Head and neck super deck Flashcards
1
Q
What is the route of the external jugular vein in the neck?
A
Over the sternocleidomastoid muscle
2
Q
Under what muscle is the route of the internal jugular vein?
A
sternocleidomastoid muscle
3
Q
What is the route of the carotid arteries?
A
Aorta -> brachiocephalic trunk -> common carotid artery -> external and internal carotid arteries
4
Q
What are the first 3 branches off the right subclavian artery in order?
A
1) Vertebral artery
2) Thyrocervical trunk
3) Internal thoracic artery
5
Q
What are the branches off the thyrocervical trunk in order of inferior to superior?
A
1- Suprascapular
2- Transverse cervical
3- Ascending cervical artery
4- Inferior thyroid artery
6
Q
Does the common carotid artery give off any branches in the neck?
A
No, it bifurcates to give the external and internal carotid arteries.
7
Q
Through which cranial foramen does the vertebral artery go through?
A
Foramen magnum
8
Q
Through what in the skull does the internal carotid artery go through and what is the bone?
A
Carotid canal in the temporal bone - the petrous part of it.
9
Q
Which vertebral foramen does the vertebral artery go through?
A
Transverse foramina on both sides
10
Q
The combination of the internal carotid artery and the vertebral artery makes which loop in the cranium?
A
Circle of Willis
11
Q
What is more lateral: internal jugular vein or the common carotid artery?
A
Internal Jugular Vein
12
Q
At which cervical level does the common carotid bifurcate and which cartilages superior border is the landmark?
A
C4
Superior border of the thyroid cartilage
13
Q
What are the borders of the carotid sheath?
A
SCM
Posterior belly of the digastric muscle
Superior belly of the omohyoid muscle
14
Q
What is the contents of the carotid triangle?
A
ECA
IJV
15
Q
What is the carotid sinus and what is the clinical significance?
A
Swelling at region of bifurcation
Location of baroreceptors for detecting changes in arterial BP
16
Q
What is the carotid body?
A
Peripheral chemoreceptors which detect arterial O2
Glossopharyngeal nerve
17
Q
What is the result of a carotid sinus massage?
A
Increases Innervation of the PNS
Decreases innervation of SNS
Slows the HR
18
Q
What nerves can be accessed via the carotid triangle?
A
Vagus and hypoglossal nerves
In addition to the glossopharyngeal nerve
19
Q
Route of the internal carotid artery from when it enters the cranium
A
1- Enter skull through the carotid canal in petrous part of temporal bone
2- Turns medially and horizontally
3- Enters cranial cavity then makes S-shaped bend
4- Courses through the cavernous sinus
20
Q
Apart from the ICA what is also in the cavernous sinus?
A
- Internal carotid a
- CNIII
- CNIV
- CNVI
- 2 Branches of trigeminal: 1- CNV1 ophthalmic and CNV2 maxillary
21
Q
What artery does ophthalmic artery arise from?
A
ICA
22
Q
What are the relevant branches of the ophthalmic artery?
A
- Ethmoidal arteries in canals in ethmoid bone
- Supratrochlear artery
- Supra-orbital artery
23
Q
What is the mnemonic and its meanings for the branches of the external carotid artery?
A
Mnemonic: Some Anatomists Like Freaking Out poor Medical Students 1- Superior thyroid 2- Lingual 3- Facial 4- Ascending pharyngeal 5- Occipital 6- Posterior auricular
Plus 2 terminal branches:
1- Superficial temporal
2- Maxillary
24
Q
What is the blood supply to the scalp from which main arteries and their branches
A
Internal carotid artery:
1- supra-orbital artery
2- supratrochlear artery
External carotid artery:
1- Superficial temporal artery
2- Posterior auricular artery
3- Occipital artery
25
What does scalp stand for?
```
Skin
Connective tissue (dense)
Aponeurosis
Loose connective tissue
Periosteum
```
26
What layer of the scalp do the vessels lie in?
Subcutaneous connective tissue layer
27
Clinical relevance of blood supply to scalp?
- Numerous anastomoses profuse bleeding
- Blood supply to skull mostly middle meningeal artery but due to anastomoses loss of blood doesn’t lead to osteonecrosis
- Walls of arteries are closely attached to connective tissue which limits their constriction - leading to profuse bleeding
28
What are the superficial arteries of the face in order from inferior to superior?
```
Superior thyroid
Lingual
Facial branches: Sup. Inf. labial arteries, lateral nasal, angular
Maxillary
Transverse facial
```
ICA branches: Supraorbital and supratrochlear.
29
What does the middle meningeal artery (MMA) branch off?
ECA -> Maxillary -> MMA
30
What artery does the sphenopalatine artery originate from?
Maxillary artery (3rd part)
31
What is the blood supply to nasal septum ant and post areas.
Ant. area: Kisselbalch area
-Greater palatine artery to Septal branch of sup. Labial artery + ant. And post. Ethmoidal arteries + sphenopalatine artery.
Post area: Septal branch of sphenopalatine artery
32
What compartment of the cranium does the foramen spinosum sit in and what goes through it?
Middle compartment
Middle meningeal artery passes through it
33
Rupture of which artery forms an extradural haemorrhage?
Middle meningeal artery
34
Fracture of which part of the bone can rupture the middle meningeal artery?
Pterion
35
What type of shape does an extradural haemorrhage take?
Lentiform
| Bleeding only goes up to the sutures of that bone that is affected.
36
What is the venous drainage of the scalp into?
