Recap lectures 3-7 Flashcards
Back, head, and neck
1) Where does the vertebral column start and end?
2) How many vertebrae are there in each section of the spine?
1) Goes from cranium to the apex of the coccyx
2) C7, T12, L5, S5, Co4
Name 6 things the vertebral column does
1) Main support of the axial skeleton
2) Protects the spinal cord and nerves
3) Supports weight of body superior to sacrum
4) Rigid-flexible axis for body
5) Pivots the head
6) Posture for body
1) What is a major stress point of the vertebral column?
2) What part(s) of the vertebral column allow for significant amount of motion?
1) Lumbosacral angle (L5-S1 junct.)
2) Superior 25 vertebrae, most in cervical
What two sections of the spinal column is most motion in?
Cervical and lumbar
What 3 things provide stability to the vertebral column?
1) Shape and strength of vertebrae and IV disc
3) Ligaments
4) Muscles
List the 4 curves of the adult spine from top to bottom. Specify whether each is primary or secondary
1) Cervical lordosis, secondary
2) Thoracic kyphosis, primary
3) Lumbar lordosis, secondary
4) Sacral kyphosis, primary
1) What is a developmental condition that can cause abnormal spinal curvature (that can be both lateral and rotational)?
2) What is a pathologic condition that can cause abnormal spinal curvature?
1) Scoliosis
2) Osteoporosis
An anterior rotation of pelvis, causing an abnormal increase in the lumbar lordosis curve, is defined as what?
Lordosis
What are the 3 components of a typical vertebrae?
1) Body
2) Arch (contains pedicle & lamina)
3) 7 processes
1) What are the endplates of a vertebral body covered in?
2) What is the epiphyseal rim made of?
3) Where on the column do vertebral bodies increase in size?
1) Hyaline cartilage
2) Bone
3) T4-S1
What are the 2 features of a typical vertebral arch? List and describe them
1) Paired pedicles: Connect arch to body; form vertebral notches and adjacent vertebral notches for intervertebral foramen
2) Paired lamina: Unite at midline
1) Define vertebral foramen
2) What do vertebral notches form
3) What is typically between vertebral bodies?
1) Spinal canal where spinal cord resides
2) Intervertebral (IV) foramina
3) IV disc
List the 7 processes of a typical vertebrae
1) Spinus process (dorsal)
2&3) Paired transverse processes
4,5,6,7) Paired superior and inferior articular processes
What do the paired superior and inferior articular processes of the vertebrae form?
Zygapophyseal (facet) joints
What are the two foramen found in cervical vertebrae, and what runs through them?
1) Large triangular vertebral foramen: spinal cord and cervical nerve roots
2) Foramen transversarium (absent C7): vertebral artery & vein, and sympathetic nerves
What is unique about C7?
It doesn’t have a foramen transversarium (unlike the other cervical vertebrae)
Do cervical and thoracic spinal nerves exit via the intervertebral (IV) foramen above or below their same numbered vertebra?
1) Cervical: exit IV foramen above the same numbered vertebra
2) Thoracic: exit IV foramen below their corresponding vertebra
1) What is the atlas?
2) What shape is it?
3) What does its transverse ligament do?
4) What does it allow for?
1) The first cervical vertebrae (C1)
2) Ring shaped
3) Separates vertebral foramen from foramen for dens (C2)
4) Allows flex/ext. of cranium (nodding yes)
1) What is the axis?
2) What is unique about the axis?
3) What does its dens (odontoid) articulate with?
4) What does this allow for?
1) C2
3) Strongest
3) Anterior arch of atlas and transverse ligament
4) Rotation of head and atlas about the axis, as in “NO”
Does the axis itself rotate?
No
What vertebrae is most likely to fracture if you dive into shallow water and hit your head?
The atlas (C1) (Jefferson’s fracture)
1) Describe the size of the vertebral bodies and vertebral foramens of the lumbar vertebrae
2) Where does the spinal cord end in adults?
3) Describe the length of the cauda equina
1) Bodies are massive, vertebral foramens are large
2) L1-2 in adults
3) Extends full length of vertebral canal
1) What exits each intervertebral (IV) foramen of the lumbar vertebrae?
2) What is the preferred site to access epidural space for anesthesia & SA space for CSF collection?
3) A defect in pars interarticularis of neural arch (lamina between the two articular processes) can cause what lumbar condition?
1) Spinal nerves
2) Below L2 (since spinal cord ends there), between L3-L4 or L4-L5
3) Spondylolysis
If a patient comes in complaining of radiating leg pain progressing from their upper to lower legs when walking that’s relieved by bending over (like leaning on a shopping cart), what condition might they have?
Lumber stenosis
1) What do spina bifida, meningoceles, and meningomyeloceles have in common?
2) What joints transmit body weight to pelvic girdle?
1) All result from incomplete closure of the neural tube
2) SI joints
What is the sacral promontory?
The anterior edge of the S1 body
1) Describe the texture and shape of the dorsal side of the sacrum
2) What is found on its surface?
3) What are the 3 sacral crests?
4) What is the sacral hiatus? What does it lead to?
1) Rough and convex
2) 4 pair of foramina
3) Median, intermediate, lateral
4) Inferior end of vertebral canal that leads into sacral canal
1) What is the coccyx a remnant of?
2) Are its vertebrae fused?
3) What is its clinical significance?
1) Vestigial tail
2) Distal 3 vertebrae fuse in mid life
3) Can palpate it rectally
1) What is the Conus medullaris?
2) Where does it terminate in newborns?
3) What about in adults?
1) The terminal, inferior end of the spinal cord
2) Newborn: opposite L2/3 IV disc
3) Adult: opposite L1/2 IV disc
What are the 2 potential causes of cauda equina syndrome?
Disc herniation or spinal stenosis
-(Can be caused by cancer, trauma, epidural abscess or hematoma)
If a patient with an epidural abscess suddenly complains of loss of bowel or bladder control, what might be the cause? What might be the cause of that?
Cauda equina syndrome secondary to disc herniation or spinal stenosis (caused by their epidural absess)
If a patient with a history of lower spinal trauma (below L1/2) suddenly complains of numbness around the anus and radiating pain down their leg, what might be the cause? What might be the cause of that?
Cauda equina syndrome secondary to disc herniation or spinal stenosis (caused by their previous spinal trauma)
1) What do superficial [extrinsic] back muscles act on?
