Head And Neck Session 4 Flashcards
1
Q
What does a nerve bundle consist of?
A
Afferent nerve and efferent fibres
2
Q
What are collections of cell bodies in the CNS called?
A
Nuclei
3
Q
What are cell bodies in the PNS called?
A
Ganglia
4
Q
Are all of the cranial nerves typical peripheral nerves?
A
No, 2 are atypical (brain tracts)
5
Q
Which cranial nerves are brain tracts?
A
CNI and II
6
Q
Name the 12 cranial nerves.
A
I: olfactory, II: optic, III: oculomotor, IV: trochlear, V: trigeminal, VI: abducens, VII: facial, VIII: vestibulocochlear, IX: glossopharyngeal, X: vagus, XI: accessory, XII: hypoglossal
7
Q
Which cranial nerves arise from the forebrain?
A
CNIII and IV
8
Q
Which cranial nerves arise from the Pons?
A
CNV, VI, VII and VIII
9
Q
Which cranial nerves arise from the medulla?
A
CNIX, X, XI and XII
10
Q
Describe the path of the olfactory nerve.
A
Olfactory mucosa –> olfactory receptor neurones –> cribriform plate –> olfactory bulbs
11
Q
Where are the olfactory bulbs located?
A
Either side of the crista galli
12
Q
What is a brain tract?
A
Outpouching of the brain
13
Q
What can cause damage to the olfactory nerve and how would it be tested?
A
Trauma/meningitis/URTI. Test with strong smelling substance
14
Q
Describe the path of the optic nerve.
A
Retina –> through optic canal –> cross at optic chiasm –> optic tract –> primary visual cortex in occipital lobe
15
Q
What is assessed when testing the optic nerve clinically?
A
Visual acuity, colour vision, visual fields, pupillary reflexes, fundoscopy
16
Q
What can testing the visual fields help to predict when testing the optic nerve?
A
Site of lesion
17
Q
Describe the path of the oculomotor nerve.
A
Oculomotor and Edinger-Westphal nucleus –> superior orbital fissure –> superior to LPS, inferior to extraocular muscles
18
Q
How is the oculomotor nerve tested clinically?
A
Ask patient to follow finger as you draw an H
19
Q
What position is the pupil found in the affected eye in oculomotor palsy?
A
Down and out
20
Q
What is mydriasis?
A
Blown pupil due to damage to the autonomic component of the oculomotor nerve
21
Q
Why is ptosis often seen with mydriasis?
A
Often associated damage to the motor component of the oculomotor nerve
22
Q
Describe the path of the trochlear nerve.
A
Trochlear nucleus –> superior orbital fissure –> dorsal midbrain –> cavernous sinus –> superior oblique muscle
23
Q
Which nerve has the longest intracranial length?
A
Trochlear
24
Q
Which important structures are found in the cavernous sinus?
A
Oculomotor nerve, abducens nerve, trigeminal nerve branches V1&2 and the ICA
25
What does a patient presenting with diplopoia on walking down stairs suggest?
Paralysis of the superior oblique muscle due to trochlear nerve damage
26
What might be seen O/E of a patient with trochlear nerve damage?
Subtle head tilt
27
Describe the path of the trigeminal nerve.
Trigeminal sensory nuclei in Pons --> trigeminal ganglion --> superior orbital fissure for ophthalmic branch, foramen rotundum for maxillary branch and foramen ovale for mandibular branch
28
What is trigeminal neuralgia?
Shooting pain in the distribution of the trigeminal nerve on light touch due to hyperactive sensory component
29
What gives innervation to the teeth?
Maxillary branch of trigeminal via superior alveolar nerve and mandibular branch of trigeminal via inferior alveolar nerve
30
How is the trigeminal nerve tested?
Corneal reflex (afferent branch), sensory function to face and clench muscles of mastication
31
Describe the path of the abducens nerve.
Abducens nucleus in Pons --> superior orbital fissure --> lateral rectus muscle of eye
32
What is 'false localising sign' in relation to the abducens nerve?
Any increase in ICP implicates the abducens nerve without necessarily indicating the site of pathology
33
What is seen on examination of a patient with damage to the abducens nerve?