Superficial temporal vein
Occipital vein
Posterior auricular vein
Supraorbital and supratrochlear veins unite at medial angle of the eye to form the angular vein which drains into the facial vein.
Deep parts of the scalp (temporal region) drain into the pterygoid venous plexus
37
What vein does the facial vein drain into?
IJV
38
What vein does the confluence of sinuses turn into?
Transverse sinus -> sigmoid sinus -> IJV
39
What 3 veins make the left brachiocephalic vein?
- Subclavian v.
- Suprascapular v. + EJV + ant jugular vein
- IJV
40
What veins connect the scalp to sinuses?
Emissary veins
41
Do emissary veins have valves, if not what’s the clinical relevance?
No, infections of the scalp can spread to the cranial cavity and affect meninges.
42
Venous drainage of the face is by which main veins?
Supraorbital + supratrochlear = angular vein + sup. Inf. labial veins -> facial vein -> common facial vein -> IJV and EJV
43
What two veins communicate at the medial angle of the eye to drain into which sinus?
Facial v and sup ophthalmic v draining into the cavernous sinus.
44
Combination of deep facial veins + inf ophthalmic vein and cavernous sinus drain into which sinus?
Pterygoid venous plexus
45
Through which foramina does the IJV leave the skull?
Jugular foramina
46
What vein is seen in an JVP examination?
IJV
47
Which two layers of the meninges makes the venous sinuses
Meningeal and periosteal layer of dura
48
Which veins within the subarachnoid space drain into dural venous sinuses
Bridging veins traverse the subdural space and into the dural venous sinus
49
Name the 3 types of intracranial haemorrhage
Extradural
Subdural
Subarachnoid
50
Of the 3 intracranial haemorrhages which are due to the middle meningeal artery?
Extradural
51
What shape gives an extradural haemorrhage on CT scan?
Lensiform shape
52
Between which layers of the meninges does the blood accumulate in an subdural haemorrhage?
Between the meningeal layer of the dura and the arachnoid mater. AKA subdural space
53
What shape on CT is characteristic of the subdural haemorrhage?
Banana shape
54
What type of bleed is a SAH arterial or venous?
Arterial
55
What are the parts of the brain stem?
Midbrain (mesencephalon)
Pons
Medulla
56
What is the function of the midbrain?
Eye movements and reflex responses to sound and vision
57
What is the function of the pons?
Feeding reflex
| Sleep
58
What is the function of the medulla?
Cardiovascular and resp centres
| Contains a major motor pathway (medullary pyramids which ultimately decussate)
59
Which is the name of the largest sulcus that we use as a landmark on the lateral view?
Central sulcus
60
What is the name of the gyrus infront and behind the central sulcus?
Precentral gyrus
| Post central gyrus
61
What is the main function of the precentral gyrus?
Motor pathways
62
What is the main function of the post central gyrus?
Sensory pathway
63
Where is the calcarine sulcus?
At the back of the brain above the cerebellum. Separating cuneus superiorly, and parietal lobe anteriorly, and cerebellum inferiorly.
64
Where is the parieto-occipital sulcus?
Ant. Is the parietal lobe
Post. Occipital lobe
Inf. cerebellum
65
Function of each: frontal lobe, parietal lobe, temporal lobe, occipital lobe, cerebellum?
Frontal lobe= higher cognition, motor function, speech, behaviour
Parietal lobe= sensation, spatial awareness
Temporal lobe= memory, smell, hearing
Occipital lobe= vision
Cerebellum= co-ordination of movement and motor learning
66
What is the function of the medullary pyramids?
Location of descending motor fibres - each has around 1 million axons
67
What is the function of the corpus callosum, thalamus, hypothalamus?
Corpus callosum= fibres connect the two cerebral hemispheres - Damage leading to alien hand syndrome
Thalamus= sensory relay station projecting to sensory cortex
Hypothalamus= essential centre for homeostasis
68
Cranial nerves in order and mnemonic?
Mnemonic= Oh Oh Oh To Touch And Feel A Girls Vagina Ahh Heaven
Olfactory, Ophthalmic, Occulomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, (spinal) Accessory, Hypoglossal
69
How many cranial nerves do we have?
12 Pairs
70
Where do the cranial nerves originate?
Brain - 2 CN’s
Midbrain - 2 CN’s
Pons - 4 CN’s
Medulla - 4 CN’s
71
Cranial nerve I - Olfactory nerve- what is the 5 step route it takes?
Olfactory nerves -> cribriform plate of ethmoid bone -> olfactory bulb -> olfactory tract -> temporal lobe
72
Olfactory nerve is which of the following? Special sensory, general sensory, Motor, Autonomic
Special sensory
73
Loss of smell is called?
| Most common cause of loss of smell?
Anosmia
| URTI
74
Cranial nerve II - Optic nerve.
| What route does it take?
Retinal ganglion cells -> axons form optic nerve -> exits back of orbit via optic canal -> fibres cross and merge at optic chiasm
75
What is the difference between optic nerve and optic tract
Optic nerve is before chains
| Optic tract is post chiasm and is a mixing of the sensory fibres from right and left optic nerves
76
How would you clinically test the optic nerve?
Visual acuity test- snellen chart
Visual field test - cover one eye and ask how much they see compared to the other eye
Pupillary light reflexes - optic nerve has to be working
77
What is the medical term for swollen optic disc
Papilloedema
78
How does the pupillary light reflex work?
Optic tracts communicate with the brain stem (midbrain) to allow for the visual reflex
79
Which 2 nerves originate from the midbrain?
