HNS Flashcards
Where are the paranasal sinuses found?
Frontal - above the eye
Maxillary - under the eye
Ethmoidal air cells - behind the eye
Sphenoidal - behind the ethmoid bone
How do you palpate the lateral mass of atlas?
Found between the mastoid process (inferior part of the temporal bone) and the ramus of the mandible (verticle part of mandible)
What passes through the foramen magnum?
Spinal fibres of accessory nerve (CN XII) Inferior portion of medulla Vertebral arteries Anterior and posterior spinal arteries
What type of movements can occur at the atlanto-axial joint?
Lateral rotation of the neck - the side to side ‘no’ rotation of the head.
What is the surface marking of C7?
1st palpable vertebrae
What passes through the carotid canal?
Internal carotid artery
What passes through the Hypoglossal canal?
Hypoglossal nerve (CN XII)
What passes through the Foramen rotundum?
Maxillary branch of trigeminal nerve (CN V2)
What is the surface marking of L2?
L1 - two down from T12.
T12 can be found as a midway point from the inferior border of the scapular and superior border of illiac crest.
How do you palpate the cervical lymph nodes?
- Inform the patient - “I am just going to feel for glands in the neck and jaw”
- Ask them to tell you if they feel any pain or discomfort
- Palpate from behind the patient where possible
- Move your fingers along in circular motions
- Don’t lift them off the patient in case you miss any
- Do it in this order:
- Submental
- Sub mandibular
- Paratracheal - along the SCM
- Antierior cervical
- Supraclavicular
- Posterior cervical nodes
Then move back up:
- Pre-auricular nodes
- Post-auricular nodes
- Occipital nodes
Describe the range of flexion/extension possible at the different regions of the vertebral column
Cervical = large range
Upper thorax (T1-T7) = no range
Lower thorax (T7-T12) = very limited range
Lumbo-sacral = large range
How would you test the motor function of the vagus nerve?
Ask the patient to open their mouth and say ‘ahh’
This is done as it depresses the tongue making the uvula easier to see (use a pen torch)
Look for any deviation in the uvula to one side
Note:
It deviates to the side opposite the lesioned side if the vagus is lesioned
“the uvula runs away from the wound”
This is because the vagus causes the levator muscles to contract which pull the uvula upwards wrong both sides
What is the surface marking of L4?
L4 - level of iliac crest
How would you test the motor function of the trigeminal nerve?
Mandibular division V3 supplies Temporalis and masseter - 2 muscles of mastication
- Inform the patient what you’re doing “I’m going to feel the muscles you use to chew with and ask you to clench your jaw when I say so”
- Tell them to inform you is there’s any pain or discomfort
- Palpate the masseter on both sides before and during clenching their jaw
- Do the same for temporalis
What are the afferent and efferent pathway of pupillary constriction?
Afferent:
- Ganglion cells in eye
- Optic nerve (CN II)
- Optic tracts
- Pretectal nucleus
- Edinger-Westphal nucleus
Efferent:
- Edinger-Westphal nucleus
- Parasympathetic fibres along occulomotor nerve (CN III)
- Ciliary ganglion
- Parasympathetic fibres along ciliary nerves (CN V1)
- Sphincter pupillae - constriction
What passes through the jugular foramen?
Glossopharyngeal nerve (CN IX) Vagus nerve (CN X) Accessory nerve (CN XI) Sigmoid sinus -> becomes internal jugular vein
What passes through the Internal acoustic meatus?
Facial nerve (CN VII) [entry into the cranium] Vestibulocochlear nerve (NC VIII) Labyrinthine artery
What is the innervation of the extrinsic muscles of the eye?
Lateral rectus - CN VI (Abducens)
Supeior oblique - CN IV (Trochlear)
Medial rectus, Inferior oblique, Superior and inferior rectus - CN III (occulomotor)
What is the surface marking for injection of an epidural?
In adults:
- L3/4 or L4/5 junction used
- Spinal cord ends at L1/2 and becomes corda equinae
- Corda equinae displaces upon injection to reduce risk of damage
In children:
- Aren’t fully developed so the spinal cord continues lower down relative to the vertebral column
- L4/5 used
What is the surface marking of T3?
In line with the inferior part of the spinous process of the scapular
How do you test the ipsilateral and contralateral pupillary light reflex?
