Session 8

Question 1

The image below is a coronal section through the primary motor cortex. Which area of the primary motor cortex is responsible for conscious control of left half of the face and arm?
slide 2 lec 1

Answer 1

panopto

Question 2

A 52 year old man presents to the Emergency Department with a unilateral facial droop which he noted on first waking. He is concerned that he is having a stroke. The doctor takes a brief history before examining him and reassures him that his symptoms are not due to a stroke. The doctor diagnoses a facial nerve palsy
What muscle(s) is affected to account for the appearance here?
What muscle(s) is affected to account for the appearance here?
slide 4 lec 1

Answer 2

panopto

Question 3

Muscles of facial expression are innervated by the facial nerve. What other functions are carried by this nerve?

Answer 3

panopto

Question 4

What might the doctor have asked the patient to do to test the integrity of the facial nerve?

Answer 4

panopto

Question 5

Why might the doctor examine the parotid gland in a patient presenting with a facial nerve palsy?

Answer 5

panopto

Question 6

What are the three branches of the facial nerve that arise within the petrous temporal bone?

Answer 6

panop

Question 7

Why might a patient with a facial nerve lesion complain of sensitivity to loud noises (hyperacusis)?

Answer 7

pan

Question 8

Give two reasons why the patient’s eye might be at risk of drying and injury as a result of a facial nerve lesion? How could this be managed?

Answer 8

lecture

Question 9

What is the corneal reflex? Describe the afferent and efferent limb of this reflex.
slide 10 lec 1

Answer 9

g

Question 10

Why might the doctor also want to examine the ear more closely? after looking at the corneal reflex

Answer 10

csdns

Question 11

A 65 year old man attends the GP with a 1 month history of ear pain (otalgia). He describes it as an ache. He has no symptoms suggestive of recent infection, and his hearing remains unchanged. The doctor examines the ear, including otoscopic examination, which is normal
Name three conditions involving structures or areas of the ear that can present with otolagia (i.e. otological causes of ear pain)

Answer 11

po

Question 12

A 65 year old man attends the GP with a 1 month history of ear pain (otalgia). He describes it as an ache. He has no symptoms suggestive of recent infection, and his hearing remains unchanged. The doctor examines the ear, including otoscopic examination, which is normal.
The doctor is concerned that the otalgia may be non-otological given examination of the ear is normal; that is the pain is referred pain to the ear due to pathology somewhere else.
Which nerves are involved in innervating structures of the external and middle ear (those carrying general sensory afferents)?

Answer 12

p

Question 13

A 65 year old man attends the GP with a 1 month history of ear pain (otalgia). He describes it as an ache. He has no symptoms suggestive of recent infection, and his hearing remains unchanged. The doctor examines the ear, including otoscopic examination, which is normal.
The doctor is concerned that the otalgia may be non-otological given examination of the ear is normal; that is the pain is referred pain to the ear due to pathology somewhere else.
To explore a potential cause for referred pain to the ear the presence of pathology in which other areas of the head and neck should be determined (through history and examination)?

Answer 13

lec

Question 14

A 65 year old man attends the GP with a 1 month history of ear pain (otalgia). He describes it as an ache. He has no symptoms suggestive of recent infection, and his hearing remains unchanged. The doctor examines the ear, including otoscopic examination, which is normal.
The doctor is concerned that the otalgia may be non-otological given examination of the ear is normal; that is the pain is referred pain to the ear due to pathology somewhere else.
The doctor enquires about the presence of ‘red flags’ and also examines the oropharynx and palpates for cervical lymphadenopathy.
What are ‘red flags’ and what might these have been in this patient’s case?

Answer 14

lo

Question 15

A 65 year old man attends the GP with a 1 month history of ear pain (otalgia). He describes it as an ache. He has no symptoms suggestive of recent infection, and his hearing remains unchanged. The doctor examines the ear, including otoscopic examination, which is normal.
The doctor is concerned that the otalgia may be non-otological given examination of the ear is normal; that is the pain is referred pain to the ear due to pathology somewhere else.
The doctor enquires about the presence of ‘red flags’ and also examines the oropharynx and palpates for cervical lymphadenopathy.
Why did the doctor examine the oropharynx and palpate for cervical lymphadenopathy?

Answer 15

l

Question 16

A 65 year old man attends the GP with a 1 month history of ear pain (otalgia). He describes it as an ache. He has no symptoms suggestive of recent infection, and his hearing remains unchanged. The doctor examines the ear, including otoscopic examination, which is normal.
The doctor is concerned that the otalgia may be non-otological given examination of the ear is normal; that is the pain is referred pain to the ear due to pathology somewhere else.
The doctor enquires about the presence of ‘red flags’ and also examines the oropharynx and palpates for cervical lymphadenopathy.
On examination of the cervical lymph nodes the doctor palpates and enlarged deep cervical lymph node. The features from palpation of the enlarged node are indicative of likely metastatic involvement.
What features on palpation of a lymph node would be indicative of metastatic involvement?

