus
medial rectus
inferior oblique

328
Q

What are the terminal branches of the ophthalmic nerve?

A

frontal
lacrimal
nasociliary

329
Q

What are the structures innervated by the ophthalmic nerve derived from?

A

FNP

330
Q

What are the structures innervated by the maxillary nerve derived from?

A

maxillary prominence of the 1st pharyngeal arch

331
Q

What are the terminal branches of the mandibular nerve?

A

buccal nerve
inferior alveolar nerve
auricotemporal nerve
lingual nerve

332
Q

Which embryological structure is associated with the facial nerve?

A

second pharyngeal arch

333
Q

Which embryological structure is associated with the trigeminal nerve?

A

first pharyngeal arch

334
Q

What branches of the facial nerve arise between the stylomastoid foramen and the parotid gland?

A

Posterior auricular nerve – Ascends in front of the mastoid process, and innervates the intrinsic and extrinsic muscles of the outer ear. It also supplies the occipital part of the occipitofrontalis muscle.

Nerve to the posterior belly of the digastric muscle – responsible for raising the hyoid bone.

Nerve to the stylohyoid muscle – responsible for raising the hyoid bone

335
Q

Which muscles does the temporal branch of the facial nerve innervate?

A

frontalis

orbicularis oculi

336
Q

Which muscles does the zygomatic branch of the facial nerve innervate?

A

orbicularis oculi.

337
Q

Which muscles does the buccal branch of the facial nerve innervate?

A

orbicularis oris

buccinator

338
Q

Which muscles does the mandibular branch of the facial nerve innervate?

A

mentalis

339
Q

Which muscles does the cervical branch of the facial nerve innervate?

A

platysma

340
Q

Describe the course of the chorda tympani

A

arises in the facial canal
travels across the bones of the middle ear, exiting via the petrotympanic fissure
enters the infratemporal fossa
‘hitchhikes’ with the lingual nerve

341
Q

Describe the corneal reflex

A

stimulus = tactile, thermal or painful stimulation of the cornea
afferent limb = ophthalmic nerve of the trigeminal nerve detecting the stimuli.
efferent limb = the facial nerve is the , causing bilateral contraction of the orbicularis oculi muscle

342
Q

Where will a pupil sparing lesion of the occulomotor nerve be?

A

distal to the ciliary ganglion

so will not affect the sphincter pupillae

343
Q

What are the symptoms and signs of an intracranial facial nerve palsy?

Why?

A

reduced salivation and loss of taste on the ipsilateral 2/3 of the tongue - Chorda tympani

ipsilateral hyperacusis (hypersensitive to sound) - nerve to stapedius

ipsilateral reduced lacrimal fluid production - Greater petrosal nerve

344
Q

Which cranial nerves carry parasympathetic fibres?

A

CN III
CN VII
CN IX
CN X

345
Q

Which structures are innervated by the parasympathetic fibres carried by CN III?

A

sphincter pupillae

ciliary muscles of the eye

346
Q

Which structures are innervated by the parasympathetic fibres carried by CN VII?

A

mucous glands of the oral cavity, nose and pharynx
lacrimal gland
submandibular and sublingual salivary glands

347
Q

Which structures are innervated by the parasympathetic fibres carried by CN IX?

A

parotid gland.

348
Q

Which structures are innervated by the parasympathetic fibres carried by CN X?

A

heart

GI system

349
Q

Where do the sympathetic fibres supplying the head and neck originate from?

A

T1-T6

350
Q

What is the sympathetic chain?

A

spans from the base of the skull to the coccyx

formed of nerve fibres and ganglia

351
Q

What structures do sympathetic fibres travel along to reach somatic targets?

A

segmental nerves

352
Q

What structures do sympathetic fibres travel along to reach visceral targets?

A

ganglionated trunks

353
Q

Describe the anatomical location of the superior cervical ganglion

A

posteriorly to the carotid artery

anterior to the C1-4 vertebrae.

354
Q

Which arteries do the nerves from the superior cervical ganglion hitch hike along?

A

common carotid
external carotid
internal carotid

355
Q

Which structures does the superior cervical ganglion innervate?

A 
eyeball
face
nasal glands
pharynx
salivary glands
lacrimal gland
sweat glands
dilator pupillae
superior tarsal muscle
carotid body
heart
arterial smooth muscles
356
Q

Describe the anatomical location of the middle cervical ganglion

A

anteriorly to the inferior thyroid artery and the C6 vertebra

absent in some individuals

357
Q

Which arteries do the nerves from the middle cervical ganglion hitch hike along?

A

inferior thyroid

358
Q

Which structures does the middle cervical ganglion innervate?

A 
larynx
trachea
pharynx
upper oesophagus
heart 
arterial smooth muscle
359
Q

Describe the anatomical location of the inferior cervical ganglion

A

anteriorly to the C7 vertebra

360
Q

Which arteries do the nerves from the inferior cervical ganglion hitch hike along?

A

vertebral

subclavian

361
Q

What causes Horner’s syndrome?

A 
sympathetic fibres stretched or damaged in the head and neck
Due to...
spinal cord lesions
traumatic injury
pancoast tumour (affecting apex of lung)
362
Q

What are the signs and symptoms of Horner’s syndrome?

Why?

