HNNS Supplementary Questions Flashcards
How many pairs of cranial nerves are there?
12
Which of the following statements may be correct regarding human nervous system?
A. Most cranial nerves belong to CNS because they attach to brain
B. Weight of adult brain is one-tenth of body weight
C. Glial cells have short processes called dendrites
D. Smarter people have more neurones
D
B: 1.X kg, ~2% only
Which of the following is true for brainstem?
A. It is a part of PNS
B. Medulla is superior to midbrain
C. Degeneration of neurones in midbrain will lead to Parkinson’s disease
D. Pons is connected to pituitary glands
E. Vagus nerve is originated from midbrain
C
Young driver in car crash. On ventilator. Cannot breathe. Where is respiratory centre?
A. Brainstem
B. Cerebellum
C. Thalamus
D. Amygdala
E. Cerebrum
A
A 32-year-old woman presents to the Emergency Department with progressive weakness of her lower limbs. Her symptoms started two days previously when she noticed her legs felt heavy when rising from a seated position. This weakness has progressed to the point now where she is unable to stand unassisted and has now started to affect some of the muscles of her abdominal wall and lower back. She is otherwise well, apart from suffering a diarrhoeal illness 10 days previously. Neurological examination of the lower limbs identifies generalised weakness, reduced tone and absent reflexes; sensory examination is unremarkable.
Which of the following organisms is most likely to have caused this patient’s diarrhoeal symptoms?
A. Bacillus cereus
B. Campylobacter jejuni
C. Escherichia coli
D. Shigella
E. Staphylococcus aureus
B
Guillain-Barré syndrome (GBS) is classically triggered by Campylobacter jejuni infection
Ascending muscle weakness, no sensory signs
Hyporeflexia, hypotonia: LMN lesion
Preceding diarrhoeal episode
=> GBS (autoimmune-mediated demyelinating disease of PNS)
B. cereus: food poisoning from rice
E. coli: watery stools, abdominal cramps, common among travellers
Shigella: bloody diarrhoea, abdominal pain, vomiting
S. aureus: severe vomiting
An 81-year-old woman is seen in falls clinic after having four falls in the last four months. She has no history of falls previous to this. She also reports experiencing a progressive headache that is worse a night over the last three months.
Upon performing a cranial nerve exam, an inferior homonymous quadrantanopia is elicited although eye movements are preserved. The rest of the cranial nerve examination as well as a full neurological examination is normal.
A lesion located in which area would result in these symptoms?
A. Inferior optic radiation
B. Lateral optic chiasm
C. Optic nerve
D. Superior optic chiasm
E. Superior optic radiation
E
Inferior homonymous quadrantanopias are caused by lesions of the superior optic radiations in the parietal lobe
Complete / Superior optic chiasm lesion:
- bitemporal hemianopia
Lateral optic chiasm lesion
- binasal hemianopia
Roger is a 32-year-old man presenting with diplopia. He is known to have type 1 diabetes and multiple sclerosis. He had been experiencing double vision over the last 3 days. This predominantly happens when he looks to the right.
He denies any associated double vision on vertical vision. He has not noticed any difficulty in moving his eyelids. He has not noticed any increased sensitivity to light and his eye is not red.
On examination, both eyelids display normal strength. With the left eye closed, the right eye displays a full range of movement. With the right eye closed, the left eye fails to adduct when looking towards the right. Nystagmus on the right eye is noted when the patient is asked to look to the right with both eyes. On convergence, both eyes can adduct towards the midline. The pupillary exam is normal with both pupils reacting appropriately to light.
What is the underlying pathology that has caused his diplopia?