Oculomotor
| Trochlear
80
Route of the oculomotor nerve
Midbrain -> cavernous sinus -> superior orbital fissure
81
Which of the below is the optic nerve: special sensory, general sensory, motor, autonomic?
Special sensory
82
Which of the below is the oculomotor nerve: Special sensory, General sensory, Motor, Autonomic or a combination of each?
Motor and Autonomic
| Autonomic - parasympathetic fibres
83
What is the function of the oculomotor nerve?
Most of the muscles that move the eyeball - extraocular muscles
Muscles of the eyelid - Levator Palpebrae Superioris (LPS)
Innervates the sphincter pupillae muscle (constricts the pupil)
84
What muscle lifts the eyelid?
Levator palpebrae superioris
85
What nerve innervates sphincter pupillae muscle and what is the action?
Oculomotor nerve
Innervation to the pupil and lens (autonomic, parasympathetic) - constriction when activated
+ other effects of nerve :
Innervation to the upper eyelid (somatic)
Innervation of the eye muscles that allow for visual tracking and gaze fixation (somatic)
86
Between which structures is the oculomotor nerve vulnerable to compression between?
Tentorium cerebelli and part of the temporal lobe (the uncus)
87
How do you clinically test for the oculomotor nerve?
Inspect eyelids and pupil size
| Test eye movements and pupillary reflexes (e.g. to light)
88
What can pathology of the oculomotor nerve cause in clinical symptoms?
Pupillary dilation and/or diplopia
Down and out position with severe ptosis (eyelid drooping)
89
Trochlear nerve is numerically which cranial nerve?
CN IV
90
Which of the below describes the Trochlear nerve: Special sensory, General sensory, Motor, Autonomic?
Purely motor
91
What is the route of the trochlear nerve?
Midbrain -> cavernous sinus -> superior orbital fissure
92
What is the function of the trochlear nerve (CN IV)?
(Remember LR6 SO4)
SO4 portion is superior oblique muscle
Innervation of this muscle moves the eyeball
93
What is special about the exiting of the trochlear nerve from the brain stem and what is the special about the route of the nerve?
It is the only nerve to emerge from the dorsal aspect of the brain stem.
It also has the longest intracranial course of any of the cranial nerves - simply because it comes off from the dorsal aspect of the brain stem.
94
How do you clinically test for the trochlear nerve and what are the signs seen in pathology?
- Test eye movements but this would be done with the other cranial nerves (CN 3, 4 and 6)
- Diplopia; correction with tilt of the head
95
What 4 nerves exit from the Pons?
Trigeminal (CN V)
Abducens (CN VI)
Facial (CN VII)
Vestibulocochlear (CN VIII)
96
CN V - trigeminal nerve has which branches?
```
Ophthalmic nerve (CN Va)
Maxillary nerve (CN Vb)
Mandibular nerve (CN Vc)
```
97
What is the route of the first branch of the trigeminal nerve?
Pons -> Trigeminal ganglion -> Va -> Supraorbital fissure -> orbit
98
What is the route of the second branch of the trigeminal nerve?
Pons -> Trigeminal ganglion -> Vb -> foramen rotundum -> pterygopalatine fissure
99
What is the route of the third branch of the trigeminal nerve?
Pons -> Trigeminal ganglion -> Vc -> Foramen ovale -> inferotemporal fossa
100
Which of the following is the trigeminal nerve: general sensory, special sensory, motor, autonomic or a combination of them?
General sensory:
- Main sensory nerve supplying skin of face and part of the scalp
- Sensory to deeper structures within the head e.g. paranasal air sinuses, nasal and oral cavity, anterior part of the tongue (general sensation NOT taste) and meninges
Motor:
- Muscles of mastication (Vc only)
101
What is the clinical testing of the trigeminal nerve?
- Checking sensation (to touch) in areas of its dermatomes (Va/b/c)
- Va = touch forehead (ophthalmic)
- Vb = touch the cheek (maxillary)
- VC = touch the jaw (mandibular)
- Test muscles of mastication (jaw jerk) and corneal reflex.
102
What areas does the ophthalmic division of the trigeminal nerve innervate?
Frontal, lacrimal and nasocilliary
| Frontal continues out of orbit as supraorbital and supratrochlear nerves (+veins and arteries of the same nerve name)
103
What areas does the maxillary branch of the trigeminal nerve innervate?
Infraorbital nerve and superior alveolar nerves (anterior, middle and posterior)
Alveolar means teeth and so the upper teeth are innervated by this nerve
104
What areas does the mandibular division of the trigeminal nerve innervate?
- Inferior alveolar (lower teeth and jaw) which continues as the mental nerve
- Auriculotemporal nerve
- Lingual nerve
105
In the event of an orbital floor fracture what nerve can be damaged?
Branch of the maxillary division of the trigeminal nerve - the infraorbital nerve.
Sensory afferent from cheek and lower eye lid
106
What nerve is blocked by local anaesthetic by dentists on dental extraction?
Trigeminal nerve -> maxillary nerve -> superior alveolar nerves
107
What is the route of the inferior alveolar nerve? And what is the exiting nerve called?
Through a bony canal in the mandible exiting as the mental nerve via the mental foramen
108
If a patient sustained a mandibular fracture what nerve would potentially be injured?
Inferior alveolar nerve or mental nerve
109
What branch of the mandibular division carries general sensory from the tongue?
Lingual nerve
110
What branch of the mandibular division carries general sensory from the ear, temple area/ lateral side of the head and scalp, temperomandibular joint
Auriculotemporal nerve
111
What areas are innervated by the auriculotemporal nerve?