- Shine a light into one eye - check the ipsliateral shrinking (miosis)
- Move the light away from the eye for 3 seconds
- Shine a light into the same eye - check the consensual shrinking of the pupil in the other eye
- Repeat with the other eye
Note:
Check for pain or discomfort
What are the afferent and efferent pathways of the corneal reflex?
Afferent:
- Touch
- opthalmic branch of trigeminal
Efferent:
- facial motor nucleus
- facial nerve (CN VII)
- orbicularis oculi muscle
How do you test the glossopharyngeal nerve?
Eliciting a gag reflex
- Ask them to open their mouth
- Inform them it will be uncomfortable
- Use a tongue depressor to touch the back of their throat
Note:
the sensory limb is mediated by CN IX (glossopharyngeal)
the motor limb is mediated by CN X (vagus)
What passes through the foramen spinosum?
Middle meningeal artery
What’s the boundaries of the anterior triangle of the neck?
Medial - Midline of neck
Superior - Inferior border of the mandible
Lateral - Anterior border of SCM
Why is one jugular preferred to the other for central line insertion?
Right is preferred to left
Right is wider and more superficial
So is safer
Where are the mastoid air cells found?
In the mastoid process
What passes through the foramen ovale?
Mandibular branch of trigeminal nerve (CN V3)
What is the accommodation reflex?
- Convergance of the eyes
- Constriction of the pupils
- Bulging of the lens
All to adjust very quickly for near object focus
- Have the patient look at a far away object
- Bring your finger 5-10cm from their eyes telling them to focus on it
Describe the range of Lateral flexion possible at the different regions of the vertebral column
Cervical = Large range
Upper Thoracic (T1-T7) = Limited range (ribs)
Lower thoracic (T7-T12) = Large range
Lumbo-sacral = limited range
How would you test the motor function of the hypoglossal nerve?
Ask the patient to stick their tongue out (protraction of the tongue)
Look for any deviation from the midline
Note:
CN XII is the only nerve innervating the tongue
The tongue deviates to the same side as the lesion if the hypoglossal nerve is lesioned.
This is because CN XII innervates the genioglossus whos action is to pull the tongue forwards
If one side is being pulled forwards and the other isnt then it will deviate to the side thats not being pulled
How would you test the motor function of the facial nerve?
Asking the patient to perform a series of facial expressions as you provide some resistance
Branches of CN VII:
- Temporal - Raise eyebrows
- Zygomatic - Squeezing eyes shut
- Buccal - Smile
- Mandibular - Puff out cheeks
- Cervical - Grimace
Make sure to check for asymmetry
How do you test the function of the accessory nerve?
Purely somatic motor function
- Test the sternocleidomastoid
- Ask the patient to rotate their head to one side whilst you provide resistance with the back of your hand
- Repeat on the other side
- Test the upper fibres of the trapezius
* Shrug the shoulders against resistance
What can be seen through an otoscope?
External acoustic meatus - begins at the opening of the ear canal and ends at the tympanic membrane
Tympanic membrane - ‘cone of light’ at roughly 5 o’clock where the light from the otoscope is reflecting off the membrane.
What type of movements can occur at the atlanto-occipital joint?
Flexion and extension at the neck - the nodding up and down ‘yes’ movement
What is done in the case of airway collapse?
Tracheostomy or cricothyroidotomy
- Tracheostomy
- Transverse incision between cartilage rings of trachea (usually 2nd and 3rd ring)
- Thyroid isthmus can be divided for better access
- Cricothyroidotomy
* Transverse incision between the cricoid and thyroid cartilage (through the cricothyroid membrane)
Note:
Larynx displaces during swallowing meaning cricothyroidotomy has more complications with long term use but is easier to perform in emergency situations.
What passes through the Optic canal?
Optic nerve (CN II) Ophthalmic artery
What is the pterion?
The joining of the frontal sphenoidal, parietal and temporal bones. Particularily weak The middle menigeal artery lies under this point.
What’s the contents of the posterior triangle of the neck?
