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MRCS part B anatomy > Head and neck anatomy > Flashcards

Head and neck anatomy Flashcards

1
Q

Where are level 1a lymph nodes found? what are they called?

A

Submental: between anterior bellies digastric

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2
Q

Where are level 1b lymph nodes found? What are they called?

A

Submandibular: between anterior and posterior bellies digastric

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3
Q

What is the clinical significance of enlargement of level 1a nodes?

A

Tumours or infections of:
1) Floor of mouth
2) Anterior tongue
3) Lower lip

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4
Q

What is the clinical significance of enlargement of level 1b nodes?

A

Tumours or infections of:
1) oral cavity
2) anteiror nasal cavity
3) Soft tissue structures of mid face
4) Submandibular gland

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5
Q

Where are level 2 lymph nodes found? What are they called?

A

Upper jugular or jugulodigastric nodes anatomical landmarks:
1) Anterior to posterior border sternocleidomastoid
2) Posterior to posteiror border submandibular gland
3) Along a line from base of skull to lower border hyoid bone

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6
Q

What is the clinical significance of enlargement of level 2 lymph nodes?

A

Tumours or infections from:
1) Oral cavity
2) Nasal cavity
3) Nasopharynx
4) Oropharynx
5) Hypopharynx
6) Larynx
7) soft tissue face or ear
8) Parotid gland

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7
Q

Where are level 3 lymph nodes found? What are they called?

A

Middle jugular nodes, anatomical landmarks:
1) Anterior to posterior border sternocleidomastoid
2) Along a line from the lower border of hyoid bone and lower border of cricoid cartilage

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8
Q

What is the clinical significance of enlargement of level 3 nodes?

A

Oral cavity, nasopharynx, oropharynx, larynx

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9
Q

Where are level 4 lymph nodes? What are they called?

A

Lower jugular. Anatomical land marks:
1) Between the lower border of cricoid cartilage and clavicle

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10
Q

What is the clinical significance of enlargement of level 4 lymph nodes?

A

Tumours or infection from:
1) Larynx
2) Hypopharynx
3) Thyroid
4) Cervical oesophagus

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11
Q

Where are level V nodes?

A

Poseterior triangle. Landmarks:
1) Va: above course of spinal accessory nerve
2) Vb: below course of spinal accessory nerve

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12
Q

Clinical significance level V node enlargement

A

Thyroid, subglottic larynx, cervical trachea, hypopharynx, cervical oesophagus

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13
Q

Level VII nodes: What are they called and what are their landmarks?

A

Superior mediastinal. Landmarks:
1) between common carotid arteries and posterior surface manubrium sternum in superior mediastinum

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14
Q

Level VII nodes clinical significance:

A

Enlarged in tumours or infection from lung, chest wall, thyroid

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15
Q

What determines neck dissection classification?

A

Classified according to lymph node groups removed and vital structures that need to be sacrificed

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16
Q

What are different types of neck dissection?

A

-Radical neck dissection
-Modified radical neck dissection
-Selective neck dissection
-Extended radical neck dissection

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17
Q

What is radical neck dissection

A

Level I-V lymph nodes
Sacrificing the:
-Spinal accessory nerve
-INternal jugular vein
-SCM muscles

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18
Q

Modified radical neck dissection

A

Level I-V lymph nodes

Preserving one or more of:
-Spinal accessory nerve
-INternal jugular vein
-SCM muscle

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19
Q

Selective neck dissection

A

-Removal of one or more levels of lymph node groups
-None of vital structures are sacrificed

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20
Q

Extended neck dissection

A

Removal of additional lymphatic or non-lymphatic structures not routinely inluded in traditional neck dissections
eg:
-Parapharyngeal and para-tracheal lymph nodes
-Carotid artery
-Hypoglossal nerve
-Vagus nerve

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21
Q

Label features of cervical vertebra

A

1: Vertebral body
2: Transverse foramen
3: Transverse process
4: Superior articular process
5:Vertebral foramen
6: Lamina
7: Bifid spinous process

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22
Q

What are characteristic features of typical cervical vertebra?

