Moore Text Practical 1

Question 1

Temporal branch of CN VII

Answer 1

Emerges from the superior border of the parotid gland and crosses the zygomatic arch to supply the auricularis superior and inferior; the frontal belly of the occipitofrontalis; and the superior part of the orbicularis oculi

Question 2

Zygomatic branch of CN VII

Answer 2

Passes via two or three branches superior and mainly inferior to the eye to supply the inferior part of the orbicularis oculi and other facial muscles inferior to the orbit

Question 3

Buccal branch of CN VII

Answer 3

Passes external to the buccinator to supply this muscle and the muscles of the upper lip- upper parts of orbicularis oris and inferior fibers of the levator labii superioris

Question 4

Marginal mandibular branch of CN VII

Answer 4

Supplies the risorius and muscles of the lower lip and chin. It emerges from inferior border of the parotid gland and crosses the inferior border of the mandible deep to the platysma to reach the face. In 20% of people, it passes inferior the the angle of the mandible

Question 5

cervical branch of CN VII

Answer 5

Passes inferiorly from the inferior border of the parotid gland and runs posterior to the mandible to supply the platysma

Question 6

Which other cranial nerve supplies motor innerv to muscles of the face besides CN VII (facial nerve)

Answer 6

Mandibular division of CN V- muscles of mastication

Question 7

Main arterial supply to the face

Answer 7

Facial artery- arises from the external carotid artery and winds its way to the inferior border of the mandible, just anterior to the masseter. The artery lies superficially here, immediately deep to the platysma. Crosses the mandible, buccinator, and maxilla as it courses over the face to the medial angle of the eye. This artery lies deep to the zygomaticus major and levator labii superioris muscles.
Sends branches to the upper and lower lips- superior and inferior labial arteries. It ascends along the side of the nose, and anastomoses with the dorsal nasal branch of the ophthalmic artery. The terminal part of the facial artery is called the angular artery, which is distal to he lateral nasal artery at the side of the nose.

Question 8

Two arteries accompanying cutaneous nerves in the face

Answer 8

Supra-orbital artery- branch of the ophthalmic artery, accompanies the Supra-orbital nerve across the eyebrows and forehead and continues to supply the anterior scalp to the vertex.
Mental artery- the only superficial branch derived from the maxillary artery, accompanies the nerve of the same name in the chin.

Question 9

Which layer of the scalp are the arteries?

Answer 9

Within layer two of the scalp, the subcutaneous connective tissue layer between the skin and the epicranial aponeurosis.
The arterial walls are firmly attaches to the dense CT in which they are embedded, limiting their ability to constrict when cut. Consequently, bleeding from scalp wounds is profuse.

Question 10

Facial veins

Answer 10

Valveless, coursing parallel with the facial arteries.
Primary superficial drainage of the face
Tributaries of the facial vein include the deep facial vein, which drains the pterygoid venous plexus of the infratemporal fossa
Drains directly or indirectly into the internal jugular vein. At the medial angle of the eye, the facial vein communicates with the superior ophthalmic vein, which drains into the cavernous sinus.

Question 11

3 main neurovascular structures that traverse the parotid gland

Answer 11

Facial nerve, retromandibular vein and the external carotid artery

Question 12

Fracture of the pterion

Answer 12

Overlies the frontal branches of the middle meningeal vessels, which lie in grooves on the internal aspect of the lateral wall of the calvaria.
The pterion is superior to the zygomatic arch and posterior to the frontal process of the zygomatic bone.
Hard blow to the side of the head may fracture the thin bones forming the pterion, resulting in a hematoma that exerts pressure on the underlying cerebral cortex- can cause death in a few hours

Question 13

Background of the facial vein

Answer 13

The facial vein makes clinically important connections with the cavernous sinus through the superior ophthalmic vein, and the pterygoid venous plexus through the inferior ophthalmic and deep facial veins. Because of these connections, an infection of the face may spread to the cavernous sinus and pterygoid venous plexus.
Blood from the medial angle of the eye, nose and lips usually drains inferiorly through the facial vein, especially when a person is erect. Because the facial vein has no valves, blood may pass through the opposite direction.

Question 14

Thrombophlebitis of facial vein

Answer 14

Inflammation of the facial vein with secondary thrombus (clot) formation
Pieces of an infected clot may extend into the intracranial venous system and produce thrombophlebitis of the cavernous sinus
Infection of facial veins spreading to the dural venous sinuses may result from lacerations of the nose or be initiated by squeezing pimples on the side of nose and upper lip- danger triangle of the face

Question 15

Blunt trauma to the head

Answer 15

A blow to the head can detach the periosteal layer of dura mater from the calvaria without fracturing the cranial bones. In the cranial base, the two dural layers are firmly attached and difficult to separate from the bones. So, a fracture of the cranial base usually tears the dura and results in leakage of CSF. The innermost part of the dura, the dural border cell layer, is composed of flattened fibroblasts that are separated by large extracellular spaces. This layer constitutes a plane of structural weakness at the dura-arachnoid junction.