General sensory from part of the ear, temple area/lateral side of the head and scalp and TMJ
112
Abducens nerve is which one numerically?
CN VI
113
What is the route of the CN VI?
Lower Pons (junction between pons and medulla) -> runs upwards before being able to pass into the cavernous sinus -> enters into orbit via superior orbital fissure
114
CN VI is which one of the following: general sensory, special sensory, motor, autonomic or a combination of any?
Purely motor
115
What is the action of CN VI?
Innervation of one muscle that moves the eye (extra ocular muscle) - Lateral rectus.
(Remember LR6 SO4) - LR6 portion of this
116
How to test Abducens nerve?
- Tested using eye movements (with CN 3, 4 and 6)
| - Patients presenting with diplopia
117
What is the route of the facial nerve?
Lower pons junction between pons and medulla -> enters petrous bone via the internal acoustic meatus -> three branches within petrous bone -> exits through base of skull at the stylomastoid foramen -> geniculate ganglion
118
What is the function of the facial nerve?
Nerve supplying muscles of facial expression
119
Which of the following explains the facial nerve: general sensory, special sensory, motor, autonomic or a combination of them?
Special sensory - anterior 2/3 of tongue (taste)
Autonomic (PNS) - lacrimal glands (tears), mucosal glands of nose and roof of mouth, salivary glands (all except the parotid gland)
Motor - Muscles of facial expression (and scalp), nerve to stapedius (in middle ear)
General sensory - small area of the external ear
120
Which nerve branches from the geniculate ganglion to innervate the lacrimal gland, nasal glands and palatine glands?
Greater petrosal nerve
121
What is the name of the nerve that innervates the tongue, sublingual gland and submandibular gland and ganglion?
Chorda tympani nerve
122
What is the clinical relevance of parotitis and the facial nerve?
The facial nerve passes through the parotid gland and so inflammation of the parotid gland can affect muscles of facial expression and therefore facial expressions.
123
Through which foramen does the greater petrosal nerve pass through?
Foramen lacerum
124
How do you test the facial nerve?
- Testing muscles of facial expression
- testing the corneal reflex
- Questions about hyperacusis, dry eyes, altered taste
125
Middle ear pathology (in petrous bone) can sometimes involve which nerve?
Facial nerve
126
Which nerve does the facial nerve closely relate to and in which cranial fossa?
Vestibulocochlear nerve and in the posterior cranial fossa.
Both has close relationship with the internal acoustic meatus
127
Which nerve is affected in Bell’s palsy?
Facial nerve
128
What is the numerical number of the Vestibulocochlear nerve?
CN VIII
129
Which one of the following is the Vestibulocochlear nerve: general sensory, special sensory, motor, autonomic or a combination of any.
Special sensory
130
What is the route of the Vestibulocochlear nerve?
Cochlea + semicircular canals (vestibular system) -> vestibulocochlear nerve -> internal acoustic meatus-> lower pons (junction between pons and medulla)
131
What is the function of the vestibulocochlear nerve?
Hearing and balance
132
How would you test the vestibulocochlear nerve?
Crude hearing test (whispering 99 in each ear) and enquiring about balance
133
Damage to which areas of the head would lead to a sensorineural hearing loss?
Cochlea, cochlear component of vestibulocochlear nerve, or brain stem nucleus
134
Damage to which structures of the vestibulocochlear nervous system would causes vertigo (disturbance of balance)
Semicircular canals, vestibular component of vestibulocochlear nerve, or brain nucleus
135
What is the medical word for old-age related hearing loss?
Presbyacusis
136
What are common signs and symptoms of an acoustic neuroma?
- Unilateral hearing loss
- Tinnitus
- Vertigo
- Numbness, pain or weakness down one half of face
137
What is an acoustic neuroma?
Benign tumour of the Schwann cells surrounding (vestibular component) of CN VIII. The physical presence causes compression of the whole nerve +/- CNs in close proximity
138
What 4 CN’s exit from the medulla?
Glossopharyngeal - CN IX
Vagus - CN X
Accessory - CN XI
Hypoglossal - CN XII
139
What nerves exit via the jugular foramen with the IJV?
Glossopharyngeal
| Vagus
140
What nerves exit through the hypoglossal canal?
Accessory
| Hypoglossal
141
Which 4 cranial nerves exit the base of the skull?
CN IX, X, XI, XII
142
Which cranial nerve runs the length of the carotid sheath?
Vagus (CN X)
143
Which foramen of the skull does the vagus nerve leave?
Jugular foramen
144
Where do the right and left recurrent laryngeal nerves run under?
```
Right = under the subclavian artery
Left = under the arch of the aorta
```
145
How do you test the vagus nerve?
| An example of a recurrent laryngeal nerve defect and symptom?
- Note patients speech, cough and ability to swallow
- Note movement of the uvula and soft palate when saying Aaah
- Gag reflex (efferent limb)
- Isolated lesions are rare
- Injury to recurrent laryngeal nerve during surgery or a pancoast tumour can cause hoarseness and dysphonia
146
What cranial nerve number is Accessory?
CN XI
147
What 3 nerves exit the cranium via the jugular foramen with the IJV?
Glossopharyngeal
Vagus
Accessory
148
What canal does the hypoglossal nerve leave through?
Hypoglossal canal
149
What of the following describes the spinal accessory nerve: Special sensory/ General sensory/ Motor/ Autonomic?
Motor
150
What does the spinal accessory nerve do?
Motor innervation to the sternocleidomastoid muscle and trapezius muscle
151
What muscle does the accessory nerve pass deep to?
