Head and Neck III

Question 1

You are asked to examine the neck of a patient with neck pain following a road traffic accident.
During the examination you identify the first palpable cervical spinous process.
Which cervical vertebrae have you identified?
(Please select 1 option)
C3
C4
C5
C6
C7

Answer 1

C7 is also known as vertebra prominens.

It has the first palpable spinous process as C1-C6 are covered with ligamentum nuchae.

Question 2

A 7-year-old boy presents with a high temperature and rapid onset of stridor with drooling of saliva. He did not have his childhood vaccinations. A lateral neck x ray shows some laryngeal swelling.

Answer 2

Epiglottis

Question 3

A 24-year-old male presents with a sore throat. Whilst examining his neck for lymph nodes you palpate the laryngeal prominence or ‘Adam’s apple’ in the midline.

Answer 3

Thyroid cartilage
The palpable laryngeal structures include the hyoid bone at the level of C3, thyroid cartilage at the level of C4 and C5 and cricoid cartilage at the level of C6. The thyroid cartilage has two laminae which meet in the midline to form the prominent laryngeal prominence or Adam’s apple.

Question 4

A 70-year-old male presents with a hoarse voice. As part of the examination the consultant examines his larynx with a flexible nasendoscope. You look through the endoscope and identify a large cartilaginous structure at the tongue base which is anterior to the vocal cords.

Answer 4

Epiglottis
The epiglottis is a leaf shaped piece of elastic cartilage situated behind the base of the tongue. Acute epiglottitis is a localised infection of the supraglottic larynx. It has become less common with the introduction of the Haemophilus influenzae vaccine. However, it is a serious disorder because it can cause acute airway obstruction.

Question 5

A 52-year-old male is unable to shrug his left shoulder after having a laryngectomy and left radical neck dissection for laryngeal carcinoma.

Answer 5

Spinal accessory nerve
The spinal accessory nerve traverses the posterior triangle of the neck and supplies the trapezius muscle. It is purposely removed as part of radical neck dissection and results in difficulty shrugging the shoulder.

Question 6

A 54-year-old lady complains of a hoarse voice following a total thyroidectomy for a large multinodular goitre.

Answer 6

Recurrent laryngeal nerve
The close relationship between the inferior thyroid artery and the recurrent laryngeal nerve means that the nerve is at risk during thyroid surgery when the vessel is divided. To avoid this, the artery is tied off laterally far away from the gland to prevent damage to the nerve.

Question 7

A 58-year-old male has drooping of the corner of his mouth following a parotidectomy for a parotid tumour.

Answer 7

Facial nerve
The course of the facial nerve through the parotid gland means that the nerve is at risk during parotid surgery. The nerve divides into five terminal branches within the parotid gland. These are the temporal, zygomatic, buccal, marginal mandibular and cervical branches, and they supply the muscles of facial expression.

Question 8

A 78-year-old female presents with severe pain over her left forehead and eye. There is a vesicular rash over the left side of her forehead and upper eyelid.

Answer 8

Ophthalmic nerve
The ophthalmic branch of the trigeminal nerve can be affected by herpes zoster infection. Typically, a vesicular rash is found on the forehead and upper eyelid and may extend to involve the nose.

Question 9

A 24-year-old female is in hospital following tonsillectomy. She complains of bilateral earache.

Answer 9

Glossopharyngeal nerve

Tonsillitis and tonsil surgery results in referred otalgia from the glossopharyngeal nerve.

Question 10

An 80-year-old lady presenting with neck pain and stiffness also complains of ear pain.

Answer 10

C2/C3
The ear is supplied by several cranial nerves and the roots of C2 and C3. If examination of the ear is normal the otalgia is known as referred pain from other areas innervated by these nerves.

Question 11

A 42-year-old male complaining of facial pain associated with nasal obstruction and mucopurulent nasal discharge. He also has earache.

Answer 11

Trigeminal nerve

Cervical spine disease can result in referred pain from C2 and C3 nerve roots and sinusitis can result in otalgia from the trigeminal nerve.

Question 12

A 64-year-old smoker with an ulcerated lesion on the tip of his tongue.

Answer 12

Submental nodes
The tip of the tongue drains into the submental nodes. The rest of the anterior the thirds of the tongue drains into the submandibular nodes. In turn these nodes drain into the deep cervical group of lymph nodes along the internal jugular vein.

Question 13

A 73-year-old male with an ulcerated lesion on the side of his tongue in the anterior two thirds.

Answer 13

Submandibular nodes

Question 14

A 74-year-old lady complains of sudden onset of hearing difficulties following a stroke.