A. Extrinsic compression of left oculomotor nerve
B. Intrinsic vascular damage to the left oculomotor nerve
C. Lesion of the left abducens nerve
D. Lesion on the left paramedian area of pons and medulla
E. Lesion on the left paramedian area of the midbrain and pons
E
Medial longitudinal fasciculus:
- on paramedian area of midbrain and pons
Centres of vision:
- mostly midbrain & superior pons
- lower pons & medulla: nuclei of CN V-XII
Internuclear ophthalmoplegia:
- disorder of conjugate gaze
- lesion in MLF => failure of ipsilateral eye to adduct
- younger patients: multiple sclerosis (demyelinating)
- older patients: stroke
- maintained convergence: due to intact CN III and EW n.
Oculomotor nerve palsy:
- ptosis (levator palpebrae superioris)
- lack of pupillary response on ipsilateral side
- failure of adduction on convergence
- surgical 3rd nerve palsy (external compression) causes: aneurysmal compression, malignancy
- medical 3rd nerve palsy (pupil sparing) causes: intrinsic vascular damage, atherosclerotic changes, DM
CN VI lesion:
- failure of abduction rather than adduction
A 45-year-old woman presents with double vision that worsens when reading. She recently had a minor head injury. There is no ptosis or limitation of eye movements. The diplopia disappears when she tilts her head towards the right shoulder.
Which cranial nerve is most likely affected?
A. Abducens nerve
B. Oculomotor nerve
C. Optic nerve
D. Trochlear nerve
E. Vestibulocochlear nerve
D
Vertical diplopia
- Classically noticed when reading a book in downgaze
- Left CN IV palsy => compensatory head tilt to the right
Horizontal diplopia
- CN VI
E.g. Right CN VI palsy => horizontal diplopia when looking to the right
CN III palsy
- ptosis
- pupillary dilation
- eye deviation down and out
CN VIII lesion
- hearing loss
- vertigo
- nystagmus
What is true about palate?
A. Under mucous membrane of palate is palatine tonsil
B. It is in the floor of mouth and connects with tongue
C. Muscle of palate will close to block pharynx when swallowing
D. There is no mucous membrane in palate
C
What are the first teeth that erupt in infants?
A. 1st premolar in upper jaw
B. Canine in upper jaw
C. 1st molar in lower jaw
D. Wisdom teeth in lower jaw
E. Central incisors in lower jaw
E
Which of the following is involved in deglutition?
A. Palatine arches
B. Soft palate
C. Salivary glands
D. Hard palate
E. Tonsils
B
The zygomatic arch encloses which two fossae?
Temporal fossa
Infratemporal fossa
The angle of the mandible is roughened for which muscles to insert?
Outside: masseter
Inside: medial pterygoid
Which two muscles arise from mental spine?
Geniohyoid (inferior genial tubercle)
Genioglossus (superior genial tubercle)
Which two nerves exit through mental foramen?
Mental nerve
Incisive nerve
= terminal branches of inferior alveolar nerve
A young boy seeks medical advice from his family physician due to high fever and severe throat pain. Throat examination shows a red swollen structure on right lateral wall of mouth, next to base of tongue. Which of following is most likely red swollen structure?
A. Lingual tonsil
B. Palatine tonsil
C. Sublingual gland
D. Tongue papilla
E. Uvula
B
_________ is shared by both digestive and respiratory system.
A. Nasopharynx
B. Oesophagus
C. Oropharynx
D. Laryngopharynx
E. Larynx
C
[Old PP]
Obstruction to CSF flow can lead to mental retardation. What clinical presentation can obstruction of interventricular foramen will result in?
A. Hydrocephalus
B. Meningitis
C. Haematoma
D. Alzheimer’s disease
E. Parkinson’s disease
A
[Old PP]
A mass in right cerebral cortex. Pupils fixed and dilated, loss of consciousness…
A. Compression of oculomotor nerve and midbrain by uncus
B. Haemorrhage of basal ganglia
C. Haemorrhage of occipital cortex
D. Ischaemia of cerebellum
E. Ischaemia of medulla oblongata
A
[Old PP]
A 35-year-old lady developed acute onset of high fever, focal neurological deficit & signs of raised intracranial pressure. A contrast computer tomography (CT) shows multiple lesions in cerebral hemisphere with ring enhancement suggestive of brain abscess. Which of following is MOST LIKELY predisposing condition or cause of abscess?
