HNS Flashcards
Bones Identify on a dry skull:
• Cranium – frontal, parietal, occipital, temporal, sphenoid and ethmoid
• Facial – zygoma, maxilla, nasal, lacrimal, vomer, palatine, inferior conchae and mandible
• Pterion
Netters
On the dry skull identify the following foramina and recall the key blood vessels and nerves that pass through them: • Cribriform plate • Optic canal • Superior orbital fissure • Foramen rotundum • Foramen ovale • Foramen spinosum • Carotid canal • Internal acoustic meatus • Jugular foramen • Hypoglossal canal • Foramen magnum • Stylomastoid foramen
- Cribriform plate – Olfactory nerve fibres (I)
- Optic Canal – Optic nerve (II), ophthalmic artery, central retinal artery
- Superior Orbital Fissure – Oculomotor nerve (III), trochlear nerve(IV), ophthalmic nerve(V1), abducens nerve (VI), superior ophthalmic vein, SNS fibres
- Foramen Rotundum – Maxillary nerve (V2), artery of foramen rotundum, emissary veins
- Foramen Ovale – Mandibular nerve (V3), accessory meningeal artery, emissary vein
- Foramen Spinosum – middle meningeal artery, middle meningeal vein, branch of mandibular nerve (V3)
- Carotid Canal – Internal carotid artery, SNS to head from superior cervical ganglion
- Internal Acoustic Meatus – vestibulocochlear nerve (VIII), Facial nerve (VII), Labyrinthine artery
- Jugular Foramen – Glossopharyngeal nerve (IX), vagus nerve (X), Accessory Nerves (XI)
- Hypoglossal Canal – Hypoglossal nerve (XII)
- Foramen Magnum – Apical ligament and tip of dens, upper band of cruciate ligament, membrana tectoria, medulla oblongata, vertebral artery, spinal roots of accessory nerves (XI), anterior and posterior spinal arteries.
- Stylomastoid Foramen – Facial nerve (VII)
On the osteological specimen of a typical vertebra identify the following structures: body, pedicle,
lamina, transverse process, spinous process, articular surfaces
Netters
Using the dry skull and osteological specimens of the atlas and axis, demonstrate the movements
which occur at the atlanto-occipital and atlanto-axial joints
- Atlanto-occipital – ‘yes’ joint
- Atlanto-Axial – ‘No’ joint
- For rotation of head on the neck
- Dens is the pivot
Demonstrate the surface landmarks of C7, T3, T7, L2 and L4 vertebrae
C7 – first palpable vertebrae T3 – Scapula spine T7 – apex of scapula L2 – Lowest part of 12th rib L4 – Supracristal plane
Demonstrate the surface landmarks used for placement of epidural injections
- Supracristal plane at the level of L4
- Posterior midline, between L3/4 or L4/5 – L4/5 in adults, L3/4 in children
Test the range of motion of the different regions of the vertebral column and describe the anatomical
basis for your findings using osteological specimens
Cervical – flexion (80°), Extension (70°), Lateral flexion (30°), Rotation (90°). Atlanto-occipital joint: YES. Atlanto-axial joint: NO.
Thoracic – Flexion (50°), Extension (45°), Lat. Flex. (40°), rot. 30°
Lumbar - Flexion (60°), Extension (25°), Lat. Flex. (25°), rot. 18°
Demonstrate the technique for palpation of the cervical lymph nodes
Sub-mental – Inside mentus of mandible
Sub-mandibular – near sub-mandibular salivary glands
Tonsillar – in front of tragus of ear, under mandible
Parotid – In front of pre-auricular
Pre-auricular – in front of tragus of ear
Post-auricular – behind tragus of ear, mastoid process
Occipital – Post to mastoid process, base of skull
Ant. Cervical chain – Along SCM anteriorly
Post. Cervical chain – Along trapezius
Supraclavicular - behind clavicle
Locate the hyoid bone, thyroid and cricoid cartilages, lateral mass of the atlas and spinous process of
C7
- Hyoid – Midline, under mandible
- Thyroid – first palpable ‘bump’ in neck
- Cricoid – Second palpable ‘bump’ in neck
- Lat. Mass of atlas – right underneath skull near foramen magnum - lateral
- C7 – First palpable vertebra
Demonstrate the boundaries of the anterior and posterior triangles of the neck and recall the contents
of each
Anterior triangle (posterior border SCM, medial border saggital plane, superior border mandible)
- Digastric muscle
- Platysma
- Mylohyoid
- Infrahyoid
- Carotid arteries
- Internal jugular vein
- Digastric muscle
- Stylohyoid muscle
Posterior triangle (posterior border trapezius, anterior border SCM, inferior border middle 1/3 clavicle)
- Mainly vessels and nerves
- External jugular vein
- Sunclavian artery
- Subclavian vein
- Trunks of the branchial plexus
- Phrenic nerve
- Vagus nerve
- Spinal accessory nerve
Demonstrate the surface landmarks for insertion of a central line into the internal jugular vein
Between the two heads of SCM, above the clavicle. Lateral to carotid. Use ultrasound in practise
Demonstrate the positions of the external and internal jugular veins and their surface landmarks
- External jugular – line from angle of mandible to middle of clavicle
- Internal jugular – Just lateral to -upper part of sternal end of clavicle, to midway between tip of mastoid process and angle of mandible.