Answer 14

Temporal lobe

The cerebrum is divided into four lobes for descriptive purposes.

The temporal lobe is associated with

Perception and recognition of auditory stimuli
Memory
Speech.

Question 15

A 67-year-old man presents with balance problems. On examination he has difficulty performing rapid alternating movements.

Answer 15

Cerebellum
The cerebellum is the largest part of the hindbrain and is concerned with balance and posture regulation, muscle tone and co-ordination.

Question 16

A 50-year-old man has a history of malignant melanoma. He complains of headaches and vomiting and his family have noticed a change in his personality with inappropriate behaviour patterns.

Answer 16

Frontal lobe
The frontal lobe is associated with

Reasoning
Planning
Parts of speech
Movement
Emotions
Problem solving.
The parietal lobe is associated with

Movement
Orientation
Recognition 
Perception of stimuli.
The occipital lobe is associated with visual processing.

Question 17

You ask a patient to clench his teeth together.

Answer 17

Trigeminal nerve
The mandibular division of the trigeminal nerve supplies the muscles of mastication. Contraction of these muscles can easily be palpated by asking a patient to clench their teeth together.

Question 18

You ask a patient to elevate their eyebrows.

Answer 18

Facial nerve
The facial nerve supplies the muscles of facial expression. Contraction of the occipitofrontalis muscle lifts the eyebrows and is a good test of facial nerve function.

Question 19

You test a patient’s visual fields.

Answer 19

Optic nerve

Testing the optic nerve includes an examination of visual acuity, examination of the fundus and visual field testing.

Question 20

Are the following true of the depth of the subarachnoid space in the thoracic region?
(Please select 1 option)
	 1 mm.
	 3 mm.
	 5 mm.
	 9 mm.
	 12 mm.

Answer 20

In the cervical and thoracic regions of the spinal cord the subarachnoid space is annular and has a depth of only 3 mm between the arachnoid mater and the pia mater which is adherent to the spinal cord.

The spinal cord terminates at the lower border of L1 (or upper border of L2 in some texts).

At this point the subarachnoid space becomes circular and has a diameter of approximately 15 mm.

Question 21

Which of the following is true with regard to the intercostal nerves?
(Please select 1 option)
Anteriorly they run in the costal groove on the upper margin of the rib.
Each is connected to a ganglion of the sympathetic trunk.
Innervate the pectoralis major
The eleventh intercostal nerve is also known as the subcostal nerve.
They represent the dorsal rami of the thoracic spinal nerves.

Answer 21

Each is connected to a ganglion of the sympathetic trunk.

The intercostal nerves represent the ventral rami of the first 11 thoracic spinal nerves.

The twelfth, being below the 12th rib is subcostal, hence is called the subcostal nerve.

Each intercostal nerve is connected to a ganglion of the sympathetic trunk by rami communicantes to and from which it carries preganglionic and postganglionic fibres which innervate blood vessels, sweat glands, and muscles.

Question 22

Which of the following is true regarding elastin?
(Please select 1 option)
Gives the skin flexibility
Is composed of beta-pleated sheets
Is found in the dermis
Is found in the epidermis
Provides the tensile strength of the skin

Answer 22

Is found in the dermis

Elastin found in the dermis and composed of irregular fibres provides the skin with its elasticity but no strength.

Amyloid is composed of beta pleated sheets.

Question 23

Which of the following is true regarding the odontoid peg?
(Please select 1 option)
Apex is joined to the anterior margin of the foramen magnum via the cruciform ligament
Articulates with the posterior arch of the atlas
Has a bursa present between it and the cruciform ligament
Is held in place by the transverse limb of the apical ligament

Answer 23

Median atlanto-axial joint is a fibrous joint

Has a bursa present between it and the cruciform ligament

The second cervical vertebra (the axis) bears a conical projection, the dens (odontoid peg) on the upper surface of its body. The odontoid peg articulates with the back of the anterior arch of the atlas and is held in position by the transverse ligament of the atlas.

The median atlanto-axial joint is where the odontoid peg articulates with the back of the anterior arch of the atlas; this is a synovial pivot joint between the odontoid peg and a ring formed by the anterior arch and the transverse ligament (cruciform ligament) of the atlas. Between the two is a relatively large bursa.

In addition to the joints, certain accessory ligaments (tectorial membrane, cruciform ligament, apical and alar ligaments) connect the axis to the occiput, bypassing the atlas.