A

-Broad body
-Small and bifid spine
-Transverse process has foramen tranversarium which transmits vertebral artery, vertebral vein and sympathetic nerves
-Plane of facet joint is oblique

(lumbar vertebra comparison)

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23
Q

How does C1 differ from typical cervical verebra? What is it called?

A

C1 (atlas) has superior articular facets for articulating with occipital condyles of skull. It is kidney shaped and lacks spinous process or body.

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24
Q

How does C2 differ from typical cervical vertebra?

A

C2 vertebra (axis) contains a peg like dens (odontoid process). It does not have a bifid spine.

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25
Q

How does C7 differ from typical cervical vertebra? What is it also known as

A

-Vertebra prominens.
-Spinous process is long and not bifid
-Transverse process is large but foramina are small, does not transmit vertebral arteries
-Transverse foramina C7 transmits vertebral vein

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26
Q

Which joint permits flexion and extension of neck? How is it formed?

A

Atlanto-occipital joint, formed by articular surfaces C1 vertebra and occipital condyles

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27
Q

What type of joint is atlanto-occipital joint?

A

synovial joint. Surrounded by loose capsule.

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28
Q

What prevents excess rotation at atlanto-occipital joint>

A

alar ligaments (which connect dens to occipital condyles)

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29
Q

What is the function of dens of C2?

A

Dens (odontoid process) is portion of C2 vertebra about which C1 and skull rotate as a unit

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30
Q

Describe clinical significance of fracture to Dens

A

-Dens can impact spinal cord, injuring or even severing it resulting in quadriplega.
-Dens extends superiorly into ring of C1, therefore is susceptible to shearing forces and fracture from C1 in neck injuries

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31
Q

What is hangman’s fracture?

A

Involves fracture of both pars interarticularis of C2, snd results from hyperextension injuries

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32
Q

Describe the anatomy of the thyroid gland

A

-Two lobes joined by isthmus
-C5-T1 vertebrae
-Isthmus lies anterior to 2nd +3rd tracheal rings
-Surrounded by capsule
-Capsule surrounded by pretracheal fascia

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33
Q

What is function of thyroid gland

A

-Produce T3 and T4 via thyroid follicular cells
-Parafollicular cells produce calcitonin, important in calcium metabolism

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34
Q

Lymphatic drainage thyroid

A

Paratracheal and deep cervical lymph nodes

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35
Q

Complications of surgery to thyroid gland

A

-Pain, bleeding, seroma, infection, scar
-Nerve injury to:
1) Superior laryngeal nerve: damage to cricothyroid muscle, loss of high pitched voice
2) Recurrent laryngeal nerve injury: difficulty in phonation, airway obstgruction if bilateral

-Hypocalcaemia if parathyroid removed
-Need for thyroid replacement

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36
Q

Describe nerve supply to larynx

A

Vagus nerve via following branches:

Superior laryngeal nerve: divides into
1) External laryngeal nerve supplying cricothyroid muscle (tensor muscle of larynx and cord adductor)
2) Internal laryngeal nerve: sensory to laryngeal mucosa above vocal cords

Recurrent laryngeal nerve: supplies remaining intrinsic laryneal muscles, sensory innervation to mucosa below cords

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37
Q

What is most common thyroid cancer?

A

Papillary carcinoma

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38
Q

What are the features of papillary thyroid carcinoma?

A

65-70% of thyroid malignancy
more common in women
3rd-4th decade
lymphatic metastases

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39
Q

Features of follicular carcinoma

A

30% of thyroid malignancy
more common in women
5th decade
haematogenous metastases

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40
Q

Features of medullary carcinoma

A

originates from parafollicular c cells of thyroid
men and women equally affected
coiuld present as a part of MEN 2a and 2b
can be monitored with calcitonin

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41
Q

Features of anaplastic carcinoma

A

Rare
7th decade
usually presents as rapidly enlarging neck mass

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42
Q

Submental triangle boundaries

A

Lateral: anterior belly digastric
Inferior: hyoid bone
Medial: midline

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43
Q

Submental triangle contents

A

Anterior jugular vein
Lymph nodes

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44
Q

Digastric (submandibular) triangle borders:

A

Anterior: anterior belly digastric
Posterior: posterior belly digastric
Superior: mandible