A. History of chronic rheumatic heart disease with recent tooth extraction
B. History of ingestion of uncooked pork
C. History of receiving vaccination two weeks ago
D. Infection with herpes simplex virus
E. Infection of virulent bacteria such as Neisseria meningitidis
A
Chronic rheumatic heart disease with recent tooth extrac tion → Infec tive endocarditi s → Associated septi c thrombi → Haematogenous spread → multiple lesions
B: Cysticercosis (rare)
[Old PP]
80/M, history of DM and hypertension, with sudden onset of left side hemiplegia. CT brain shows acute infarct of 1 cm diameter of right basal ganglia and internal capsule. What is most likely cause?
A. Cerebral vasculitis
B. Emboli from heart
C. Lipohyalinosis of deep penetrating artery
D. Ruptured berry aneurysm
E. Sagittal sinus venous thrombosis
C
Right lenticulostriate artery
[Old PP]
A 34-year-old man developed a progressively enlarging tumour in his left cerebral cortex which was inoperable. He has progressive increase in headache, especially severe in the morning. A few days before his death, he began to develop impaired consciousness with fixed and dilated left pupil. Which of the following is the MOST LIKELY pathological lesion to account for his deterioration in consciousness?
A. Haemorrhage and infarction of midbrain
B. Haemorrhage and infarction of occipital lobe
C. Haemorrhage in basal ganglia
D. Infarction of cerebellum
E. Infarction of medulla oblongata
A
[Old PP]
During a boxing game, a young male was accidentally hit on head. He felt all right and went out for dinner with his friends. Suddenly he suffered a headache and vomited. He even could not walk and went into a coma. Which of following is most likely diagnosis?
A. Meningitis
B. Encephalitis
C. Intracranial tumour
D. Subarachnoid haematoma
E. Stroke
D
[Old PP]
A 39-year-old woman complaint of sudden onset of severe headache (and neck stiffness?) CT shows blood in subarachnoid space. No intracerebral haematoma.
A. Saccular aneurysm at bifurcation of middle cerebral artery
B. Vascular malformation of white matter
C. Microaneurysm of anterior choroid artery
A
[Old PP]
Raised ICP
A. Cerebral aqueduct
B. 4th ventricle
C. Left CN III
D. Left CN II sheath
E. Left posterior cerebral artery
F. Left posterior cerebral hemisphere
G. Midbrain
H. Right internal capsule
I. Right cerebral peduncle
J. Right motor cortex
A man was found to have infarcts in left cerebral hemisphere, left internal capsule and basal ganglia. He progressed from GCS 15 to developing following signs and symptoms. Which of above are likely to be compressed?
Fixed and dilated pupils in left eye
C
[Old PP]
Raised ICP
A. Cerebral aqueduct
B. 4th ventricle
C. Left CN III
D. Left CN II sheath
E. Left posterior cerebral artery
F. Left posterior cerebral hemisphere
G. Midbrain
H. Right internal capsule
I. Right cerebral peduncle
J. Right motor cortex
A man was found to have infarcts in left cerebral hemisphere, left internal capsule and basal ganglia. He progressed from GCS 15 to developing following signs and symptoms. Which of above are likely to be compressed?
Left hemiplegia
I
False localising sign (left hemiplegia & true lesion also on the left)
[PP]
Raised ICP
A. Cerebral aqueduct
B. 4th ventricle
C. Left CN III
D. Left CN II sheath
E. Left posterior cerebral artery
F. Left posterior cerebral hemisphere
G. Midbrain
H. Right internal capsule
I. Right cerebral peduncle
J. Right motor cortex
A man was found to have infarcts in left cerebral hemisphere, left internal capsule and basal ganglia. He progressed from GCS 15 to developing following signs and symptoms. Which of above are likely to be compressed?