A
  • Partial Ptosis– drooping of the upper eyelid. This is due to paralysis of the superior tarsal muscle, which acts to help open the eyelid.
  • Miosis – constriction of the pupil. This is due to paralysis of the dilator pupillae, a muscle located within the eye that acts to dilate the pupil.
  • Anhydrosis – decreased sweating (affecting the same side of the face as the lesion). This is due to a loss of innervation to the sweat glands of the face.
363
Q

What effects does an increase in sympathetic stimulation have to the head and neck?

A

pupillary dilation
vaso-constriction
lid retraction
sweating

364
Q

Name the four parasympathetic ganglia in the head

A

ciliary,
otic,
pterygopalatine
submandibular

365
Q

Where do the parasympathetic fibres of the head originate?

A

four nuclei in the brainstem

366
Q

Where is the ciliary ganglion located?

A

within the bony orbit
anterior to superior orbital fissure
between lateral rectus and optic nerve

367
Q

Where do the pre-ganglionic fibres entering the ciliary ganglion originate?

A

Edinger-Westphal nucleus

368
Q

Which nerve are the pre-ganglionic fibres of the ciliary ganglion associated with?

A

occulomotor nerve - inferior division

369
Q

Name the post-ganglionic fibres of the ciliary ganglion

A

short ciliary nerves

370
Q

What are the target organs of the post-ganglionic parasympathetic fibres of the ciliary ganglion?

What is their effect?

A

sphincter pupillae - constricts the pupil

ciliary muscles - contracts to make lens more spherical, accommodating near vision

371
Q

What is Adie’s pupil?

What is the cause?

A

dilated pupil that does not constrict in the presence of light
ciliary ganglion is damaged, due to infection and subsequent inflammation, so there is a loss of innervation to the sphincter pupillae

372
Q

Where is the pterygopalatine ganglion located?

A

within the pterygopalatine fossa
inferior to the base of the skull
posterior to the maxilla.

373
Q

Where do the pre-ganglionic fibres entering the pterygopalatine ganglion originate?

A

superior salivary nucleus

374
Q

Which nerve are the pre-ganglionic fibres of the pterygopalatine ganglion associated with?

A

facial nerve - greater petrosal nerve

375
Q

Which nerve are the post-ganglionic fibres of the pterygopalatine ganglion associated with?

A

maxillary nerve V2

376
Q

What are the target organs of the post-ganglionic parasympathetic fibres of the pterygopalatine ganglion?

What is their effect?

A

lacrimal gland
mucous glands of posterosuperior nasal cavity, nasopharynx, and the palate

secretion

377
Q

Where do the pre-ganglionic fibres entering the submandibular ganglion originate?

A

the superior salivary nucleus

378
Q

Which nerve are the pre-ganglionic fibres of the submandibular ganglion associated with?

A

carried within CN VII - chorda tympani

hitchhikes along lingual branch of the mandinbular nerve CNV

379
Q

Describe the post-ganglionic fibres of the submandibular ganglion

A

Fibres leave the ganglion and travel directly to the submandibular and sublingual glands.

380
Q

What are the target organs of the post-ganglionic parasympathetic fibres of the submandibular ganglion?

What is their effect?

A

submandibular and sublingual salivary glands

secretion

381
Q

Where is the otic ganglion located?

A

inferiorly to the foramen ovale within the infratemporal fossa
medial to the mandibular branch of the trigeminal nerve.

382
Q

Where do the pre-ganglionic fibres entering the otic ganglion originate?

A

inferior salivary nucleus

383
Q

Which nerve are the pre-ganglionic fibres of the otic ganglion associated with?

A

CN IX - lesser petrosal nerve

384
Q

Which nerve are the post-ganglionic fibres of the otic ganglion associated with

A

auricotemporal nerve - branch of CN V3

385
Q

What are the target organs of the post-ganglionic parasympathetic fibres of the otic ganglion?

What is their effect?

A

parotid gland

secretion

386
Q

Where do the parasympathetic fibres associated with the vagus nerve originate?

A

dorsal vagus motor nucleus

387
Q

What are the target organs of the post-ganglionic parasympathetic fibres associated with the vagus nerve?

What is their effect?

A

smooth muscle of the trachea, bronchi and GI tract

glands in laryngopharynx, oesophagus and trachea

388
Q

State the boundaries of the oral cavity

A

anterior - oral fissure

posterior - oropharyngeal isthmus

389
Q

Name the two divisions of the oral cavity

A

vestibule

mouth cavity proper

390
Q

State the boundaries of the vestibule

A

anterior - oral fissure

posterior - upper and lower dental arches

391
Q

Where is the opening of the parotid duct?

A

Opposite the upper second molar tooth

salivary juices are secreted into the vestibule

392
Q

State the boundaries of the mouth proper

A

anterior - upper and lower dental arches

posterior - oropharyngeal isthmus

393
Q

What forms the hard palate?

A

maxilla

palatine bone

394
Q

What forms the soft palate?

A 
muscles!
palatoglossus
palatopharyngeus
tensor veli palatini
levator veli palatini
395
Q

What are the actions of the soft palate?

A

lowers to close the oropharyngeal isthmus,

elevates to separate the nasopharynx from the oropharynx

396
Q

DEscribe the innervation of the muscles of the soft palate

A

vagus nerve

apart from tensor veli palatini = CN V3

397
Q

What forms the palatoglossal arch?

A

palatoglossus muscle

398
Q

What forms the palatopharyngeal arch?