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45
Q

Digastric (submandibular) triangle contents

A

Arteries:
-Facial artery, submental artery
Vein:
-facial vein
Nerves
-Hypoglossal nerve
-marginal mandibular
-lingual
-nerve to mylohyoid
Other
-Submandibular gland
-Lymph nodes

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46
Q

Carotid triangle boundaries

A

Anteiror: superior belly omohyoid
Posteiror: scm
Superior: posterior belly digastric

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47
Q

Carotid triangle contents

A

Arteries:
-Common carotid bifurcation, branches external carotid
Veins
-Internal jugular vein and tributaries
Nerves
-Vagus nerve, superior branches ansa cervicalis

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48
Q

Muscular triangel boundaries

A

Superior: hyoid bone
Medially: imaginary midline of neck
Supero-laterally: superior belly omohyoid
Infero-laterally: Inferior portion SCM

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49
Q

Muscular triangle contents

A

Infrahyoid strap muscles:
-Sternohyoid
-Sternothyroid
-thyrohyoid
Larynx
Thyroid
Parathyroid glands
lymph nodes

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50
Q

boundaries occipital triangle

A

Anterior: posterior border sternocleidomastoid
Posterior: anterior border of trapezius
Inferior: inferior belly of omohyoid

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51
Q

Contents occipital triangle

A

Vein: external jugular
Nerves: spinal accessory, upper trunk brachial plexus (deep)
Occipital lymph nodes

52
Q

Boundaries supraclavicular (subclavian) triangle

A

Anterior: posterior border sternocleidomastoid
Posterior/superior: inferior border omohyoid
Inferior: clavicle

53
Q

Contents supraclavicular triangle:

A

Arteries: subclavian, suprascapular
Veins: subclavian vein
Nerves: lower trunk brachial plexus, phrenic
Others: Supraclavicular lymph nodes, apex of lung,, thoracic duct left side

54
Q

Differential diagnosis swelling in anterior triangle of neck

A

Thyroglossal cyst
salivary gland swellings
branchial cyst
thyroid pathologies
carotid body tumour
skin conditions incluidng malignancies
lymphadenopathy

55
Q

Differential diagnosis posterior triangle of neck

A

cystic hygroma
cervical rib
subclavian artery aneurysm
skin conditions including malignancies
lymphadenopathy

56
Q

Describe course of facial nerve

A

-Mixed nerve comprising large motor and smaller sensory component
–>Motor component from pons,
–>sensory component from nervus intermedius
–>Emerges from junction between pons and medulla
–> petrous temporal bone via internal auditory meatus
–> Runs through facial canal
–> gives off ‘tear, hear, taste’ branches in facial canal
–> Exits skull via stylomastoid foramen
–> gives off posterior auricular nerve, nerve to posterior belly digastric, nerve to stylohyoid
–> enters parotid gland between superficial and deep lobes
–> gives off 5 branches within parotid

57
Q

Venous drainage of scalp

A

-Veins same as arteries (supraorbital, supratrochlear, superficial temporal, posterior auricular, occipital)
-valveless emissary veins connect superficial veins of scalp with diploic veins of skull
-these drain into intracranial venous sinuses

58
Q

Surgical considerations when closing scalp wound

A

-Rich blood supply, may bleed profusely
-Lacerations deep to aponeurosis may gape, making wound closure more difficult
-inelastic nature of tissue may require undermining adjacent tissue
-Larger lesions may need flap/ssg

59
Q

clinical significance of infections involving scalp

A

-can spread intracranially via venous system as emissary veins have no valves
-Can involve dural venous sinuses

60
Q

Name orbital bones

A

Many zebras enjoy lazy summer
-Maxillary
-Zygomatic
-Ethmoid
-Lacrimal
-Sphenoid

61
Q

Superior oblique action

A

Abducts, depresses and laterally rotates globe

62
Q

Inferior oblique action

A

Abducts, elevates, laterally rotates globe

63
Q

Name foramina in middle cranial fossa

A

Optic canal
Superior orbital fissure
Foramen rotundum
Foramen ovale
Foramen spinosum
Foramen lacerum
Hiatus greater petrosal nerve
Carotid canal

64
Q

Name foramina in posterior cranial fossa

A

Internal acoustic meatus
Jugular foramen
Condylar canal
Hypoglossal canal
Foramen magnum

65
Q

complications of cavernous sinus thrombosis

A

Can cause symptoms related to orbital and cranial nerve involvement
-Orbital symptoms: periorbital oedema, ptosis, chemosis, proptosis
-Cranial nerve palsies: 3, 4, 6, V1, V2

66
Q

What techniques are available to arrest epistaxis?