Question 24

Which of the following is true regarding the inferior hypogastric (pelvic) plexus?
(Please select 1 option)
Contains sensory fibres
Extends into the round ligament of the uterus
Gives rise to the vesical plexus
Is situated on the side of the anal canal
Lies lateral to the internal iliac vessels

Answer 24

Gives rise to the vesical plexus

The source of the inferior hypogastric plexus are the hypogastric nerves and sacral splanchnic nerves (postganglionic sympathetic axons); pelvic splanchnic nerves (preganglionic parasympathetic axons from the ventral primary rami of spinal nerves S2-S4).

The inferior hypogastric plexus lies between the pelvic viscera (vagina and rectum) and the pelvic wall. It lies between the two iliac vessels.

It contributes branches to: uterine/vaginal plexus, vesical plexus/ male the prostatic plexus.

Question 25

Which of the following is true of the femoral ring?
(Please select 1 option)
Is bounded laterally by the femoral artery
Is bounded posteriorly by the lacunar ligament
Is lined by peritoneum
Is traversed by lymph vessels
Lies medial to the inguinal ligament

Answer 25

Is traversed by lymph vessels

The femoral ring is the medial compartment of the femoral canal in the lower abdomen.

Its boundaries are:

Anteriorly: inguinal ligament
Medially: lacunar ligament
Laterally: medial border of femoral vein
Posteriorly: pectineal ligament and pectineus muscle.
It is not lined by peritoneum.

The contents of the femoral ring are Cloquet’s node and lymphatics.

The femoral ring is the main site for a femoral hernia where the lining of the hernia would be peritoneum.

Question 26

Which of the following are true of a cervical rib?
(Please select 1 option)
All of the above.
It commonly causes compression of the subclavian artery and brachial plexus.
It is apparent on palpation in the supraclavicular region.
It occurs commonly
It originates from the seventh cervical vertebra.

Answer 26

It originates from the seventh cervical vertebra. This is the correct answerThis is the correct answer
In 0.5-1% of individuals, the costal elements of the seventh cervical vertebra form projections called cervical ribs.

Commonly they have a head, neck, and tubercle, with varying amounts of body. They extend into the posterior triangle of the neck where they may be free anteriorly, or be attached to the first rib and/or sternum.

Usually these ribs cause no symptoms, and are diagnosed after incidental finding on CXR. In some cases, the subclavian artery and the lower trunk of the brachial plexus are kinked where they pass over the cervical rib. Compression of these structures between this extra rib and the anterior scalene muscle may produce symptoms of nerve and arterial compression, producing the “neurovascular compression syndrome”.

Often the tingling, numbness, and impaired circulation to the upper limb do not appear until the age of puberty when the neck elongates and the shoulders tend to droop slightly.

Question 27

A 37-year-old male presents with a painful swelling below his right jaw. The symptoms are worse at mealtimes.

Answer 27

Submandibular gland
The submandibular gland is located in the floor of the mouth, below and medial to the mandible. Eighty percent of salivary gland stones are found in the submandibular gland and typically present with pain and swelling which is worse at mealtimes.

Question 28

A 26-year-old lady presents with a diffuse, smooth midline swelling which moves when she swallows.

Answer 28

Thyroid gland
Midline neck swellings which move when the patient swallows but not with tongue protrusion are typical of thyroid swellings. This is because the thyroid gland is enclosed in pretracheal fascia which is attached to the larynx.

Question 29

A 60-year-old male presents with a painless, enlarging smooth mass in front of his right ear.

Answer 29

Parotid gland
The parotid gland lies in the space between the mastoid process, styloid process and the ramus of the mandible, so is closely related to the ear. Parotid tumours are most likely to be benign pleomorphic adenomas.

Question 30

You are practising your examination techniques on a colleague at work. You examine the cervical spine starting cranially and feel a prominent vertebra.

Answer 30

C7
The C7 vertebra is termed vertebra prominens because of its prominent spinous process which is palpable through the skin.

Question 31

A 60 year old female attends the preoperative hernia clinic. She reports some visual difficulty. On examination she is noted to have a homonymous hemianopia. Where is the lesion most likely to be?

	A.	Frontal lobe
	B.	Pituitary gland
	C.	Parietal lobe
	D.	Optic chiasm
	E.	Optic tract

Answer 31

Optic tract

Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion

Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion

Theme from April 2012 exam
Unfortunately we thought as surgeons we could forget about visual field defects! However the college seem to like them. Remember a homonymous hemianopia is indicative of an optic tract lesion. Parietal lobe lesions tend to cause inferior quadranopias and there is a bitemporal hemianopia with optic chiasm lesion or pituitary tumours.