Question 16

Tentorial herniation

Answer 16

The tentorial notch is the opening in the tentorium cerebelli for the brain stem, which is slightly large than is necessary to accommodate the midbrain. So, space-occupying lesions, such as tumors in the supratentorial compartment, produce increased ICP, and may cause part of the adjacent temporal love of the brain to herniated through the tentorial notch. During tentorial herniation, the temporal lobe may be lacerated by the tough tentorium cerebelli, and the oculomotor nerve (CN III) may be stretched, compressed or both. Oculomotor lesions may produce paralysis of the extrinsic eye muscles supplied by this CN.

Question 17

Bulging of the diaphragma sellae

Answer 17

Pituitary tumors may extend superiorly through the aperture in the diaphragma sellae, or cause it to bulge. These tumors often expand the diaphragma sellae, producing disturbances in endocrine function before or after expansion. Superior extension of a tumor may cause visual symptoms owing to pressure on the optic chiasm, the place where the optic nerve fibers cross.

Question 18

Occlusion of cerebral veins and dural venous sinuses

Answer 18

Can result from thrombi, thrombophlebitis, or tumors. The dural sinuses most frequently thrombosis are the transverse, cavernous and superior sagittal sinuses.
Cavernous sinus thrombosis usually results from infections in the orbit, nasal sinuses and superior part of the face. Cavernous sinus thrombophlebitis can go on to affect the abducens nerve as it traverses the sinus and may also affect the nerves embedded within the lateral wall of the sinus.
Septic thrombosis of the cavernous sinus often results in development of acute meningitis

Question 19

Metastasis of tumor cells to dural venous sinuses

Answer 19

The basilar and occipital sinuses communicate through the foramen magnum with the internal vertebral venous plexuses. Because these venous channels are valveless, compression of the thorax, abdomen, or pelvis as occurs during heavy coughing or straining, may force venous blood from these regions into the internal vertebral venous system and from it into the dural venous sinuses. So, pus in abscesses and tumor cells in these regions may spread to the vertebrae and brain.

Question 20

Fractures of the cranial base

Answer 20

The internal carotid artery may be torn, producing an ateriovenous fistula within the cavernous sinus. Arterial blood rushes into the sinus, enlarging it and forcing retrograde blood flow into its venous tributaries, especially the ophthalmic veins, causing the eyeball to protrude (exophthalmos) and the conjunctiva becomes engorged (chemosis). The protruding eyeball pulsates in synchrony with radial pulse (pulsating exophthalmos). Because CN III, IV, V1, V2, and VI lie in or close to the lateral wall of the cavernous sinus, these nerves may also be affected when the sinus is injured.

Question 21

Dural origin of headaches

Answer 21

Pulling on arteries at the cranial base or veins near the vertex, where they pierce the dura will cause pain. Dissension of the scalp or meningeal vessels is believed to be one of the causes of headaches.
Many headaches appear to be dural in origin, such as the headache occurring after a lumbar spinal puncture for removal of CSF. These are thought to result from stimulation of sensory nerve endings in the dura. When CSF is removed, the brain sags slightly, pulling on the dura. So, patients are asked to keep their heads down after a lumbar puncture to minimize the pull on the dura.

Question 22

Leptomeningitis

Answer 22

Inflammation of the leptomeninges (arachnoid and pia) resulting from pathogenic microorganisms. The infection and inflammation are usually confined to the SAS and the arachnoid-pia. Bacteria may enter the SAS through the blood or spread from an infection of the heart, lungs or other viscera. They may also enter the SAS from a fracture of the cranium or nasal sinuses. Acute purulent meningitis can result from infection with almost any pathogenic bacteria

Question 23

Head injuries and intracranial hemmorrhage- epidural

Answer 23

Arterial in origin. Blood from torn branches of a middle meningeal artery collects between external periosteal layer of the dura and the calvaria. The extravasated blood strips the dura from the cranium. Usually this follows a hard blow to the head. A brief concussion (loss of consciousness) usually occurs, followed by a lucid interval of some hours. Later, drowsiness and coma occur. Compression of brain occurs as the blood mass increases.

Question 24

Subdural hematoma

Answer 24

Dural border hematoma. No naturally occurring space between the dura-arachnoid junction. Usually caused by extravasated blood that splits open the dural border cell layer. The blood does not collect within a preexisting space, but rather creates a space. Hard blow to the head that jerks the brain inside the cranium. The precipitating trauma may be trivial or forgotten. Typically venous in origin and commonly results from tearing a superior cerebral vein as it enters the superior sagittal sinus.

Question 25

Subarachnoid hemorrhage

Answer 25

Extravasation of blood, usually arterial, into the SAS. Usually result from rupture of an aneurysm (like of the internal carotid artery in strokes). Some are involved with head trauma involving cranial fractures and cerebral lacerations. Bleeding into the SAS results in meningeal irritation, severe headaches, stiff neck and often loss of consciousness

Question 26

Danger area of the scalp

Answer 26

Loose connective tissue layer, since blood or pus spreads easily into it. Infection in this layer can also pass into the cranial cavity through small emissary veins, which pass through the parietal foramina in the calvaria, and reach intracranial sutures such as the meninges. An infection cannot pass into the neck, because the occipital bellies of the occipitofrontalis muscle attach to the occipital bone and mastoid parts of the temporal bones. Nor can a scalp infection spread laterally beyond the zygomatic arches because the epicranial aponeurosis is continuous with the temporal fascia that attaches to these arches. An infection or fluid can enter the eyelids and the root of the nose because the occipitofrontalis inserts into the skin and subcutaneous tissues and does not attach to the bone.