A

palatopharyngeus

399
Q

Where do the submandibular glands enter the oral cavity?

A

papillae either side of lingual frenulum

400
Q

Describe the sensory innervation of the oral cavity

A

trigeminal nerve

palate - greater palatine and nasopalatine CN V2
floor - lingual CN V3
cheeks - buccal CN V3

401
Q

Describe the special sensory innervation of the tongue

A

anterior 2/3rds - chorda tympani CN VII

posterior 1/3rd - glossopharyngeal

402
Q

Describe the clinical appearance of the uvula losing its innervation

A

unilateral vagus nerve denervation

uvula points AWAY from lesion

403
Q

What are the gingivae composed of?

A

dense fibrous connective tissue

covered by smooth and vascular mucous membrane

404
Q

Describe the innervation of the intrinsic muscles of the tongue

A

hypoglossal nerve

405
Q

State the name and action of the intrinsic muscles of the tongue

A
  • superior longitudinal – sides of tongue up
  • vertical – flatten and broadens
  • transverse – pulls sides of tongue in to push tongue out
  • inferior longitudinal - sides of tongue down
406
Q

Describe the sensory innervation of the tongue

A

anteriorly - lingual nerve CN Vs

posteriorly - glossopharyngeal nerve CN IX

407
Q

What causes Dental Caries?

A

trauma or inadequacy of the enamel causes the hard layer of enamel to be broken down

the most common cause of breakdown of enamel is by lactic acid that is formed by bacteria when sugars are left in contact with the teeth.

408
Q

What are the risk factors for dental caries?

A

a diet high in sugars

poor dental hygiene

409
Q

Describe the presenting features of a patient with tonsillitis

A 
pain in throat
pain on swallowing
headache
hoarse voice
fever
swollen jugolodigastric lymph nodes
erythema of tonsils
pus on tonsils
swollen tonsils
410
Q

State the common causes of tonsillitis

A

rhinovirus
influenza

group A streptococci

411
Q

Describe the treatment of tonsillitis

A

pain relief

severe bacterial cases:
penicillin

412
Q

Where is pus trapped in a peritonsillar abscess?

A

trapped between the palatine tonsillar capsule and the lateral pharyngeal wall

413
Q

Describe the presenting features of a patient with a peritonsillar abscess

A 
severe sore throat
hoarse/croaky voice
dysphagia  
fever. 
Stridor
uvula deviates away from abscess
414
Q

Why is anaphylaxis of great danger in the oral cavity?

A

space between the oral cavity and the oropharynx can become obstructed due to the severe swelling of the tissues
AIRWAY OBSTRUCTION

415
Q

Anterior to posterior, name the teeth

A 
central incisor
lateral incisor
canine
first premolar
second premolar
first molar
second molar
third molar
416
Q

State the location of the Adenoid tonsils

A

at the bottom of the nasopharynx

417
Q

State the location of the tubal tonsils

A

end of the Eustachian tube

418
Q

State the location of the palatine tonsils

A

between the anterior and posterior arches

419
Q

State the location of the lingual tonsils

A

at the back of the tongue

420
Q

Where are the mastoid air cells found?

A

in the mastoid antrum of the mastoid process of the temporal bone

421
Q

What is the function of the mastoid air cells?

A

act as a reservoir of air

releases air into the tympanic cavity when pressure is too low

422
Q

Which portion of the temporal bone contains the inner ear?

A

petrous part

423
Q

Which portion of the temporal bone contains the outer ear?

A

tympanic

424
Q

How is mastoiditis caused?

A

Middle ear infections (otitis media) can spread to the mastoid air cells

425
Q

Why does mastoiditis lead to meningitis?

A

sigmoid venous sinus lies behind the air cells

spread of infection leads to meningitis

426
Q

Name the parts of the ear

A

lobule - only part not supported by cartilage.

helix = The outer curvature of the ear
antihelix =  curved elevation, which is parallel to the helix but inner

The antihelix divides into two cura superiorly – the inferoanterior crus, and the superoposterior crus.

concha = hollow depression in the middle of the auricle
It continues into the skull as the external acoustic meatus.

tragus = Immediately anterior to the start of the external acoustic meatus

antitragus = Opposite the tragus

427
Q

Describe the blood supply to the outer ear

A

posterior auricular, superficial temporal and occipital arteries and veins.

428
Q

What is an auricular haematoma?

A

blood collects between the cartilage and the overlying perichondrium

429
Q

Describe a complication of an auricular haematoma

A

accumulation of blood disrupts the vascular supply to the cartilage of the pinna.

If it is not drained quickly, a gross deformity results, called ‘cauliflower ear‘.

430
Q

Describe the sensory innervation of the external acoustic meatus

A

mandibular CN V3

vagus nerves.

431
Q

What is ear wax made up of?

A

cerumen (modified sebum)

dead skin cells

432
Q

Describe the course of the external acoustic meatus

A
  • Initially travels in a superoanterior direction.
  • Turns slightly to move superoposterior.
  • Ends in an inferoanterior direction.
433
Q

Describe the structure of the tympanic membrane

A

double layered structure
skin on the outside
mucous membrane on the inside

434
Q

Name the point that the handle of the malleus attaches to the tympanic membrane

A

umbo

435
Q

What causes perforation of the tympanic membrane?

A

trauma

infection

436
Q

How does otitis media lead to tympanic membrane perforation?