Answer 16

lectur

Question 17

A 65 year old man attends the GP with a 1 month history of ear pain (otalgia). He describes it as an ache. He has no symptoms suggestive of recent infection, and his hearing remains unchanged. The doctor examines the ear, including otoscopic examination, which is normal.
The doctor is concerned that the otalgia may be non-otological given examination of the ear is normal; that is the pain is referred pain to the ear due to pathology somewhere else.
The doctor enquires about the presence of ‘red flags’ and also examines the oropharynx and palpates for cervical lymphadenopathy.
On examination of the cervical lymph nodes the doctor palpates and enlarged deep cervical lymph node. The features from palpation of the enlarged node are indicative of likely metastatic involvement.
What do you think could be the underlying diagnosis and what would be the appropriate next step for the GP to take in managing this patient?

Answer 17

k

Question 18

A 3 year old girl is brought to her GP by her dad. Her dad is concerned that his daughter is unwell. Over the last few days she has been running a high fever, has had a runny nose and yesterday started pulling at her ear and complaining that it was sore. On otoscopic examination, the doctor sees the following.
insert image from slide 18 lec 1
1.What is the likely diagnosis?
2. What features in the girl’s history and examination of the tympanic membrane led you to your diagnosis?
3. Why is this condition more common in young children than in adults (your answer should refer to the anatomy of the ear)?
4. What are the most common pathogens involved in causing this type of infection?

Answer 18

pani

Question 19

A 3 year old girl is brought to her GP by her dad. Her dad is concerned that his daughter is unwell. Over the last few days she has been running a high fever, has had a runny nose and yesterday started pulling at her ear and complaining that it was sore. On otoscopic examination, the doctor sees the following.
insert image from slide 18
Two days later the dad returns to the GP concerned that his daughter is more unwell, and seems quite lethargic. On examination the doctor notes that the right ear now appears pushed forward and the area behind the ear is red, swollen and tender. insert slide 21
5. What condition has now developed?
6. Explain, with reference to the anatomy of the ear, how the original infection was able to spread leading to the condition seen in the above image?
7. How should the GP manage the girl?
8. Name two other anatomical structures within the skull, which can (in any patient) be affected by the spread of infection from the middle ear.

Answer 19

pan

Question 20

Motor function of tongue

Answer 20

Intrinsic muscles • 4 paired muscles • Motor innervation (hypoglossal nerve)
Extrinsic muscles • Genioglossus • Hypoglossus • Styloglossus • Motor innervation (hypoglossal nerve) • Palatoglossus • Motor innervation (Vagus nerve)
insert slide 4 lc 2

Question 21

sensory function of tongue

Answer 21

Divide tongue into • Anterior 2/3 • Sensation –trigeminal (V3) • Taste -facial • Posterior 1/3 • Sensation and taste- glossopharyngeal
slide 5 lec 2

Question 22

Salivary glands submandibular

Answer 22

slide 6 lec 2

Question 23

Salivary glands -Parotid

Answer 23

slide 7 lec 2

Question 24

Salivary glands -Sublingual

Answer 24

Only produce 3-5% of saliva • Smallest and most diffuse of the major salivary glands • 8-20 excretory ducts per gland
slide 8 lec 2

Question 25

Sialolithiasis

Answer 25

Salivary gland stones (Sialolithiasis)
Most stones are located in the submandibular glands • Dehydration, reduced salivary flow • Most stones less than 1cm diameter • Symptoms (eating stimulates) • Pain in gland • Swelling • Infection • Diagnosis- history, x-ray, sialogram

Question 26

Tonsillitis

Answer 26

Inflammation of the palatine tonsils
Fever • Sore throat • Pain/difficulty swallowing • Cervical lymph nodes • Bad breath • Viral causes (most common) • Bacterial causes (up to 40% of cases) • Strep pyogenes

Question 27

Peritonsillar abscess

Answer 27

Severe throat pain • Fever • Bad breath • Drooling • Difficulty opening mouth • Can follow on from an untreated or partially treated tonsillitis • Can arise on its own • Aerobic and anaerobic bacteria

Question 28

Nasopharynx

Answer 28

• Boundaries • Base of skull to upper border of soft palate • Posterior (C1, C2) • Anterior (nasal cavity)
• Contains • Pharyngeal tonsil

Question 29

Pharyngeal tonsil

Answer 29

adenoid
• Enlarged pharyngeal tonsils • Block ET • Recurrent/persistent middle ear infections • Snoring/sleep apnoea • Sleeping with mouth open • Chronic sinusitis • Sore throat • Nasal tone to voice