Inability to abduct the affected eye
34
Describe the path of the facial nerve.
Motor and visceral nuclei in Pons --> IAM --> facial canal --> stylomastoid foramen --> 5 branches
35
What are the 5 branches of the facial nerve?
Temporal, zygomatic, buccal, mandibular and cervical
36
When does the facial nerve become extracranial?
When it enters the stylomastoid foramen
37
What gives special sensory innervation to the anterior 2/3 of the tongue?
Chorda tympani
38
What is given parasympathetic supply via the facial nerve?
Salivary and lacrimal glands
39
What is Bell's palsy?
Idiopathic one-sided facial paralysis
40
How can Bell's palsy be differentiated from a stroke on examination?
Forehead is spared in a stroke
41
How is the facial nerve tested clinically?
Test facial expression and ask about taste
42
Describe the path of the vestibulocochlear nerve.
Cerebellopontine angle --> IAM --> vestibular nerve goes to vestibular ganglion and semicircular canals, cochlear nerve goes to spiral ganglion in cochlea
43
Which two nerves travel together through the facial canal?
Facial and vestibulocochlear
44
What is vestibular schwannoma?
Benign neoplasm of Schwann cells that causes sensorineural hearing loss
45
What is the difference between sensorineural and conductive hearing loss?
Sensorineural is due to nerve damage whereas conductive is due to blockage of sound waves
46
How is the vestibulocochlear nerve tested clinically?
Whisper in each ear whilst making noise in the other. Rinne and Weber tests
47
Should sound conduct better through air or bone?
Air
48
Describe the path of the glossopharyngeal nerve.
Medulla oblongata --> jugular foramen --> tongue, Otic ganglion to parotid gland, carotid and,stylopharyngeus
49
What innervation does the glossopharyngeal nerve give?
Sensation to oropharynx, posterior 1/3 of tongue and carotid sinus/body. Motor to stylopharyngeus muscle. Parasymapthatetic to parotid gland
50
How is the afferent branch of the glossopharyngeal nerve tested clinically?
Gag reflex
51
What happens in a carotid sinus massage?
Increase in pressure is detected and signal via vagus nerve to decrease heart rate
52
What is the difference in neural supply to carotid sinus and aortic arch receptors?
Carotid sinus --> CNIX, aortic arch receptors --> CNX
53
Describe the path of the vagus nerve.
Medulla --> jugular foramen --> laryngopharynx, ear, pharynx, heart and lungs
54
What do the left and right recurrent laryngeal nerves hook around respectively?
```
Left= arch of aorta
Right = R. Subclavian artery
```
55
What innervation does the vagus nerve provide?
Sensation to the laryngopharynx and ear. Motor to muscles of pharynx and larynx. Parasympathetic innervation to the heart, lungs and GI tract
56
What does vagus stimulation cause in the lungs?
Bronchoconstriction
57
Where, other than the tonsils, can the gag reflex be stimulated?
EAM
58
What tests the efferent branch of the vagus nerve?
Carotid sinus massage
59
How might an aortic aneurysm present in relation to the left recurrent laryngeal nerve?
Hoarseness of voice
60
Describe the path of the accessory nerve.
Spinal nerve roots C1-5/6 --> up through foramen magnum --> down jugular foramen --> along ICA --> SCM and trapezius
61
What is the cranial portion of the accessory nerve often considered as?
Part of the vagus nerve
62
How is the accessory nerve assessed clinically?
SCM and trapezius wasting, rotate head against resistance, shrug shoulders against resistance
63
Describe the path of the hypoglossal nerve.
Hypoglossal nucleus in the medulla --> hypoglossal canal --> emerges just inferior to tongue
64
What innervation does the hypoglossal nerve provide?
Motor to intrinsic and extrinsic muscles of tongue
65
How is the hypoglossal nerve assessed clinically?
Fasciculations of the tongue, deviation towards site of lesion
66
Why does the tongue deviate to the side of the lesion in hypoglossal nerve damage?