Question 27

Occipitofrontalis facial expression

Answer 27

Front belly- elevates the eyebrows and wrinkles skin of forehead, protracts scalp (indicating surprise or curiosity)
Occipital belly- retracts scalp; increasing effectiveness of frontal belly

Question 28

Orbicularis oculi facial expression

Answer 28

Closes eyelids: palpebral part blinks gently, orbital part tightly- winking.

Question 29

Levator labii superioris and zygomatic minor facial expression

Answer 29

Part of dilators of mouth, retract (elevate) and/or evert upper lip; deepen nasolabial sulcus (showing sadness)

Question 30

Orbicularis oris facial expression

Answer 30

Tonus closes oral fissure; phasic contraction compresses and protrudes lips (kissing) or resists distension (when blowing)

Question 31

Buccinator facial expression

Answer 31

Presses cheek against molar teeth; works with tongue to keep food between occlusal surfaces and out of oral vestibule; resists distension (when blowing)

Question 32

Zygomaticus major

Answer 32

Part of dilators of mouth; elevate labial commissary- bilaterally to smile (happy), unilaterally to sneer (disdain)

Question 33

Levator Angeli oris

Answer 33

Part of dilators of mouth; widens oral fissure, as when grinning or grimacing.

Question 34

Risorius and depressor anguli oris facial expression

Answer 34

Part of dilators of mouth; depresses labial commissure bilaterally to frown (sadness)

Question 35

Depressor labii inferioris

Answer 35

Parts of dilators of mouth; retracts (depresses) and/or everts lower lip (pouting, sadness)

Question 36

Mentalis muscle facial expression

Answer 36

Elevates and protrudes lower lip (“boo-boo lip”); elevates skin of chin (showing doubt)

Question 37

Platysma facial expression

Answer 37

Depresses mandible against resistance; tenses skin of inferior face and neck (conveying tension and stress)

Question 38

Neuralgias

Answer 38

Characterized by severe throbbing or stabbing pain in the course of a nerve caused by demyelinating lesion. Common cause of facial pain that is diffuse

Question 39

3 common fractures of the maxilla

Answer 39

Le fort 1- horizontal fracture passing superior to the maxilla alveolar process (roots of the teeth) crossing the bony nasal septum and possibly the pterygoid plates of the sphenoid
Le fort 2- passes from the posterolateral parts of the maxillary sinuses superomedially through the infraorbital foramina, lacrimnals, or ethmoidal to the bridge of the nose. Entire central part of the face, including the hard palate and alveolar processes, is separated from rest of cranium
Le fort 3- horizontal fracture that passes through the superior orbital fissures and the ethmoid and nasal bones and extends laterally through greater wings of the sphenoid and frontozygomatic sutures. Concurrent fractures of zygomatic arches cause the maxilla and zygomatic bone to separate from the rest of the cranium

Question 40

fractures of the mandible

Answer 40

Usually involves two fractures, which frequently occur on opposite sides of the mandible.
Fractures of the coronoid process are uncommon and usually single
Fractures of the neck of mandible are often transverse and may dislocate the TMJ on same side
Fractures of the angle are usually oblique and may involve the bony socket or alveolus of 3rd molar tooth
Fractures of the body pass through the socket of a canine tooth

Question 41

Fractures of the calvaria

Answer 41

Hard blows in thin areas= depressed fractures, where bone is depressed inward
Linear calvaria fractures are most common, at the point of impact with fracture lines radiating away
Contrecoup fracture- no fractures occur at point of impact, but one occurs on the opposite side of the cranium

Question 42

What two bony features of the skull are not present at birth

Answer 42

Mastoid and styloid processes
So the facial nerves are close to the surface when they emerge from the SM foramina, so they may be injured by forceps during a difficult delivery or later by an incision posterior to the auricle of the external ear (for mastoiditis)

Question 43

Fontanelle positions

Answer 43

Anterior- bregma
Posterior- lambda
Sphenoidal and mastoid- overlain by the temporalis muscle

Question 44

Which cranial bone is the most dynamic with age

Answer 44

Mandible

Question 45

Premature closure of the cranial sutures

Types

Answer 45

Primary craniosynostosis
Results in several cranial malformations
Theory to be caused by abnormal development of cranial base that may exaggerate the dura mater that disrupt normal cranial suture development

Scaphocephaly- premature closure of sagittal suture= small, long, narrow wedge shaped cranium
Plagiocephaly- coronal or lambdoid suture on one side= cranium is twisted and asymmetrical
Oxycephaly or turricephaly- coronal suture= high, tower-like cranium

Usually do no affect brain development