HAD UNIT II CALM REVIEW Tom Eck – ecktw@umdnj.edu - PowerPoint Presentation

1. HAD UNIT II CALM REVIEWTom Eck – ecktw@umdnj.edu

2. Major PointsCranial nerves are tested directly or indirectly on the majority of questionsKnow the course of each nerve, especially the foramen each passes throughKnow cutaneous distribution for sensory nerves and muscles innervated for motor nervesMemorize presentation of deficits associated with loss of each nerve

3. Major topicsCranial Nerves: SensoryCranial Nerves: MotorCranial Nerves: AutonomicVasculatureNeckLymphaticsEmbryologyConnections

4. CRANIAL NERVES: SENSORYCN I – Olfactory – OlfactionCN II – Optic – VisionCN V – Trigeminal – Facial SensationCN VII – Facial – Taste CN VIII – Vestibulocochlear – Balance, HearingCN IX – Glossopharyngeal – Pharyngeal SensationCN X – Vagus – Laryngeal Sensation

5. Cranial Foramina, Ophthalmic arteryMiddle meningeal artery Labyrinthine artery, Posterior meningeal artery,

6. 1. which bone, when fractured, may be associated with inability to smell (Anosmia) as well as leakage of CSF?NasalEthmoidVomerSphenoid Lacrimal10

7. Ethmoidal fractureMay result in damage to CN I fibers as they pass through the cribriform plate of the ethmoidEthmoid is particularly vulnerable to traumaAlso associated with CSF leakage (CSF rhinorrhea)

8. Don’t Do this!NasogastricTube

9. 1 23 45 2. Where might tumor invasion lead to anesthesia over the upper lip, infraorbital region, and temporal region?10

10. Numbness in the upper lip, infraorbital region, and temporal region suggests the tumor has invaded the maxillary nerve (V2), which exits the skull via the foramen rotundum.It becomes the infraorbital nerve as it exits the skull via the infraorbital foramenYou would also expect loss of sensation in the nasal mucosa and oral cavityMaxillary Nerve Injury (V2)

11. 3. Which of the following Nerves does not contribute to the cutaneous innervation of the ear?Maxillary nerve (V2)Mandibular nerve (V3)Facial nerve (CN VII)Glossopharyngeal nerve (CN IX)Vagus nerve (CN X)10

12. Cutaneous Innervation of EarAuriculotemporal nerve (CN V3)Root, superior helix, crus, tragus, ext auditory canal, tympanic membraneAuricular branch (CN VII)Concha, ext auditory canalJacobsen’s nerve (CN IX)Concha, ext auditory canalArnold’s nerve (CN X)Concha, ext auditory canal, antihelixLesser occipital nerve (C2)Superoposterior earGreat auricular (C2,3)Lateral helix, lobule, posteroinferior ear

13. 4. What nerve has been compromised if a patient experiences numbness of the anterior tongue?Chorda tympaniLingualHypoglossalGlossopharyngealVagus10

14. Tongue InnervationLingual nerve = sensation to anterior 2/3 of tongueChorda tympani = taste to anterior 2/3 of tongueHypoglossal = motor to intrinsic and extrinsic tongue muscles (except palatoglossus)Glossopharyngeal = taste AND sensation to posterior 1/3 of tongueVagus = taste for small patch near epiglottis

15. 5. Which of the following nerves carries the afferent limb of the corneal reflex?0OphthalmicMaxillaryFacialOcculomotorMandibular

16. Corneal ReflexAfferent Limb: Ophthalmic Nerve, V1 (Nasociliary Branch)Efferent Limb: Zygomatic Branch of Facial Nerve (CN VII) to palpebral portion of orbicularis oculiRemember: V1 includes the eyes and the tip of the nose

17. 6. Which nerve supplies the skin overlying the vertex of the skull?0LacrimalSupratrochlearInfratrochlearInfraorbitalSupraorbital

18. Vertex

19. Supraorbital nerveSupplies much of the forehead and scalpa branch of the ophthalmic nerve (V1  frontal nerve  supraorbital)Exits the skull via the supraorbital foramen