Question 30

Oropharynx
label parts too
slide 16 without answers lec 2

Answer 30

• Boundaries • Soft palate to epiglottis • Anterior (oral cavity) • Posterior (C2, C3)
• Contains • Palatine tonsils

slide 16 lec 2

Question 31

Laryngopharynx

Answer 31

• Boundaries • Oropharynx to oesophagus • Epiglottis to cricoid cartilage • Anterior (larynx) • Posterior (C4,C5,C6) • Contains • Piriform fossa

Question 32

General overview of muscle arrangements in pharynx

Answer 32

• 3 x longitudinal muscles- (elevate pharynx and larynx during swallowing) • Stylopharyngeus • Palatopharyngeus • Salpingopharngeus
Stylopharyngeus • Styloid process- posterior border of thyroid cartilage • Glossopharyngeal nerve (CN IX)
Palatopharyngeus • Hard palate- posterior border of thyroid cartilage • Pharyngeal branch of vagus (CN X)
Salpingopharyngeus • Cartilaginous part of ET- merges with palatopharyngeus • Pharyngeal branch of vagus (CN X)
pic from slide 20 and 21 lec 2

Question 33

Pharyngeal constrictors

Answer 33

3 x circular muscles- (constrict walls of pharynx when swallowing) • Superior pharyngeal constrictor • Origin -Pterygomandibular raphe • Middle pharyngeal constrictor • Origin- Hyoid bone • Inferior pharyngeal constrictor • Has 2 parts • Thyropharyngeal (origin- thyroid cartilage) • Cricopharyngeal (origin-cricoid cartilage)
• Vagus (CN X)
slide 22 / 23

Question 34

• 70 year old man presents with • Bad breath • Regurgitation of food • Occasional choking on fluids • General difficulty swallowing

Answer 34

Pharyngeal pouch
• A posteromedial (false) diverticulum • Arises in weakness between the two parts of the inferior constrictor • Killian’s dehiscence
• Probably due to: • Failure of the UOS to relax • Abnormal timing of swallowing • Essentially there is a higher pressure in laryngopharynx • Weakness in Inferior constrictor muscle produces outpouching
• Symptoms related to food material collecting in pouch or disruption of swallow

Question 35

General overview of nerve innervation of pharynx

Answer 35

Pharyngeal plexus • Located mainly on surface of middle constrictor muscle • Vagus, glossopharyngeal and cervical sympathetic nerves
Motor • CN X innervates all muscles • Except stylopharyngeus (Glossopharygeal nerve (CN IX)
Sensory • Naospharynx (maxillary nerve CN V2) • Oropharynx (glossopharyngeal nerve CN IX) * • Laryngopharynx (vagus nerve (CN X)

Question 36

Phases of swallowing

Answer 36

Stage 1 (Oral)• Voluntary • Preparatory phase • Making bolus • Transit phase • Bolus compressed against palate and pushed into oropharynx by tongue and soft palate
(Hypoglossal N (CN XII) muscles of tongue)
Stage 2 (Pharyngeal) • Involuntary • Tongue positioned against hard palate (food cannot re-enter mouth) (CN XII) • Soft palate elevated sealing off nasopharynx (tensor palatini CN V3, levator palatini CN X) • Opens ET tube • Suprahyoid (CN V3, CN VII, CN XII) and longitudinal muscles shorten (CN IX, CN X) • Pharynx widens and shortens to receive bolus • Larynx elevated and sealed off by vocal folds • Epiglottis closes over larynx (result of elevated hyoid) • Bolus moves through pharynx by sequential contraction of constrictors • Relaxation of UOS
Stage 3 (oesophageal) • Involuntary • Upper striated muscle of oesophagus (CN X) • Lower smooth muscle
• LOS covered in GI unit

Question 37

• 78 year old lady • Presents with: • left sided facial weakness • Slurred speech • Left limb weakness • Hypertensive

Answer 37

Dysphagia
Stroke • Progressive neurological disease • Parkinson’s/ MS • COPD • Dementia
• 30% of post stroke deaths are due to pneumonia
Signs and symptoms
All the usual symptoms • Coughing & choking • Sialorrhoea (drooling) • Recurrent pneumonia • Change in voice/speech (wet voice) • Nasal regurgitation

Question 38

Cranial nerve problems involved with dysphagia

Answer 38

IX, X • Obvious things • Absent gag • Uvula deviated away from lesion (LMN)
• Bit more subtle • Dysphagia • Taste impairment (posterior tongue) • Loss of sensation oropharynx
• Caused by: • medullary infarct, jugular foramen issue (fracture)
slide 37 and 38 lec 2
XII • Wasted tongue • Stick tongue out- tongue may deviate • Damage to nerve itself (LMN) -point to side of lesion • Muscle wasting • Fasiculations