SCM and Trapezius
152
In the posterior triangle what is the track of the accessory nerve?
Runs posterolaterally across the posterior triangle
153
How do you test the spinal accessory nerve?
- Shrug shoulders against resistance (trapezius)
| - Turn head against resistance (SCM)
154
Which of the following best describes the hypoglossal nerve: Special sensory/ General Sensory/ Motor/ Autonomic?
Motor
155
What cranial nerve number is the hypoglossal nerve?
CN XII
156
What are the actions of the hypoglossal nerve (CN XII)?
Muscles of the tongue (all except one)
157
What is the route of the hypoglossal nerve in relation to the face and neck?
Medial to the angle of the mandible
| Cross internal and external carotid arteries in neck.
158
How do you test the CN XII?
Inspection and movement of the tongue
159
What is the result of hypoglossal nerve injury?
Damage to the nerve will cause weakness and atrophy of the tongue muscles on the ipsilateral side
160
What is interesting about week 4 of the embryonic life?
What week during the embryonic life is the face not distinguishable but the head and neck are 50% of the length of the embryo?
161
What are the pharyngeal arches?
System of mesenchymal proliferation’s in the neck region of the embryo
162
How many pharyngeal arches are there?
5 in total however numbering system there are 6 (5th one doesn’t form in humans)
163
Together with which area make up the building blocks of the head and neck region?
Frontonasal prominence (FNP)
164
Within each arch what is else is important in the development of that arch?
Artery, nerve and cartilage bar
165
What is the stomadeum?
An area of the embryo which will form the oral cavity
166
What are the lens and optic placode?
Thickened portion of ectoderm that serves as the precursor of the lens of the eye
167
What is the pharyngeal cleft?
The gap between the pharyngeal arches
168
What does each pharyngeal arch correlate to in terms of cranial nerves?
Pharyngeal arch 1 - CN V
Pharyngeal arch 2 - CN VII
Pharyngeal arch 3 - CN IX
Pharyngeal arch 4 - CNX
169
What is the action of the pharyngeal arch cranial nerves?
Mixed sensory and motor functions
170
What are the muscular derivatives of the pharyngeal arches?
Ph Arch 1 = muscles of mastication
Ph Arch 2 = muscles of facial expression
Ph Arch 3 - Stylopharyngeus
Ph Arch 4 = Cricothyroid, levator palatine, constrictors of the pharynx
Ph Arch 6 = Intrinsic muscles of the larynx
171
What pharyngeal arch does Meckel’s cartilage come from?
Ph Arch 1
172
What pharyngeal arch does Reichert’s cartilage come from?
Ph Arch 2
173
What pharyngeal arches do the cartilages of the larynx derive from?
Ph Arch 4 and 6
174
What are pharyngeal pouches?
Endoderm lined pockets in the pharynx
175
What does the first pharyngeal pouch become?
It is the largest and becomes the tympanic cavity
176
What structures are derived from the pharyngeal pouches?
Palatine tonsils and parathyroid gland and thymus
177
What is left after development of the pharyngeal arches in normal people?
1st arch is all that remains and becomes the external acoustic meatus
2nd arch grows down to cover others, obliterating all other clefts
178
If a pharyngeal arch doesn’t close properly what is the result?
Bronchial cysts or fistulae can occur if there are remnants
179
What is the contents of a branchial cyst?
Serous fluid into the sac
180
Where is a branchial cyst found?
Around the SCM anteriorly
181
What drives the development of the face?
- Expansion of the cranial neural tube
| - Appearance of a complex tissue system associated with: -the cranial gut tube and - the outflow of the developing heart
182
What structures develop into the face?
1st Ph Arch and the frontonasal prominence (FNP)
| They surround the ventero-lateral part of the forebrain
183
What are the branches of the 1st Ph arch?
Maxillary and mandibular
184
What part of the face is produced from the FNP?
Forehead, bridge of nose, nose, philtrum
185
What parts of the face are derived from the maxillary Ph Arch?
Cheeks, lateral upper lip, lateral upper jaw
186
What structures are derived from the Mandibular division of the first pharyngeal arch?
Lower lip and jaw
187
What appears on the FNP to suggest production of the nose?
Nasal placodes which then sink to become the nasal pits.
| Medial and lateral nasal prominences form on either side of the pits
188
How does the nose go from a lateral to a medial structure in the embryo?
Maxillary prominences grow medically, pushing the nasal prominences closer together in the midline.
Maxillary prominences fuse with medial nasal prominence
Medial nasal prominences then fuse in the midline
189
What structure is produced by the fusion of the medial nasal prominences?
Intermaxillary segment=
- labial component - philtrum
- Upper jaw - 4 incisors
- Palate - primary palate
190
How is the hard palate formed?
Maxillary prominences give rise to two palatal shelves
These grow vertically downwards into the oral cavity on each side of developing tongue
The mandible grows large enough to allow the tongue to drop therefore the palatine shelves grow towards each other
The palatal shelves then grow towards each other and fuse in the midline
The nasal septum develops as a midline downgrowth and ultimately fuses with palatal shelves
191
What is the cause of a lateral cleft lip?
Failure of fusion of medial nasal prominence and maxillary prominence
192
What is the cause of a cleft lip and cleft palate?
Combination of failure of fusion of medial nasal prominence and maxillary prominence with failure of palatal shelves to meet in the midline
193
What Ph Arches do the ossicles develop from?
Cartilages from 1st and 2nd Pharyngeal Arches
194
What Ph arch forms the middle ear cavity?