20. 7. Which area of the face would be expected to experience anesthesia following a fracture of the body of the mandible?Angle of jawLower lipUpper lipBuccal regionZygomatic region10

21. Mental Nervebranches off the inferior alveolar nerve (V3), which courses through the mandible, supplying the skin of the chin (mental region) and lower lipexits the mandible via the mental foramen

22. CRANIAL NERVES: MOTORCN III – OculomotorCN IV – Trochlear extraocular musclesCN VI – AbducensCN V3 – Mandibular – muscles of masticationCN VII – Facial – muscles of expressionCN IX – Glossopharyngeal – stylopharyngeusCN X – Vagus – muscles of pharynx and larynxCN XI – Spinal Accessory – trapezius, SCMCN XII – Hypoglossal – tongue muscles

23. 8. A posterior fossa tumor impinges on the jugular foramen. Which of the following will be entirely preserved?swallowingphonationchewingshruggingtaste 10

24. Jugular foramen syndromeJugular foramen: glossopharyngeal (CN IX), vagus (X), spinal accessory (CN XI)Swallowing = vagus, glossopharyngeal, etc.Phonation = vagus (laryngeal muscles)Taste = vagus, glossopharyngeal, (and facial)Shrugging = spinal accessory, etc.Chewing = mandibular nerve (V3)

25. 9. Which of the following most directly opposes the action of the temporalis?MasseterInfrahyoid musclesLateral pterygoidMedial pterygoid10

26. Muscles of Mastication (V3)temporalis = elevate and retract the mandiblelateral pterygoid = depress and protrude mandibleElevation: Temporalis, Masseter, Medial PterygoidDepression: Lateral Pterygoid, Suprahyoid/Infrahyoid MusclesProtrusion: Lateral Pterygoid, Masseter, Medial PterygoidRetrusion: Temporalis, MasseterLateral Movements: Temporalis of same side, Pterygoids of Opposite Side, MasseterRemember: Unilateral V3 lesion causes deviation to same side as lesion due to unopposed action of the contralateral medial and lateral pterygoidTemporalisLateral Pterygoid

27. 10. Patients with paralysis of the trigeminal nerve Lose function in which of the following muscles?Levator veli palatiniPalatopharyngeusStylohyoidStylopharyngeusTensor veli palatini10

28. CN V3 - Mandibular nerve (motor)TemporalisMasseterLateral pterygoidMedial pterygoidMylohyoidAnterior belly of digastricTensor tympaniTensor veli palatini

29. 11. Which of the following dominates the efferent Limb of the gag reflex?CN VCN IXCN XCN XII10

30. Gag reflexThe nerve supply to the pharynx is derived from the pharyngeal plexusGlossopharyngeal = sensory supply (afferent limb)Vagus = motor supply (efferent limb)Sensory Exceptions: upper nasopharynx supplied by V2 (along with nasal mucosa); lower laryngopharynx supplied by internal laryngeal (CN X)Motor Exceptions: stylopharyngeus (CN IX), tensor veli palatini (CN V3) *These are also involved in the reflex

31. 12. Which nerve is damaged if a person must constantly press their cheek in while eating?CN VCN VIICN IXCN XCN XII10

32. Buccinatorinnervated by the Facial Nervekeeps food out of the oral vestibulemeets the superior pharyngeal constrictor (CN X) posteriorly at the pterygomandibular raphe

33. 13. Which of the following would remain functional following compression of the common tendinous ring?Superior rectusLateral rectusSuperior ObliqueSphincter pupillaeDilator pupillae10

34. Common tendinous ringThrough the common tendinous ringOPTIC NERVEOphthalmic arteryMotor (Occulomotor n. , Abducens n.), except the Trochlear nerveNasociliary nerveOutside:Opthalmic veinSensory (Lacrimal n., Frontal n.), except the nasociliary nerve (which supplies the eyeball)Trochlear nerve