2) What innervates them?
1) UE
2) Anterior rami or CN XI
1) Trapezius, lat. dorsi, levator scapulae, rhomboid, and serratus posterior are all examples of what type of back muscle?
2) The 3 serratus muscles and the proprioceptive respiratory muscles are examples of what type of back muscle?
1) Superficial extrinsic
2) Intermediate extrinsic
1) The splenius group that does lateral flexion and rotation and extension of the head/ neck are what layer of back muscles?
2) What layer of muscles are the erector spinae (main extensors of spine) a part of?
3) What layer are the transversospinalis group a part of?
1) Intrinsic superficial
2) Intrinsic intermediate
3) Intrinsic deep
1) What two things are IV discs associated with?
2) What is the more exterior part of the IV discs called? Where does it attach?
3) What is the more interior part of the IV discs called? Where is it located?
1) ROM and natural curvatures of spine
2) Annulus fibrosus (85% water); attaches to end plates
3) Nucleus pulposis; positioned more posteriorly
Describe the shape of annulus fibrosus
Thinner posteriorly (why herniated discs can happen)
List the 5 types of joints found in the vertebral column
1) Vertebral bodies: IV Discs, uncovertebral joints
2) Vertebral arches: Zygapophysial (facet) joints
3) Craniovertebral: occipital condyle with atlas
4) Costovertebral: ribs
5) Sacroiliac: SI joint
1) Describe the joints of the vertebral arches; what type of joints are they?
2) What do they allow for?
3) What are they innervated by?
1) Zygapophysial (facet) joints; synovial
2) Gliding movement
3) Medial branch of posterior rami spinal nerves
What are the 3 branches of the median branch of the posterior rami of spinal nerves?
Muscular, cutaneous and articular branches
1) What are the 4 movements of the spine?
2) What reduces these movements in some people?
3) Why?
4) What innately limits movement?
1) Flexion, extension, lateral flex, rotation
2) Age
3) Primarily from IV-disc compression and elasticity
4) Physical characteristics of the anatomy
Is age the primary cause of reduced spinal movement? Explain
No, it’s secondary to degenerative changes in IV disc and other structures
What 3 things allow movement of the spine?
1) Back and abdominal muscles (like rectus abdominus and obliques)
2) Gravity
3) Movement between adjacent vertebra (Zygapophyseal joints and IV-disc)
What are the two types things that allow movement between adjacent vertebrae?
Zygapophyseal joints and IV-disc
What part of the spine has the greatest degree of flexion ROM?
Cervical spine
What two things limit ROM of the thoracic spine?
Ribs and sternum
1) What allows for greater flexion and extension of the lumbar spine?
2) Is there a lot of rotation of the lumbar spine? Why?
3) Describe the IV discs of the lumbar spine
1) Facet joints
2) Minimal rotation due to interlocking facets
3) Relatively large IV discs
Is extension or flexion greater in the lumbar area?
1) Extension > flexion
(spondylosis in gymnast)
What are the 3 longitudinal arteries that supply the vertebral column?
1) Anterior spinal artery
2&3) Paired posterior spinal arteries
Describe venous drainage of the vertebral column
-Forms venous plexuses:
1) External plexus
2) Internal plexus
Describe the manner in which the venous plexuses that drain the spine communicate
Communicate freely
1) Where is the internal vertebral venous plexus?
2) Where does it drain?
3) What does it communicate with?
1) In epidural space
2) Drains superiorly into dural venous sinus in cranium
3) With external vertebral plexus on external surface of vertebra
What innervates the vertebral column?
Meningeal branches of spinal nerves
1) Where is most body weight in relation to the vertebral column?
2) Where is most muscle support in relation to the vertebral column?
3) What are the two types of back muscles?
1) Anterior
2) Posterior
3) Intrinsic and extrinsic
What are the two types of extrinsic back muscles? What does each do?
1) Superficial: control limb movement
2) Intermediate: control respiratory movement
What are the 3 kinds of intrinsic back muscles? (bonus: give examples of each)
1) Superficial: splenius
2) Intermediate: erector spinae
3) Deep: transversospinalis
1) How are the extrinsic back muscles innervated and what do they do?
2) What is the exception?
1) By anterior rami of c-spinal nerves, act on UE (except for trapezius).
2) Trapezius m. innervated by spinal accessory n., CN XI
1) What are the muscles of the back proper?
2) What innervates them?
3) What do they do?
4) Where are they?
5) What are their groups?
1) The intrinsic muscles of the back
2) Posterior rami branches of spinal nerves
3) Maintain posture and control ROM of the vertebral column
4) Below investing fascial (“invested” in deep fascia) midline to transverse processes and angle of the ribs
5) Superficial, intermediate, and deep layers
1) Give the brief explanation of what intrinsic muscles are innervated by and what they do
2) What are the enclosed in?
1) Innervated by posterior rami of spinal n.; control posture and movement of the spine
2) In deep fascia (thoracolumbar fascia)
1) Where are the suboccipital region and suboccipital triangle?
2) What is it made of?
1) Deep to trapezius and semispinalis capitis mm.
2) 4 small muscles
1) What kinds of muscles form suboccipital region/ what do they act on?
-bonus: what are they?
2) What CN innervates these triangle region muscles? Does this CN provide skin sensory?
1) Mainly postural muscles, act on head (capitis): ext of head and rotate head b/t C1-2
-2 rectus capitis and 2 obliquus capitis
2) Posterior ramus of C1; suboccipital nerve; no skin sensory
What is the clinical correlation of the greater and lesser occipital nerves?
-Can cause occipital neuralgia, which is defined as chronic headaches by the occipital nerves
-Sometimes a nerve block is placed in the greater occipital nerve at the back of the neck
1) What space is spinal anesthesia placed for surgical procedures?
2) What space are CSF samples collected from? What are they also called, and where on the spine do they go?
3) What space is epidural anesthesia placed?
1) Spinal anesthesia: subarachnoid space
2) Subarachnoid space; aka lumbar taps. Done on lumbar cistern below L1-2 where spinal cord ends.
3) Epidural space
What is the pathway of epidurals and LPs (lumbar punctures)?