Ph Arch 1
195
Describe the development of the positioning of the ears?
External ears develop initially in the neck
As mandible grows the ears ascend to the side of the head to lie in line with the eyes
(All common chromosomal abnormalities have associated external ear anomalies)
(Hypoplasia of the jaw - lower set ears)
196
How does foetal alcohol syndrome present in children?
- Small head
- Epicanthal folds
- Flat midface
- Smooth philtrum
- Underdeveloped jaw
- Low nasal bridge
- Small eye openings
- Short nose
- Thin upper lip
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What cell population does the facial skeleton derive from?
Neural crest cells populating the pharyngeal arches
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From which spinal levels is the parasympathetic outflow and what are the segments called?
Cranial - four cranial nerves
| Sacral (S2-S4) - pelvic splanchnics
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From which spinal levels is the sympathetic outflow?
Segments are T1-L2 of spinal cord only
| Cell bodies within lateral horn of grey matter of spinal cord
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How do thoracic sympathetic nerves reach the head?
They hitch-hike onto blood vessels. Post-ganglionic sympathetic nerves join common carotid artery and follows the external carotid artery up to the face and internal carotid artery to the orbit
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Describe the 3 signs of Horners syndrome and why they happen?
Partial ptosis - occulomotor n. Innervates the LPS muscle which due to unopposed parasympathetic innervation causes the drooping of the eyelid.
Myosis - more constricted pupils due to the reduced sympathetic innervation
Anhydosis- reduced sweating on the ipsilateral side again due to decreased sympathetic innervation
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What areas of pathology will cause the following cluster of signs: Anyhydrosis, partial ptosis, myosis
Pathology involving the apex of the lung and common carotid artery and its branches can cause autonomic dysfunction in the eye and face
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Which cranial nerves carry parasympathetic fibres from the brain stem?
CN III (occulomotor), CN VII (facial), CN IX (glossopharyngeal), CN X (vagus)
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What is the rule of 4’s for the PS innervation to the head and neck?
- 4 cranial nerves that arise from the brainstem from the parasympathetic nuclei
- Hitchhike onto one of 4 CNs
- 4 PS ganglia
- Hitchhike on branches of CN V (exception to this is CN X)
- To reach the target tissues
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Where is the location of the Edinger Westphal nucleus?
In the brain stem
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What CN is associated with the Edinger Westphal Nucleus and what is the name of the parasympathetic ganglion?
CN III
| Ciliary
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What is the action of the CN III on the target tissues?
Smooth muscle and ciliary muscle control
Sphincter pupillae constriction - pupil constrictor
Ciliary muscle - controls lens shape
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What is the ganglion and target tissues for CN VII?
- Submandibular ganglion
| - Lacrimal gland innervation
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What is the ganglion name for CN IX and the target tissue?
- Pterygopalatine ganglion
| - Mucosal gland in nasal/oral/mucosa/ respiratory tract
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What is the parasympathetic ganglion name and the target tissues of CN X?
- Otic ganglion
| - Salivary glands
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What does anisocoria mean?
Unequal size of the pupils
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What 2 branches of the facial nerve arise from te petrous bone and are parasympathetic?
Greater petrosal nerve
| Chorda tympani nerve
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What nerve supplies sensory to the middle ear?
Tympanic nerve branch of glossopharyngeal nerve
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What is the name of the parasympathetic nerve exiting the middle ear?
Lesser petrosal nerve
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What is the post ganglionic innervation of the lesser petrosal nerve (which is preganglionic)?
Parotid gland
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What are the 3 parts of the ear?
External
Middle
Inner
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Name 4 signs and symptoms of ear disease?
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Otalgia
Tinnitus
Discharge
Vertigo
Hearing loss (sensorineural or conductive)
Facial nerve palsy
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What type of cells line the external ear?
Skin-lined=
| Keratinising, stratified squamous epithelium continuous onto the lateral surface of the tympanic membrane
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What cells line the middle ear?
Respiratory epithelium
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What 2 structures form the inner ear?
Cochlea
| Semicircular canals
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What is the name of the tube connecting the middle ear and the oropharynx?
Pharyngotympanic tube
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What is the main structure in the middle ear?
Ossicles
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What fills the middle ear air or fluid?
Air
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What fills the inner ear fluid or air?
Fluid
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What nerves carry general sensation from the ear?
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Cervical spinal nerves (C2/3)
Vagus
Trigeminal (auriculotemporal n.)
Glossopharyngeal (tympanic n.)
Small contribution from CN VII
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What nerve does pharyngitis refer the pain to?
Glossopharyngeal nerve
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Name 3 non-otological causes of otalgia?
1- TMJ dysfunction (CN Vc)
2- Disease of the oropharynx (CN IX)
3- Disease of the larynx and pharynx
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Is the tympanic membrane external ear, middle ear or inner ear?
External ear
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What deformity is caused by a subperichondrial haematoma of the ear?
Cauliflower deformity
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Why does cauliflower ear develop?
Blunt force trauma to the pinnacle of the ear
The haematoma deprives the cartilage of blood supply
Pressure necrosis of the tissue
Fibrosis
Asymmetrical cartilage development
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How to treat a subperichondrial haematoma?
Drainage of the haematoma
Prevent re-accumulation
Re-apposition of the two layers by tamponading the bleeding and pushing the two layers together
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What is the name of the gland that produces ear wax?
Ceruminous glands
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What is the self cleaning function of the ear?