35. 14. When a patient sticks out her tongue, it deviates to the right side. Which nerve has been damaged?Left glossopharyngealRight glossopharyngealLeft hypoglossalRight hypoglossal10

36. Hypoglossal nerveUnilateral lesion causes the tongue to deviate to the SAME side when protrudedThe intact genioglossus pulls the back of the tongue forward, deviating the tongue to the other side

37. CRANIAL NERVES: AUTONOMICSCOPS 3977 (Parasympathetic Ganglia)Ciliary = CN 3 (pupillary constriction and accomodation)Otic = CN 9 (salivation)Pterygopalatine = CN 7 (lacrimation)Submandibular = CN 7 (salivation)Sympathetic fibers carried by arteries from superior cervical ganglion

38. 15. A patient complains of dry eyes following trauma. Which of the following nerves may have been damaged at its origin?OphthalmicOculomotorLong CiliaryFacialMaxillary10

39. PTERYGOPALATINE GANGLION

40. 16. Which ganglion is located just below the foramen ovale and, when damaged, leads to Dry mouth (xerostomia)?CiliaryPterygopalatineOticSubmandibularGeniculateTrigeminal (semilunar)10

41.

42. OTIC GANGLION

43. 17. Which of the following nerves carries presynaptic parasympathetic fibers to the submandibular gland?Greater palatineLesser petrosalGreater petrosalChorda tympaniInferior alveolar10

44. SUBMANDIBULARGANGLION

45. CILIARY GANGLIONOculomotor Nerve (Pre)  Ciliary Ganglion  Short Ciliary Nerves (Post)

46. VasculatureExternal Carotid and its branchesAnterior: superior thyroid, lingual, facialPosterior: Occipital, Posterior AuricularMedial: Ascending PharyngealTerminal: Superfical Temporal, Maxillary Internal Carotid and Circle of WillisDural Venous SinusesBasic Venous DrainageBe familiar with major branches of maxillary, facial arteries

47. 18. When significant trauma is inflicted at the pterion, an epidural hematoma often results. By what route does the involved artery enter the cranium?Foramen ovaleForamen rotundumForamen spinosumForamen lacerumSphenopalatine foramen10

48. Middle Meningeal arterypterion = major weak point in skull; location where the frontal, sphenoid, temporal, and parietal bones meetfracture here associated with laceration of underlying middle meningeal artery (responsible for 70-80% of epidural hematomas)enters the skull via the foramen spinosum

49. 19. Which Of the following does Not typically branch from the internal carotid artery?Anterior cerebral arteryMiddle cerebral artery Posterior cerebral arteryPosterior communicating arteryOphthalmic artery10

50. Circle of willisRepresents a major site of anastomosis between the two vertebral arteries (via the basilar artery) and the two internal carotid arteries, which together supply the brain

51. 20. Which of the following drains blood away from the confluence of the sinuses?Transverse sinusSuperior sagittal sinusOccipital sinusStraight sinusSigmoid sinus10

52. The Confluence of the sinusesReceives blood from the superior sagittal, straight, and occipital sinusesBlood drains into the (R/L) transverse sinuses, and from there to the (R/L) sigmoid sinuses

53. NeckFascial planesMajor vesselsStrap muscles – innervated by ansa cervicalis (C1 to C5) * know segments contributed to each muscleLarynx – structure, muscles, innervation

54. 21. Upon swallowing, what helps to elevate the thyroid along with the trachea and larynx? Superficial (investing) fasciaPrevertebral fasciaPretracheal fasciaSuspensory ligamentsPyramid lobe of the thyroid10

55. Fascial Layers of NeckSuperficial investing fasciaSuprahyoid musclesSCMTrapeziusPretracheal fasciaThyroidTracheaMove as a unitPrevertebral fasciaScalenesParavertebral muscles

56. 22. Between which structures would a pharyngeal infection be most likely to spread to the mediastinum?Between the trachea and the carotid sheathBetween the trachea and the strap musclesBetween the trachea and the esophagusBetween the esophagus and the prevertebral musclesBetween the trapezius and the prevertebral muscles10