A

Conservative:
-Nasal pressure/packing

Surgical:
-Silver nitrate cautery
-Electrocautery
-Anteiror/posterior ethmoidal artery ligation
-Sphenopalatine artery ligation
-maxillary artery ligation
-external carotid artery’s ligation

67
Q

What arteries supply nasal cavity

A

Sphenopalatine artery (maxillary)
Greater palatine artery (maxillary)
Anterior ethmoid artery (ophthalmic)
Posterior ethmoid artery (ophthalmic)
Superior labial artery (facial artery)

68
Q

Structures attachign to styloid process

A

stylohyoid ligament
Stylomandibular ligament

and the stylohyoid
stylopharyngeus
styloglossus muscles

69
Q

What is kiesselbach’s plexus

A

Littles area: region in atnerioinferior part of nasal septum where four arteries form anastamosis
-Anterior ethmoidal (from ophthalmic artery)
-Sphenopalatine (terminal branch maxillary artery)
-Greater palatine (maxillary artery)
Septal branch superior labial (from facial)

70
Q

How are fascial layers of neck broadly divided?

A

Superficial cervical fascia
Deep cervical fascia

71
Q

Where is superficial cervical fascia located? What are its contents?

A

-Superficial cervical fascia lies deep to dermis, surrounds muscles of facial expression and platysma
-Contains fat, neurovascular bundles, lymphatics

72
Q

Name different layers deep cervical fascia

A

-Superficial layer (external investing layer)
-Middle layer (pre-tracheal fascia/carotid sheath)
-Internal layer/prevertebral fascia

73
Q

Name different layers deep cervical fascia

A

-Superficial layer (external investing layer)
-Middle layer (pre-tracheal fascia/carotid sheath)
-Internal layer/prevertebral fascia

74
Q

Where is superficial layer (external investing) of deep cervical fascia found?

A

Layer that surrounds neck and wraps around scm, trapezius, muscles of mastication, submandibular + parotid glands

75
Q

Describe how middle layer is subdivided

A

Divided into two parts: carotid sheath, pretracheal fascia

76
Q

What are the contents of carotid sheath?

A

Carotid artery (common and internal), internal jugular vein, vagus nerve, deep lymph nodes

77
Q

What are the components of the pretracheal fascia?

A

Muscular part: encloses infrahyoid muscles
Visceral part: encloses thyroid and parathyroid glands
Buccopharyngeal fascia: encloses pharynx and oesophagus

78
Q

Describe internal layer of deep fascia/prevertebral fascia

A

Limited to posterior neck and much thicker than middle layer

Encloses vertebral column and associated prevertebral muscles

79
Q

Describe internal layer of deep fascia/prevertebral fascia

A

Limited to posterior neck and much thicker than middle layer

Encloses vertebral column and associated prevertebral muscles

80
Q

What are the layers of the scalp?

A

Skin
Connective tissue
Aponeurosis (Galea)
Loose areolar tissue
Periosteum

81
Q

In which layer of scalp does neurovascular bundle lie?

A

Connective tissue layer

82
Q

Describe arterial supply to scalp

A

2 front, 2 sides, 2 back
-Supratrochlear, supraorbital (internal carotid–> ophthalmic)
-Zygomaticotemporal (internal carotid–> ophthalmic)
-Superficial temporal (ext carotid
-Posterior auricular, occipital (external carotid)

83
Q

Through which layer of scalp do soft tissue infections spread and why?

A

Loose areolar tissue, because valveless emissary veins open here: infections can be transmitted intracranially

84
Q

What medical conditions can arise from superficial temporal artery?

A

Migraines
Giant cell arteritis

85
Q

What are the signs and symptoms of temporal arteritis?