Question 32

A 38 year old lady is due to undergo a parathyroidectomy for hyperparathyroidism. At operation the inferior parathyroid gland is identified as being enlarged. A vessel is located adjacent to the gland laterally. This vessel is most likely to be the:

	A.	External carotid artery
	B.	Common carotid artery
	C.	Internal carotid artery
	D.	External jugular vein
	E.	None of the above

Answer 32

The common carotid artery is a lateral relation of the inferior parathyroid.

Question 33

Following a carotid endarterectomy a man notices that he has a weakness of his tongue. Damage to which of the following nerves is the most likely explanation for this process?

	A.	Hypoglossal
	B.	Accessory
	C.	Ansa cervicalis
	D.	Vagus
	E.	Cervical plexus

Answer 33

The hypoglossal nerve innervates the tongue and is one of the structures more commonly at risk in carotid surgery.

Question 34

Cranial nerves

Answer 34

Cranial nerve lesions
Olfactory nerve May be injured in basal skull fractures or involved in frontal lobe tumour extension. Loss of olfactory nerve function in relation to major CNS pathology is seldom an isolated event and thus it is poor localiser of CNS pathology.
Optic nerve Problems with visual acuity may result from intra ocular disorders. Problems with the blood supply such as amaurosis fugax may produce temporary visual distortion. More important surgically is the pupillary response to light. The pupillary size may be altered in a number of disorders. Nerves involved in the resizing of the pupil connect to the pretectal nucleus of the high midbrain, bypassing the lateral geniculate nucleus and the primary visual cortex. From the pretectal nucleus neurones pass to the Edinger - Westphal nucleus, motor axons from here pass along with the oculomotor nerve. They synapse with ciliary ganglion neurones; the parasympathetic axons from this then innervate the iris and produce miosis. The miotic pupil is seen in disorders such a Horner’s syndrome or opiate overdose.
Mydriasis is the dilatation of the pupil in response to disease, trauma, drugs (or the dark!). It is pathological when light fails to induce miosis. The radial muscle is innervated by the sympathetic nervous system. Because the parasympathetic fibres travel with the oculomotor nerve they will be damaged by lesions affecting this nerve (e.g. cranial trauma).
The response to light shone in one eye is usually a constriction of both pupils. This indicates intact direct and consensual light reflexes. When the optic nerve has an afferent defect the light shining on the affected eye will produce a diminished pupillary response in both eyes. Whereas light shone on the unaffected eye will produce a normal pupillary response in both eyes. This is referred to as the Marcus Gunn pupil and is seen in conditions such as optic neuritis. In a total CN II lesion shining the light in the affected eye will produce no response.
Oculomotor nerve The pupillary effects are described above. In addition it supplies all ocular muscles apart from lateral rectus and superior oblique. Thus the affected eye will be deviated inferolaterally. Levator palpebrae superioris may also be impaired resulting in impaired ability to close the eye.
Trochlear nerve The eye will not be able to look down.
Trigeminal nerve Largest cranial nerve. Exits the brainstem at the pons. Branches are ophthalmic, maxillary and mandibular. Only the mandibular branch has both sensory and motor fibres. Branches converge to form the trigeminal ganglion (located in Meckels cave). It supplies the muscles of mastication and also tensor veli palatine, mylohyoid, anterior belly of digastric and tensor tympani. The detailed descriptions of the various sensory functions are described in other areas of the website. The corneal reflex is important and is elicited by applying a small tip of cotton wool to the cornea, a reflex blink should occur if it is intact. It is mediated by: the naso ciliary branch of the ophthalmic branch of the trigeminal (sensory component) and the facial nerve producing the motor response. Lesions of the afferent arc will produce bilateral absent blink and lesions of the efferent arc will result in a unilateral absent blink.
Abducens nerve The affected eye will have a deficit of abduction. This cranial nerve exits the brainstem between the pons and medulla. It thus has a relatively long intra cranial course which renders it susceptible to damage in raised intra cranial pressure.
Facial nerve Emerges from brainstem between pons and medulla. It controls muscles of facial expression and taste from the anterior 2/3 of the tongue. The nerve passes into the petrous temporal bone and into the internal auditory meatus. It then passes through the facial canal and exits at the stylomastoid foramen. It passes through the parotid gland and divides at this point. It does not innervate the parotid gland. Its divisions are considered in other parts of the website. Its motor fibres innervate orbicularis oculi to produce the efferent arm of the corneal reflex. In surgical practice it may be injured during parotid gland surgery or invaded by malignancies of the gland and a lower motor neurone on the ipsilateral side will result.
Vestibulo-cochlear nerve Exits from the pons and then passes through the internal auditory meatus. It is implicated in sensorineural hearing loss. Individuals with sensorineural hearing loss will localise the sound in webers test to the normal ear. Rinnes test will be reduced on the affected side but should still work. These two tests will distinguish sensorineural hearing loss from conductive deafness. In the latter condition webers test will localise to the affected ear and Rinnes test will be impaired on the affected side. Surgical lesions affecting this nerve include CNS tumours and basal skull fractures. It may also be damaged by the administration of ototoxic drugs (of which gentamicin is the most commonly used in surgical practice).
Glossopharyngeal nerve Exits the pons just above the vagus. Receives sensory fibres from posterior 1/3 tongue, tonsils, pharynx and middle ear (otalgia may occur following tonsillectomy). It receives visceral afferents from the carotid bodies. It supplies parasympathetic fibres to the parotid gland via the otic ganglion and motor function to stylopharyngeaus muscle. The sensory function of the nerve is tested using the gag reflex.
Vagus nerve Leaves the medulla between the olivary nucleus and the inferior cerebellar peduncle. Passes through the jugular foramen and into the carotid sheath. Details of the functions of the vagus nerve are covered in the website under relevant organ sub headings.
Accessory nerve Exists from the caudal aspect of the brainstem (multiple branches) supplies trapezius and sternocleidomastoid muscles. The distal portion of this nerve is most prone to injury during surgical procedures.
Hypoglossal nerve Emerges from the medulla at the preolivary sulcus, passes through the hypoglossal canal. It lies on the carotid sheath and passes deep to the posterior belly of digastric to supply muscles of the tongue (except palatoglossus). Its location of the carotid sheath makes it vulnerable during carotid endarterectomy surgery and damage will produce ipsilateral defect in muscle function.