1) Skin
2) Spinous ligament
3) Ligamentum flavum
4) Epidural space: epidurals stop here
5) Dura-arachnoid meninges
6) Subarachnoid space: lumbar punctures stop here
Bonus: Describe the origins and courses of the greater and lesser occipital nerves
1) Greater occipital nerve: comes from the dorsal rami of C2, goes up the back of head, emerges inferior to obliquus capitis inferior and ascending to posterior scalp
2) Lesser occipital: come from anterior rami of C2-3, goes directly to skin
What makes up the scalp proper? List each part
The first 3 layers:
1) Skin
2) Subcutaneous Connective tissue
3) Epicranial Aponeurosis
What are the layers of the scalp (NOT scalp proper)
1) Skin
2) Subcutaneous Connective tissue (SQ)
3) Epicranial Aponeurosis
4) Loose connective tissue
5) Pericranium
1) Describe skin of the scalp
2) Describe Subcutaneous Connective tissue of the scalp and its clinical correlation
1) Skin: typical with pilosebaceous units and sweat glands, abundant vascular supply
2) SQ: Thick, dense, richly vascularized with cutaneous nerves
-Embedded in dense connective tissue (limited ability to constrict when injured; bleeds a lot)
What is the Epicranial Aponeurosis?
A tendonous sheet of fibrous tissue that covers the calvarium
-Connects the 2 bellies of the occipitofrontalis m. & superior auricular m.
-Continuous with the temporal fascia
Describe the jobs of the occipitalis and frontalis
1) Occipitalis muscles: pull scalp posterior
2) Frontalis muscles: wrinkles forehead, raises eyebrows, pulls scalp forward
Why can a black eye result from injury to scalp of the forehead?
Frontal belly of the occipitofrontalis m. inserts into the skin and SQ tissue, not to the bone
-Loose connective tissue of scalp is a sponge-like layer w potential spaces that may distend w fluid/blood from injury or infection
1) What stops blood and pus from passing from the forehead to the neck?
2) What stops blood and pus from spreading laterally beyond the zygomatic arches?
2) Explain why loose connective tissue of the scalp is such a dangerous area
1) Occipital belly of occipitofrontalis m. attaches to the occipital bone and mastoid parts to mastoid bone.
2) Epicranial aponeurosis is continuous with the temporal fascia that attaches to the arches.
3) Infection can pass into cranium via emissary veins
1) What is the BREGMA?
2) What is lambda?
3) Where are sinuses in relation to the orbits? Why is this clinically relevant?
1) The intersection of the coronal and sagittal suture lines (soft spot in baby)
2) The intersection of the sagittal and lambdoid suture lines
3) Medial and inferior to orbits; extension of infections can lead to orbital abscess
1) Fractures of floor of middle cranial fossa may result in leakage to where? What does this result in?
2) Fractures of floor of anterior cranial fossa may involve what? What does this result in?
What can both increase risk of?
1) External acoustic meatus, CSF otorrhea
2) Cribriform plate of the ethmoid, CSF rhinorrhea
-Meningitis
1) Describe the pericranium
2) What does it form?
1) Dense layer of connective tissue
2) External layer of the periosteum of skull
What can scalp stand for?
1) Skin
2) subcutanous Connective tissue
3) epicranial Aponeurosis
4) Pericranium
What are the two structural and functional parts of the cranium? Briefly describe each
1) Neurocranium: cranial vault or “brain bucket” (made up by calvaria + cranial base)
2) Viscerocranium: facial skeleton
What are the two parts of the neurocranium?
1) Calvaria (skullcap)
2) Cranial base
1) What 5 things does the neurocranium contain?
2) What are its two parts?
3) What bones make it up?
1) Brain, meninges, CSF, proximal CN, vessels
2) Calvaria and cranial base
3) Formed by 8 bones
-4 unpaired: frontal, ethmoid, sphenoid, occipital
-2 paired: temporal and parietal (bilateral)
1) What two things are behind the pterion?
2) What is its clinical significance?
1) Temporal lobe and MMA
2) Can fracture with trauma (and mess with the MMA)
What makes up the facial aspect of the cranium (viscerocranium)? List all parts
15 bones:
-Three unpaired midline bones: mandible, ethmoid, vomer
-Six paired or bilateral bones: maxilla, inferior nasal concha (turbinate) zygomatic, palatine, nasal, lacrimal.
What are the two primary sources of blood to the brain? List the basic path of each
1) Anterior circulation: Internal carotids > middle and anterior cerebral aa. of circle of Willis.
2) Posterior circulation: Vertebral arteries > basilar artery > circle of Willis
What supplies blood to the meninges? (bonus: Describe the basic path)
External carotids
(via maxillary artery through foramen spinosum to middle meningeal artery)
What are the two sources of blood supply to the face and viscera of the head? Describe where each goes
1) External carotid: to major branches to face and viscera
2) Internal carotid: to supra orbital/trochlear vessels for frontal region of scalp (mostly brain tho)
What is the clinical correlation of the meningeal arteries?
-The middle meningeal artery (off the maxillary artery) is in groove of the pterion (the meeting of 3 skull bones)
-Trauma to area/fracture can cause epidural bleed
What artery is at risk if the infratemporal fossa is injured? What CN? What veins?
MMA; CNV2; pterygoid venous plexus
Describe the general vascular supply of the tongue
External carotid and lingual arteries, lingual veins drain into IJV
What are the 3 salivary glands?
Parotids, submandibular, sublingual
1) Where is the submandibular duct?
2) Where do the sublingual glands’ ducts open? What innervates them?
1) Opens onto sublingual papilla opposite of 2nd molar
2) On floor of the mouth; CN8 parasymp. (same as submandib.)
What are the 2 nerves of the face? Describe them
1) CN VII: facial nerve, mostly motor (for facial expression)
2) CN V: trigeminal nerve, mostly sensory, has three named branches called V1-2-3
1) What 2 areas does CNVII innervate?
2) What does it travel? Why is this unique?
3) Where does it exit the face?
4) Where is it located?
1) Internal acoustic meatus and muscles of facial expression
2) Goes through facial canal, which is the longest boney canal any nerve must traverse, so it’s at risk
3) Styloid mastoid foramen
4) Deep to parotid gland
1) What nerve innervates the top half of the head?
2) What does it transmit?
1) CNV (has 3 branches, V1-3. )
2) Just somatic sensory
What does CNI do?