Right homonymous hemianopia
E
With macular sparing
Contralateral homonymous hemianopia: optic tract, optic radiation, occipital lobe
[Old PP]
Raised ICP
A. Cerebral aqueduct
B. 4th ventricle
C. Left CN III
D. Left CN II sheath
E. Left posterior cerebral artery
F. Left posterior cerebral hemisphere
G. Midbrain
H. Right internal capsule
I. Right cerebral peduncle
J. Right motor cortex
A man was found to have infarcts in left cerebral hemisphere, left internal capsule and basal ganglia. He progressed from GCS 15 to developing following signs and symptoms. Which of above are likely to be compressed?
Decreased conscious level
G
[Old PP]
Raised ICP
A. Cerebral aqueduct
B. 4th ventricle
C. Left CN III
D. Left CN II sheath
E. Left posterior cerebral artery
F. Left posterior cerebral hemisphere
G. Midbrain
H. Right internal capsule
I. Right cerebral peduncle
J. Right motor cortex
A man was found to have infarcts in left cerebral hemisphere, left internal capsule and basal ganglia. He progressed from GCS 15 to developing following signs and symptoms. Which of above are likely to be compressed?
Dilated ventricles
A
[Old PP]
Which of following is MOST LIKELY location for a berry/saccular aneurysm of brain?
A. Anterior inferior cerebellar artery
B. Bifurcation of anterior cerebral and anterior communicating arteries
C. Penetrating arteries supplying basal ganglia
D. Terminal small arteries supplying frontal lobes
E. Vertebral artery
B
[Old PP]
Which of following disease processes is association with an increase in cerebrospinal fluid volume but no increase in intracranial pressure?
A. Cerebral atrophy
B. Cerebral oedema
C. Meningitis
D. Obstruction of aqueduct of Sylvius
E. Thrombosis of dural venous sinuses
A
Compensation for constant volume
[Old PP]
In a patient with a cerebral infarct, a hypodense area is shown by a CT scan (non-contrast) in an area supplied by right middle cerebral artery. Which of following is MOST LIKELY associated clinical or pathological findings?
A. A large haematoma in right basal ganglia
B. Chronic rheumatic heart disease with mitral stenosis and atrial fibrillation
C. High fever and neck rigidity
D. Lewy bodies in substantia nigra
E. Lymphocytic infiltration of intracerebral arteries
B
C: meningitis
D: Parkinson’s disease
E: viral infections
Hyperdense (more white): Blood (haematoma), calcified, tumour, etc
Hypodense (more black): Infarct, fluid, hypoxia, etc
[Self-assessment]
A 34-year-old lady has sudden onset of very severe headache. She was healthy all along before the current presentation. There is no history of hypertension. Upon admission into the A&E department, mild neck rigidity was observed. An urgent CT scan showed presence of haemorrhage in the subarachnoid space. There is no intracerebral haemorrhage. What is the most likely underlying cause of her bleeding.
A. Microaneurysm located at the deep penetrating arteries of the brain
B. Berry aneurysm located at the bifurcation of major cerebral arteries at the circle of Willis
C. Severe atherosclerosis of the intracranial major cerebral arteries
B
Chronic HT -> lipohyalinosis of deep penetrating arteries -> weakened walls -> microaneurysm -> rupture -> intracerebral haemorrhage
Sites of predilection: basal ganglia/thalamus; cerebellum or pons.
Severe atherosclerosis -> obstruction , X haemorrhage
A 46-year-old female patient comes to the emergency department complaining of pain in the area just below her mandible on the right side of her face. She says that the pain is particularly severe when she eats. The area of the submandibular gland is tender and swollen, as is the area in the floor of her mouth lateral to the tongue. You suspect a stone in the submandibular duct, and a plain film radiograph shows a density in that region consistent with a stone. In order to remove the stone, the duct must be incised in the floor of the mouth. What nerve, that loops around the duct, is in danger in such an incision?