Desquamation and skin migration laterally off tympanic membrane out of the canal - epithelial migration
234
Name 5 functions of the nose
1- Sense of smell
2- Provide a route for inspired air (mainly at rest the nose is used)
3- Filters inspired air - trapping particles in nasal hair and mucous
4- Moistens (humidifies) and warms inspired air
5- Resonating chamber for speech
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What type of cell is found in the nose?
Pseudostratified columnar epithelium with goblet cells
| The vestibule is lined with skin containing sebaceous/ sweat glands and hair - filters inspired air
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What bone forms the bridge of the nose?
Nasal bone
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What is the most fractured bone of the face?
Nasal bone
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What is the nasal vestibule?
The entrance fo the nose
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What makes up the roof and floor of the nasal cavity?
Roof - cribriform plate
| Floor - Hard palate (roof of the oral cavity)
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Where does the Eustachian tube exit?
Nasopharynx posteriorly in line with the inferior conchae
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What are the names of the bony projections on the nasal lateral wall and what is the name given to the gap between them and the nasal lateral wall?
Superior, middle and inferior conchae
Superior, middle and inferior meatus
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Where does the paranasal sinuses communicate with the nasal cavity?
Middle meatus
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Where does the lacrimal gland spill into the nasal cavity?
Via the lacrimal duct at the inferior meatus
244
Where does the maxillary sinus communicate with the nasal cavity?
At the inferior meatus
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What bone are the conchae from?
Ethmoid bone
246
What causes a saddle-nose deformity?
Untreated septal haematoma leading to a vascular necrosis of the cartilaginous septum of the nose which causes a saddling of the nasal dorsum
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What nerve innervates the nose and nasal cavity?
Trigeminal nerve
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What is a nasal polyp and what patient group mostly develops them?
>40 year olds develop it
Usually bilateral in nature
Pale or yellow in appearance/ fleshy and reddened
Commonly found in middle meatus = much less pain when compared to touching the middle conchae.
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Name 3 symptoms of a nasal polyp and one red flag
1- Blocked nose and watery rhinorrhoea
2- Post nasal drip
3- Decreased smell and reduced taste
Red-flag symptoms= unilateral polyp +/- blood-tinged secretion may suggest tumour
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What is the treatment of a nasal polyp?
Steroids
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What is rhinitis?
Inflammation of the nasal mucosal lining
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What are the symptoms of rhinitis?
- Nasal congestion
- Rhinorrhoea
- Sneezing
- Nasal irritation
- Postnasal dip
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What is a common cause of rhinitis?
- Simple acute infective rhinitis (viral - common cold)
| - Allergic reaction
254
What is the medical term for nose bleeding?
Epistaxis
255
What arteries carry blood to nasal cavity?
Branches of ophthalmic artery and maxillary artery
256
What is the name given to the anastomoses of arteries supplying the anterior septum of the nose?
Kisselbach’s plexus
257
What is acute sinusitis?
Symptomatic inflammation of mucosal lining of nasal cavity and paranasal air sinuses
258
What are common causes of acute sinusitis?
- secondary to viral infection of nasal cavity (last <10/7)
259
How would you diagnose acute sinusitis?
- Recent URTI
- Blocked nose and rhinorrhoea +/- green/yellow discharge
- Pyrexia
- Headache / facial pain (in area affected sinus worse on leaning forward
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When would you suspect a acute bacterial sinusitis?
- Symptoms particularly severe at onset
- Symptoms >10/7 without improvement (but <4/52)
- Symptoms that worsen after an initial improvement (suggest secondary bacterial infection)
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What are the 4 steps of pathophysiology of acute sinusitis?
1- Primary infection leads to reduced ciliary function, oedema of nasal mucosa and sinus Ostia and increased nasal secretions
2- Drainage from sinus is impeded
3- Maxillary sinus is the most commonly affected
4- Stagnant secretions within the sinus becomes ideal breading ground for bacteria - secondary infection ensues
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What 3 bacteria are causes for acute bacterial sinusitis?
Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis
263
What is the vestibule of the oral cavity?
The part of the oral cavity in front o the teeth
264
What is the medical term for the gums?
Gingiva
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What two arches make up the fauces of the oral cavity?
Palatoglossal arch
| Palatopharyngeal arch
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What is the soft palate?
The uvula
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What is the ridge of tissue that connects the tongue to the floor of the mouth?
Lingual frenulum
268
How many of each teeth do we have?
2 incisors
1 canine
2 premolars
3 molars
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What are the muscles of the tongue?
```
Intrinsic muscles=
4 paired muscles
Extrinsic muscles=
1-Genioglossus
2-Hypoglossus
3-Styloglossus (hypoglossal nerve)
4- Palatoglossus (Vagus nerve)
```
270
What nerves innervate the tongue and what areas?
Anterior 2/3 = sensation - trigeminal nerve (V3)
Taste -facial nerve
Posterior 1/3 = Sensation and taste - glossopharyngeal (IX)
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What is the name of the duct that comes out of the base of lingual frenulum and what two glands secrete through it?
Wharton Duct
Submandibular and sublingual glands
272
What tooth is lateral to the parotid duct?
2nd premolar
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What are the borders of the parotid gland?
Superior border= zygomatic arch
Posterior border= sternocleidomastoid muscle
Anterior border= Masseter muscle
Buccinator is pierced by the parotid gland duct
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Sialolithiasis is what?
Stones in the salivary ducts
275
What is the most common duct that gets blocked in sialolithiasis?
Submandibular glands
276
What are 3 common symptoms of sialolithiasis?
Pain in gland
Swelling
Infection
(Eating stimulates the problem)
277
Causes of tonsillitis?