A

Constitutional: fever, night sweats
MSK: PMR
Specific: -thrombosed, hardened and pulseless superficial temporal artery
-Scalp tenderness, jaw claudication, visual disturbance

86
Q

What eye conditions associated with GCA, what is commonest type?

A

-Anterior ischaemic optic neuropathy (most common)
-Amaurosis fugax
-Double vision

87
Q

How would you investigate gca

A

ESR, CRP
US (dark halo around artery), temporal artery biopsy

88
Q

What would be histological features arterial biopsy gca?

A

-Granulomatous inflammation (usually involving internal elastic lamina)
-Fibrinoid necrosis
-Skip lesions

89
Q

What is main treatment for GCA?

A

Pred 1mg/kg, max 60mg for 2/52, then tapering
Treatment 18mths-2yrs
If visual disturbance: ophthalmology referral, methypred

90
Q

What are signs and symptoms of trigeminal neuralgia?

A

Sharp stabbing pain in distrubution trigeminal nerve
Unilateral, does not cross midline
triggered when brushing teeth, shaving
Mask like face: movement painful

91
Q

What are drug treatments for trigeminal neuralgia?

A

Carbamazapine, lamotrigine

92
Q

What are surgical options for trigneminal neuralgia?

A

gamma knife radiosurgery
Microvascular decompression (decompress vessels around trigeminal nerve)

93
Q

What are main sutures of cranial vault and what do they separate?

A

Frontal bones: metopic
Sagittal: parietal bones
Coronal: frontal and parietal
Lamdoid: parietal/occipital
Squamous: parietal/temporal

94
Q

At what ages do the fontanelles fuse? What is significance of sphenoid fontanelle, what bones abut it?

A

Anterior: frontal/parietal bones (18-24 months-last fontanelle)
Posterior: 2-3 months (first)
Sphenoid fontanelle: pterion when fuses (comprises parietal, temporal, frontal, sphenoid bones)

95
Q

What pathologies are associated with improper fusion of suture lines?

A

Craniosynestosis: improper/premature fusion sutures lines
Clinical significance:
-Hydrocephalus
-Speech and language development

96
Q

What bones make up pterion? What is its clinical significance?

A

Frontal, parietal, temporal, greater wing of sphenoid
Weakest part of skull
Middle meningeal travels underneath pterion: rupture can cause extradural

97
Q

What are the main parts sphenoid bone?

A

Greater wing
lesser wing
Body
Sella turcica
Pterygoid plates

98
Q

What are main components of sella turcica?

A

Tuberculum sellae
Dorsum sellae
Hypophyseal fossa
Diaphragma sellae (dural roof hypophyseal fossa, with hole allowing passage pituitary stalk)
Clinoid processes (2 front, 2 back)

99
Q

Name boundaries anterior cranial fossa

A

Anterior and lateral: inner surface of frontal bone

Posteriorly and medially: limbus of the sphenoid bone. Limbus is a bony ridge that forms the anterior border of the prechiasmatic sulcus (a groove running between the right and left optic canals).

Posterior and lateral: lesser wings of the sphenoid bone

Floor: frontal bone, ethmoid bone, lesser wing sphenoid

100
Q

Name boundaries middle cranial fossa

A

Anteriorly and lateral: lesser wings of the sphenoid bone

Anteriorly and medially: limbus

Posteriorly and lateral: petrous part of the temporal bone

Posteriorly and medial: dorsum sellae.

Floor: body and greater wing of the sphenoid, squamous and petrous parts of the temporal bone.

101
Q

Boundaries posterior cranial fossa

A

Anteriorly and medially: dorsum sellae

Anteriorly and laterally: petrous part of the temporal bone.

Posteriorly: internal surface of the squamous part of the occipital bone.