Chorda Tympani
Glossopharyngeal
Hypoglossal
Internal branch of the superior laryngeal
Lingual
Lingual
The cell bodies of the taste fibers from the anterior two-thirds of the tongue are located in the:
Geniculate ganglion
Otic ganglion
Pterygopalatine ganglion
Submandibular ganglion
Trigeminal ganglion
Geniculate ganglion
The chorda tympani contains which component before it joins the lingual nerve?
Preganglionic sympathetics
Postganglionic sympathetics
Preganglionic parasympathetics
Postganglionic parasympathetics
Taste fibers to the posterior third of the tongue
Preganglionic parasympathetic
The muscle responsible for raising the floor of the mouth in the early stages of swallowing is the:
genioglossus
geniohyoid
hyoglossus
mylohyoid
palatoglossus
Mylohyoid
All of the following may be found in the paralingual space EXCEPT:
Hypoglossal nerve
Lingual nerve
Sublingual gland
Submandibular gland duct
Superficial lobe of submandibular gland
Superficial lobe of submandibular gland (below mylohyoid)
Lingual nerve (wrap around submandibular duct / Wharton’s duct - between genioglossus and sublingual gland)
Hypoglossal nerve - inferior to tongue
When one presses the tongue tip against the anterior (incisor) teeth, which of the following muscles must contract?
Styloglossus
Hyoglossus
Genioglossus
Superior longitudinal
Verticalis
Genioglossus - protrusion
Which of the following structures is located in the vestibule of the oral cavity?
Tongue
Opening of the parotid duct
Opening of the submandibular duct
Sublingual fold
Uvula
Opening of parotid duct (parotid papilla opposite 2nd upper/maxillary molar)
The difficulty in swallowing was due to involvement of which muscle that elevates the tongue?
Genioglossus
Hyoglossus
Styloglossus
Stylohyoid
Stylopharyngeus
Styloglossus
The teeth and gums separate the oral cavity proper from the:
Nasal cavity
Oral vestibule
Oropharynx
Paralingual space
Submandibular space
Oral vestibule
Damage of the lingual nerve before it is joined by the chorda tympani in the infratemporal fossa would cause loss of:
A. general sensation to the anterior two thirds of the tongue
B. general sensation to the posterior one third of the tongue
C. secretion of the submandibular gland
D. taste sensation from the anterior two thirds of the tongue
E. taste sensation from the posterior one third of the tongue
F. A+D
A
After a radiograph revealed a sialolith (stone) in a patient’s right submandibular duct, the surgeon exposed the duct via an intraoral approach. In this approach, what tissues or structures must be cut through?
Mucous membrane only
Mucous membrane and genioglossus muscle
Mucous membrane and mylohyoid muscle
Mucous membrane and hyoglossus muscle
Mucous membrane only
Sympathetic fibers reach the tongue by way of the:
lingual nerve
maxillary artery
hypoglossal nerve
lingual artery
glossopharyngeal nerve
1 target of sympathetic fibres = vasculature
Lingual artery
In dislocation of the jaw, displacement of the articular disc beyond the articular tubercle of the temporomandibular joint results from excessive contraction of which muscle?
Buccinator
Lateral pterygoid
Medial pterygoid
Masseter
Temporalis
Lateral pterygoid
In acute inflammation (arthritis) of the TMJ, the muscle most likely to be affected by the inflammatory process is the:
Temporal
Medial pterygoid
Masseter
Lateral pterygoid
Lateral pterygoid
The middle meningeal artery:
enters the skull through the foramen ovale
passes through a split in the trunk of the mandibular nerve (V3)
is typically a branch of the second part of the maxillary artery
supplies blood to the temporal lobe of the brain
usually arises deep to the neck of the mandible
usually arises deep to the neck of the mandible
To drill a mandibular tooth without causing undue pain, a dentist has injected an anesthetic into the space located between the medial pterygoid muscle and the mandible near the lingula. Given the nerves passing through the immediate vicinity of the injection site, where would one expect anesthesia in addition to the mandibular teeth?
back of tongue
external ear
maxillary incisor teeth
skin of chin
upper lip
Skin of chin
Which muscle is also known as the sphenomeniscus?