Viral cause - most common
| Bacterial causes - up to 40% of cases - Strep pyogenes
278
What are the 4 most common symptoms of tonsillitis?
Sore throat
Pain/ difficulty swallowing
Cervical lymph nodes
Bad breath
279
What is a good distinguishing feature between tonsillitis and peritonsillar abcess?
Drooling with peritonsillar abcess
PTA - difficulty opening mouth but tonsillitis - pain/difficulty swallowing
PTA - uvula deviation but tonsilitis no uvula deviation
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What are the boundaries of the nasopharynx?
Base of skull to upper border of soft palate-
Posterior (C1, C2)
Anterior (nasal cavity)
Contains - pharyngeal tonsil/ aka adenoids
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What are the boundaries of the oropharynx?
Soft palate to epiglottis
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Ant= oral cavity
Posterior = C2, C3
```
Contains palatine tonsils
282
What are the boundaries of the laryngopharynx?
```
Boundaries=
- Oropharynx to oesophagus
- Epiglottis to cricoid cartilage
Anterior- Larynx
Posterior - C4-C6
```
Contains - piriform fossa
283
What is the piriform fossa?
The gap between the tracheal inlet and the aryepiglottic folds
284
What muscles elevate the pharynx and larynx during swallowing and what are their innervation?
Stylopharyngeus - styloid process - posterior border of thyroid cartilage - Glossopharyngeal nerve (CN IX)
Palatopharyngeus - hard palate - post. Border of thyroid cartilage - Pharyngeal branch of vagus (CN X)
Salpingopharyngeus - cartilaginous part of ET - merges with palatopharyngeus - opens the ET tube to balance the pressures too - Pharyngeal branch of vagus (CN X)
285
What are the pharyngeal constrictors and where d0 they insert?
3x circular muscles - constrict walls of pharynx when swallowing
1- Superior pharyngeal constrictor - origin - pterygomandibular raphe
2- Middle pharyngeal constrictor - Origin - Hyoid bone
3- Inferior pharyngeal constrictor
- has 2 parts a) thyropharyngeal (origin-thyroid cartilage) b) cricopharyngeal (origin - cricoid cartilage)
Insertion point - Pharyngeal raphe
286
What is a pharyngeal pouch and what is the cause of the symptoms?
Posteromedial (false) diverticulum- arises in weakness between the two parts of the inferior constrictors - Killian’s dehiscence
Food material collecting in pouch or disruption of swallow
287
What are the phases of swallowing?
1- oral
2- pharyngeal
3- oesophageal
288
Describe the oral phase of swallowing?
Voluntary
Preparatory phase- making bolus
Transit phase - bolus compressed against palate and pushed into oropharynx by tongue and soft palate
289
Describe the pharyngeal phase of swallowing?
- Involuntary
- Tongue positioned against hard palate
- Soft palate elevated sealing off nasopharynx
- Suprahyoid and longitudinal muscles shorten - pharynx widens and shortens to receive bolus
- larynx elevated and sealed off by vocal folds
- Epiglottis closes over larynx sequential contraction of constrictors
- Relaxation of UOS
290
Describe the oesophageal phase of swallowing
- involuntary
- upper striated muscle of oesophagus
- lower smooth muscle
291
What are the usual symptoms of dysphasia?
- Coughing + choking
- Sialorrhoea (drooling)
- Recurrent pneumonia - problems coordination swallow
- Change in voice/ speech (wet voice)
- Nasal regurgitation - soft palate not working
292
What are the anatomical relations of the orbit
- Paranasal air sinuses (maxillary and ethmoid)
- Nasal cavity - nasolacrimal duct - drains tears into nose
- Anterior cranial fossa - sits superior to orbit
293
What are the components of the eye lid?
Skin, cutaneous tissue, tarsal plate, muscles=
- orbicularis oculi - palpebral part -> closes the eye lid
- Levator palpebrae superioris -> lifts the eye lid
Glands -
Meibomian glands - halo rise exocrine glands - produce meibum an oily substance that prevents evaporation of liquid eye film
Sebaceous glands associated with lash follicle - allows waterproof coating to coat the eye lash as it sits around the follicle.
294
What are the glands of the eye and what problems does it cause?
Meibomian gland blockage - meibomian cyst= not painful, difficult to treat. Wash eye w/ baby shampoo.
Eyelash follicle or its associated sebaceous gland can block - (staph infection) causing styes
Blepharitis - inflammation of lids (including skin, lashes and meibomian glands)
295
Difference between pre-septal cellulitis and post-septal cellulitis
Ocular functions remains unaffected in pre-septal but visual acuity and movement (proptosis/ exophthalmos) are found in
Post- septal more likely to lead to permanent damage to optic nerve as it is generally to do with locality of the infection/ inflammation behind protective septum, pre-septal - generally to do with trauma/ wounds but in front of protective septum
Post-septal = can track to affect the cavernous sinus causing thrombosis or even meningitis
296
Structures involved in tear film production?
Lacrimal gland - tear production, lacrimal sac and ducts (tear drainage) - ducts= canaliculi and nasolacrimal duct
Blinking - orbicularis oculi distributes tear film across front of eye, rinsing and lubricating conjunctivae and cornea
Tears are ultimately drained into nasal cavity
297
Name the layers of the eyeball
Outer: sclera - continuous anteriorly as transparent cornea - continuous with dura
Middle: choroid, ciliary body and iris (vascular)
Inner: retina (inner photosensitive layer lining on an outer pigmented layer)