A

pus and fluid to build up.
increase in pressure
the eardrum ruptures

437
Q

State the boundaries of the middle ear

A
  • Roof – Formed by a thin bone from the petrous part of the temporal bone. It separates the middle ear from the middle cranial fossa.
  • Floor – Known as the jugular wall, it consists of a thin layer of bone, which separates the middle ear from the internal jugular vein
  • Lateral Wall – This is made up of the tympanic membrane and the lateral wall of the epitympanic recess.
  • Medial Wall – Formed by the lateral wall of the internal ear. It contains a prominent bulge, produced by the facial nerve as it travels nearby.
  • Anterior Wall – The anterior wall is a thin bony plate with two openings; for the auditory tube and the tensor tympani muscle. It separates the middle ear from the internal carotid artery.
  • Posterior Wall – Also known as the mastoid wall, it consists of a bony partition between the tympanic cavity and the mastoid air cells. Superiorly, there is a hole in this partition, allowing the two areas to communication. This hole is known as the aditus to the mastoid antrum.
438
Q

Name the bones of the middle ear

A

malleus
incus
stapes

439
Q

How are the tympanic membrane and the inner ear connected?

A

auditory ossicles link up to connect it to the oval window

440
Q

How is the middle ear divided?

A

tympanic cavity = medially to the tympanic membrane. It contains the majority of the bones of the middle ear.

epitympanic recess = superiorly, near the mastoid air cells.

441
Q

How do the mastoid air cells communicate with the middle ear?

A

aditus to the mastoid antrum

442
Q

Which muscles have a protective function in the middle ear?

A

tensor tympani

stapedius.

443
Q

Describe the action of the tensor tympani and stapedius

A

acoustic reflex = contract in response to loud noise
inhibit the vibrations of the malleus, incus and stapes,
reducing the transmission of sound to the inner ear

444
Q

Describe the innervation of the tensor tympani and the stapedius

A

tensor tympani = mandibular nerve

stapedius = facial nerve

445
Q

Describe the course of the Eustachian tube

A

extends from the anterior wall of the middle ear
in an anterior, medioinferior direction,
opening onto the lateral wall of the nasopharynx at the inferior nasal concha

446
Q

What causes otitis media?

A

dysfunction of the auditory tube

negative pressure inside middle ear

447
Q

How is otitis media observed?

A

tympanic retraction

448
Q

What causes otitis media with effusion?

A

the negative pressure inside the middle ear leads to a transudate being secreted from the mucosa
chronic accumulation of fluid

449
Q

What is the function of the ossicles?

A

amplify and concentrate sound energy from the eardrum to the oval window

450
Q

What are the functions of the inner ear?

A
  • To convert mechanical signals from the middle ear into electrical signals, which can transfer information to the auditory pathway in the brain.
  • To maintain balance by detecting position and motion.
451
Q

Where is the oval window of the inner ear found?

A

between the middle ear and the vestibule

452
Q

Where is the round window of the inner ear found?

A

between the middle ear and the scala tympani (part of the cochlear duct).

453
Q

Name the parts of the bony labyrinth

A

semi-circular canals
vestibule
cochlea

454
Q

What is inside the bony labyrinth?

A

lined by periosteum

contain perilymph

455
Q

Describe the anatomical location of the vestibule

A

within the petrous part of the temporal bone
posterior to cochlea
anterior to semicircular canals

456
Q

What is located within the vestibule?

A

saccule

utricle

457
Q

What is the modiolus?

A

the central portion of bone in the cochlea

spiral lamina extend from it

458
Q

Where is the scala vestibuli found?

A

superiorly to the cochlear duct.

it is continuous with the vestibule

459
Q

Where is the scala tympani found?

A

inferiorly to the cochlear duct.

terminates at the round window.

460
Q

Where is the membranous labyrinth found?

A

within the bony labyrinth, surrounded by perilymph

461
Q

Name the parts of the membranous labyrinth

A

cochlear duct,
semicircular ducts,
utricle
saccule

462
Q

What is the membranous labyrinth filled with?

A

endolymph

463
Q

What is Reissner’s membrane?

A

membrane that separates the cochlear duct from the scala vestibuli

464
Q

What is the basilar membrane?

A

membrane that separates the cochlear duct from the scala tympani
contains the epithelial cells of hearing - Organ of Corti

465
Q

What is the function of the saccule?

A

receives fluid from the cochlear duct

466
Q

What is the function of the utricle?

A

receives fluid from the semicirular ducts

467
Q

Where are the sensory receptors that detect movement and allow process of balance?

A

ampullae of the semicircular canals

468
Q

What causes Meniere’s disease?

A

disorder of the inner ear
excess accumulation of endolymph within membranous labyrinth
distension of the ducts
pressure fluctuations damage the membranes

469
Q

What are the symptoms of Meniere’s disease?

A

vertigo
tinnitus
hearing loss

470
Q

Describe the innervation of the inner ear

A

vestibulocochlear nerve

  • Vestibular nerve – enlarges to form the vestibular ganglion, which then splits into superior and inferior parts to supply the utricle, saccule and three semicircular duct.
  • Cochlear nerve – enters at the base of the modiolus and its branches pass through the lamina to supply the receptors of the Organ of Corti.
471
Q

Why is the facial nerve vulnerable to damage from middle ear disease?