Inferior head of the lateral pterygoid
Masseter
Medial pterygoid
Superior head of the lateral pterygoid
Temporalis
Superior head of the lateral pterygoid
Attached to articular disc (meniscus)
A cranial fracture through the foramen ovale that compresses the enclosed nerve, will have an effect on all muscles EXCEPT :
Tensor tympani
Masseter
Buccinator
Mylohyoid
Temporalis
Buccinator
All muscles of mastication - CN V3
Tensor tympani & tensor veli palatini - CN V3
Two nerves usually emerge from between the two heads of the lateral pterygoid muscle: the anterior deep temporal nerve and the:
Masseteric n.
Buccal n.
Lingual n.
Inferior alveolar n.
Buccal nerve
After the mandibular condyle is moved forward onto the articular eminence (e.g., by opening the mouth widely), what muscle can then retract the mandible?
Superficial head of masseter m.
Deep head of masseter m.
Posterior part of temporalis m.
Anterior part of temporalis m.
Posterior part of temporalis
Which nerve is endangered during surgical removal of an impacted third mandibular molar tooth?
Hypoglossal n.
Glossopharyngeal n.
Inferior alveolar n.
Lingual n.
Lingual n
Which of the following suprahyoid muscles would be paralyzed if the inferior alveolar nerve were severed at its origin?
Geniohyoid m.
Hyoglossus m.
Mylohyoid m.
Stylohyoid m.
Mylohyoid
What bony feature of the mandible can be used to find and palpate the facial artery?
Oblique line
Mental trigone
Angle
Premasseteric notch
Premasseteric notch
The lesser petrosal nerve carries preganglionic parasympathetic fibers to the:
Geniculate ganglion
Otic ganglion
Submandibular ganglion
Ciliary ganglion
Otic ganglion
Damage to the facial nerve near the stylomastoid foramen would likely cause each of the following motor deficits EXCEPT:
Paralysis of the buccinator muscle
Inability to whistle
Paralysis of the muscles that elevate the mandible
Inability to close the lips
Paralysis of the muscles that elevate the mandible
At the temporomandibular joint (TMJ), hinge movements occur between the:
condyle and articular eminence
articular disc and articular eminence
condyle and articular disc
articular disc and articular cavity
condyle and articular cavity
condyle and articular disc
Lower synovial cavity
In reducing an ankylosis of the TMJ, a surgeon provoked an intense hemorrhage by lacerating the artery coursing transversely just medial to the neck of the condyle. Which artery was involved in the accident?
Buccal
External carotid
Maxillary
Middle meningeal
Superficial temporal
Maxillary
A patient who experienced bilateral anterior dislocation of the jaw (temporomandibular joints) could not swallow or talk since the mouth was held open. What is the position of the condyles of the mandible as a result of the dislocation?
against the external acoustic meatus
against the anterior slope of the articular eminence
against the posterior slope of the articular eminence
in the mandibular fossa
in the pterygoid fossa
against the anterior slope of the articular eminence
To drain an abscess (a closed collection of pus) affecting the cheek area, an emergency room physician used local anesthesia for the surgery. Which of the following nerves must be anesthetized because it carries pain sensation from the cheek area?
buccal (V3)
buccal (VII)
inferior alveolar
lingual
mental
Buccal (V3)
A 68-year-old patient has come to your neurology clinic for a routine review a few months after being diagnosed with progressive muscular atrophy, which is a variant of motor neurone disease (MND). This variant of MND causes a lower motor neurone lesion pattern.
Which of the following signs would you expect to see on examination?
Hypertonia and hyperreflexia
Hypertonia and hyporeflexia
Hypotonia and hyperreflexia
Hypotonia and hyporeflexia
Normal tone and reflexes
Hypotonia and hyporeflexia
UMN lesion: hypertonia, hyperreflexia