Doesn’t really do much to skin, just to muscles in suboccipital triangle
List what’s embedded in the parotid gland from superficial to deep
1) Parotid plexus of facial nerve
2) CN VII
3) Retromandibular vein
4) External carotid artery + lymph nodes
What are the 3 parts of CNV?
1) V1 - ophthalmic (cornea, nose, forehead)
2) V2 - maxillary (cheeks, tiny piece of nose and top of teeth)
3) V3 - mandibular (mandible, some temporal)
What are the afferent and efferent components of the corneal touch reflex?
Afferent component is V1, motor component is CVII
What are the afferent and efferent components of the light reflex?
Optic nerve is afferent, constriction would be CNIII’s sympathetic division
Where does each part of the trigeminal nerve exit?
V1: supraorbital foramen or notch
V2: infraorbital foramen
V3: mental foramen via mandibular canal
When contracted unilaterally, the lateral and medial pterygoid muscles do what?
Cause a lateral chewing motion, grinding motion
1) What are most arteries to the face branches of?
2) What are most external facial veins drained by?
3) Does this vary? If so, what are the alternate routes?
1) External carotid a.
2) Veins that accompany the arteries
3) Varies; alternate route include superficial and deep drainage
1) Where does the facial artery arise from?
2) What does it supply?
3) Can you palpate its pulse?
1) External carotid a.
2) It’s the major artery to superficial face
3) Yes
1) What does the superficial temporal artery arise from?
2) What is one of its characteristics?
1) External carotid a.
2) Can palpate its pulse
1) What is an inflamed temporal artery called? (2 names)
2) What causes it?
3) What are its symptoms?
1) Temporal arteritis (Giant Cell Arteritis)
2) The cause of the blood vessel inflammation is unknown; maybe autoimmune?
3) Headaches, jaw pain, vision loss, fever, and fatigue
1) What 3 arteries arise from the external carotid artery?
2) What 2 arteries arise from the internal carotid artery?
1) External: Occipital, posterior auricular, and superficial temporal arteries
2) Internal: Supratrochlear and supra-orbital arteries
Do arteries of scalp and face anastomose?
Yes, they anastomose freely with each other
1) What is the primary vein that drains the face?
2) Do facial veins drain anastomosis? Elaborate.
3) What vein drains the cranial sinuses?
1) Facial vein
2) Variable, frequent anastomosis between internal/external jugular vv.
3) Internal jugular vein
1) What area doesn’t have lymph nodes? What is the exception?
2) Where does lymph drain into? Name each place and where they’re located.
1) No lymph nodes in scalp or face except for parotid/buccal region
2) Lymph drains into superficial cervical ring of nodes, which are: Submental, submandibular, parotid, mastoid and occipital nodes
-Located at junction of head and neck; deep cervical along the IJV
What is the one muscle of mastication that’s not supplied by the anterior trunk of the mandibular nerve/ V3?
Buccinator; supplied by CN VII (facial nerve)
Slide 39
1) What artery does CNIII follow? What do they do?
2) What type of innervation controls the constriction muscles of the eye? What else does it do?
3) What does the sympathetic part of CNIII control?
1) Internal carotid and CNIII run together; helps with eye dilation
2) Parasympathetic does constriction muscles of iris and interacts w ciliary body
3) Sympathetic only works on the iris (not ciliary body)
List all of the 6 clinical implications to injury to the infratemporal region
1) Disruption of zygomatic arch, TMJ, mandible
2) Blood loss to region to include teeth, meninges, etc.
3) V3 somatic motor (muscles of mastication)
4) Parasympathetic via Submandibular ganglia to lingual n. to SM and SL salivary glands
5) Special sensory (taste anterior 2/3 of tongue via chordae tympani branch of CN VII)
6) Parasympathetic via Otic ganglion to parotid gland
What two parts of the tongue are mobile?
Body and apex
What are the 2 categories of muscles that control the tongue? Describe each
1) 4 Extrinsic muscles alter position: Originate from bony formations outside the tongue (more anchored to floor)
2) 4 Intrinsic muscles alter shape: Confined to tongue
What control the gag reflex? (afferent and efferent)
1) Afferent (sensory): Glossopharyngeal n. (CN 9)
2) Efferent (motor): Vagus n. (CN10)
1) What allows you to generally sense with the anterior 2/3rds of your tongue? (also name specific branch)
2) What allows you to taste with the front of your tongue? (also name specific branch)
1) General sensation = CN V3; lingual n.
2) Taste = CN VII; tympani nerve
1) Does the tongue’s lymphatics drain bilaterally or unilaterally?
2) What are the lymph nodes of the tongue?
1) Posteriorly and midline area drain bilaterally
2) Lateral and front drain to mental and submandibular nodes; posterior drains to cervical nodes
Where is the submandibular duct?
Opens onto sublingual papilla opposite of 2nd molar
What allows you to sense with the posterior 1/3 of the tongue?
1) General and special sensory = CN IX
2) Minor contribution from CN X
List the 5 branches of the external carotid artery that supply the face
1) Lingual a.
2) Facial a.
3) Occipital a.
4) Posterior auricular a.
5) Maxillary a
What two arteries that supply the face don’t originate from the external carotid? Where do they come from?
Supratrochlear and supra-orbital arteries are from internal carotid branches
What two arteries of the face can you palpate the pulses of?
Facial arteries and temporal arteries
What supplies the 4 muscles of mastication?
The anterior trunk of the mandibular nerve (V3)
What sinuses make up the paranasal sinuses? List each and whether they’re paired or unpaired
Frontal: Paired
Ethmoid: midline/paired
Sphenoid: midline
Maxillary: paired
1) What nerve innervates the frontal sinuses?
2) What sections of ethmoid sinus cells drain to the middle meatus? What other sinus drains to the middle meatus?
3) What section(s) of the ethmoid sinus drain to the superior meatus?
1) CN6
2) Anterior and middle; maxillary sinus [via maxillary osteum]
3) Posterior
1) Where are the sphenoid sinuses?
2) Do they open into the nasal cavity?
1) Occupy the cavity in delicate sphenoid bone, drain into. 2) No real opening into the nasal cavity.
What is the rich plexus where all the arteries supplying the septum anastomose? What is the clinical significance of this area?
Keisselbach; profuse epistaxis (nosebleeds)
What nerves innervate the nose? (2)
1) Posterio-inferior ½ to 2/3 of cavity is primarily: CN V2 (maxillary n.)