57. Retropharyngeal spaceSituated between the buccopharyngeal fascia and the alar fascia Permits spread of infections into the mediastinum from the head and neck

58. 23. Which of the following muscles would be most active in forced respiration, as in when taking a deep breath?cricothyroidthyroarytenoidposterior cricoarytenoidlateral cricoarytenoidvocalis10

59. The LarynxKnow actions of muscles (use names to give you clues)Know motor innervation (all inferior laryngeal, except cricothyroid = external laryngeal)Know sensory innervationSuperior to vocal ligament = internal laryngealInferior to vocal ligament = inferior laryngeal (from recurrent laryngeal)

60. LymphaticsExpect 2 or 3 lymph questionsLymph drainage of the face and tongue are keyRemember to keep an eye out for small details when studying

61. 24. To which lymph nodes would you expect this squamous cell carcinoma to metastasize first?submentalsubmandibularInferior jugularbuccalparotid10

62. Major Drainage patternssubmental: central lower lip, chin, apex of tonguesubmandibular: upper lip, lateral lower lip, lateral part of anterior 2/3 of tongueInferior deep cervical: medial part of anterior 2/3Superior deep cervical: posterior 1/3 of tongueParotid: lateral face and scalp, eyelids

63. EmbryologyBranchial ArchesEye DevelopmentEar DevelopmentKnow the precursors

64. 25. from which of the branchial arches is the affected nerve derived?0FirstSecondThirdFourthFifth

65. 26. The external auditory meatus develops from which of the following embryologic structures?First branchial archSecond branchial archThird branchial archFirst branchial cleftSecond branchial pouch10

66. Branchial arch derivativesArchNerveSkeletal StructuresMuscles1CN VMandible, malleus, incus, greater wing of sphenoidMuscles of mastication, mylohyoid, anterior belly of digastric, tensor tympani, tensor veli palatini2CN VIIStylohyoid process, stapes, upper body & lesser horn of hyoidMuscles of facial expression, stylohyoid, stapedius, postberior belly digastric3CN IXLower body & greater horn of hyoidStylopharyngeus4CN XSuperior laryngealThyroid cartilageCricothyroid, levator veli palatini, palatopharyngeus, palatoglossus, pharyngeal constrictors5-6CN XRecurrent laryngealCricoid cartilageIntrinsic muscles of larynx (except cricothyroid & stylopharyngeus)

67. Branchial Clefts & Pouches

68. 27. The semicircular canals develop from the _________________ of the otic vesicle, which is itself derived from _______________.0Utricular part; surface ectodermUtricular part; neural ectodermSaccular part; surface ectodermSaccular part; neural ectoderm

69. Inner Ear Developmentotic placode  otic pit  otic vesicleDorsal Utricular Part  utricle, semicircular canals (U looks like canals)Ventral Saccular Part  saccule, cochlea (S for Spiral shape of cochlea)

70. Connectionsthe cranium is a mazelearn the major passagewaysespecially true for the face

71. 28. Where do tears Enter the nasal cavity?Inferior meatusMiddle meatusSuperior meatusSphenopalatine foramenPterygomaxillary fissure10

72. Sinus DrainageInferior meatusNasolacrimal ductMiddle meatusFrontal sinusAnterior ethmoidal air cellsMaxillary sinusSuperior meatusPosterior ethmoidal air cellsSphenoethmoidal recessSphenoidal sinus (associated with pituitary gland)

73. 29. A tumor from the infratemporal fossa gains entrance to the orbit. What is the most likely route?Superior orbital fissureInferior orbital fissureOptic canalSphenopalatine foramenPterygoid canal10

74. TO ORBITA tumor could also invade the nasal cavity by passing through the pterygomaxillary fissure and sphenopalatine foramen.

75. PracticalBe sure to spend some time with the models; there are a lot more on this examBe able to identify structures with the head in various positionsNo mock practical this time, but use the structured lab review as a guide

76. How soon before the exam would you like the review?10EarlierA week is goodLater

77. Good luck!