A

lies in facial canal

separated from middle ear by thin bony partition

472
Q

Describe the sensory innervation of the auricle

A

superior - auricotemporal

inferior and posterior - greater auricular CN V2

473
Q

Why do patients complain of an involuntary cough when cleaning their ears?

A

stimulation of the auricular branch of the vagus nerve

cough reflex

474
Q

Describe the innervation of the tympanic membrane

A

Outer tympanic membrane = auricotemporal CN V3 and vagus

Inner tympanic membrane = glossopharyngeal

475
Q

What causes Benign Paroxysmal Positional Vertigo?

A

otoliths detach from lining of vestibule and enter the semicircular ducts
Detached otoliths may continue to move after the head has stopped moving
movement detected by vestibular nerve
vertigo results from the conflicting sensation of ongoing movement with other sensory inputs.

476
Q

How is the external acoustic meatus examined?

A

pull auricle upwards and backwards

NB: downwards and backwards in children!

477
Q

Describe conductive hearing loss

A

o Results from anything in the external or middle ear that interferes with the conduction of sound or movement of the oval or round windows.

o People with this type of hearing loss often speak with a soft voice
 To them, their own voices sound louder than background sounds

478
Q

`Describe sensorineural hearing loss

A

o Results from defects in the pathway from cochlea to brain
 Defects of cochlea
 Defects of cochlea nerve
 Defects of brainstem

o Cochlear implants can restore hearing
 External microphone transmitting to an implanted receiver that sends electrical impulses to the cochlea, stimulating the cochlear nerve

479
Q

describe the Rinne and Weber’s tests

A

Rinne = tuning fork held in front of ear and then on mastoid process

Webers = tuning fork held in middle of forehead

480
Q

What does Rinne’s examine?

A

conductive hearing loss

if bone > air

481
Q

What does Weber’s examine?

A

Localisation of sound

482
Q

How will conductive hearing loss present on Rinne and Weber’s?

A 
Rinne = bone > air
Weber's = localise to affected ear
483
Q

What shape is the bony orbit?

A

pyramid

484
Q

State the boundaries of the bony orbit

A
  • Roof – frontal bone and the lesser wing of the sphenoid.
  • Floor – maxilla, palatine and zygomatic bones.
  • Medial wall – ethmoid, maxilla, lacrimal and sphenoid bones.
  • Lateral wall – zygomatic bone and greater wing of the sphenoid.
  • Apex – the optic foramen.
  • Base – Opens out into the face, and is bounded by the eyelids. It is also known as the orbital rim.
485
Q

How is the orbit separated from the anterior cranial fossa?

A

The frontal bone

486
Q

How is the orbit separated from the maxillary sinus?

A

The maxilla

487
Q

How is the orbit separated from the ethmoid sinus?

A

The ethmoid bone

488
Q

What structures does the bony orbit contain?

A

• Extra-ocular muscles
• Nerves: optic, oculomotor, trochlear, trigeminal and abducens nerves.
• Blood vessels: ophthalmic artery, central retinal artery,central retinal vein, inferior and superior ophthalmic veins
Orbit fat

489
Q

When the eye is medial, which muscles act to move it up and down?

A

obliques

490
Q

When the eye is lateral, which muscles act to move it up and down?

A

rectus

491
Q

Where do the rectus muscles originate from?

A

common tendinous ring

492
Q

Describe the action of the superior rectus

A

elevation.

Also contributes to adduction and medial rotation of the eyeball.

493
Q

Describe the action of the inferior rectus

A

depression.

Also contributes to adduction and lateral rotation of the eyeball.

494
Q

Describe the action of the medial rectus

A

Adducts the eyeball.

495
Q

Describe the action of the lateral rectus

A

Abducts the eyeball.

496
Q

Where does the superior oblique originate from and attach to?

A

sphenoid bone

posterior to the superior rectus

497
Q

Describe the action of the superior oblique

A

Depresses, abducts and medially rotates the eyeball

498
Q

Describe the action of the inferior oblique

A

Elevates, abducts and laterally rotates the eyeball.

499
Q

State the innervation of the extraocular muscles

A

CN III: others
CN IV: superior oblique
CN VI: lateral rectus

500
Q

What passes through the optic canal?

A

optic nerve

ophthalmic artery

501
Q

What passes through the superior orbital fissure?

A 
lacrimal nerve
frontal nerve 
CN IV
CN III
nasociliary nerve
CN VI
superior ophthalmic vein
502
Q

What passes through the inferior orbital fissure?

A

maxillary nerve (a branch of CN V),
inferior ophthalmic vein
sympathetic nerves.

503
Q

Where is the nasolacrimal canal located?

A

medial wall of the orbit

504
Q

Where is the lacrimal gland located?

A

in a fossa on the superolateral part of the orbit

505
Q

What is the function of the lacrimal canaliculi?

A

Commence at the medial angle of the eye where lacrimal fluid is drained into the lacrimal sac

506
Q

What is the function of the nasolacriml duct?

A

Conveys lacrimal fluid to the inferior nasal meatus

507
Q

What is the function of the sclera and cornea?

A

provide shape to the eye
support the deeper structures
sclera provides attachment to the extraocular muscles
cornea refracts light entering the eye

508
Q

What is the choroid?

A

layer of connective tissue and blood vessels, providing nourishment to the outer layers of the retina

509
Q

What makes up the ciliary body?