- External jugular vein (angle of mandible to middle of clavicle)
- Subclavian vein
- Subclavian artery
- Trunks of brachial plexus
- Phrenic nerve
- Vagus nerve
- Spinal accessory nerve
How do you palpate the:
hyoid bone
thyroid cartilage
cricoid cartilage
cervical part of the trachea
thyroid isthmus
- Hyoid bone - 2cm above the laryngeal prominence, hold your fingers in a ‘pincer’ to feel the horns of the hyoid
- Thyroid cartilage - this is what the laryngeal prominence is comprised of
- Cricoid cartilage - inferior to the thyroid cartilage
- Cervical trachea - rings of cartilage below the cricoid cartilage
- Thyroid isthmus - part of the thyroid cartilage below the prominence that separates the 2 wings of the thyroid cartilage
What’s the contents of the anterior triangle of the neck?
- Hyoid bone
- Common carotid artery
- Internal jugular vein (parallel and lateral to common carotid)
- Supra-hyoid muscles (sytlohyoid, digastric, mylohyoid, geniohyoid)
- Infrahyoid muscles (omohyoid, sternohyoid, thyrohyoid, sternothyroid)
What are the functions of the extrinsic muscles of the eye?
- Superior oblique - depression, abduction, medial rotation
- Inferior oblique - elevation, abduction, lateral rotation
- Medial rectus - Adduction
- Lateral rectus - Abduction
- Superior rectus - Elevation, adduction, medial roatation
- Inferior rectus - depression, adduction lateral rotation
What is the surface marking of T7?
At the level of the inferior angle of the scapular
How is a central line inserted into the internal jugular vein?
The internal jugular runs parallel and lateral to the internal carotid artery
For central line access, a triangle of the neck used, defined by:
- Sternal head of SCM
- Medial third of clavicle
- Clavicular head of SCM
The superior apex is used as an insertion point for the needle
Inserted at a 30o angle
Towards the ipsilateral nipple
What passes through the stylomastiod foramen?
Facial nerve (CN VII) [exit from cranium]
What is the corneal reflex?
Placing some cotton wool on the sclera of the eye
Rapid eye closure to protect the eye
How do you examine a patient’s teeth?
- Ask them to open their mouth as wide as possible
- Then ask if they’re in any discomfort
- Count the teeth in a clockwise manner - a complete set in each quadrant is:
- 2x incisors
- 1x canine
- 2x premolars
- 3x molars
8 in each quadrant - 32 in total
What passes through the Superior orbital fissure?
Oculomotor nerve (CN III) Trochlear nerve (CN IV) Ophthalmic branch of trigeminal nerve (CNV1) Abducens nerve (CN VI) Superior Ophthalmic vein
How do you test the sensory function of the trigeminal nerve?
- Tell the patient what you’re going to do “I am just going to test the sensation of the regions of your face with a blunt pin”
- Ask them to close their eyes and say yes every time they feel the pin touch their face
- Test the areas shown in the picture
- Ensure to test both left and right of each division before moving onto the next division
- After each division ask if it felt the same on each side
What is the anatomical reasoning for the range of movement possible in each region of the vertebral column?
Cervical:
- Atlanto-occipital and atlanto-axial joints allow full range of movement
- zygapophysial joints slope inferiorly anterior to posterior - facilitates flexion and extension
Upper thorax:
- movement restricted by ribs
- flexion/extension restricted due to zygapophysial joints orientated vertically which enhances rotation
Lower thorax:
- the ribs are floating so restrict movement less
Lumbo-sacral:
- Joint surfaces are curved so limit lateral flexion and rotation
- articulations are verticle so prevent rotation
What are the branches of CN VII?
- Temporal ‘The’
- Zygomatic ‘Zebra’
- Buccal ‘Bit’
- Mandibular ‘My’
- Cervical ‘Coccyx’
What’s the boundaries of the posterior triangle of the neck?
Medial - Posterior border of SCM
Laterally - Anterior border of trapezius
Inferiorly - Medial 1/3rd of clavicle
How do you perform a H-test for the extrinsic eye muscles?
- Hold the finger 30-40cm from the eyes
- Ask the patient to cover one eye and follow the finger with the other
- Move your finger away from the midline (ABDUCT)
- Lift it up and down (put your finger in the horizontal plane)
- Repeat this but on the other side so they had adducted their eye
What passes through the Cribriform plate?
Olfactory nerve fibres (CN I)
Describe the range of rotation possible at the different regions of the vertebral column
Cervical = large range
Upper thorax (T1-T7) = very limited range
Lower thorax (T7-T12) = large range
Lumbo-sacral = no range