Tongue is bilaterally innervated and usually muscles contract against each other therefore in damage opposition is lost
67
Which cranial nerves are exclusively sensory?
Olfactory, optic, vestibulocochlear
68
Which cranial nerves are exclusively motor?
Oculomotor, trochlear, abducens, accessory and hypoglossal
69
Which cranial nerves have both sensory and motor function?
Trigeminal, facial, glossopharyngeal and vagus
70
Which cranial nerves have associated autonomic fibres?
Oculomotor, facial, glossopharyngeal and vagus
71
How are nerves classified?
By general function (somatic or autonomic/visceral) and direction of conduction (afferent/sensory or efferent)
72
Which cranial nerves contain special visceral efferents?
CNV, VII, IX and X
73
What function do special somatic afferents have in the cranial nerves?
Equilibration, hearing and sight
74
What functions do the special visceral afferents of the cranial nerves give?
General taste and temperature of food and special test (sweet, sour etc)
75
How does a lesion of the spinal cord above the thoracic vertebral level present differently to a lesion below?
Above --> quadriplegia
| Below --> paraplesia
76
Describe the overall structure of the parasympathetic nervous system.
High brain structures --> brainstem (medulla and midbrain)/spinal cord --> ganglia on wall of effector organ --> short post-ganglionic fibres to effector organ
77
Describe the general overall structure of the sympathetic nous system.
High brain structures --> spinal cord --> short preganglionic fibres to para-/prevertebral chain --> effector organ
78
How do efferent fibres of the ANS supply the head and neck?
Accompany visceral branches of sympathetic plexuses
79
Describe the passage of parasympathetic fibres from the Edinger-Westphal nucleus.
Enters orbit with inferior division of optic nerve, synapses at ciliary ganglion just lateral to optic nerve giving post-ganglionic fibres with short ciliary nerves to the eye
80
What function does the parasympathetic portion of CNIII have?
Constrict pupil and accommodation
81
Which ganglia are supplied by the superior salivatory nucleus?
Pterygopalatine and submandibular
82
What structures do fibres from the pterygopalatine ganglion innervate?
Lacrimal gland, mucus glands of neck and mucus glands of palate
83
What branches do fibres from the submandibular ganglion form?
Submandibular and sublingual salivary
84
Which ganglion is associated with the inferior salivatory nucleus?
Otic
85
What is the nerve called that travels between the inferior salivatory nucleus and Otic ganglion?
Lesser petrosal
86
What is the name of the nerve that travels between the Otic ganglion and oropharynx/parotid gland?
Auriculotemporal nerve
87
How is the oropharynx supplied by the auriculotempral nerve?
Via the pharyngeal plexus synapsing at postganglionic cells in its wall
88
At what level do the postganglionic sympathetic fibres become associated with CNIII?
Ciliary ganglion
89
What do the postganglionic sympathetic fibres associated with CNIII supply?
Levator palpebrae superioris
90
Describe the path of fibres from the dorsal vagal motor nucleus.
Move into neck --> postganglionic cells in walls of target organs supplying glands of laryngopharynx, larynx, oesophagus and trachea
91
State the nucleus, organs and action of the parasympathetic autonomic division of CNIII.
Edinger-Westphal. Eye, pupil and ciliary. Pupillary constriction
92
State the nucleus, organs and action of the parasympathetic autonomic division of CNVII
Superior salivatory. Nasal, lacrimal, submandibular and sublingual glands. Serous secretions
93
State the nucleus, organ and action of the parasympathetic autonomic division of CNIX.
Inferior salivatory. Parotid. Serous secretions
94
State the nucleus, organs and action of the parasympathetic autonomic division of CNX.
Dorsal vagal motor nucleus, many and laryngeal function
95
Where does all CNS outflow originate from?
Entirely spinal, T1-L2/3
96
Where do axons of most preganglionic sympathetic ANS neurones terminate?
Immediately in the paravertebral sympathetic chain of ganglia (sympathetic trunk)
97
Where are sympathetic autonomic ganglia found?
All in peripheral nervous system
98
Where is the paravertebral chain located?
Bilaterally alongside vertebral column
99
Where is the prevertebral chain located?