A

ciliary muscle

ciliary processes

510
Q

What is the function of the ciliary body?

A

ciliary smooth muscles attached to the lens by the ciliary processes
controls the shape of the lens

also contributes to formation of aqueous humour

511
Q

Describe the layers of the retina

A
  • Neural layer – Consists of photoreceptors, located posteriorly and laterally in the eye.
  • Pigmented layer – Lies underneath the neural layer and is attached to the choroid layer. It acts to support the neural layer, and continues around the whole inner surface of the eye.
512
Q

Where is the non-visual retina found?

A

anteriorly (no neural layer)

513
Q

Where is the optic retina found?

A

Posteriorly and laterally, both layers of the retina are present

514
Q

How can the optic part of the retina be viewed?

A

ophthalmoscopy

515
Q

Where is the macula found?

How can it be identified?

A

centre of the retina

highly pigmented - yellow

516
Q

Where is the fovea found?

A

depression in the centre of the macula

517
Q

What is the fovea responsible for?

A

high acuity vision

518
Q

Where does the optic nerve enter the retina?

A

optic disc

519
Q

Describe the location of the lens

A

between the vitreous humor and the pupil

520
Q

Explain the difference between the anterior and posterior segments of the eye

A

The anterior segment of the eye contains aqueous humor and supplies the lens of the eye. In front of lens.
The posterior segment of the eye contains vitreous humor and keeps the eye in shape. Behind lens

521
Q

Explain the difference between the anterior and posterior chambers of the eye

A

The anterior chamber is located between the cornea and the iris.
The posterior chamber is located between the iris and ciliary processes.
Both located in the anterior segment and filled with aqueous humour

522
Q

Describe the arterial supply of the eyeball

A

the ophthalmic artery - a branch of the internal carotid artery

523
Q

Describe the arterial supply of the internal surface of the retina

A

central artery of the retina
a branch of the ophthalmic artery
branch of the internal carotid artery

524
Q

Describe the venous drainage of the eyeball

A

the superior and inferior ophthalmic veins.

These drain into the cavernous sinus

525
Q

What is an orbital rim fracture?

A

fracture of the bones forming the outer rim of the bony orbit.
It usually occurs at the sutures joining the three bones of the orbital rim – the maxilla, zygomatic and frontal.

526
Q

What is a blowout fracture?

A

partial herniation of the orbital contents through one of its walls.
The medial and inferior walls are the weakest, with the contents herniating into the ethmoid and maxillary sinuses respectively

527
Q

What is the cause of a blowout fracture?

A

blunt force trauma to the eye

528
Q

What are the clinical consequences of a fracture to the bony orbit?

A 
increased intraorbital pressure
raising the pressure in the orbit, 
causing exophthalmos (protrusion of the eye)
529
Q

What lines the inner surface o the eyelids?

A

conjuctiva

530
Q

Which muscles acts to elevate the eyelid?

A

levator palpebrae superioris

531
Q

How is the superior tarsal muscle innervated?

A

sympathetic nervous system

532
Q

How is the levator palpebrae superioris innervated?

A

oculomotor nerve (CN III)

533
Q

What structure does a Meibomian Cyst affect?

A

tarsal gland, lying behind the eyelash

534
Q

What structure does a Stye affect?

A

ciliary gland

535
Q

What is a key difference between a Meibomian Cyst and a Stye?

A

stye = infective. most commonly Staph A

536
Q

Explain the difference between partial and complete ptosis with regards to the neural innervation of the eyelid

A

Partial ptosis = loss of sympathetic innervation of superior tarsal
Complete ptosis = oculomotor lesion, damage to levator palpabrae superioris

537
Q

What is glaucoma?

A

an increase in intra-ocular pressure, secondary to an increased amount of aqueous humor

538
Q

what are the consequences of glaucoma?

A

compression of the retinal arteries,
damage to the retina
loss of vision

539
Q

Describe closed angle glaucoma

A

iris is forced against the trabecular meshwork, preventing any drainage of aqueous humor
OPTHALMIC EMERGENCY

540
Q

Describe open angle glaucoma

A

the outflow of aqueous humor through the trabecular meshwork is reduced.
It causes a gradual reduction of the peripheral vision, until the end stages of the disease.

541
Q

What causes cataracts?

A

disruption of the crystallin fibres within the lens, leading to protein aggregation in lens
accumulation of pigment within the lens
causing, light scattering, obstruction of vision

542
Q

What are the symptoms of cataracts?

A

gradual painless loss of vision,
diplopia in one eye
haloes

543
Q

What are the symptoms of conjunctivitis?

A
  • Red eye - usually generalised, often bilateral.
  • Irritation, grittiness and discomfort
  • Discharge - may be watery, mucoid, sticky or purulent depending on the cause.
  • Photophobia - this suggests corneal involvement.
  • Visual acuity unaltered -
544
Q

What is orbital cellulitis?

A

infection of the soft tissues behind the orbital septum (separates the eyelids from the contents of the orbital cavity)

545
Q

What are the symptoms of orbital cellulitis?

A

sudden onset of unilateral swelling of conjunctiva and eyelids, pain and sticky discharge.
Fever,
painful eye movements
decreased vision
proptosis (eye pushed forwards)
RAPD (Relative Afferent Pupillary Defect)

546
Q

Describe the signs and symptoms of an occulomotor nerve lesion

A

affected eye is displaced laterally by the lateral rectus and inferiorly by the superior oblique.
The eye adopts a position known as ‘down and out’. There will also be a dilated pupil (loss of sympathetic dilator pupillae) and ptosis.