2) Anterior superior cavity (both septum & lateral wall) is primarily: anterior ethmoidal nerves from CN V1 (ophthalmic n.)
True or false: Mucosa of the oral cavity is continuous with the gingiva
True
Where can you find gingiva?
Around the neck of teeth
True or false: There’s both ipsilateral and contralateral drainage of cheeks, lips, and chin lymphatics
True
True or false: infections don’t easily spread from one side of the face to another
False; infections and cancers can spread easily because there’s both ipsilateral and contralateral lymphatic drainage
What covers the roots of teeth?
Cementin
Describe the path of V3 through the lower face
Into mandible at mandibular foramen; provides alveolar nerves
Then comes out mental foramen for skin
Where is lidocaine placed to numb an entire side of the bottom teeth?
V3
1) What does the hard palate separate?
2) What does the soft palate separate?
1) Oral cavity from nasal cavity
2) Oral cavity from nasopharynx
Where are the lingual tonsils found?
Posterior 1/3 of tongue
1) What is the soft palate?
2) What is it made of?
3) How is it attached?
1) Movable posterior 1/3rd of the palate
2) Mainly muscular
3) Palatine aponeurosis; attached to hard palate anteriorly
What does the soft palate do?
Assists in swallowing and prevents bolus entering nasal cavity (by moving/ closing while swallowing)
Which cranial nerve provides:
1) Motor innervation for tongue protrusion?
2) Taste sensation?
3) Somatic sensory innervation to the oral cavity?
1) CN 12
2) CN 7 chordae tympani
3) CN V3 (lingual n.)
1) Where are the sphenoid sinuses?
2) Do they open into the nasal cavity?
1) Occupy the cavity in delicate sphenoid bone, drain into. 2) No real opening into the nasal cavity.
What is the rich plexus where all the arteries supplying the septum anastomose? What is the clinical significance of this area?
Keisselbach; profuse epistaxis (nosebleeds)
What nerves innervate the nose? (2)
1) Posterio-inferior ½ to 2/3 of cavity is primarily: CN V2 (maxillary n.)
2) Anterior superior cavity (both septum & lateral wall) is primarily: anterior ethmoidal nerves from CN V1 (ophthalmic n.)
True or false: Mucosa of the oral cavity is continuous with the gingiva
True
Where can you find gingiva?
Around the neck of teeth
True or false: There’s both ipsilateral and contralateral drainage of cheeks, lips, and chin lymphatics
True
True or false: infections don’t easily spread from one side of the face to another
False; infections and cancers can spread easily because there’s both ipsilateral and contralateral lymphatic drainage
What covers the roots of teeth?
Cementin
Describe the path of V3 through the lower face
Into mandible at mandibular foramen; provides alveolar nerves
Then comes out mental foramen for skin
Where is lidocaine placed to numb an entire side of the bottom teeth?
V3
1) What does the hard palate separate?
2) What does the soft palate separate?
1) Oral cavity from nasal cavity
2) Oral cavity from nasopharynx
Where are the lingual tonsils found?
Posterior 1/3 of tongue
1) What is the soft palate?
2) What is it made of?
3) How is it attached?
1) Movable posterior 1/3rd of the palate
2) Mainly muscular
3) Palatine aponeurosis; attached to hard palate anteriorly
What does the soft palate do?
Assists in swallowing and prevents bolus entering nasal cavity (by moving/ closing while swallowing)
How are the palates innervated with sensory nerve fibers?
Branches of CN V2 (maxillary n; foramen rotundum) (that pass through pterygopalatine ganglia)
What two nerves supply the palates with motor fibers?
1) CN V3: Tensor veli palatini (forms palatine aponeurosis)
2) Pharyngeal plexus from vagus n. CN X: All other (motor) muscles of soft palate (& much of oral pharynx)
1) What nerve does the pharyngeal plexus of nerves come from?
2) What does this nerve do?
1) Vagus n.
2) Acts as motor arm of GAG reflex
True or false: Only way CNV conveys motor is via V3, mandibular n., (foramen ovale)
True
1) What term do you use to refer to both ears?
2) What term do you use to refer to the left ear?
3) What term do you use to refer to the right ear?
1) AU(bilateral)
2) AS (left)
3) AD(right)
What are the 3 parts of the external ear?
1) Auricle (Pinna)
2) External acoustic meatus of Auditory Canal (EAC)
3) Tympanic membrane (TM) (separates outer and middle)
What two nerves provide primary innervation to skin of auricle?
1) Great auricular n.
2) Auriculotemporal n. (CN V3)
What two nerves have a minor contribution to innervation of skin of auricle?
1) CN7
2) CN10
What two nerves innervate the auditory canal and external TM?
CN V3 & CN X
What does it mean if the tympanic membrane is in a neutral position?
The pressure is equal between the middle ear and outside
What are the two openings of the middle ear?
1) Posterosuperior with mastoid antrum (i.e. to mastoid air cells)
2) Pharyngotympanic tube (aka Eustachian tube)
What is found within the middle ear/ tympanic cavity? (4 things)
1) Auditory ossicles
2) Tendons of stapedius and tensor tympani m.
3) Chorda tympani n. (br. of CN VII )
4) Tympanic plexus of nerves
Is the carotid plexus sympathetic or parasympathetic?
Sympathetic
1) What is the stapes (stirrup)?
2) How are sound waves converted from air to mechanical force?
1) Base or footplate occupies the oval window
2) At TM through ossicles
What allows for 10x vibratory amplification in the middle ear?
Base of stapes is considerably smaller than TM
Two muscles of middle ear slide 43
1) What do the two muscles of the middle ear collectively do?
2A&B) Name the two muscles of the ear, describe what each does, and what each is innervated by
1) Resist or dampen movement of auditory ossicles
2a) Tensor tympani: Inserts into handle of malleolus
-CN V3
2b) Stapedius: Pyramidal eminence that inserts onto stapes
-CN VII (nerve to stapedius)
What equalizes pressure between the middle ear cavity and external atmosphere?
Eustachian tube; opens into nasopharynx
What does the vestibulocochlear organ do? (2 things)
Sound and balance
What are the two labyrinths of the inner ear? Describe each
1) Boney labyrinth: fluid filled space of the surrounded by otic capsule
2) Membranous labyrinth: sacs and ducts suspended in the boney labyrinth
What are the two parts of the membranous labyrinth? What does each contain?