Question 35

Which of the following is the first vessel to branch from the external carotid artery?

	A.	Superior thyroid artery
	B.	Inferior thyroid artery
	C.	Lingual artery
	D.	Facial artery
	E.	Occipital artery

Answer 35

Superior thyroid artery

Mnemonic
(Order in which they branch off)Some (sup thyroid)Attendings (Ascending Pharyngeal)Like (Lingual)Freaking (Facial)Out (Occipital)Potential (Post auricular)Medical (Maxillary)Students (Sup temporal)

The first branch of the external carotid artery is the superior thyroid artery. The inferior thyroid artery is derived from the thyrocervical trunk. The other branches are illustrated below.

Question 36

A motorcyclist is injured in a road traffic accident and is not wearing a helmet. He suffers a severe closed head injury and develops raised intracranial pressure. The first cranial nerve to be affected by this process is likely to be:

	A.	Oculomotor
	B.	Hypoglossal
	C.	Motor branch of the trigeminal
	D.	Abducens
	E.	Trochlear

Answer 36

The abducens nerve (CN VI) has the longest intra cranial course and is thus the most susceptible to raised intra cranial pressure. It also passes over the petrous temporal bone and 6th nerve palsies are also seen in mastoiditis.

Question 37

A 43 year old lady underwent an attempted placement of a central line into the internal jugular vein. Unfortunately, the doctor damaged the carotid artery and this necessitated surgical exploration. As the surgeons incise the carotid sheath a nerve is identified lying between the internal jugular vein and the carotid artery. Which of the following is this nerve most likely to be?

	A.	Glossopharyngeal nerve
	B.	Hypoglossal nerve
	C.	Superior laryngeal nerve
	D.	Recurrent laryngeal nerve
	E.	Vagus

Answer 37

Vagus

The vagus lies in the carotid sheath. The hypoglossal nerve crosses the sheath, but does not lie within it.

Question 38

Which of the following nerves is not contained within the posterior triangle of the neck?

	A.	Accessory nerve
	B.	Phrenic nerve
	C.	Greater auricular nerve
	D.	Ansa cervicalis
	E.	Lesser occiptal nerve

Answer 38

Ansa cervicalis is a content of the anterior triangle of the neck.

Posterior triangle of the neck

Boundaries
Apex Sternocleidomastoid and the Trapezius muscles at the Occipital bone
Anterior Posterior border of the Sternocleidomastoid
Posterior Anterior border of the Trapezius
Base Middle third of the clavicle

Question 39

Which of the structures listed below lies posterior to the carotid sheath at the level of the 6th cervical vertebra?

	A.	Hypoglossal nerve
	B.	Vagus nerve
	C.	Cervical sympathetic chain
	D.	Ansa cervicalis
	E.	Glossopharyngeal nerve

Answer 39

Cervical sympathetic chain

The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis. The vagus lies within it. The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.