547
Q

Describe the signs and symptoms of a trochlear nerve lesion

A

paralysis of superior oblique
problem rotating the eye
diplopia (double vision)
head tilt away from the site of the lesion

548
Q

Describe the signs and symptoms of an abducens nerve lesion

A

paralysis of lateral rectus

affected eye will adducted by the resting tone of the medial rectus.

549
Q

What is papilloedema?

A

optic disc swelling secondary to raised intracranial pressure (ICP)

550
Q

What are the symptoms of raised intracranial pressure?

A

headache (worse on waking, straining and bending)
nausea
vomiting

551
Q

How can the central retinal artery become occluded?

A

embolus

552
Q

What are the symptoms of central retinal artery occlusion?

A

sudden (over a few seconds), unilateral painless visual loss

553
Q

What will be seen on examination of central retinal artery occlusion?

A

afferent pupillary defect
pale retina with attenuation of the vessels.
centre of the macula (supplied by the intact underlying choroid) stands out as a cherry-red spot.

554
Q

How can the central retinal vein become occluded?

A

thrombophlebitis

thrombus formation

555
Q

What are the symptoms of central retinal vein occlusion?

A

sudden painless unilateral loss of vision

556
Q

Describe the pathophysiology of central retinal vein occlusion

A

backlog of stagnated blood combined with hypoxia
results in extravasation of blood constituents, causing further stagnation
Ischaemic damage to the retina stimulates increased production of vascular endothelial growth factor (VEGF)
neovascularisation - can result in haemorrhage or neovascular glaucoma (the new vessels grow into the aqueous drainage system, so clogging it up)

557
Q

What will be seen on examination of non-ischaemic central retinal vein occlusion?

A

mild or absent afferent pupillary defect.
widespread dot-blot and flame haemorrhages throughout the fundus
some disc oedema

558
Q

What will be seen on examination of ischaemic central retinal vein occlusion?

A

marked afferent pupillary defect.
widespread dot-blot and flame haemorrhages throughout the fundus
disc oedema is more severe. Haemorrhages scattered throughout the fundus in typical blood-storm pattern with cotton wool spots
occasionally be an associated retinal detachment.

559
Q

What are the symptoms of retinal detachment?

A

flashes of light

specks floating in the eye

560
Q

What are the afferent fibres of the corneal reflex?

A

Opthalmic Branch of the Trigeminal Nerve (CN V1)

561
Q

What are the efferent fibres of the corneal reflex?

A

Temporal and Zygomatic Branches of the Facial Nerve (CN VII)

562
Q

What is the response of the corneal reflex?

A

Contraction of the Orbicularis Oculi, causing the eye to blink

563
Q

What is an RAPD?

A

one eye doesn’t sense light as well as the other
swinging light test
eye dilates instead of constricts

564
Q

What are the afferent fibres of the light reflex?

A

Optic nerve (carries impulse to brain)

565
Q

What are the efferent fibres of the light reflex?

A

Parasympathetic fibres travel along CN III via the edinger westphal nucleus and ciliary ganglion to cause constriction of iris and ciliary muscle of lens

566
Q

What is used to asses visual acuity?

A

Snellen Chart

567
Q

Describe the features of the external nose

A

nasal root = superiorly, continuous with the forehead. apex = inferior rounded ‘tip’. dorsum = between the root and apex
nares = immediately inferiorly to the apex, piriform openings into the vestibule of the nasal cavity
nasal septum = medial boundary of nares
ala nasi = lateral cartilaginous wings nares

568
Q

What is the skeleton of the nose composed of?

A

cartilage inferiorly

bone superiorly

569
Q

State the bony components of the nasal skeleton

A

nasal bones,
maxillae
frontal bone.

570
Q

State the cartilaginous components of the nasal skeleton

A

the two lateral cartilages,
two alar cartilages
one septal cartilage.
There are also some smaller alar cartilages present

571
Q

Identify the structures that make up the septum of the nasal cavity

A 
o	Anterior Portion
Septal cartilage
o	Middle Portion
Perpendicular plate of the Ethmoid Bone
o	Posterior Portion
Vomer
o	Inferiorly, 
the hard palate, made up of the palatine posteriorly and maxillary bones anteriorly
572
Q

What forms the inferior concha?

A

independent bone - inferior concha!

573
Q

What forms the superior and middle concha?

A

medial processes of the ethmoid bone

574
Q

Where is the sphenoethmoidal recess?

A

superior and posterior to the superior concha

575
Q

What is the function of the conchae?

A

increase the surface area of the nasal cavity – this increases the amount of heat exchange.
disruption of the fast, laminar flow of air, making it slow and turbulent.
The air spends longer in the nasal cavity, so that it can be humidified.

576
Q

What communicates with the nasal cavity via the cribriform plate?

A

olfactory nerve

CSF

577
Q

What communicates with the nasal cavity via the sphenopalatine foramen?

A

pterygopalatine fossa
sphenopalatine artery
nasopalatine nerve
superior nasal nerve

578
Q

Where is the sphenopalatine foramen located?

A

superior meatus

posterior

579
Q

What communicates with the nasal cavity via the incisive foramen?