1) Cochlear labyrinth
-Cochlear duct
2) Vestibular labyrinth
-Utricle and saccule
What are the 3 symptoms of Meniere’s disease (CN7)? Are these bilateral or ipsilateral?
1) Tinnitus
2) Vertigo
3) Hearing loss
-Often unilateral symptoms
What is an acoustic neuroma? Are its symptoms bilateral or ipsilateral?
1) Peripheral lesion (cerebellopontine angle) of CN7
2) Ipsilateral symptoms
1) What two muscles open the eyelid?
2) What innervates these?
1) Levator palpebrae superioris and superior tarsal mm. opens lid
2) CN 3 somatic and visceral motor
When the sclera of someone’s eye becomes red, what is occurring?
Subconjunctival hemorrhage
True or false: the lacrimal gland is above the rim of the orbit and can’t usually be palpated
True
1) What do the lacrimal canaliculi terminate as? What do they lead to?
2) What do they do?
1) The lacrimal punctum (openings of canaliculi); lead to lacrimal lake w papillae [elevation in eyelids].
2) Convey fluid to nasolacrimal duct [then goes to nasal cavity]
1) What leads to the nasolacrimal duct?
2) Where does it drain?
1) Lacrimal sac
2) Into nasal cavity into inferior meatus (lateral to the inferior concha)
Where is the apex of the orbit?
Optic canal in the lesser wing of sphenoid
What produces aqueous humor?
Ciliary body
1) What is periorbital (pre-septal) cellulitis?
2) Where does venous blood here flow?
1) A skin and soft tissue infection around that eye that is anterior to the orbital septum
2) Into the cavernous sinus
1) What is orbital cellulitis?
2) What can cause it?
3) How is it diagnosed?
4) What are some complications it can cause?
1) Infection of the orbital tissue posterior to the orbital septum.
2) An external focus of infection (e.g., a wound), infection that extends from the nasal sinuses or teeth, or metastatic spread from infection elsewhere.
3) CT/MRI
4) Can become an orbital abscess, which can easily become a subperiosteal abscess, which can become cavernous sinus thrombosis
1) What is the limbus?
2) How large is it, what color, and what does it contain?
1) Angle formed at junction of sclera and cornea
2) 1mm, grey, with numerous capillary loops to nourish the cornea
1) Name 2 attributes of the cornea.
2) What two things keep it moist?
1) Transparent, avascular
2) Bathed in lacrimal fluid and aqueous humor on surface
What are the 3 parts of the fibrous layer of the eyeball?
Sclera, limbus, and cornea
1) What nerve provides sensory innervation for the corneal touch reflex?
2) What provides motor innervation for the corneal reflex?
1) CN V1 (afferent)
2) CN 7 (efferent)
What are the 3 parts of the vascular layer of eyeball?
1) Choroid (uveal tract)
2) Ciliary body/processes (involved w aqueous humor and fibers)
3) Iris/pupil
1) What is the choroid?
2) What does it do? Where is it attached?
3) What is it continuous with?
4) What does it cause? [hint: red]
1) Vascular bed between sclera and retina
2) Nourishes retina; attached to retina’s pigmented layer
3) Continuous anterior with ciliary body and iris
4) Red reflex in infant
1) What part of the ciliary body is constricted? By sympathetic or parasympathetic?
2) What part of the ciliary body is dilated ? By sympathetic or parasympathetic?
1) Parasympathetic constricts sphincter papillae m,
2) Sympathetic dilates pupil dilator pupillae
1) What does ciliary body provide attachment for? How? What does this allow for?
2) What does it fold on? What does this form and what does that do?
3) Where does it get its innervation from?
1) The lens via zonular fibers; allows for fine focus & accommodation
2) On internal surface of body; ciliary process, secretes aqueous humor
3) Parasympathetic from ciliary ganglia (from CNIII)
Are ciliary ganglia sympathetic or parasympathetic and motor or sensory? What do they do?
Parasympathetic motor ganglia; allow for constriction of the iris, pupil, and accommodation
1) What does the iris control?
2) What innervation causes it to constrict the pupil?
3) What innervation causes it to dilate the pupil?
1) Aperture (pupil) for light regulation
2) Parasympathetic via ciliary ganglia to sphincter pupillae
3) Sympathetic to dilator pupillae
What cranial nerve parasympathetically stimulates the iris? How?
CN III; postsynaptic fibers from ciliary ganglia
What two nerves are involved in pupillary response?
1) CN II (afferent/ sensory)
2) CN III (efferent/ motor)
What are the two parts of the optic part of the retina? What does each do?
1) Neural layer: sensitive to visual light
2) Pigment layer: absorbs light, reduce scatter
What are the two parts of the retina?
1) Optic part
2) Nonvisual part
1) What is the nonvisual part of the retina?
2) What does it extend anteriorly over?
1) Anterior extension of pigmented layer of retina
2) Ciliary body and iris
What is the ocular fundus?
Part of eye light strikes when entering eye; what you can visualize during fundoscopic exam
1) What happens at the optic disc/papilla?
2) Why is this location unique?
1) Optic n. enters and radiates to periphery
2) No receptors; our vision’s blind spot
What is lateral to the optic disc? What does it do?
Macula/fovea; specialized for acuity vision
1) What is at the center of the macula? What is this in our vision?
2) What is unique about the center of the macula?
1) Fovea centralis; area of most acute vision
2) Fovea lacks capillary network visible elsewhere deep to retina
What are the important parts of the ocular fundus?
1) Optic disc/papilla
2) Macula/fovea
Where does most refraction of the eye occur?
Cornea
What 5 parts of the eye are reflective?
1) Tear film
2) Cornea
3) Aqueous humor
4) Lens (accommodation)
5) Vitreous humor
What is the pathway of light from the environment to the retina? (8 steps)
1) Environment
2) Cornea
3) AC (aqueous humor)
4) Through pupil
5) PC (aqueous humor)
6) Lens
7) Vitreous
8) Retina/optic nerve
Aqueous humor:
1) Where is it produced
2) Where does it flow through?
3) What does it do?
1) By ciliary process in posterior chamber
2) Flows thru pupil into anterior chamber
3) Nourishes lens and cornea
1) What drains the aqueous humor? Where does it go?
2) What removes it?
3) What is this similar to?