The floor consists of the mastoid part of the temporal bone and the squamous, condylar and basilar parts of the occipital bone

102
Q

Foramina posterior cranial fossa (and bones)

A

Temporal bone:
-Internal acoustic meatus

Occipital bone
-Foramen magnum
-jugular foramen
-Hypoglossal canal

103
Q

Internal acoustic meatus contents and bone

A

-Petrous part of the temporal bone.
-VII, VIII, labyrinthine artery

104
Q

Foramen magnum

A

Bone: occipital bone

Contents:
-Arteries: vertebral arteries forming basilar artery, anterior and posterior spinal arteries
-Veins: spinal veins
-Nerve: Spinal part of accessory nerve (ascends up and joins cranial part of accessory nerve to exit via jugular foramen)
-Soft tissue: End of medulla and beginning of spinal cord, meninges

105
Q

Jugular foramen: contents and bone

A

Occipital bone

-IX, X, XI (descending)
-Inferior petrosal and sigmoid sinuses uniting to form IJ vein
-Posterior meningeal arteries

106
Q

Superior orbital fissure

A

Bone: sphenoid

Lazy french tarts sit nakedly in anticipation

-Lacrimal branch V1
-Frontal branch V1
-Trochlear nerve
-Superior division oculomotor nerve
-Nasociliary branch V1
-Inferior division oculomotor
-Abducens

Plus superior ophthalmic vein, sympathetic fibres

107
Q

Foramen rotundum (bone and contents)

A

V2
Bone: sphenoid

108
Q

Foramen ovale contents and bone

A

Bone: sphenoid

Otic ganglion
V3
Accessory meningeal artery
Lesser petrosal nerve
Emissary veins

109
Q

Foramen spinosum (bone and contents)

A

-Middle meningeal artery
-Middle meningeal vein
-Meningeal branch of V3.

Sphenoid bone

110
Q

Carotid canal bone and contents

A

Petrous part temporal bone

Internal carotid artery

111
Q

What structures are in relation to the clivus and what is it’s significance?

A

-Midbrain and pons
-Basilar artery
-VI cranial nerve
–> has long intracranial course, first to be affected in raised icp.

Trauma: line from clivus to top of dens should intersect radiologically without disruption. Line can be disrupted in # dens/c1

112
Q

What is the embryological origin of pituitary gland?

A

Anterior: rathke’s pouch
Posterior: continuation of hypothalamus arising from neural tube

113
Q

What is blood supply to anterior and posterior pituitary glands?

A

Internal carotid
–>anterior: superior hypophyseal artery
–> posterior: inferior hypophyseal artery

114
Q

What hormones are secreted by anterior and posterior pituitary glands?

A

Anterior: growth hormone, ACTH, TSH, FSH, LH, prolactin

Intermediate lobe: MSH (melanocyte stimulating hormone)

Posteiror: ADH, oxytocin

115
Q

What does pineal gland secrete?

A

Melatonin

116
Q

What structures pass through the optic canal?

A

-Optic nerve
-Ophthalmic artery
-CSF, meninges
-Central retinal artery and vein
-Sympathetic nerve

117
Q

Which part of optic pathway is affected if pt has bitemporal inferior quadrantinopia?

A

Superior part optic chiasm (craniopharyngioma)

118
Q

Which part optic pathway affected if pt has bitemporal hemianopia?

A

Optic chiasm

119
Q

Which part optic pathway affected if pt has superior quadrantanopia?

A

Inferior part optic chiasm (pituitary adenoma from below)

120
Q

Which part of brain affected with contralateral homonymous hemianopia?

A

MCA strokes, temporal lobe

121
Q

Which nerves are responsible for the corneal reflex?

A

Afferent: nasociliary branch V1
Efferent: Temporal + zygomatic branches of facial (orbicularis oculi muscle)

122
Q

Where does stylomandibular ligament attach and what is its function?

A

Styloid process –> mandible
Prevents excessive opening of mouth

123
Q

Spinothalamic tract location, function, testing

A

Location:
-Anterolateral cord

Function
-Pain and temperature from opposite side of body

Testing
-Pinprick

124
Q

Spinothalamic tract location, function, testing

A

Location:
-Anterolateral cord

Function
-Pain and temperature from opposite side of body

Testing
-Pinprick

125
Q

Corticospinal tract location, function, testing

A

Location:
-anterior and lateral cord

Function
-Motor power same side of body

Testing
-Voluntary muscle contractions, involuntary response to painful stimuli

126
Q

Dorsal colums location, function, testing

A

Location
-Posteromedial

Function:
-Proprioception, vibration, light touch

Testing
-Position sense
-Tuning fork

MRCS part B anatomy (16 decks)

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