Head and Neck Exam 3

Question 1

Central Nervous System (CNS)

Answer 1

Divisions 
     -central (brain and spinal cord) 
     -peripheral (ganglia and nerves) 
Functions 
     -sensory and motor functions 
Responses 
      -somatic (voluntary) 
      -autonomic (involuntary)

Question 2

Cranial Nerves

Answer 2

I - olfactory 
II - optic 
III - oculomotor 
IV - trochlear 
V - trigeminal 
VI - abducens 
VII - facial 
VIII - acoustic 
IX - glossopharyngeal 
X - vagus 
XI - accessory 
XII - hypoglossal

Question 3

CN I

Answer 3

Olfactory nerve 
Assessment of smell 
Not normally tested in routine CN exam 
Tested by ID-ing familiar odors 
     -coffee, mint, citrus, soap 
     -test one nostril at a time

Question 4

CN II

Answer 4

Optic nerve
Test visual acuity 
     -use Snellen chart 
Test visual field 
     -observe for discrepancies (R/L)
     -test peripheral vision with fingers

Question 5

CN III

Answer 5

Oculomotor nerve

Question 6

CN IV

Answer 6

Trochlear nerve

Question 7

CN VI

Answer 7

Abducens nerve

Question 8

CN III, IV, and VI

Answer 8

Test extraocular muscles

 - movement 
 - nystagmus (eye shaking) 
    - indicates CN problems 
  - "follow my finger" - left, right, up, down, in-between 

Test pupillary reactions

 - look at general size, shape, equality 
 - light reflex 
 - consensual reflex (other pupil should constrict too even w/o light exposure) 
 - accommodation reflex (eyes cross a little and pupils constrict when put finger by nose)

Question 9

CN V

Answer 9

Trigeminal nerve
Important to test all 3 divisions
-opthalmic (V1) - top 1/3 of face - forehead to below eye
-maxillary (V2) - below eye to corner of mouth
-mandibular (V3) - corner of mouth to chin

Question 10

CN V - Sensory Test

Answer 10

Want to make sure that patient can distinguish between different sensations

 - light touch 
 - sharp/dull 
 - cold: use back of metal mirror

Question 11

CN V - Motor Test

Answer 11

Jaw clench

 - masseter muscles should come out 
 - jaw jerk 

• **also corneal reflex
  
  • gentle touch patient’s cornea with cotton wisp

Question 12

CN VII

Answer 12

Facial nerve

Question 13

CN VII - Motor Test

Answer 13

Test all 5 divisions

 - temporal 
 - zygomatic 
 - buccal 
 - mandibular 
 - cervical  * **"To Zanzibar by Motor Car" 

Test facial movements
-raise eyebrows, smile, close eyes really tight, puff out cheeks

Question 14

CN VII - Sensory Test

Answer 14

Normally not tested in routine CN exam

Taste to anterior tongue (2/3)
-distinguish salt, sweet, sour, and bitter

Question 15

CN VIII

Answer 15

Vestibuloconchlear (Acoustic) nerve

Balance/coordination

 - not normally tested in CN exam 
 - BUT can be observed in general survey 

Test hearing
-rub fingers together in front of ear (R/L)

Hearing Loss
-Rinne/Weber Testing

Question 16

CN IX

Answer 16

Glossopharyngeal nerve

Question 17

CN X

Answer 17

Vagus nerve

Question 18

CN IX and X

Answer 18

Usually tested together
Both nerves supply palate, throat, larynx

Observe symmetric rise and fall of soft palate and uvula when patient says “ah”

Gag reflex

Question 19

CN XI

Answer 19

Spinal Accessory nerve

Motor to sternocleidomastoid and trapezius muscles

Push down on patient’s shoulder and have them push up, feel for resistance

Question 20

CN XII

Answer 20

Hypoglossal nerve

Motor to tongue muscles

Evaluate at rest and protrusion (ask patient to stick out tongue)

 - out, left, right 
 - observe for deviation/fasciculation

Question 21

TMJ Facts

Answer 21

Ginglymoarthroidal joint
-“hinging” and “sliding” joint
Compound joint
-two bones: temporal bone, mandibular bone
Synovial joint
Articular surfaces/articular cartilage
-composed of dense fibrous connective tissue
Retrodiscal tissue
-highly vascularized/innervated
-open lock jaw often puts pressure here - very painful

Question 22

Muscles of the Jaw

Answer 22

Temporalis muscle 
     -pain here can be confused for migraine pain 
Masseter muscle
Mylohyoid muscle 
Digastric muscle (anterior belly)
Digastric muscle (posterior belly)
Stylohyoid muscle 
     -by square of the jaw 
Hyoglossus muscle 
     -below stylohyoid 
Below masseter... 
     -Lateral pterygoid muscle 
     -medial pterygoid muscle 
In middle of TMJ - articular disk

Question 23

Capsular Ligament

Answer 23

thin, loose envelope attached above circumference of mandibular fossa and below the neck of the condyle in the mandible

Question 24

TM Ligament

Answer 24

OOP - Outer Oblique Portion
-limits rotation
IHP - Inner Horizontal Portion
-limits posterior movement

Question 25

Neck Muscles

Answer 25

Hyoid bone - bone just below chin on neck

Suprahyoid muscle 
     -some role in mastication 
Infrahyoid muscle 
Sternocleodomastoid muscle 
     -big strap neck muscle

Question 26

Range of Opening

Answer 26

Normal opening: 35-55 mm 
Condylar rotation: up to 20 mm 
     -hinge movement 
Condylar translation: 20 mm+
     -gliding or sliding movement

Question 27

TMJ Palpation - Pre-Tragus

Answer 27

In front of ear
Listening for…
-opening/closing clicking - suggests articular disorder
-crepitation (crunching) suggested arthritic problem

Question 28

TMJ Palpation - Intra-Aurticular

Answer 28

Pinkies inside ear
Listening for…
-opening/closing clicking - suggests articular disorder
-crepitation (crunching) suggested arthritic problem

Question 29

Muscles of Mastication Palpation

Answer 29

Apply 2-4 pounds of pressure per square inch (gives most reliable result)
-press down on finger, when it turns white that’s ~2.5 lbs. of pressure

Examples…

 - temporalis muscle 
 - masseter muscle 
 - sternocleidomastoid muscle 
 - trapezius muscle 
 - Intraoral lateral pterygoid muscle  
    - shift jaw to one side and poke 
 - Intraoral temporalis insertion 
    - inserts directly into jaw bone 
    - how you have feel head pain when you have jaw pain 
 - Intraoral medial pterygoid 
    - FOM; hurts A LOT