1) Drains thru trabecular meshwork at iridocorneal angle into scleral venous sinus (canal of Schlemm)
2) Removed by limbal plexus
3) Like CSF: production – flow – absorption
1) What are the types of glaucoma?
2) What is it a common cause of?
3) What typically accompanies it?
4) What causes it?
1) Chronic or acute
2) Blindness
3) Increased IOP
4) Compression of retina and retinal arteries causing damage to optic nerve
What does absence of the tarsal muscle cause?
Ptosis or droopy upper lid
True or false: The orbital axis is different from the visual axis
True
If someone had complete CN III palsy (an injury due to increased intracranial pressure from bleed), what would this cause? Why? (5 things)
1) Ptosis: unopposed orbicularis oculi
2) No pupillary light reflex
3) Dilated pupil (“blown pupil”): unopposed dilator pupillae m. due to loss of parasympathetic input
4) No accommodation
5) Eyeball (pupil) fully abducted and depressed: unopposed LR and SO
What would a CN 6 (Abducent n.) injury cause? (2 things)
1) Affected abduct pupil on ipsilateral side
2) Space occupying lesion, increased intercranial pressure
What 3 nerves traverse the superior orbital fissure?
1) CN 3, Oculomotor n. (AO)
2) CN 4, Trochlear n. (SO)
3) CN 6, Abducens n. (LR)
1) What kind of vision loss does central retinal artery occlusion (CRAO) cause? Is it abrupt? Is it painful?
2) What usually causes it?
1) Acute, painless, vision loss, ipsilateral lesion
2) Temporal arteritis (autoimmune d/o); emboli from carotid stenosis
1) What kind of vision loss does central retinal venous occlusion (CRVO) cause? Is it abrupt? Is it painful?
2) What usually causes it?
3) Where can it extend to?
1) Less abrupt, painless, vision loss ipsilateral
2) Emboli or infection
3) Cavernous sinus
1) What is the primary blood supply to the eye?
2) What is the only supply to the neuronal layer of the retina?
3) What do the choroid vessels supply blood to?
4) Where do the veins of the eye drain?
1) Internal carotid via ophthalmic artery
2) Central artery of retina
3) External aspect of retina
4) Cavernous and pterygoid sinuses
Name an afferent pupillary light defect
“Marcus Gunn” pupil
Define presbyopia
Loss of accommodation
Define accommodation and what innervation is involved
Active process of changing shape of lens for near vision; CN3, parasympathetic postganglionic fibers
What are the two main layers of fascia in the neck?
1) Superficial fascia
2) Deep cervical facia (which has 3 compartments itself)
What are the 3 compartments of the deep cervical facia?
1) Investing
2) Pretracheal
3) Prevertebral
1) What is the superficial fascia of the neck made of?
2) What does it contain?
1) SQ tissue
2) Contains nerves, vessels, nodes, adipose, and Platysma muscle
1) What does the deep cervical facia allow for?
2) What does it contain, and how is this medically significant?
1) Slippery for movement (swallowing and turning head)
2) Natural cleavage planes; used in surgical contexts and kept in mind as infection spreads
Describe the investing fascia of the deep cervical fascia of the neck; what does it surround and invest in?
1) Surrounds entire neck deep to skin and Superficial fascia
2) “4 corners” “invests” in SCM (sternocleidomastoid) and Trapezius mm.
What innervates the SCM (sternocleidomastoid) and Trapezius mm?
CN11
Name 5 groups of structures found within the carotid sheath
1) Common and internal carotid a., carotid sinus n.
2) Sympathetic nerve plexus
3) IJV
4) CNs 9, 10, 11, 12
5) Deep cervical nodes
1) What does the retropharyngeal space permit?
2) Where is it?
1) Movement of neck visceral relative to the cervical vertebrae during swallowing
2) Between pre-vertebral facia and pre-tracheal (buccopharyngeal) fascia
1) What is the the largest and most clinically important interfascial space in the neck? Why?
2) Where is it?
3) How is the alar fascia related to it?
1) Retropharyngeal space; major pathway for spread of infection in the neck
2) Between pre-vertebral facia and pre-tracheal (buccopharyngeal) fascia
3) Forms the anterior extent of the retropharyngeal space
1) Where is the platysma muscle?
2) What does it do?
1) Covers anterolateral aspect of the neck
2) Muscle of facial expression
What is a major landmark of the lateral-posterior region of neck?
Trapezius muscle
What are the 3 superficial structures of the Neck?
1) Platysma muscle
2) SCM muscle
3) Trapezius muscle
List the 4 regions of the neck from medial to lateral
1) Anterior cervical
2) SCM region: visibly divides the anterior + lateral regions 3) Lateral cervical
4) Posterior cervical
What nerve is very superficial on the neck?
Spinal accessory nerve (CN11)
What are the nerves of the lateral cervical region?
1) Spinal accessory n., CN XI
2) Root of the brachial plexus (made of anterior rami of C5-8, T1)
1) Where is the spinal accessory nerve (CN11) in the neck?
2) What innervation does it provide to the neck?
1) Passes deep to the SCM into the lateral cervical region 2) Motor to the trap and SCM
1) What does the root of the brachial plexus contain?
2) Where does it appear?
3) Where does it descend? Into what?
4) What does it provide innervation to?
1) Anterior rami of C5-8, T1
2) Between anterior & middle scalene muscles
3) Between the 1st rib, clavicle and superior boarder of the scapula (cervico-axillary canal) into the axilla
4) Innervation to most of the UE
1) What forms the cervical plexus? What do they form?
2) What are the superficial branches of this plexus?
3) What are the deep branches?
1) Anterior rami C1-4; form series of loops
2) Cutaneous sensory nerves
3) Motor
1) Name a nerve that comes from the cervical plexus that does motor innervation
2) What does it do?
1) Phrenic nerve
2) Traverses entire thoracic cavity to allow diaphragm to contract (somatic motor)
What is the “nerve point of the neck”? What does it provide?
The superficial branches of the cervical plexus; provides cutaneous sensory information
What is the clinical significance of the nerve point of the neck?
Anesthesia Cervical block for procedures in neck and upper arm; infiltrate along posterior boarder of the SCM jct superior and middle 3rds
Name two deep nerves of the deep branches (passing anteromedially) of the cervical plexus
1) Phrenic
2) Ansi Cervicalis (anterior cervical region) is made of branches of C1-3 [of the plexus]
1) What part of the cervical plexus is the phrenic nerve?