Anterior to vertebral bodies in relation to carotids and anterior to the abdominal aorta
100
Where do the para- and prevertebral chains extend from and to?
Base of skull to coccyx
101
Why is there a difference between the number of neural levels and number of ganglia in the vertebral chains?
Some ganglia fuse
102
How many cervical ganglia are there in comparison to the number of neural levels there?
2/3 ganglia from 8 neural levels
103
How are somatic targets reached by fibres from the vertebral ganglia?
Along segmental nerves
104
How are visceral targets reached by fibres from the vertebral chains?
Along ganglionated trunks (like pre-ganglionic fibres of PSNS)
105
Is there sympathetic outflow from the cervical spinal cord?
No
106
Which 3 cervical ganglia supply the head and neck?
Superior, middle and inferior (Stellate)
107
Are the cervical ganglia supplying the head from the cervical spinal cord?
No, they are displaced thoracic ganglia
108
Where do each of the cervical ganglia lie in relation to other structures?
Superior: anterior to C1-4 (carotids)
Middle: anterior to C6 and inferior thyroid artery
Inferior: anterior to C7 (vertebral arteries)
109
What ascends along the ICA into the cranium to form the internal carotid plexus?
Internal carotid nerve
110
Which structures are associated with the internal carotid plexus?
Ophthalmic nerve, trochlear nerve, CNIII, CNIX, vessels from ICA, abducens nerve and pterygopalatine ganglion
111
How do sympathetic post-ganglionic fibres reach the head and neck targets?
Via walls of common, external and internal carotids outside of the carotid sheath
112
What is the somatic function of the superior cervical ganglion travelling along ICA and ECA?
Trigeminal Dermatome sweat glands
113
What is the visceral function of the superior cervical ganglion travelling along the ICA and ECA?
Dilator pupillae, smooth muscle of LPS, nasal glands and salivatory glands
114
What are the targets of the middle cervical ganglion fibres?
Lower larynx, trachea, hypo-pharynx and upper oesophagus
115
What are the targets of the inferior cervical ganglion fibres?
Posterior head and neck structures
116
What does a neurone consist of?
Dendrites, 1 cell body and 1 axon
117
What gives arterial supply to the extraocular muscles?
ICA via ophthalmic artery that becomes the central artery to retina
118
What provides venous drainage to the extraocular muscles?
Tributaries of the ophthalmic veins that drain via the superior ophthalmic vein into the cavernous sinus
119
What gives innervation to the extraocular muscles?
CNIII, IV and VI
120
What gives innervation to the orbital structures?
CNII, CNV-ophthalmic division
121
What are the seven muscles of the eye?
Superior rectus, superior oblique, lateral rectus, medial rectus, inferior rectus, inferior oblique and levator palpebrae superioris
122
What is the name of the small smooth muscle portion of the muscle that raises the superior eyelid with sympathetic innervation?
Superior tarsal portion of LPS
123
Which muscles closes the eye?
Obicularis oculi
124
What gives innervation to obicularis oculi?
CNVII
125
How are the recti muscles attached to the eye?
Arise from common tendinous ring surrounding the optic canal that attaches to the sclera on its anterior half
126
Why does occlusion of the central retinal artery cause ischaemia?
The terminal branches are end arteries
127
Where do the terminal branches of the central retinal artery travel?
Through the optic canal
128
How does the retina appear in central retinal artery occlusion?
Pale
129
Why does the macula/fovea still appear dark in central retinal artery occlusion?
It receives its blood supply from the choroid
130
Describe the mechanism by which papilloedema arises.
Raised ICP (tumour, haemorrhage, increased CSF pressure) --> impaired venous drainage --> oedema in retina --> optic disc swelling
131
How might a patient with papilloedema present?
Visual loss and headaches
132
How might a patient with central retinal vein occlusion present?
Slow, painless loss of vision
133
Why is central retinal vein occlusion said to give a 'stormy sunset appearance' on fundoscopy?
Stasis of blood causes formation of small haemorrhages with a normal sized optic disc
134
What can cause central retinal vein occlusion?
Dehydration, thrombophlebitis