- Joins with SCV at sternoclavicular joint to form brachiocephalic vein.
Test the functions of the accessory nerve
Trapezius - Ask patient to raise shoulders against resistance
Sternocleidomastoid - Ask patient to rotate head against resistance
Test the general sensory function of the three divisions of the trigeminal nerve (ophthalmic, maxillary
and mandibular) by stimulating the appropriate dermatomes with a pin
Before: Consent, tell pt. to close eyes, put cotton wool on sternum/neck to ensure they can feel it. Do all just lateral to midline.
V1 – Forehead
V2 – Zygoma (either side of nose)
V3 – Jaw
Test the motor function of the mandibular division of the trigeminal nerve
- Ask to clench jaw
- Palpate masseater and temporalis
Test the motor function of the facial nerve
Ask patient to raise eyebrows, close eyes against resistance, puff out cheeks against resistance and smile.
– Look for asymmetry
Recall the testing of the glossopharyngeal nerve
Use a tongue depressor on the back of the tongue
to evoke a gag reflex (glossopharyngeal nerve is sensory to posterior 1/3 of the tongue)
Test the motor function of the vagus nerve
- Ask the subject to open their mouth and say “ahh”
and observing the elevation of the uvula to see if there is any deviation from the midline - Deviation away from the lesioned side
Test the motor function of the hypoglossal nerve
- Ask the subject to protract their tongue and
observing any deviation from the midline - Deviation towards the lesioned side
Examine the teeth in the subject’s mouth using a penlight. Identify incisors, canines, premolars and
molars, and record the number of each in each quadrant of the mouth
In each quadrant:
- 2 incisors
- 1 canine
- 2 premolar
- 3 molar
On the dry skull identify the bones of the nasal cavity and the locations of the paranasal sinuses
Bones: Nasal, ethmoid, frontal, hard palate
Sinuses: Frontal, sphenoid, ethmoid, maxillar
Locate the hyoid bone, the thyroid and cricoid cartilages, the cervical part of the trachea, and the
thyroid isthmus
Netters
Demonstrate the positions of the paranasal sinuses and the mastoid air cells
- Frontal – above top of nose
- Sphenoid – back of nose
- Ethmoid – above nose
- Maxillary – behind sphenoid sinus
- Mastoid Air cells – mastoid process
Demonstrate the anatomical basis of tracheostomy and cricothyroidotomy
Tracheostomy – below first ring of trachea, usually between 3 and 4, used for long term
Cricothyroidotomy – between cricoid cartilage and thyroid cartilage. Through cricothyroid membrane. Used in emergency
Identify the features of the external auditory meatus and eardrum that can be seen through an
otoscope
See diagram
Using visual pursuit of the finger, test the function of the extrinsic muscles of the eye
MR – look medially (III) LR – Look laterally (VI) IO – Look medially and superiorly (III) SO – Look medially and inferiorly (IV) SR – Look laterally and superiorly (III) IR – Look laterally and inferiorly (III)
Lesions:
- CNIII – down and out
- CNIV – Up and in
- CNVI – in
Using a penlight, test the ipsilateral and consensual pupillary light reflex
- Shine in R, look for dilation in R.
- Shine in R, look for dilation in L.
- Shine in L, look for dilation in L.
- Shine in L, look for dilation in R
- Swinging torch – RAPD – both pupils constrict when light swings to undamaged side, both pupils paradoxically dilate when light swings to damaged side.
Recall the afferent and efferent arms of the accommodation reflex
- Reflex of eye to focus on near or distant object.
- Test – Look at distant object, then to you. And vice versa. Look for convergence/divergence of eyes.
- Afferent – Optic nerve (CNII)
- Efferent – Oculomotor (CNIII
Recall the afferent and efferent arms of the light reflex
- Light
- Afferent from the primary visual pathway: retina -> optic nerve (CN2) -> optic chiasm -> optic tract -> Edinger Westphal nucleus
- Efferent starts in visual cortex: Edinger-Westphal nucleus -> oculomotor nerve and short ciliary nerves -> sphincter pupillae.
Recall the afferent and efferent arms of the corneal reflex
‘Blink reflex’ – Touch cornea with sterile cotton wool.
Afferent – nasociliary branch of ophthalmic branch of trigeminal nerve (CNV1)
Efferent – Temporal and zygomatic branches of the facial nerve (CNVII)
Ask patient if they use contact lenses – may diminish/abolish reflex
Describe the main movements of the TMJ
Hinge and gliding