2) What innervation does it provide?
3) Where is the accessory phrenic nerve?
1) C3-4-5
2) Mixed somatic motor, sensory, sympathetic to mediastinum
-Sole motor to diaphragm
3) C-5
1) What would disruption of phrenic nerve cause?
2) Give an example of this
1) Paralysis of the ipsilateral diaphragm
2) Local anesthesia via phrenic nerve block paralyses ipsilateral diaphragm for thoracic surgery
-Infiltrate around the nerve where it lies on the anterior surface of the anterior scalene muscle.
When is jugular venous distention seen, where, and on which side?
When a patient is in their bed around 30 degrees, their right IJV (between heads of SCM) can be seen distended with visible pulsations when IJV has high pressure.
Why is the EJV (external jugular v) often “full”?
Due to volume overload in HF (heart failure)
1) What may the EJV serve as?
2) What does it look like when pressure is normal?
3) What about when pressure rises (like in HF)?
1) An “internal barometer.”
2) EJV is usually visible superior to the clavicle for only a short distance.
3) The vein is prominent throughout its course along the side of the neck.
1) What are the two clinically relevant veins in the lateral cervical region?
2) Where are central lines placed?
3) What is at risk of puncture when that’s done?
1) Brachiocephalic and subclavian veins
2) Subclavian vein
3) Pleura and subclavian artery at risk of puncture
Where is the carotid artery in comparison to the IVJ?
Runs medial to IJV
What are the two types of muscles that attach to the hyoid bone?
1) Suprahyoid muscles - superior
2) Infrahyoid muscles - inferior
hyoid
1) What do the muscles of the anterior cervical region (aka extrinsic muscles of the pharynx) do?
2) What are they innervated by?
1) Steady or move the hyoid and larynx
2) CNs (9&10) and cervical plexus
What forms the Adam’s apple?
Anterior aspect of thyroid cartilage
1) Where are the suprahyoid muscles?
2) What do they make up?
3) What do they support?
4) What do they do?
1) Superior to hyoid bone connecting the hyoid to head/jaw
2) Floor of the mouth
3) Supports hyoid bone; providing a base from which the tongue functions
4) Elevating hyoid and larynx in relation to swallowing and tone production
1) Where are the infrahyoid muscles?
2) What do they anchor? To where?
3) What are they generally innervated by?
1) Inferior to hyoid bone
2) Anchor hyoid to sternum, clavicle, & scapula, depressing the hyoid and larynx during swallowing & speaking
3) Cervical plexus
1) What does the internal carotid not have branches to?
2) What does it enter? Via what?
3) What does it supply? Using what branches?
4) How does it provide the central retinal artery?
1) No branches in the neck
2) Cranium via carotid canal
3) Main blood supply to brain and orbits; supratrochlear and supraorbital arteries
4) Via ophthalmic artery
What carotid artery has branches in the neck?
External
What 7 arteries come from external carotid?
1) Superior thyroid
2) Lingual
3) Facial (pulse)
4) Occipital
5) Posterior auricular
6) Maxillary
7) Superficial temporal (pulse)
1) When is an IJV stick done?
2) Which side is better? Why?
3) How is it done?
4) Where is the needle directed?
5) What artery do you need to be careful to avoid?
1) Diagnostic or therapeutic purposes.
2) The right IJV is preferable because it is usually larger and straighter.
3) Palpate the common carotid artery and inserts the needle into the IJV just lateral to it at a 30-degree angle, aiming at the apex of the triangle between the sternal and clavicular heads of the SCM.
4) The needle is then directed inferolateral toward the ipsilateral nipple
5) Carotid artery; just anterior to IVJ
Name 3 structures within the carotid sheath
1) Common carotid artery
2) IJV
3) Vagus n., CN X
1) What provides visceral afferent innervation to the carotid body?
2) What does low PO2 cause the carotid body to do?
1) CN IX (Glossopharyngeal n.) & CN X (Vagus n.)
2) Increase rate and depth of respiration & HR, BP
1) What does the carotid sinus do?
2) What kind of receptor is it? What stimulates it?
3) What provides its visceral afferent stimulation?
1) Monitors Systemic BP
2) Baroreceptor; increases in BP
3) CNs 9 & 10 (Glossopharyngeal & Vagus)
What part of the head does not have lymph nodes?
The scalp
What structure is only parasympathetic?
Ciliary body (is constricted by parasympathetic for accommodation)
*probably on quiz
What innervates the iris?
Sympathetic
*probably on quiz
Name a structure that is only sympathetically innervated
Smooth muscle of arteries
What causes Horner’s syndrome?
Lesion to sympathetic trunk in the neck
If you can’t shrug your shoulders, what nerve could be malfunctioning?
CN11 (spinal accessory)
1) What do the intrinsic laryngeal muscles do?
2) What nerve(s) supply them?
1) Move laryngeal parts for voice
2) All but one (cricothyroid m. supplied by external laryngeal n.) are supplied by recurrent laryngeal nerve (br. of CN X, Vagus n.)
What muscles are responsible for Voice change and abnormal efferent GAG reflex? What do they give clues to?
Intrinsic laryngeal muscles; vagus n. function
What is the afferent pathway for the cough reflex to the brain? (3 steps)
1) Internal laryngeal n.
2) Via superior laryngeal n.
3) Via Vagus n. to medulla then on to cortex ( no identified cough center)
What is the efferent pathway for the cough reflex from the brain? (3 steps)
1) Vagus n.
2) To superior laryngeal n. and nerves
3) To glottis and respiratory/expiratory muscles
1) What is a tracheotomy?
2) Is it temporary or permanent?
1) An O.R. procedure for airway placement
2) Permanent
What two things are found in the nasopharynx?
Pharyngeal tonsils (adenoids)
Eustachian tube
1) What is the oropharynx responsible for?
2) What can you find within it?
1) Swallowing function
2) Tonsils (palatine)
What are the two layers of pharyngeal muscles? What do they do?
1) External layer: constricts wall during swallowing
2) Internal layer: elevate pharynx and larynx during swallowing and speaking
71) What does the cervical plexus provide the most innervation to?
2) What nerves are involved with the cervical plexus?
1) Motor to infrahyoid
2) Mostly spinal, but some hypoglossal nerve involvement