A

incisive fossa of oral cavity
nasopalatine nerve
greater palatine artery

580
Q

What are the functions of the nasal cavity?

A
  • Warms and humidifies the inspired air.
  • Removes and traps pathogens and particulate matter from the inspired air.
  • Responsible for sense of smell.
  • Drains and clears the paranasal sinuses and lacrimal ducts.
581
Q

What are the regions of the nasal cavity?

A

vestibule
olfactory region
respiratory region

582
Q

Where is the vestibule of the nasal cavity?

A

the area surrounding the external opening to the nasal cavity.

583
Q

Describe the olfactory region of the nasal cavity

A

at the apex of the nasal cavity.

It is lined by olfactory cells with olfactory receptors.

584
Q

Describe the respiratory region of the nasal cavity

A

lined by ciliated psudeostratified epithelium. Within the epithelium are interspersed mucus-secreting goblet cells.

585
Q

When do the frontal sinuses appear?

A

7

586
Q

Where do the frontal sinuses drain into the nasal cavity?

A

via the frontonasal duct
to the ethmoidal infundiubulum
middle meatus - hiatus semilunaris

587
Q

Describe the relation of the sphenoid sinus to the pituitary gland and how it can be utilised in surgery

A

the pituitary gland can be surgically accessed via passing through the nasal roof, into the sphenoid sinus and through the sphenoid bone

588
Q

Where do the sphenoid sinuses drain into the nasal cavity?

A

Sphenoethmoidal Recess

589
Q

Where do the anterior ethmoid sinuses drain into the nasal cavity?

A

middle meatus via the infundibulum

590
Q

Where do the middle ethmoid sinuses drain into the nasal cavity?

A

directly into the middle meatus

591
Q

Where do the posterior ethmoid sinuses drain into the nasal cavity?

A

superior meatus

592
Q

Describe the anatomical relations of the maxillary sinus

A

roof = floor of the orbit,
floor = the alveolar part of the maxilla (relating them to the roots of the first two molars and the superior alveolar nerve.)
Posteriorly lie the pterygopalatine and infratemporal fossae.

593
Q

Where do the maxillary sinuses drain into the nasal cavity?

A

at the hiatus semilunaris, underneath the frontal sinus opening in the middle meatus.

594
Q

Describe the anatomical relations of the ethmoid sinus

A

lateral to the orbit of the eye

595
Q

Which structures drain into the middle meatus?

A

The frontal, maxillary and anterior ethmoidal sinuses
= semilunar hiatus anteriorly

Middle ethmoidal sinus = ethmoid bulla posteriorly

596
Q

Which structures drain into the superior meatus?

A

posterior ethmoidal sinuses

597
Q

Which structures drain into the inferior meatus?

A

nasolacrimal duct anteriorly

Eustachian tube posteriorly

598
Q

Describe the arterial supply to the nose

A

Internal carotid branches:
• Anterior ethmoidal artery
• Posterior ethmoidal artery
- branches of the opthalmic artery.

External carotid branches:
• Sphenopalatine artery
• Greater palatine artery
• Superior labial artery

599
Q

What is Kiesselbach’s area?

A

anastomoses in anterior third of nasal septum

600
Q

Where do the veins of the nose drain into?

A

pterygoid plexus,
facial vein
cavernous sinus

601
Q

Describe the general sensory innervation of the nose

A

posteroinferior septum and lateral walls = nasociliary nerve (branch of the ophthalmic nerve CN V2)

anterosuperior septum and lateral walls = nasopalatine nerve (branch of maxillary nerve CN V1)

external skin = trigeminal nerve (V1/V2)

602
Q

How can epistaxis be managed clinically?

A

first achieved by pinching of the bridge of the nose whilst sitting with the head forwards.
This prevents aspiration or swallowing of blood.

Cautery can be useful if bleeding does not stop.

Nasal tampons, posterior packing and surgical ligation of nasal arteries can be used in very severe bleeds.

603
Q

What causes saddle nose deformity?

A

direct damage to the septal bone or cartilage, or a consequence of nasal septal haematoma
septal support to the nose is lost,
the middle part of the nose appears sunken

604
Q

Describe the clinical presentation of a severe nasal septal deviation

A

obstructs breathing

snoring.

605
Q

What is rhinitis?

A

Inflammation of the nasal mucosa, leading to swelling and increased volume of secretion

606
Q

What causes rhinitis?

A 
o	Infective (Viral)
	Adenovirus
	Rhinovirus
	Respiratory Syncytial Virus (RSV) 
o	Allergic 
o	Nasal Polyps
607
Q

What are nasal polyps?

A

lesions arising from the nasal mucosa, occurring at any site in the nasal cavity or paranasal sinuses

608
Q

Where are nasal polyps most commonly seen?

A

the clefts of the middle meatus

609
Q

How can a nasal infection spread to the anterior cranial fossa?

A

cribriform plate

610
Q

How can a nasal infection spread to the lacrimal apparatus and conjunctiva?

A

nasolacrimal duct

611
Q

How can a nasal infection spread to the middle ear?

A

Eustachian tube

612
Q

What causes sinusitis?

A

Viral infection with a secondary bacterial infection with Streptococcus pneumoniae or Haemophilus influenzae

613
Q

Why can sinusitis present as tooth ache?

A

The maxillary nerve supplies both the maxillary sinus and maxillary teeth

ESA4 (4 decks)

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